Varicocele: an overview of information

Varicocele first described Celsius in the 1st century AD in the form of "swollen and tortuous veins over the testicle, which is less than the opposite." In 1889 WH Bennet established the relationship between changes in the scrotum and functional testicular failure. He gave the definition of varicocele as "a pathological condition of the vein of the spermatic cord, which, in most cases, occurs due to or in combination with functional testicular failure." It is the criterion of the functional consistency of the testes and determines the interest of clinicians in this urological disease. This is due to the demographic situation observed in most developed countries. At least 40% of infertile marriages are due to male infertility. In this regard, the problem of varicocele, which affects up to 30% of men, considered to be the cause of fertility decline in 40-80% of cases, is becoming more urgent.

Ambiguity and inconsistency of existing approaches and interpretations are noted already at the stage of terminological definition of the disease. Varicocele - varicose (groinlike) veins of the lobate (plexus pampiniformis) plexus of the spermatic cord, accompanied by intermittent or permanent venous reflux.

Epidemiology

Varicocele is one of the most common diseases among men, whose frequency varies according to the data of different authors, from 2.3 to 30%. Having innate prerequisites for development, the incidence in different age groups is not uniform.

At preschool age, it does not exceed 0.12% and increases with growth and maturation. The most frequent varicocele is observed at the age of 15-30 years, as well as among athletes and manual workers.

Causes of the varicoceles

In 1918, O. Ivanissevich defined varicocele as "an anatomical clinical syndrome, anatomically manifested by varicose inside the scrotum, and clinically by venous reflux, for example, caused by valve failure." He saw the interrelation of varicocele with the failure of the valves of the testicle vein, leading to retrograde blood flow along it. Later this was confirmed in connection with the introduction of vascular studies into clinical practice, allowing to visually assess the condition of the internal spermatic vein throughout its entire length. The defining concept for today is the concept that treats varicocele not as an independent disease, but as a symptom of an anomaly of development or disease of the inferior vena cava or renal veins.

The extreme variability in the structure of both the venous system in general, both the left and right renal veins is a consequence of a reduction in the reduction of cardinal and subcardinal veins. Retrograde blood flow is observed with a congenital (primary) absence of valves in the testicle vein, as well as genetically determined weakness of the venous wall due to underdevelopment of the muscular layer, connective tissue dysplasia leading to primary valvular insufficiency. Secondary valvular insufficiency develops as a result of venous hypertension in the system of the inferior vena cava and renal veins. In such cases varicocele is considered as a bypass reno-caval anastomosis (through the internal and external spermatic veins into the common iliac), compensating renal venous hypertension. Given the anatomical features of the left ovarian vein flowing into the renal vein, and the right in most cases directly into the inferior hollow and only 10% in the right renal vein, the left-sided varicocele prevails in the morbidity structure - 80-86%, right-sided - 7-15%, bilateral - 1-6% of cases.

Any pathological conditions at the level of the scrotum, inguinal canal, abdominal cavity (hernia), renal and inferior vena cava, leading to compression of the spermatic cord, an increase in intra-abdominal pressure, pressure in the inferior vena cava and renal veins complicating the outflow from the veins of the spermatic cord, is considered the cause of refluxing blood flow and development varicocele.

The main reasons for the permanent increase in hydrodynamic pressure in the renal veins and reno-testicular reflux system: stenosis of the renal vein, retroaortic location of the left renal vein, annular renal vein, arteriovenous fistula. Varikotsele in such cases is defined as in ortho- and in clenostasis, it exists from childhood and progresses. Particular attention is paid to the intermittent nature of reflux, often observed with aorto-mesenteric forceps, which is considered one of the causes of orthostatic varicocele. Sometimes this urological disease develops with tumors of the left kidney, the abdominal cavity, compressing the main venous collectors, with a tendency to rapid progression as the tumor grows.

[1], [2], [3], [4], [5], [6], [7]

Pathogenesis

The role of pathogenetic factors leading to disturbances of spermatogenesis in varicocele has not been fully established. They include:

• local hyperthermia;
• hypoxia;
• violation of the hematotestick barrier, including from the contralateral side due to collateral blood flow, leading to the development of antisperm antibodies;
• excess production of hydrocortisone in adrenal venous hypertension;
• disorders of the receptor apparatus and steroidogenesis;
• disturbance of the reciprocal relationship of the testicle-pituitary-hypothalamus.

The role of local and general, relative and absolute androgen deficiency and other hormonal disorders is currently being studied. Recently, the influence of genetic factors leading to a violation of spermatogenesis in varicocele has been investigated. A direct correlation between the degree of varicocele manifestation and the degree of spermatogenesis disturbance does not exist the question of the effect of extrafunkicular varicocele on spermatogenesis is being studied. Given the anatomical and physiological features of the structure of the cremaster vein and the superficial venous system of the testicle, there is no uniform opinion on the pathogenetic significance for the gametogenesis of the refluxing type of blood flow, which is sometimes observed in the norm in this vascular system.

