The management of varicoceles by microdissection of the spermatic cord at the external inguinal ring

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1 FERTILITY AND STERILITY Copyright 1985 The American Fertility Society Printed in U.8A. The management of varicoceles by microdissection of the spermatic cord at the external inguinal ring Joel L. Marmar, M.D.*t+ Thomas J. DeBenedictis, M.D.*:j: Donald Praiss, M.D.*:j: Rutgers Medical School, Camden, New Jersey, and The Andrology Center, Philadelphia, Pennsylvania A new technique for the management of varicoceles was carried out on 71 infertile men. The procedure combined microdissection of the spermatic cord at the external inguinal ring, ligation of the dilated veins, and controlled sclerosis of small crosscollateral veins. These procedures were performed on an outpatient basis and usually with local anesthesia. The surgery was completed within 20 to 30 minutes, and the postoperative morbidity was minimal. Twenty-four cases were followed for at least 18 months postoperatively. Among this group, the mean values for sperm density and sperm motility increased after surgery. The differences between the means were significant (P < 0.001). The pregnancy rate among this group was 29.3%. Fertil Steril43:583, 1985 The correction of a varicocele has been an important procedure for the management of male infertility, and several different techniques have been utilized. Urologists have operated by high ligation of the internal spermatic veins via an inguinal l or retroperitoneal 2 approach. Radiologists have embolized 3 or sclerosed 4 these veins by percutaneous venography. Recently, microsurgeons have diverted the internal spermatic veins. 5 Although these procedures have been used successfully to eliminate retrograde blood flow, improved techniques seem desirable because a grow- Received October 11, 1984; revised and accepted December 13, *Department of Urology, Cooper Hospital/University Medical Center, Rutgers Medical School at Camden. treprint requests: Joel L. Marmar, M.D., 1301 North Kings Highway, Cherry Hill, New Jersey :j:the Andrology Center, Philadelphia, Pennsylvania. ing list of unwanted effects have been cited in association with these procedures. For example, with open surgery, the spermatic artery may be injured during the dissection, 6 the lymphatics may be disrupted, producing a hydrocele,7 and there may be postoperative pain requiring 7 to 10 days of convalescence. With selective venography, the procedures may take 1 to 3 hours to accomplish, the veins may perforate,8 the embolic devices may migrate,9 and for technical reasons, the veins may not be catheterized in 15% to 20% of the cases. lo With microsurgical diversion, the clinical experience has been limited, and these procedures may be too complex for routine usage. 11 In this report, we describe a new technique for the management of varicoceles which combines microdissection ofthe cord, ligation of the dilated veins, and controlled sclerosis of small cross-collateral veins. We found that this approach was simple and eliminated many of the unwanted effects noted with the other standard techniques. Marmar et al. Management of varicoceles 583

2 o int. inguinal ring Ext. inguinal ring, cm incision JJ Pubic symphysis Figure 1 The anatomic relationship between the internal inguinal ring, the external inguinal ring, and the pubic symphysis. A 2-cm mini-incision was located just over the external inguinal ring. MATERIALS AND METHODS The patients for this study were seen in our infertility clinic. They demonstrated at least three semen specimens with various combinations of oligozoospermia «20 x 10 6 /ml), asthenozoospermia «40%, < 3 + motility), and teratozoospermia «30% normal forms). The presence of a varicocele was demonstrated by physical examination and/or adjunctive studies, including Doppler examination, thermography, isotope scans, or venography. At least two separate positive studies were required before surgery was recommended. Each operative case was performed on an outpatient basis according to the following steps: (1) The area over the external inguinal ring was identified for localization of the anesthetic and placement of the incision (Fig. 1). (2) The local anesthetic (1% Xylocaine, Astra Pharmaceutical Products, Inc., Worcester, MA) was administered by a simple skin wheal. The area was identified by introducing the index finger into the external ring (Fig. 2). (3) A 2-cm incision was placed just above the pubic symphysis at an area over the external inguinal ring. The skin incision was just wide enough to admit the index finger. Once the external inguinal ring and spermatic cord were identified, the cord was anesthetized at a higher level by a single injection into the inguinal canal. The needle tip was guided by the index finger in the external inguinal ring (Fig. 3). 