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Lai, C.; Chen, S.; Huang, C.; Chen, H.; Tsai, M.; Liu, P.; Chen, Y.; Chen, W. Diagnosis and Grading of Varicocelectomy. Encyclopedia. Available online: https://encyclopedia.pub/entry/43276 (accessed on 20 August 2024).
Lai C, Chen S, Huang C, Chen H, Tsai M, Liu P, et al. Diagnosis and Grading of Varicocelectomy. Encyclopedia. Available at: https://encyclopedia.pub/entry/43276. Accessed August 20, 2024.
Lai, Chien-Zhi, Szu-Ju Chen, Chi-Ping Huang, Huey-Yi Chen, Ming-Yen Tsai, Po-Len Liu, Yung-Hsiang Chen, Wen-Chi Chen. "Diagnosis and Grading of Varicocelectomy" Encyclopedia, https://encyclopedia.pub/entry/43276 (accessed August 20, 2024).
Lai, C., Chen, S., Huang, C., Chen, H., Tsai, M., Liu, P., Chen, Y., & Chen, W. (2023, April 20). Diagnosis and Grading of Varicocelectomy. In Encyclopedia. https://encyclopedia.pub/entry/43276
Lai, Chien-Zhi, et al. "Diagnosis and Grading of Varicocelectomy." Encyclopedia. Web. 20 April, 2023.
Diagnosis and Grading of Varicocelectomy
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This entry is adapted from the peer-reviewed paper 10.3390/biomedicines11041070

Varicocele is a frequently encountered urological disorder, which has a prevalence rate of 8 to 15% among healthy men. However, the incidence is higher in male patients with primary or secondary infertility, with up to 35 to 80% of varicocele cases occurring in this population. The clinical manifestations of varicocele typically include the presence of an asymptomatic mass that feels like a “bag of worms”, chronic scrotal pain, and infertility.

varicocelectomy chronic scrotal pain infertility

1. Physical Examination

Physical examination is the cornerstone of diagnosing varicocele, and it involves a thorough evaluation of the scrotum and its content. To facilitate the examination, the patient is generally placed in a warm room to help relax the cremaster and dartos muscles, which can otherwise cause the scrotum to retract and make it difficult to visualize the veins. During the examination, the patient is usually evaluated in both standing and supine positions. The scrotum is exposed, and the examiner uses their fingers to palpate the spermatic cord, which should feel smooth and uniform in texture. In cases of varicocele, the veins in the pampiniform plexus will appear dilated and tortuous, giving the appearance of a “bag of worms”.
To enhance the visualization of the varicocele, the Valsalva maneuver is often employed. This involves the patient taking a deep breath and holding it while bearing down as if trying to have a bowel movement. This increases the intraabdominal and intrathoracic pressure, which reduces venous return to the heart and increases the peripheral venous volume, making the varicocele more apparent. In addition to the physical examination, imaging tests such as ultrasound or venography may also be used to confirm the diagnosis of varicocele, particularly in cases where the physical examination is equivocal or when the patient is obese. However, physical examination remains the most important method for diagnosing varicocele and guiding treatment decisions.
When diagnosing varicocele, it is essential to grade the severity of the condition to determine the most appropriate treatment plan. Since there are no universally accepted classification systems yet, several classification methods were proposed. In 1970, Dubin and Amelar described a grading scale as the following content with a patient in the upright position [1]. Grade 1 varicoceles are small (<1 cm) and palpable only during a Valsalva maneuver, while grade 2 varicoceles are moderate (1–2 cm) and easily palpable but not visible. Grade 3 varicoceles are large (>2 cm) and easily visible without the need for palpation. In 1994, Tauber proposed a classification based on Dubin and Amelar’s with Doppler examination and added Grade 0 varicoceles, which are subclinical, not palpable but can be detected under Doppler ultrasonography (Table 1) [2].
Table 1. Classification of varicocele.
Dubin and Amelar;
Tauber		 Grade Clinical Vein Convolution Nomenclature
0 Not palpable but can be detected under Doppler ultrasonography 0 Subclinical
1 Palpable only during a Valsalva maneuver 0–1 cm Small
2 Easily palpable but not visible 1–2 cm Moderate
3 Easily visible without the need for palpation >2 cm Large
Sarteschi Grade Reflux Varicosities Testicular Hypotrophy
1 During a Valsalva maneuver None No
2 During a Valsalva maneuver Small No
3 Obvious during a Valsalva maneuver Apparent No
4 Spontaneous reflux and increase during a Valsalva maneuver or standing Present in all positions Common
5 Spontaneous reflux at rest without increases during a Valsalva maneuver Venous dilatation in all positions Yes
In addition to physical examination, imaging studies can also provide a more precise evaluation of varicocele. Ultrasonography is a noninvasive and widely used imaging technique that can accurately detect and grade varicocele. Sarteschi utilized ultrasonography to grade varicocele from grade 1 to 5 according to the severity of reflux, varicosities, and testicular atrophy [3]. Computed tomography (CT) and magnetic resonance imaging (MRI) are more advanced imaging techniques that can provide a clearer anatomical picture of the pelvic area, allowing for the detection of varicocele as well as other underlying conditions. Venography, which involves the injection of a contrast dye into the veins, is an invasive but highly accurate method for diagnosing varicocele and can be used to plan the optimal surgical approach.
Overall, the combination of physical examination and imaging studies can help diagnose and grade varicocele, allowing for appropriate treatment decisions to be made.