[8], [9], [10], [11]

Symptoms of the varicoceles

Symptoms varicocele flow imperceptibly. Sometimes patients note the severity and pain in the left half of the scrotum, which must be differentiated from inflammatory diseases of the scrotal organs.

Forms

Depending on the nature of the phlebo-testicular relationship, Coolsaet identifies three hemodynamic types of reflux:

• Reno-testicular:
• ileo-testicular;
• mixed.

In terms of severity, there is a large number of varicocele classifications.

[12], [13], [14]

Degrees varicocele by WHO (1997)

• I degree varicocele - enlarged veins protrude through the skin of the scrotum, are clearly visible. The testicle is reduced in size, has a testic consistency.
• II degree varicocele - dilated veins are not visible, but are well palpated.
• III degree varicocele - dilated veins are determined only with a Valsalva test.

The asymptomatic varicocele is determined with the help of a cough test or with the scrotal dopplerometry using the Valsalva test.

In domestic practice, the classification of Yu.F. Isakova (1977), based on the reverse gradation of manifestations of the disease, in contrast to the WHO classification.

• I degree varicocele is palpable only with a Valsalva (tensing) in orthostasis.
• II degree - varicocele is well defined palpation and visually. The testicle has not been changed.
• III degree pronounced dilatation of veins of the plexus plexus. The testicle is reduced in size, has a testic consistency.

[15], [16], [17], [18]

Diagnostics of the varicoceles

Diagnosis of varicocele is based on palpation, ultrasound and Doppler studies. Of non-invasive methods, ultrasound in combination with dopplerographic mapping of renal vessels and the testicle vein has the greatest sensitivity. The study is performed in ortho- and clinostasis with a mandatory assessment of the nature of the changes in the blood flow (the rate of renal venous blood flow, the rate and duration of testicular reflux) with the Valsalva test and the transfer of the patient to the orthostatic position. Normally, the diameter of the testicle at the level of the scrotum is no more than 2 mm, the blood flow velocity does not exceed 10 cm / s, the reflux is not determined. With a subclinical varicocele, the diameter of the testicular vein increases to 3-4 mm, a short (up to 3 s) reflux is determined with a Valsalva test.

Further increase in reflux parameters corresponds to more pronounced stages of the pathological process. Carrying out a study using this technique allows in most cases to suggest a hemodynamic type of varicocele, to reveal signs of renal venous hypertension and to identify subclinical forms of the disease that are difficult to diagnose on palpation, which is considered a subjective method of assessing the condition of the spermatic cord and its elements. The urine is examined before and after physical exertion. A positive march test (the appearance of microhematuria, proteinuria) indicates renal venous hypertension, negative - does not exclude the presence of the latter, since reno-caval shunting blood flow through the system of testicular veins is sufficient to compensate it. In such cases, the march test can become positive after dressing, clipping or embolization of the testicle vein due to worsening of renal venous hypertension.

The ultrasound method has a high sensitivity and is considered the main one in the diagnosis of varicocele, invasive x-ray methods are also relevant and have the greatest visibility and informativeness. Antegrade phlebotestickography and retrograde renal phlebography with retrograde phlebotestoculography and multipoint phlebotonometry are used in unclear cases and in the diagnosis of recurrent forms of the disease. Sometimes dynamic nephroscintigraphy is performed to determine the functional state of the kidneys. Depending on the results of the survey, the type of surgical intervention is chosen.

Diagnosis varicocele has the following tasks:

• determination of the hemodynamic type of varicocele;
• evaluation of the severity of renal venous hypertension, the nature and severity of venous reflux;
• the study of the initial hormonal status and spermatogenesis.

A semiological study, an MRI test, a hormonal profile test (the concentration of testosterone, estradiol, prolactin, follicle stimulating hormone (FSH), luteinizing hormone (LH)), the majority of patients in a semiological study diagnose pathospermia of varying severity, which is a decrease in the concentration of active-mobile forms spermatozoa and an increase in the number of pathological forms.In 60% of patients noted oligospermia.

The wording of the diagnosis varicocele

Orthostatic left varicocele, II stage, I hemodynamic type, oligoastenozoospermia, infertile marriage.

Aortomethangular tweezers, intermittent renal venous hypertension, orthostatic left-sided varicocele, III stage, I hemodynamic type, asthenoteratozoospermia, infertile marriage.

[19], [20], [21], [22], [23], [24], [25], [26], [27]

Treatment of the varicoceles

Non-drug treatment varicocele

Conservative treatment varicocele does not exist.