584 Marmar et al. Management of varicoceles (4) Once the cord was adequately blocked, it was grasped by a Babcock clamp and brought to the surface. The cord was supported by two small Penrose drains. The distal drain was held taut for traction on the spermatic cord, but the proximal drain was maintained loosely to avoid occlusion of the arterial flow. (5) At this point, the dissection proceeded under the operating microscope, which was set in the midrange (x 7 to 10 magnification). The cremasteric fascia was opened in two layers, and the lymphatics were preserved. Any dilated cremasteric veins were ligated with small hemoclips. When the fascia was opened, it was retracted laterally with rakes. The vas deferens was observed and maintained out of the field of dissection. The vasal veins were seen parallel to the vas and were ligated if they exceeded 2 mm in diameter (Fig. 4). (6) The remaining vascular structures of the cord were sprayed with 2 to 3 ml of papaverine hydrochloride (Eli Lilly & Company, Indianapolis, IN) (30 mg/ml) in order to augment the arterial beats. In this way, the artery was observed during the remainder of the dissection in order to avoid injury. If the artery was in spasm, a second application of papaverine was required during the procedure. (7) All dilated veins were ligated with hemoclips. Although veins were more numerous at this level of the spermatic cord, with experience, the operator learned to dissect the vessels into two distinct groups with micro-instruments. The pos- Figure 2 The index finger was introduced via the scrotum toward the external inguinal ring. The anesthetic was delivered by a skin wheal just over the external inguinal ring. Fertility and Sterility

3 \ Loeep Injection ~ Into con! "Y----2 cm Incision Figure 3 The index finger was advanced through the 2-cm incision. The finger identified the external inguinal ring, so that a cord block might be accomplished by deep injection into the spermatic cord at a higher level than that of the external inguinal ring. terior group of veins were ligated quickly with hemoclips because they were distant from the artery, but the anterior group of veins were ligated only after cautious microdissection because the artery usually coursed among them. (8) At this point, a sclerosing agent was injected into the veins to ensure that obliteration occurred to all small collateral vessels. The Penrose drains were cinched tightly around the spermatic cord in order to gain proximal and distal control, and then the anterior and posterior veins were injected directly with a 30-gauge needle attached to a tuberculin syringe. Approximately 0.2 to 0;5 ml of 3% sodium tetradecyl sulfate (Sotradecol, Elkins-Sinn, Inc., Cherry Hill, NJ) was injected into the vein by direct vision. The sclerosing fluid was observed coursing through the collateral branches. Care was taken to avoid overdistension of these vessels, and the puncture sites were sealed with small hemoclips when the needle was removed (Fig. 5). (9) The Penrose drains were released, the arterial beat was noted, and the spermatic cord was replaced in its anatomic bed. The incision was closed with a subcuticular suture. The wound was simply covered by a small dressing. RESULTS Seventy-one patients underwent microdissection of the spermatic cord at the external inguinal ring. Seventeen cases were bilateral, and 54 were unilateral, on the left side. After surgery, the patients were examined at 2 weeks and then again at 3-month intervals. There were no hydroceles, but five patients had ecchymosis over the incision, two had wound infections, and one developed epididymitis. All complications were self-limiting with conservative therapy. Among these cases, there were four recurrences (5.6%). Two recurrences were palpable on physical examination, but two other recurrences were nonpalpable and documented only by Doppler examination. These recurrent cases were studied with selective venography, and the remaining refluxive veins were obliterated with coils. Twenty-four cases were followed for at least 18 months postoperatively. At least three preoperative and three postoperative semen analyses were available for statistical evaluation for each of these patients. The mean values for the parameters of the semen analysis are listed in Table 1. The differences between the means are significant for sperm density (millions per milliliter) and percent motility (P < 0.001). However, there was no significant difference in the mean for sperm morphology. There were seven pregnancies among this group (29.3%). Figure 4 The cord was draped over two small Penrose drains. The distal Penrose drain was held taut in order to stabilize the cord. The proximal drain remained loose. The cremasteric fascia was examined under the operating microscope and opened in two layers. Marmar et ai. Management of varicoceles 585