2. Treatments of Varicocele: Indications, Type of Surgery, and Its Results

2.1. Conservative Treatments

Initially, for chronic pain, patients may be managed with conservative treatments, such as bed rest, scrotal elevation or support, perineal pelvic floor exercise [4], limitations on physical activities, and non-steroidal anti-inflammatory drugs (NSAIDs). Moreover, as per Kilic [5], it has been reported that phlebotrophic drugs such as the micronized purified flavonoid fraction (MPFF) can help to improve venous tone and elasticity and reduce vein distension. At the same time, it was not recommended to use MPFF as a conservative treatment, given that randomized placebo-controlled trials are not yet available.
In cases where conservative treatments are not effective, surgical intervention may be necessary. Surgical intervention is recommended mostly if there is a sperminogram impairment, and for patients experiencing persistent scrotal pain, testicular atrophy, and infertility despite receiving conservative treatment. This recommendation is supported by a retrospective review that showed that varicocele ligation was effective [6].

2.2. Surgical treatments

Varicocelectomy
Retroperitoneal high ligation technique = Palomo approach
Varicocelectomy is a surgical procedure that involves ligating the dilated testicular veins to alleviate symptoms associated with varicocele (Table 2). The Palomo approach, first proposed by Palomo in 1949 [7], is a widely used technique for performing this procedure. It can be performed either openly, using a surgical microscope, or via laparoscopy. During the procedure, after accessing the retroperitoneal cavity, the testicular veins are ligated above the internal inguinal ring, with or without sparing the testicular artery. However, one limitation of the retroperitoneal approach is that it does not allow access to the collateral veins of the pampiniform plexus, which may lead to a higher recurrence rate [8][9]. Therefore, microsurgical subinguinal varicocelectomy, which allows for the identification and ligation of all dilated veins in the pampiniform plexus, has become a popular alternative. In addition to the risk of recurrence, the Palomo approach may also be associated with a lower pain remission rate compared to microsurgical subinguinal varicocelectomy [10]. Thus, it is essential to consider the patient’s specific circumstances and seek the opinion of an experienced surgeon when deciding on the most appropriate surgical approach.
Inguinal approach = Ivanissevich approach
Another approach for varicocelectomy is the inguinal approach, also known as the Ivanissevich approach. This technique involves making an incision in the external oblique aponeurosis to expose the inguinal canal, followed by dissection of the spermatic cord near the internal inguinal ring and ligation of the pampiniform plexus of veins. Despite its effectiveness, the inguinal approach carries the risk of damaging the ilioinguinal nerve and genital branch of the genitofemoral nerve, which can lead to chronic pain and numbness in the groin area [10]. Moreover, this approach may increase the risk of herniation due to the weakening of the abdominal wall. Additionally, opening the external oblique aponeurosis may increase the incidence of postoperative pain and prolong recovery time. As a result, while the inguinal approach may be effective in certain cases, it is generally considered less favorable than microsurgical subinguinal varicocelectomy, which has a lower risk of complications and offers comparable success rates. Ultimately, the choice of surgical approach will depend on the individual patient’s medical history, physical examination findings, and surgeon preference.
Subinguinal approach = Goldstein approach