Drug treatment varicocele

Medical treatment varikotsele used in the postoperative period to stimulate spermatogenesis. It includes vitamins, biologically active food additives (containing selenium and zinc) and hormonal preparations (androgens, chorionic gonadotropin), prescribed for strict indications by courses under strict laboratory control.

[28], [29], [30], [31], [32], [33], [34]

Varicocel surgery

To date, varicocele is used approximately 120 types of operations. Some of them have only historical significance. Applied currently manuals are divided into two groups.

I group - preserving the renal graft. These include shunting operations: proximal testiculo-ical and proximal testiculophrenic vascular anastomoses. The implementation of bi-directional anastomoses is not advisable.

II group - not retaining the transplant shunt.

• Suprainguinal non-selective.
  • Operation A. Palomo (1949) - the internal spermatic vein is bandaged together with all accompanying vascular structures.
  • Operation A.P. Erokhina (1979) ligation of the internal spermatic vein and artery with preservation of lymphatic vessels, for the best visualization of which apply the introduction of a solution of indigo carmine for the egg white shell.
  • Operation Bernardi, Kondakova and other benefits.
• Supraingivalnie selective.
  • Operation O. Ivanissevich (1918).
  • High ligation of the testicle vein.
  • Surgery Speriongano (1999) - vein ligation in the inner ring of the inguinal canal under the control of intraoperative color Doppler sonography.
• Subingual selective.
  • Subinginal ligation of the testicle vein (microsurgical method).

Preferring reconstructive vascular and selective supra- and subgingual interventions, it is advisable to use optical magnification and precision technique. Execution of surgical intervention with the use of microsurgical techniques allows, on the one hand, to reduce the number of relapses by increasing the effectiveness of the intervention, and on the other - to reduce the number of complications associated with difficult differentiation of the elements of the spermatic cord and the vascular structures accompanying the internal seminiferous vein.

The most common operation is according to Ivanissevich. The ligation and crossing of the left testicular vein interrupts the reverse blood flow from the renal vein into the groin-like plexus, in connection with which the varicose veins are eliminated.

However, in this operation, eliminating the varicocele, undergoing changes in the venous renocaval anastomosis, compensatory development in connection with the difficulty of venous outflow from the kidney. Considering the cause varikotsele not only reflux on the testicle vein, but also increased arterial blood flow to the testicle along the testicle artery. A. Palomo (1949) proposed to tie up the vein and the artery together. In this operation, the testicle vein is bandaged together with the accompanying it in the form of a thin crimped trunk with an ovarian artery. It is proved that ligation of the testicular artery does not cause a violation of the blood supply to the testicle and its atrophy, provided that the arterial inflow to it is preserved along the external seminal artery and the artery of the vas deferens. It has been established that spermatogenesis is restored more slowly when the testicle is ligated.

Introduction before the operation of 0.5 ml of 0.4% solution of indigo carmine for the testicle of the egg allows to see the proximal lymphatic pathways of the vascular bundle of the left testicle during surgery in children and to avoid their accidental dressing together with the artery and vein.

Recurrence of varicocele develops in the case of a thin venous trunk remaining unattached during surgery, accompanying the main one. The remaining reverse blood flow through this vein quickly transforms it into a wide trunk. The dropsy of the testicle shells that appeared after the operation (in 7% of cases) develops as a result of a block of lymphatic outflow from the testicle.

Laparoscopic clipping of the testicle vein

Laparoscopic varicoctomy is considered a minimally invasive endoscopic analogue of open supra-inginal interventions. Contraindication - several surgical interventions on the abdominal organs in the anamnesis. One of the important advantages is the possibility of performing laparoscopic clipping of veins in bilateral lesions. Terms of stay in the hospital - from 1 to 3 days.

To identify the lymphatic vessels under the testicle of the testicle, it is necessary to introduce methylthioninium chloride and carefully separate the artery and lymphatic vessels, which is considered a preventive measure of relapse.

According to I.V. Podzubnogo et al., The advantage of laparoscopic occlusion of the testicular veins compared with angioembolization is more promising and economically advantageous.

Technique of laparoscopic occlusion of the testicle vein. The operation is performed under endotracheal anesthesia. After applying carboxyperitoneum at point 1, a 5 mm trocar is inserted near the navel and a revision of the abdominal cavity is performed using a 5 mm laparoscope. Often in the operation, they find spikes with the sigmoid colon, which are separated. Detect the vessels of the testicle. With spikes, the testicles are visualized to the left less clearly than to the right. Conduct a Valsalva test (squeezing the testicle with the hand - the testicle is pulled down by the doctor, not participating in the operation), after which the vessels are revealed more clearly. In the retroperitoneal space, 5-8 ml of 0.5% procaine solution is administered. A transverse incision is made over vessels 1.5-3.0 cm long. The artery is separated from the veins, after which they are clipped and crossed. Increasing the laparoscope allows you to see lymphatic vessels and leave them intact. Carefully check whether all veins are crossed, since sometimes a vein is seen that is very close to the artery, which is difficult to distinguish.

