Varicocele: To Fix or Not to Fix? That is the Question. Edmund S. Sabanegh, MD

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1 Varicocele: To Fix or Not to Fix? That is the Question. Edmund S. Sabanegh, MD Professor and Chairman, Department of Urology, Cleveland Clinic Lerner College of Medicine; Cleveland, Ohio Objectives: Review pros and cons of available surgical approaches for varicocele ligation Summarize available research associating varicocele with hypogonadism

2 Varicocele: To Fix or Not to Fix Edmund Sabanegh, Jr., M.D. Chairman, Department of Urology Glickman Urological and Kidney Institute Cleveland Clinic

3 Male Subfertility Etiology Incidence (%) Varicocele 42 Idiopathic 23 Obstruction 14 Cryptorchidism 3 Immunologic 3 Ejaculatory Dysfunction 1.5 Testicular failure 1.5 Endocrinopathies 1 Other 11 Nagler HM, Martinis FG. Varicocele. In Lipshultz LI, Howards S, editors. Infertility in the Male; 1997

4 Objective: To study the effect of varicocele on Leydig cell function/testosterone Group I 10 pts with varicocele and erectile dysfunction Group II 23 pts with varicocele and infertility but no ED Group III 31 pts with psychogenic ED 154 healthy males, age 10 to 90 J Clin Endocrinol Metab (1975). 40: 824

5 Men with varicocele Trend towards decrease in testosterone in older men with varicocele Increase in duration of the varicocele result in gradual impairment of Leydig cell function? Men without varicocele

6 Time 0 = varicocelectomy

7 108 varicocele patients, mean age 30.9 years 46 control men, mean age 30 years Testosterone (T), 17-OH-progesterone (17-OH-P), dihydrotestosterone (DHT) and estradiol (E2) were assayed J Androl (1984); 5:

8

9 Controls Controls Varicocele patients Varicocele patients

10 In varicocele patients, Leydig cell function was impaired, as demonstrated by the low T levels. These data suggest that the duration of idiopathic varicocele influences testicular hormone secretion.

11 Does varicocelectomy improve hypogonadism?

12 Retrospective review of the effect of varicocelectomy on serum testosterone levels in 53 infertile men with varicoceles. Mean age 35, range Journal of Urology (1995). 154:

13 Varicocelectomy can increase serum testosterone, especially in patients with abnormally low serum testosterone levels. There may be a trend towards greater improvement in testosterone with lower grade varicocele.

14 78 patients, mean age 29.5 years 10 fertile men without varicoceles control, mean age 30 years 40 patients had left varicocelectomy, 38 pts had bilateral Serum hormonal levels measured 1 year after surgery Varicocelectomy promotes Leydig cell function. BJUI (1999). 84:

15 48 patients: 16 with ED, 32 with infertility who underwent bilateral varicocelectomy Mean age 37± 5.9; follow-up 3-36 months Serum testosterone was significantly increased in impotent and infertile patients ( p<.0005) Improvement of sexual activity was 50 75%: in libido, morning erection, duration and percentage of erection, sexual interest, and frequency of erection per week Archives of Andrology (2003). 49:

16 Goal: To determine whether men with varicoceles have lower testosterone levels than those without and to ascertain if testosterone levels increase after varicocelectomy. 200 men with palpable varicocele and 510 men without varicoceles (who were undergoing vasectomy reversal) BJUI (2011).108:

17 Men with varicocele had significantly lower testosterone levels than the comparison group, with mean (SD) levels of 416 (156) vs 469 (192) ng/dl (P<0.001). This difference persisted when analysed by age.

18 The testosterone levels significantly increased after repair from 358 (126) to 454(168) ng/dl (P<0.001).

19 Of the 70% of patients with postoperative improvement in testosterone levels, the mean (SD) increase in testosterone was 178 (142) ng/dl. The percentage change in testosterone levels was: 30% had no increase, 41% increased by 50%, 19% increased between by %, and 10% increased by >100%. There was no association between change in testosterone level and age, laterality of varicocele, or varicocele grade.

20 Men with varicoceles had significantly lower testosterone levels than the comparison group of men with vasectomy reversal. Microsurgical varicocele ligation resulted in a significant increase in serum testosterone levels in more than two-thirds of men. These findings suggest that varicocele is a significant risk factor for androgen deficiency and that repair may increase testosterone levels in men with varicocele and low testosterone levels.

21 Optimal Technique for Ligation Difficult question Individual studies come to very different conclusions All of them flawed to varying degrees

22 Surgical approach to varicocelectomy Randomized prospective study of 120 pts with mean follow-up of 18months Microsurgical varicocelectomy: increased surgical time, decreased post-op recurrence and hydrocele

23 Surgical approach to varicocelectomy Improved semen parameters with varicocelectomy though not among groups No difference among groups in pregnancy rates at 1-year» Open: 28%» Lap: 30%» Microscopic: 40%

24 Surgical approach to varicocelectomy Randomized prospective study of 298 pts Microsurgical varicocelectomy: better improvement in sperm count and motility

25 Surgical approach to varicocelectomy Microsurgical varicocelectomy: no hydrocele formation, a lower incidence of recurrent varicocele The pregnancy rate at 1 year was not significantly different» Open: 31%» Laparoscopic: 33%» Microsurgical: 38%

26 Technique of Subinguinal Varicocelectomy Incision

27 Technique of Subinguinal Varicocelectomy Exposure of spermatic cord

28 Technique of Subinguinal Varicocelectomy Cord isolation

29 Technique of Subinguinal Varicocelectomy Cord isolation

30 Technique of Subinguinal Varicocelectomy Microscope Preparation

31 Varicocele: To Fix or Not to Fix Edmund Sabanegh, Jr., M.D. Chairman, Department of Urology Glickman Urological and Kidney Institute Cleveland Clinic

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