One of the most widely used techniques for varicocelectomy is the subinguinal approach. This procedure involves the dissection of the spermatic cord inferior to the external inguinal ring while maintaining an intact external oblique aponeurosis. The microanatomy of this approach involves the identification and ligation of more small internal spermatic veins and fewer large internal spermatic veins, with a greater number of external spermatic veins requiring ligation compared to the inguinal approach. Furthermore, the presence of more veins surrounding the spermatic arteries makes the subinguinal approach more challenging, requiring longer surgical time and a higher level of technical skill [11][12]. Despite the technical challenges, the subinguinal approach has become the preferred method for varicocelectomy due to its many advantages. These include less postoperative pain, shorter recovery time, and a lower rate of recurrence compared to other approaches [13]. Furthermore, the preservation of the external oblique aponeurosis reduces the risk of postoperative hernia and abdominal wall weakness, making this approach ideal for patients who are at higher risk for these complications. Therefore, the subinguinal approach has emerged as the mainstay of varicocelectomy due to its many advantages, including a lower rate of recurrence, shorter recovery time, and less postoperative pain. However, the choice of surgical approach should always be tailored to the individual patient, taking into account the surgeon’s experience and the patient’s unique anatomy and medical history.
Laparoscopic transperitoneal intra-abdominal approach
Laparoscopic varicocelectomy aims to ligate the gonadal veins above the internal inguinal ring with intact gonadal arteries. Thus, surgeons can perform bilateral varicocelectomy sequentially to magnify the testicular vessels, which improves effectiveness [10].
Microscopic varicocelectomy was found to be superior to the laparoscopic approach in terms of surgical outcomes (p < 0.0001) [14]. Furthermore, due to its inability to reach the external gonadal vessels or external spermatic veins [15], laparoscopic varicocelectomy was reported to have a higher recurrence rate (17.2%, 34 of 198 patients) compared with microsurgical and open nonmicrosurgical methods [16].
Percutaneous embolization = endovascular approach
Percutaneous embolization can be performed through the puncture of the internal jugular vein (antegrade) or common femoral vein (retrograde) to access the renal and internal spermatic veins with an appropriate catheter. The sources of occlusion may be sclerosants, solid embolic devices [17], or balloon embolotherapy [18]. As a minimally invasive procedure, in addition to the high success rate (95.7%, 68 of 71 patients) and low recurrence rate (1.96%) as reported by Nabi in 2004 [19], percutaneous embolization plays an important role in the treatment of varicoceles.
Table 2. Surgical treatments for varicocele.
Varicocelectomy Patients (n) Rate of Pain Relief Recurrence or Failure References
Partial Complete
Retroperitoneal 37 32/37 (86.5%) 5/37 (13.5%) [20]
87 8/87 (9.2%) 72/87 (82.8%) 7/87 (8%) [21]
Inguinal 114 104/114 (91.2%) 10/114 (8.8%) [22]
44 18/44 (40.9%) 24/44 (54.5%) 2/44 (4.6%) [23]
Sub-inguinal 9 4/9 (44.4%) 4/9 (44.4%) 1/9 (11.1%) [23]
34 30/34 (89.5%) 4/34 (10.5%) [24]
81 16/81 (19.8%) 58/81 (71.6%) 7/81 (8.6%) [25]
132 110/132 (83.3%) 22/132 (16.7%) [26]
237 15/237 (6.3%) 203/237 (85.6%) 19/237 (8.1%) [27]
Laparoscopic 60 16/60 (26.7%) 27/60 (45%) 17/60 (28.3%) [28]
48 5/48 (10.4%) 42/48 (87.5%) 1/48 (2%) [29]
Percutaneous embolization 71 68/71 (95.8%) 3/71 (4.2%) [19]
Causes of persistent scrotal pain after treatment: recurrent, neuralgia, refer pain, hydrocele, ureteral lesion, nutcracker syndrome, and unknown.