4 Varicocelectomy by microdissection of the cord at the external inguinal ring was performed in 71 cases on an outpatient basis. This represented a significant cost saving and convenience to the patient. It seems that all procedures for the management of varicoceles may be accomplished on an outpatient basis in the future. LOCAL ANESTHETIC Although other open operative procedures for varicocelectomy have been accomplished by local anesthesia,12 the field block for these other procedures was more extensive and time-consuming because the dissection required exposure into the inguinal canal or retroperitoneal space. With varicocelectomy at the external inguinal ring, the canal does not require open dissection. Therefore, the block may be accomplished by a simple skin wheal over the external ring and a single injection into the spermatic cord structures at a higher level. ACCOMPLISHED QUICKLY Figure 5 The varicosities were clipped with hemoclips. Then proximal and distal control of the spermatic cord was obtained by cinching the Penrose drains. The varicosities were injected with a 3D-gauge needle, and the sclerosing agent was delivered under direct vision in order to obliterate the small cross-collateral vessels. DISCUSSION In an attempt to critically examine the new technique for the management of varicoceles, we have listed a set of criteria to be considered for a varicocelectomy. In this discussion, we will refer to these criteria and compare the new technique to the other standard procedures. OUTPATIENT PROCEDURE The correction of varicoceles by percutaneous venography and embolization may take 1 to 3 hours. Radiation exposure during these procedures may be significant. Furthermore, for technical reasons, the veins may not be catheterized in 15% to 20% of these cases. 10 The new technique described in this report was accomplished within 20 to 30 minutes, including time for administration of the local anesthetic. During the course of this dissection, all of the veins of the spermatic cord were easily accessed, so that the procedures were completed in all cases. PRESERVATION OF THE SPERMATIC ARTERY Advocates of percutaneous venography and embolization or sclerosis for the management of varicoceles suggest that the spermatic artery remained unharmed during their procedures. This represented an advantage over open surgery, because these arteries may be permanently damaged. Woznitzer and Roth 6 demonstrated arterial segments among the pathology specimens obtained during varicocelectomy. Although Palom02 reported that the spermatic artery may be Table 1. Mean Values for Parameters of Semen Analysis Among 24 Patients, Followed at Least 18 Months After VaricocelectomyU No. Sperm density Motility Normal morphology Preoperative Postoperative l06/ml 12.3 ± ± 1O.1b % 36.1 ± ± 18.5 b % 46.5 ± ± 18.3 aseven pregnancies (29.3%). bp < Marmar et a1. Management of varicoceles Fertility and Sterility

5 ligated intentionally above the internal ring with no effect on the testis, others l3, 14 have questioned the wisdom of sacrificing this artery in patients with already compromised spermatogenesis. With the new technique described in this report, every attempt was made to preserve the spermatic artery. Once the spermatic cord was opened, the vascular structures were sprayed with the vasodilator papaverine hydrochloride. This agent helped to augment and sustain the arterial beat, which was observed under the operating microscope. During the course of the venous dissection, the beating artery was carefully avoided. Postoperatively, there was no evidence of testicular atrophy, and the spermatic artery was audible by Doppler examination. PRESERVATION OF THE LYMPHATICS When the spermatic cord was dissected under the operating microscope, two layers of the cremasteric fascia were cut sharply. The lymphatics were observed and carefully avoided. With this approach, there were no late hydroceles. These results represented an improvement over other open surgical techniques, which reported 2% to 5% hydrocele formation.7 ACCESS TO INTERNAL SPERMATIC, CREMASTERIC, AND VASAL VEINS WITHOUT TECHNICAL PROBLEMS Hanley and Harrison15 advocated a scrotal approach for varicocelectomy in order to access the internal spermatic, cremasteric, and vasal veins along with their cross-collaterals. However, these procedures were abandoned because of the multiplicity of veins at this level. Recently, other investigators renewed interest in the low approach. Sayfan and Adam16 performed intraoperative phlebography and demonstrated multiple internal spermatic veins and incompetent cremasteric veins, which might be overlooked by high ligation. Howards ll commented on the theoretic advantage of a low dissection and noted that all of the veins that anastomose with the internal spermatic veins may be ligated at this level. In this report, we have demonstrated that microdissection of the spermatic cord at the external inguinal ring will access the entire venous drainage of the spermatic cord. The dilated veins were sealed with hemoclips. The remaining collateral vessels were sealed off by the controlled intravenous injection of a sclerosing agent. This fluid was observed to flow into the small vessels. Since the collateral vessels were sclerosed under direct vision and with proximal and distal control of a small segment of the spermatic cord, the veins were not overdistended or ruptured. With this approach, there were no untoward effects from the sclerosing material. When all of the refluxive veins were obliterated, the venous drainage seemed to be routed through the external pudendal system. These findings agreed with those of Hill et al.,17 who carried out venography after varicocelectomy and demonstrated drainage via the external pudendal system in a high percentage of these men. MINIMIAL MORBIDITY One disadvantage of open surgery has been the postoperative pain and protracted convalescence. With the new technique described in this report, the patients had minimal