MICROSCOPIC AND CONVENTIONAL SUB INGUINAL VARICOCELECTOMY COMPARITIVE STUDY

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1 MICROSCOPIC AND CONVENTIONAL SUB INGUINAL VARICOCELECTOMY COMPARITIVE STUDY Mahmoud Abou Amraa Surgery Department, Al-Azhar University, Assiut SUMMARY Background : Microscopic sub inguinal varicocelectomy is an alternative to conventional sub inguinal varicocelectomy Method : Most operations upon varicocele were done in general surgery department of Al Alzar University Hospital. Operations done though out microscopic subinguinal or conventional inguinal approach RESULT : 50 men with age group ranged from years old underwent for varicocelectomy. 25 men was done via magnifying loupe. 25 men was done via conventional sub inguinal approach. Testicular artery preserved via magnified loupe, incidence of failure rate very low about 4% ( 1case ) and no postoperative hydrocele. Conventional subinguinal approach,testicular artery not known to preserved, failure rate 12% (3 cases ) and post operative hydrocele was occurred in 2 cases (8%) CONCLUSION : Microscopic subinguinal varicocelectomy is more better than conventional subinguinal varicocelectomy as related to testicular artery preservation, recurrence rate and post operative complication. INTRODUCTION Varicocele is observed in 12% of adult men. Varicocele is the most common treatable cause of infertility and it is repair has been demonstrated to improve semen quality and fertitity. The goal of treatment of varicocele is to the obstruct the refluxing venous drainage to the testis while maintaining arterial inflow and lymphatic drainage ( fish etal, 2004 ). Various out patients techniques has been described for repair of varicocele including, miro surgery, embolization, laparocopic and conventional approaches ( KUJH etal, 2002 ) The varicocele develops because of defective valves that normally allow the blood to flow from the testicle to the abdomin. Harmfull testicular effect occurs due to abnormal backflow of blood from the abdomin into scrotum, thus increasing the local temprature and creating a hostile environment for the sperm development. (Peterson etal, 1998 ) in the present study, we used both conventional subinguinal and microscopic subinguinal approach for varicocelectomy under spinal anaesthesia. PATIENTS AND METHOD 208

2 Mahmoud Abou Amraa In our study 50 men with age group ranged from years old underwent for varicocelectomy. 25 men was done via magnifying loupe.25 men was done via conventional subinguinal approach. Patient with varicoceles were examined and admitted to the department of surgery, AL- Azhar University Hospitals in March 2007 to March For each patient, ( 1 ) complete history and examination was done. ( 2 ) Investigation, all patient were investigated as a part of routine pre operative preparations, complete blood picture, random blood sugar,kidney function tests, semen analysis, testicular douplex and testicular uls.. ( 3 ) surgical technique,the surgeon and the assistant are using magnifying lens with at least 2.5 times magnification. Once the patient prepared, 2.5 cm sub inguinal incision over the cord was done. External inguinal ring and external oblique fascia are not open, once the subcutaneous fat is exposed then Infero medial dissection toward the spermatic cord. Babcock clamp is used to gently grasp the cord, enabling the surgeon to pass his finger beneath the cord. The cord is then tented anteriorly over one finger. The external spermatic veins which run lateral to the cord Isolated and ligated using vicryl 3/0. Now the cremasteric fascia covering the spermatic cord is opened. The structures of the cord are surrounded by a thin sheath which can now be bluntly entered exposing the vessels clearly. The vas deferens is then held at the medial aspect of the cord in order to keep it from harm. After the primary vascular bundle has been identified, the artery within it is located which often lies between two or more small veins and its first vessel to fill with blood. The artery isolated from surrounding veins which ligated with vicryl. Likewise, the posterior sheath, in which the lymphatic lie, is spared, then veins of the primary vascular bundle are ligated. The remaining veins of the spermatic cord are ligated,gabernucular veins also must be ligated. The cord can be placed can be back inside its canal. The Incision is then closed in two layers. Good post operative care with good post operative analgesia and care for any post operative complications. RESULT This study was carried out on 50 patients with varicoceles. The age group of the patients range from years old. unilateral varicocele was present in 14 men, while bilateral varicocele was present in 36 patients. In our study 25 patients was done via conventional sub inguinal approach as testicular artery not known to preserved, failure rate occurred in 3 cases as varicocele recur within 1year this rate of recurrence is high (12%) in comparison with microscopic subinguinal approach. Post operative hydrocele were occurred in two cases ( 8%),this complication due to ligation of lymphatic vessels during operation. 209