References

  1. Dubin, L.; Amelar, R.D. Varicocele Size And Results of Varicocelectomy in Selected Subfertile Men with Varicocele*. Fertil. Steril. 1970, 21, 606–609.
  2. Tauber, R.; Johnsen, N. Antegrade scrotal sclerotherapy for the treatment of varicocele: Technique and late results. J. Urol. 1994, 151, 386–390.
  3. Sarteschi, M. Lo studio del varicocele con eco-color-Doppler. G It Ultrason 1993, 4, 43–49.
  4. Malaguti, S.A.; Lund, L. Gold Standard Care of Chronic Scrotal Pain. Res. Rep. Urol. 2021, 13, 283–288.
  5. Kiliç, S.; Güneş, A.; Ipek, D.; Dusak, A.; Güneş, G.; Balbay, M.D.; Baydinç, Y.C. Effects of micronised purified flavonoid fraction on pain, spermiogram and scrotal color Doppler parameters in patients with painful varicocele. Urol. Int. 2005, 74, 173–179.
  6. Peterson, A.C.; Lance, R.S.; Ruiz, H.E. Outcomes of varicocele ligation done for pain. J. Urol. 1998, 159, 1565–1567.
  7. Palomo, A. Radical cure of varicocele by a new technique; preliminary report. J. Urol. 1949, 61, 604–607.
  8. Paick, S.; Choi, W.S. Varicocele and Testicular Pain: A Review. World J. Mens. Health 2019, 37, 4–11.
  9. Tsai, C.S.; Lin, F.Y.; Chen, Y.H.; Yang, T.L.; Wang, H.J.; Huang, G.S.; Lin, C.Y.; Tsai, Y.T.; Lin, S.J.; Li, C.Y. Cilostazol attenuates MCP-1 and MMP-9 expression in vivo in LPS-administrated balloon-injured rabbit aorta and in vitro in LPS-treated monocytic THP-1 cells. J. Cell. Biochem. 2008, 103, 54–66.
  10. Lundy, S.D.; Sabanegh, E.S., Jr. Varicocele management for infertility and pain: A systematic review. Arab. J. Urol. 2018, 16, 157–170.
  11. Hopps, C.V.; Lemer, M.L.; Schlegel, P.N.; Goldstein, M. Intraoperative varicocele anatomy: A microscopic study of the inguinal versus subinguinal approach. J. Urol. 2003, 170, 2366–2370.
  12. Liu, W.L.; Chang, J.M.; Chong, I.W.; Hung, Y.L.; Chen, Y.H.; Huang, W.T.; Kuo, H.F.; Hsieh, C.C.; Liu, P.L. Curcumin Inhibits LIN-28A through the Activation of miRNA-98 in the Lung Cancer Cell Line A549. Molecules 2017, 22, 929.
  13. Owen, R.C.; McCormick, B.J.; Figler, B.D.; Coward, R.M. A review of varicocele repair for pain. Transl. Androl. Urol. 2017, 6, S20–S29.
  14. Park, J.H.; Pak, K.; Park, N.C.; Park, H.J. How Can We Predict a Successful Outcome after Varicocelectomy in Painful Varicocele Patients? An Updated Meta-Analysis. World J. Mens. Health 2021, 39, 645–653.
  15. Rotker, K.; Sigman, M. Recurrent varicocele. Asian J. Androl. 2015, 18, 229.
  16. Ding, H.; Tian, J.; Du, W.; Zhang, L.; Wang, H.; Wang, Z. Open non-microsurgical, laparoscopic or open microsurgical varicocelectomy for male infertility: A meta-analysis of randomized controlled trials. BJU Int. 2012, 110, 1536–1542.
  17. JR, D.B. Percutaneous varicocele embolization. Can. Urol. Assoc. J. 2007, 1, 278–280.
