Grade III Varicocele Surgical Treatment using Spermatic Vein-Superficial Abdominal Vein Shunt

Summary

Here, we present a protocol for grade III varicocele surgical treatment that aims to rebuild the venous drainage of the spermatic cord by a spermatic vein-superficial abdominal vein shunt performed under the microscope.

Abstract

Microsurgical varicocelectomy is the most commonly used method for the treatment of varicocele (VC) in recent years. However, it is technically demanding with the risk of damaging the normal anatomical structure of the spermatic cord, such as the cremaster muscle, testicular artery, and vas deferens during the pampiniform plexus ligation. Also, traditional varicocelectomy hinders the drainage of the stagnant venous blood of the affected testicle, resulting in a persistent scrotal appearance of varicose veins and slower remission of swelling sensation in postoperative patients with grade III VC. Therefore, we developed a retroperitoneal varicocelectomy with a microscopical spermatic venous-superficial vein of the abdominal wall bypass procedure. The spermatic vein was transected and ligated proximally through the retroperitoneal space. Then, the distal spermatic vein was freed and passed through the internal ring; under the skin of the groin, a microscopic vascular anastomosis was performed to build the bypass of the distal spermatic vein and proximal inferior epigastric vein. The high ligation facilitates the protection of the normal anatomy of the spermatic cord, and the venous bypass allows rapid testicular blood drainage, which can effectively improve the degree of varicocele, testicular pain, and even spermatogenic function. In conclusion, the present protocol describes a promising way to reconstruct the spermatic return through high retroperitoneal ligation of the spermatic vein and anastomosis of the spermatic vein-inferior epigastric vein, which resulted in faster and more obvious improvement in symptoms and better prognosis of grade III VC.

Introduction

The incidence of varicocele (VC) in adult males is 11.7%, and in males with abnormal semen quality, the incidence is up to 25.4%¹. Clinical manifestations include symptoms of ipsilateral testicular growth and developmental disorders accompanied by pain, discomfort, low fertility, and hypogonadism. Clinical specialist examinations can detect and grade varicocele². VC III grade shows positive for clinical palpation and ultrasonic varicocele inner diameter ≥ 3.1 mm and reflux time ≥ 6 s, often accompanied by more severe testicular pain or swelling discomfort^3,4.

Recent studies have shown that VC microsurgical varicocelectomy is considered to be the most effective way of VC repair due to its advantages of fewer complications and low recurrence rate^5,6,7. However, this procedure has some shortcomings: as in the past, scrotal, inguinal, or subinguinal incisions are often used, which easily damage the cremaster muscle, testicular artery, vas deferens artery and lymphatic vessels. Especially in grade III VC, it is more likely to be accidentally injured due to the many branches of the pampiniform plexus, and damage to the normal anatomical structure of the spermatic cord will cause postoperative complications such as testicular pain, swelling, and atrophy⁸. Additionally, traditional varicocelectomy by simple ligation of the spermatic vein hinders the drainage of the stagnant venous blood of the affected testicle, resulting in a persistent scrotal appearance of varicose veins and slower remission of swelling sensation in postoperative patients with grade III VC and the relief of testicular pain or swelling discomfort is slow or not obvious, with poor efficacy⁹. It is conducive to restoring the physiological hemodynamics of the testes by varicocele repair rather than simple varicocelectomy¹⁰. For example, microscopic internal spermatic vein-inferior epigastric vein anastomosis has also been reported to be applied to the treatment of varicocele¹¹. Here, we describe a protocol for grade III varicocele surgical treatment that aims to ligate spermatic veins at the high retroperitoneal level and rebuild the venous drainage of the spermatic cord by a spermatic vein-superficial abdominal vein (also known as superficial epigastrin vein or vena epigastrica superficialis) shunt under the microscope.

For this study, a retrospective analysis was performed on the clinical data of 96 patients in the hospital from June 2018 to August 2021 who had grade III VC and complained of testicular pain or distension discomfort, who had received spermatic vein ligation, and who had complete follow-up data. The pain score was assessed by visual scoring (VAS). They were divided into two groups according to the surgical methods: study group A was treated with high ligation of the spermatic vein under a microscope and transfer of spermatic venue-superficial abdominal vein (49 cases), and study group B was treated with low ligation of the spermatic vein under a microscope (47 cases).