3 Table(1): techniques of varicocelectomy Potentional for serious morbidty Failure Hydocele Artery Preserved No 3 2 Not known To be Preserved No 1 O Known to Be Preserved Technique Conventional Sub Ingninal Microscopic Sub Inguinal In our study 25 men was done via microscopic sub Inguinal approach, testicular artery known to be preserved as its well identified during operation via magnified loupe. Failure rate or recurrence of varicocele is very low 1case ( 4% ) as most veins are well identified and ligated. Post operative complication as hydrocele formation not present as lymphatics which present at posterior sheath are well identified and preserved. DISCUSSION It reported that the incidence of varicocele is 15 %. Although varicoceles have been associated with impaired male fertitlity potential, it also clear that a significant proportion of men with a varicocele are fertile. ( Akbay etal, 2000). As such, a cause and effect relationship between varicocele and male infertility has not been conclusively established ( Jarow ; 2001 ) The etiology of varicocele is multi factorial but the incompetence of venous valves resulting in reflux of venous blood and Increased hydrostatic pressure are the most popular theories ( krause etal, 2002 ). Macleod ( 1965) and other Investigators observed that most semen samples from Infertile men with varicocele have poorer sperm parameters ( lower sperm count,increased number of spermatozoa with abnormal forms, and decreased sperm motility ) than fertile men. (Macleod etal, 1962 ) There are several approaches for varicocelectomy, these include, inguinal approach, subinguinal approach, microscopic subinguinal approach, radio graphic embolization and laparoscopic repair ( Grober etal, 2004 ) The micro surgical varicocelectomy is considered the "gold standard " be cause it is associated with a higher success rate ( disappearance of varicocele ) and a lower 210

4 Mahmoud Abou Amraa complication rate ( recurrence rate and hydrocele formation ), compared with non microsurgical techniques ( Ghanem etal,2004 ). Uses a magnifying loupe enables asurgeon to find and preseve testicular artery also allows identification and preservation of the lymphatic which eleminating the risk of hydrocele after surgery ( AL- kandari etal 2007 ). Surgical loupe give the necessary magnification which needed for anatomical identification and prevention of post operative complications ( Gontero etal, 2002 ). In our study 25 men were done via conventional sub Inguinal approach,artery not known to preserved, failure rate 12% ( 3 cases ) and post operative hydrocele 8% ( 2 cases ).Microscopic sub inguinal approach were done for 25 men with vaicoceles. The testicular artery well known and preserved. Failure rate is very low 4% ( 1 case ) and no post operative hydrocele. CONCLUSION :- The most common complications after varicocelectomy are testicular artery injury, recurrence and hydrocele. Microscopic subinguinal varicocelectomy is more better than conventional subinguinal varicocelectomy as related to testicular artery preservation, recurrence rate and post operative complication. REFERENCES 1) Akbay E, Cayan S, Doruk E,etal. The prevelence of varicocele and varicocele related testicular atropy tn Turkish children and adloscent. BJU Int ; ) AL Kandari AM, Shobaan H, Ibrahim HM, et al. Comparison of outcomes of different varicocelectomy techniques a randomized clinical trial urology 2007; 69 : ( pubmed ) 3) Fish H, Johnson CW, Bingh JB, Anastasiadis AG, A novel surgical approach to subinguinal varicocelectomy : Artery and lymphatic isolation technique; urol. Int.2004, 77: ) Ghanem H, Anis T, EL Nashor A,et al. Sub inguinal micro varicocelectomy versus retro peritoneal varicocelectomy comparative study of complications and surgical outcome. Urology 2004 ; 64 ; ) Gontero P,pretty G, Fontana F, et al. Inguinal versus sub inguinal varicocele vein ligation using magnifying loupe which technique is preferable in clinical practice? urology 2002 ; 66 : ( pubmed ) 6) Grober ED. O'brien J, Joruik A, Sini A. Preservation of testicular arteries during subinguinal micro surgical varicocelectomy clinical considerations J Androl 2004 ; 25 ;

5 7) Jarow J P. Effects ot varicocele on male fertility. Hum repoted update 2001 ; 7 : ) Krause w, Muller HH, Schofer, et al. Does treatment of varicocele improve male fertility? Results of ' Deutsche varikoselen studie ; a multicentre study of 14 collaborating centres. Andrologia 2002 ; 34 : 164 : 71 9) Ku Jh, Son H, kwak, Lee Nk, Parky H. Impact of varicocele on testicular volume in young men : significance of compensatory hypertrophy of the contralateral testis. J urol 2002 oct ; 168 ( 4 ) : ) Mac leod J: seminal cytology in the presence of varicoceles. fertile. Steril, ) Peterson AC, Gold Stein M Lance ks. Outcomes varicocele ligation done for pain. J urol 1998 ; 159 :