postoperative discomfort, and they returned to work within 48 hours. The reduced pain and reduced need for convalescence were related to the fact that the inguinal canal or retroperitoneal space was not dissected. IMPROVED SEMEN QUALITY Several review articles have indicated improved semen quality following varicocelectomy In this report, we have demonstrated increased values for mean sperm density and mean sperm motility among a group of patients followed for more than 18 months after microdissection of the cord at the external inguinal ring. When compared with the preoperative values, the differences between the means were statistically significant (P < 0.001). The pregnancy rate among this group was 29.3%. MINIMAL RECURRENCE In one large series, only one recurrence was reported among 986 cases after open surgery. 7 However, the follow-up of these cases was based on physical examination alone. In another report, Comhaire21 indicated that the frequency of varicocele persistence or recurrence after surgery varied from 5% to 20% and depended upon both the surgical technique and the methods used to detect recurrence. In the present report, all patients were followed by postoperative physical examination, Doppler examination, and thermography. In many cases, scrotal scans along with selective Marmar et al. Management of varicoceles 587

6 venography were used to detect recurrences. The recurrence rate with the new technique was 5.4%. Two of these recurrent lesions were palpable, but two other recurrences were nonpalpable. These findings illustrated that a clinically palpable varicocele may be converted to a nonpalpable or subclinical lesion after surgery. Thus, adjunctive studies must be used to evaluate the results of surgery, because physical examination alone may be insufficient to document "subclinical" lesions. After selective venography and occlusion with detachable balloons, Kaufman et al. 22 reported recurrent lesions in 8 of 70 patients (11%). However, these recurrences were detected by palpation alone. When these individuals were studied by repeat spermatic venography, c;linically undetected right-sided varicoceles were incidentally discovered in two patients who had recurrent leftsided varicoceles. These findings further illustrated the need for adjunctive studies for the detection of varicoceles. Kaufman et al. 22 have recommended placement of the embolic devices lower in the inguinal canal, because recurrent varicoceles were usually caused by collateral channels that bypassed the point of balloon occlusion. With microdissection of the cord at the external ring, there was direct access to these veins at a very low level. This dissection, combined with venous ligation and sclerosis, may reduce recurrences. REFERENCES 1. Ivanissevieh 0: Left varicocele due to reflux: experience with 4,470 operative cases in 42 years. J Int ColI Surg 34:742, Palomo A: Radical cure of varicocele by a new technique: preliminary report. J Urol 61:604, Formanek A, Rusnak B, Zollikofer C, Castaneda-Zunigl,l WR, Narayan P, Gonzalez R, Amplatz K: Embolization of the spermatic vein for treatment of infertility: a new ap-' proach. Radiology 139:315, Lima SS, Castro MF, Costa OF: A new method for the treatment of varicoceles. Andrologia 10: 103, Fox U, Romagnoli G, Colombo F: The microsurgical drainage of the varicocele. Fertil Steril 41:475, Woznitzer M, Roth JA: Optical magnification and Doppler ultrasound probe for varicocelectomy. Urology 22:24, Dubin L, Amelar RD: Varicocelectomy: 986 cases in a twelve-year study. Urology 10:446, Richter EI, Zeitler E: Complications and risks of percutaneous sclerotherapy and Gianturco coil embolization. In Varicocele and Male Infertility, Edited by WE Jecht, E Zeitler. Berlin, Heidelberg, New York, Springer-Verlag, 1982, p White HI Jr, Kaufman SL, Barth KH, Kadir S, Smyth JW, Walsh PC: Occlusion of varicoceles with detachable balloons. Radiology 139:327, Porst H, Bahren W, Lenz M, Altwein JE: Percutaneous sclerotherapy of varicoceles-an alternative to conventional surgical methods. Br J Urol 56:73, Howards SS: Varicocele. Fertil Steril 41:356, Ross LS, Lipson D, Dritz S: Surgical treatment of varicocele. Urology 19: 179, Ramadan AE-S, Eldemiry MIM, Ramadan AEAE-S: Doppler-controlled varicocelectomy. Br J Urol 56:432, Silber SJ: Microsurgical aspects of varicocele. Fertil Steril 31:230, Hanley HG, Harrison RG: The nature and surgical treatment of varicocele. Br J Surg 50:64, Sayfan J, Adam YG: Intraoperative internal spermatic vein phlebography in the subfertile male with varicocele. Fertil Steril 29:669, Hill JT, Hirsh AV, Pryor JP, Kellett MJ: Changes in the appearance of venography after ligation of a varicocele. J Anat 135:47, Cockett ATK, Takihara H, Cosentino MJ: The varicocele. Fertil Steril 41:5, Lewis RW, Harrison RM: Diagnosis and treatment of varicocele. Clin Obstet Gynecol 25:501, Saypol DC: Varicocele. J Androl 2:61, Comhaire FH: Varicocele infertility: an enigma. Int J Androl 6:401, Kaufman SL, Kadir S, Barth KH, Smyth JW, Walsh PC, White HI Jr: Mechanisms of recurrent varicocele after balloon occlusion or surgical ligation of the internal spermatic vein. Radiology 147:435, Marmar et ai. Management of varicoceles Fertility and Sterility