That is why carefully and carefully examine the artery at the level of the crossed veins. Repeat the Valsalva test to confirm the absence of bleeding. After revision of the abdominal cavity, desulfation is carried out and 5 mm trocars are removed. Sew up only the skin. Performing laparoscopic operation with clipping of the testicular veins in comparison with open surgery has advantages.

Given the above, it should be concluded that along with a wide range of surgical benefits offered for varicocele treatment, a laparoscopic operation performed according to strict indications is considered a worthy alternative.

Evdovascular phlebosclerosis

Performed simultaneously with phlebography and phlebotonometry, is shown when the first hemodynamic type of varicocele is identified, the absence of organic disease (stenosis, retroaortic renal vein location), and renal venous hypertension.

Endovascular obliteration of the testicle vein is an alternative to surgery in children and adults. For endovascular occlusion, various materials are used: spiral emboli. Tissue glue, wire umbrella devices, separating cylinders, scleropreparations, etc. Perform catheterization of the femoral vein according to Seldinger. After superselective sensing of the testicular vein, one of the thrombotic preparations (8-15 ml) is injected into it, retreating 5-8 cm from the mouth of the testicular vein. The absence of testicular vein contrast at the level of the iliac crest 30 minutes after the administration of the sclerosing preparation indicates the thrombosis of the vessel.

The direct contact of the thrombosed substance with the blood of the patient is of primary importance. Thrombosis occurs at the border thrombotic preparation - blood. Some authors recommend providing a relatively fixed boundary between thrombotic preparation and blood for 2-3 minutes and not filling the entire testic vein with a solution of the thrombosed preparation. Thrombosis on average ends in 20-25 minutes.

This method is contraindicated in a loose type of veins. Disadvantages of the method: the possibility of recanalization and the entry of sclerosing substances into the general bloodstream, the phlebitis of the groinlike plexus. To exclude the last complications, it is recommended to carefully tighten the seminal cord at the entrance to the scrotum during the injection of the thrombotic preparation.

Absolute contraindications for endovascular occlusion in children:

• Diagnosis of large testicular cavity testicular and testicular colurals, according to which the sclerosing drug is dislocated into the central veins, which leads to its entry into the systemic circulation;
• absence of occlusion of the trunk of the testicle vein distal to these collaterals;
• absence of phlebographic signs of renal-ovarian reflux, which can be caused either by the absence of varicocele, or by an abnormal flow of the left testic vein into the lower hollow, lumbar veins, etc .;
• diagnosis of a single stem of the testicle vein, accompanied by marked signs of renal venous hypertension, hematuria and protenuria with a combination of a single trunk with agenesis of the right kidney.

Advantages of the method of endovascular percutaneous transfemoral sclerotherapy of the left testicular vein:

• manipulation is performed under local anesthesia;
• term of hospitalization is reduced to 2-3 days;
• the method allows to avoid surgical intervention;
• sclerosing drug causes thrombosis of not only 1 stem of the testicle vein, but also small anastomoses;
• Embolization helps to avoid lymphostasis and hydrocele;
• It is possible to re-embolize if a relapse occurs.

Each of the listed methods of the second group has its advantages and disadvantages, and their application is largely motivated by the individual preferences of the urologist. The choice between interventions of the first and second group is considered to be a principle one.

Varicocele of the 1st hemodynamic type with an organic narrowing of the renal vein, permanent or intermittent renal venous hypertension with a high orthostatic or functional (Valsalva trial) pressure gradient and other parameters of renotestick reflux is an indication for shunting operations of the 1st group.

Thus, the predominant hemodynamic type of varicocele is considered to be renotesticular reflux, surgical treatment is the only method for treating this disease. The type of operational benefit is determined by the hemodynamic type of varicocele, the presence of renal venous hypertension and the nature of phlebotestick reflux. Operative intervention should be undertaken when the disease was detected.

[35], [36], [37]

Prevention

Specific prevention varicocele does not exist. Restriction of physical activity can not be considered as a rational and adequate preventive measure.

[38], [39], [40], [41]

Forecast

According to different authors, relapse of the disease is noted in 2-30% of cases. On average, relapses occur in 10% of operated patients and are associated not only with operational equipment defects, but also with erroneous determination of the hemodynamic type of varicocele. In 90% of patients, improvement in spermatogenesis is observed, but only in 45% of the indicators were approaching the norm. The longer the disease and the older the age group of operated patients, the lower this index and the longer the recovery period (up to 5-10 cycles).

[42], [43], [44], [45], [46]