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,....

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. Exclu.......

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