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Abstract Varicocele is defined as dilatation of pampiniform plexus that has long been recognized as treatable cause of male fertility. Most varicocele is noted in teens or early life, however it is difficult to estimate the exact incidence of varicoceles because most of them are asymptomatic and impalpable and are diagnosed only with sonographic evaluation. The left side is affected in 95 % of cases. Varicocele is the result of retrograde flow of blood into the pampiniform plexus with subsequent dilatation of the veins and formation of varicosities with stasis of blood. The etiology of varicocele is probably multifactorial. An adult male who is not currently attempting to achieve conception, but has a palpable varicocele, abnormal semen analyses and a desire for future fertility, is also a candidate for varicocele repair. Young adult males with varicoceles, who have normal semen parameters, may be at risk for progressive testicular dysfunction and should be offered monitoring with semen analyses every one to two years, in order to detect the earliest sign of reduced spermatogenesis. The causes of varicocele are multifactorial, but the end result is a pathological dilation of the veins draining the testicles, leading to increased temperature in the seminiferous tubules and decreased sperm quality. Over 13.4% of the general population and 37% of infertile men will be diagnosed with varicocele. A dramatic improvement can be seen after treating varicoceles, especially in conjunction with other infertility treatment methods. The spermatogenic function rate in patients who have undergone varicocelectomy increases substantially from 14% with no treatment to 29.7% Summary and Conclusion 86 after varicocelectomy, and up to 72% with varicocelectomy and in vitro fertilization (IVF) in a 2-year period. A number of techniques for varicocelectomy are practised worldwide, including open surgical and laparoscopic techniques. Each of these approaches has multiple sub-techniques and innovations, which can theoretically increase fertility and decrease complications. These techniques have been well described in the literature for diagnosis and indications for treatment have also been published, but to date there has been no consensus on which technique should be considered to be the ‘gold standard’. The question of which is the best surgical procedure for treating varicocele continues to be widely debated. However, treatment of this pathology cannot only solve the clinical symptoms that are sometimes associated with it, but it can also block ongoing damage in terms of spermatogenesis, potentially improving fertility. Antegrade sclerotherapy could be considered a valid alternative to other surgical techniques that are commonly used to correct varicocele. The inguinal procedure has the benefit of being able to ligate collaterals as they come out from the inguinal ring, and is an easier approach in obese patients. The collaterals seen at this level give the surgeon an opportunity to ligate the external spermatic veins, which cannot be done in a high ligation as with the Palomo’s technique. There have been modifications to this technique as well: the term ‘modified inguinal or modified Ivanisevich’ is typically reserved for artery sparing, but injection of dye into the lymphatics has also been used for the lymphatic-sparing technique. In this technique the ileoinguinal nerve must be identified and preserved. An operating microscope may be used to assist in dissection. While laparoscopy has fewer recurrent varicoceles than nonmicrosurgical open approaches, it is still used less frequently because of the Summary and Conclusion 87 need for an experienced laparoscopic surgeon and the higher cost than for the open techniques, including the microscopic technique. Laparoscopic varicocelectomy had more reported complications and is more invasive than other techniques. Local anesthesia can be used in open surgical approaches, but laparoscopy will always require general anesthesia with complete control over the respiratory system and acid-base status of the patient. For each approach evaluated one or more researches reported varicocelectomy as an outpatient procedure and in the absence of major complications, it would appear that this is becoming standard. Recovery time varied between different studies and within each approach, with return to work ranging from 1–2 days to 2 weeks. Radiological embolization resulted in a shorter time to discharge and return to work compared with other techniques, and microsurgical subinguinal had the best recovery time of the surgical techniques. Hospital stay and return to work time for the other techniques was too varied to analyse. While some recent studies have shown a statistically highly significant increase in spermatogenic function after microsurgical techniques, other publications show no change. Some studies reported a significant increase and one did not. Other sdudies showed in other varicocelectomy there no significant increase in spermatogenic functions after varicocele repair because the complications effects of the sperm function. While an increase in spermatogenic function may show an improvement of leydig cell function, this may not be an accurate measure of improved spermatogenesis because it is intratesticular testosterone, not serum testosterone that influences spermatogenesis. FSH levels followed the expected trend: a postoperative decrease to normal or seminormal ranges in level. Summary and Conclusion 88 A variety of approaches have been advocated for management of varicoceles but recent evidence supports the premise that the microsurgical technique is the “gold standard. In a number of studies, it has been shown that microsurgical varicocelectomy (inguinal or subinguinal) is superior to nonmicrosurgical procedures with respect to the development of postoperative complications such as hydrocele or recurrence. Hydrocele formation is believed to be due to ligation of lymphatic channels and recurrence generally results from incomplete ligation of collateral venous channels. Magnification of the spermatic cord with the use of the operating microscope reduces the potential for development of such complications. However, microsurgical varicocelectomy, particularly the subinguinal approach, remains a technically challenging procedure that requires microsurgical expertise. |