Protocol

This study was approved by the ethics committee of the First Affiliated Hospital, Sun Yat-sen University (NO. 2020-478), prior to the start of the clinical study. All subjects provided informed consent before the study. The inclusion criteria for cases are (1) grade III varicocele confirmed by clinical palpation and ultrasonic examination of varicocele inner diameter ≥ 3.1 mm and reflux time ≥ 6 s; (2) Combined scrotal pain and discomfort; (3) Completed surgical treatment for varicocele in the hospital. Exclusion criteria: (1) any of the following pelvic-related histories: pelvic operation, pelvic radiotherapy, or pelvic trauma; (2) perineal skin disease; or (3) surgical contraindications.

1. High ligation of spermatic veins

1. Administer intravenous-inhalational anesthesia and assess depth by disappearance of the patient's consciousness and pain response, as well as skeletal muscle relaxation.
2. Make an external oblique incision parallel to the groin through the internal ring with a length of 3 cm. Cut the skin and subcutaneous tissue with a scalpel, and use a unipolar electric scalpel combined with blunt separation to separate the aponeurosis of the external oblique and internal oblique muscles. Then, on the outside of the incision, forceps is applied through the internal obliquus into the retroperitoneum.
3. Push open the peritoneal tissue with saline wet gauze and find the flexed and thickened spermatic vein in front of the psoas major muscle and behind the peritoneum while paying attention to protecting the artery.
4. The spermatic cord sheath was opened bluntly with a vascular clamp to carefully free a spermatic vein of about 6-8 cm in length to the proximal end. Lift the vascular sling, ligate the proximal end with a non-absorbable 2-0 suture, and cut. Lift the distal end knot and free it to the vicinity of the peritoneal junction. Use the spermatic vein with a larger diameter for subsequent spermatic vein-inferior epigastric vein shunt (Figure 1).
5. Ligate other branches of the spermatic vein with a non-absorbable 2-0 suture.

2. Releasing the inferior epigastric vein

1. On the medial aspect of the incision, identify and retract the spermatic cord. The inferior epigastric vein was located beneath the fascia surrounding the spermatic cord left to the internal ring.
2. Lift the vascular sling, free inferior epigastric vein with a sufficient length of about 3cm towards its distal end and observe the direction of blood flow. After ligation with a non-absorbable 3-0 suture, the distal end was excised and the proximal end was dissected for subsequent anastomose with the distal end of the spermatic vein with a vascular clamp (Figure 2).

3. Anastomosis of spermatic vein - inferior epigastric vein

1. Relying on the manipulation of bending forceps, the spermatic vein was carefully guided through the inner ring opening to the abdominal incision and secured with a vascular clamp in preparation for subsequent anastomosis with inferior epigastric vein.
2. Check that there is no tension in connection with the free spare superficial vein of the abdominal wall, and then suture 6-8 stitches with 8-0 Polypropylene suture (Figure 3).
3. Release the vascular clamp to ensure that the vein is full, the blood flow is smooth, and there is no blood leakage when pressing the testicle.

4. Closing the incision

1. To close the incision layer by layer, use 2-0 absorbable sutures to suture the external oblique aponeurosis and subcutaneous tissue. Use 3-0 absorbable sutures to suture the skin.

5. Postoperative management

1. Ask the patient to pay attention to rest and avoid strenuous exercise. After surgery, administer a subcutaneous injection of 40 mg Enoxaparin Sodium, and the next day, switch to oral Rivaroxaban, 10 mg daily for 1 month.

Results

For this study, the 96 patients were divided into two groups: study group A, treated with high ligation of the spermatic vein under a microscope and transfer of spermatic vein-inferior epigastric vein (49 cases), and study group B, treated with low ligation^{9,12,13,14,15} of the spermatic vein under a microscope (47 cases). The basic data, operation time, hospit...

Discussion

Increasing evidence has shown that microsurgical varicocelectomy has more advantages than open or laparoscopic varicocelectomy for the surgical management of VC^5,6. The surgical microscope can magnify the anatomical details with a clear field of vision, and the arteriovenous, lymphatic vessels and nerves can be discerned more readily. In contrast, it is difficult to distinguish the arteries and veins clearly in other surgical procedures. They may miss venous vess...

Materials

Name	Company	Catalog Number	Comments
Clexan (Enoxaparin Sodium Injection)	Sanofi (Beijing) Pharmaceutical Co., LTD
CROWNJUN (Nylon suture)	Kono Seisakusho Co., Ltd., Japan
Doppler ultrasonography	Mindray, Shenzhen, China	Resona R9
Microscope	Zeiss, Jena, Germany	OPMI PENTERO 800
Non-absorbable suture	Johnson, (Shanghai) Medical Equipment Co., LTD
Rivaroxaban	Bayer Healthcare GMBH
VICRYL (absorbable surgical suture)	Johnson, (Shanghai) Medical Equipment Co., LTD