  18. Shuman, L.; White, R.I., Jr.; Mitchell, S.E.; Kadir, S.; Kaufman, S.L.; Chang, R. Right-sided varicocele: Technique and clinical results of balloon embolotherapy from the femoral approach. Radiology 1986, 158, 787–791.
  19. Nabi, G.; Asterlings, S.; Greene, D.R.; Marsh, R.L. Percutaneous embolization of varicoceles: Outcomes and correlation of semen improvement with pregnancy. Urology 2004, 63, 359–363.
  20. Abd Ellatif, M.E.; Asker, W.; Abbas, A.; Negm, A.; Al-Katary, M.; El-Kaffas, H.; Moatamed, A. Varicocelectomy to treat pain, and predictors of success: A prospective study. Curr. Urol. 2012, 6, 33–36.
  21. Yeniyol, C.O.; Tuna, A.; Yener, H.; Zeyrek, N.; Tilki, A. High ligation to treat pain in varicocele. Int. Urol. Nephrol. 2003, 35, 65–68.
  22. Kim, H.T.; Song, P.H.; Moon, K.H. Microsurgical ligation for painful varicocele: Effectiveness and predictors of pain resolution. Yonsei Med. J. 2012, 53, 145–150.
  23. Park, H.J.; Lee, S.S.; Park, N.C. Predictors of pain resolution after varicocelectomy for painful varicocele. Asian J. Androl. 2011, 13, 754–758.
  24. Alkhamees, M.; Bin Hamri, S.; Alhumaid, T.; Alissa, L.; Al-Lishlish, H.; Abudalo, R.; Iqbal, Z.; Albajhan, G.; Alasker, A. Factors Associated with Varicocele Recurrence After Microscopic Sub-Inguinal Varicocelectomy. Res. Rep. Urol. 2020, 12, 651–657.
  25. Kim, S.-O.; Jung, H.; Park, K. Outcomes of Microsurgical Subinguinal Varicocelectomy for Painful Varicoceles. J. Androl. 2012, 33, 872–875.
  26. Al-Gadheeb, A.; El-Tholoth, H.S.; Albalawi, A.; Althobity, A.; AlNumi, M.; Alafraa, T.; Jad, A. Microscopic subinguinal varicocelectomy for testicular pain: A retrospective study on outcomes and predictors of pain relief. Basic Clin. Androl. 2021, 31, 1.
  27. Altunoluk, B.; Soylemez, H.; Efe, E.; Malkoc, O. Duration of preoperative scrotal pain may predict the success of microsurgical varicocelectomy. Int. Braz. J. Urol. 2010, 36, 55–59.
  28. Park, Y.W.; Lee, J.H. Preoperative Predictors of Varicocelectomy Success in the Treatment of Testicular Pain. World J. Mens. Health 2013, 31, 58–63.
  29. Kachrilas, S.; Popov, E.; Bourdoumis, A.; Akhter, W.; El Howairis, M.; Aghaways, I.; Masood, J.; Buchholz, N. Laparoscopic varicocelectomy in the management of chronic scrotal pain. JSLS J. Soc. Laparoendosc. Surg. 2014, 18, e2014.00302.
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Subjects: Urology & Nephrology
Contributors MDPI registered users' name will be linked to their SciProfiles pages. To register with us, please refer to https://encyclopedia.pub/register :
Chien-Zhi Lai
,
Szu-Ju Chen
,
Chi-Ping Huang
,
Huey-Yi Chen
,
Ming-Yen Tsai
,
Po-Len Liu
,
Yung-Hsiang Chen
,
Wen-Chi Chen
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Update Date: 23 Apr 2023
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