Early and Late Complications of Inguinal Varicocelectomy

0022-5347/03/1702-0366/0 THE JOURNAL OF UROLOGY® Copyright © 2003 by AMERICAN UROLOGICAL ASSOCIATION

Vol. 170, 366 –369, August 2003 Printed in U.S.A.

DOI: 10.1097/01.ju.0000074975.79734.17

Historical Article EARLY AND LATE COMPLICATIONS OF INGUINAL VARICOCELECTOMY RICHARD D. AMELAR* From the Department of Urology, New York University School of Medicine, New York, New York

ABSTRACT

Purpose: I reviewed the early and late complications of inguinal and subinguinal varicocelectomy that I have personally encountered in an experience of more than 40 years as a urologist dealing with male infertility and offer suggestions to my colleagues for avoiding some of these pitfalls in the future. Materials and Methods: These complications occurred as a consequence of surgery that I performed while using 4⫻ to 6⫻ power optical loupe magnification or they were complications of surgery performed elsewhere that I saw later in consultation. Results: My commentary and suggestions for dealing with and decreasing the incidence of or avoiding such complications should be helpful to urologists performing inguinal or subinguinal varicocelectomy. Conclusions: Forewarned is forearmed. KEY WORDS: testis, postoperative complications, varicocele, vascularization, castration

It is widely considered that the operation for ligation of the internal spermatic vein for varicocele correction carries with it an extremely low incidence of complications and adverse reactions. Nevertheless, in an experience of more than 40 years with inguinal and subinguinal varicocelectomy using 4⫻ to 6⫻ ocular loupe magnification in dealing with male infertility1– 4 I have personally encountered occasional complications and have seen or learned of the consequences of occasional misadventures with varicocele surgery performed by others. Hopefully this review with my commentary on such complications may be helpful to others in avoiding some of these pitfalls in the future. MINOR COMPLICATIONS

Minor wound infections occurred in a small number of patients. They cleared rapidly with treatment. A rare patient had a small wound hematoma or serum collection that required evacuation. HYDROCELE

The most frequent complication, which occurred in 3% of my patients, is hydrocele on the same side as varicocelectomy.5, 6 Of course, should bilateral varicocelectomy be performed, bilateral hydroceles might occur. This complication is probably associated with obstruction of filamentous, delicate lymphatic channels lying in and along the spermatic cord. That lymphatic obstruction is more likely than venous obstruction to be the cause of hydrocele is suggested by the finding that the average protein content of postvaricocelectomy hydroceles is between 5 and 6 gm/100 ml instead of the less than 1.5 gm/100 ml that would be found in edema fluid due to venous obstruction.7 Lymphatic obstruction is also more likely to cause post-varicocelectomy hydroceles than is venous obstruction because hydrocele formation

has not been reported as a complication of transvenous balloon embolization.8 The tunica vaginalis always secretes some fluid. Decreased resorption rather than overproduction of the fluid has the major role in post-varicocelectomy hydrocele formation.9 It is noteworthy that in the early days of renal transplantation when the original technique for kidney transplantation described in 1958 by Murray and Harrison10 was being used, hydrocele was a common complication. In that procedure the spermatic cord was severed to provide space for the transplanted kidney in the iliac fossa. Thus, in an early series of Penn et al from Denver, in which the transplanted kidney was placed extraperitoneally in the iliac fossa through an inguinal incision, 70% of the 86 patients had hydrocele and 20% had ipsilateral testicular atrophy.11 Prospects for long postoperative survival were so poor in the early decades of renal transplantation that considerations of hydrocele formation were given little attention. However, by the late 1960s when long-term survival could be expected in the majority of patients, this attitude could no longer be justified. Starzl changed his operative procedure, eliminating the step of spermatic cord division, and subsequently hydrocele formation has no longer been a complication of renal transplantation.12, 13 By using 4⫻ to 6⫻ ocular loupe magnification during varicocelectomy and staying close to the veins, while avoiding unnecessary clamping or crushing of surrounding tissues within the spermatic cord, it is possible to minimize damage to lymphatic channels and, thus, the chances of post-varicocelectomy hydrocele formation. Ipsilateral hydrocele formation may occur anywhere from 1 month to more than 8 years following varicocele correction. In those markedly delayed onset instances it might require only minimal scrotal trauma, such as an inadvertent knock or mild epididymitis, to produce a reactive hydrocele, which then fails to resolve and may bring the patient back to the urologist. In adults hydroceles have also been associated with

Accepted for publication March 7, 2003. * Requests for reprints: 526 Bull Mill Rd., Chester, New York 10918. 366

EARLY AND LATE VARICOCELECTOMY COMPLICATIONS

infections, such as epididymitis, trauma or tumor. During our years of practice Dr. Larry Dubin and I discovered underlying testicular tumors in several such patients who had ipsilateral or contralateral hydroceles following varicocelectomy. These testicular tumors were unmasked by sonography. Scrotal ultrasonography is the prime imaging technique for the evaluation of a patient who presents with a fluid containing scrotal swelling. Transillumination alone is insufficient in this regard. While 3% of our patients had hydroceles, many were mild in degree and less than half ultimately required surgical correction. In our experience an ipsilateral hydrocele following varicocele ligation did not preclude improvement in semen quality and fertility in our patients.6 VASCULAR COMPROMISE AND TESTICULAR ATROPHY

Vascular compromise leading to testicular atrophy is among the most serious of potential complications of varicocelectomy. I believe that this complication is more likely due to ligating the entire venous circulation of the testicle with subsequent venous infarction rather than to arterial compromise. At times it is not possible to distinguish whether only venous, only arterial or total vascular infarction has occurred. I suspect that some cases of so-called epididymitis occurring in the immediate postoperative period are actually instances of venous or arterial infarction, which may result in subsequent deterioration in semen quality with testicular atrophy. An appreciation of the triple arterial and venous blood supply of the testis is essential to avoid testicular atrophy due to vascular compromise. The arterial blood supply to the testis arises from 3 sources. 1) The internal spermatic artery contributes about two-thirds of the testicular blood supply and it originates from the abdominal aorta just below the renal artery. Embryologically the testicles lie opposite the second lumbar vertebra and keep their original blood supply, which is acquired during the first weeks of life. Each internal spermatic artery joins the spermatic cord above the internal inguinal ring and pursues a course adjacent to the testicular veins to the mediastinal area of the testis, where it divides into branches that enter the testis to surround the seminiferous tubules. 2) The deferential artery (or artery of the vas) contributes about a sixth of the testicular blood supply. It may originate from the inferior or superior vesical artery and it supplies the vas deferens and globus minor of the epididymis. Near the testis the internal spermatic artery and deferential artery anastomose. Thus, if the spermatic artery is inadvertently ligated during inguinal varicocelectomy, the arterial supply of the testis can be maintained by the deferential artery with contribution from the cremasteric artery. 3) The cremasteric artery, also called the external spermatic artery, arises from the inferior epigastric artery inside the internal inguinal ring, where it enters the spermatic cord. This artery, which also contributes a sixth of the testicular blood supply, forms a network over the tunica vaginalis of the testis and usually anastomoses at the testicular mediastinum with the internal spermatic and deferential arteries. Should the internal spermatic artery be inadvertently ligated, it is believed that the deferential and cremasteric arteries could accommodate increased blood flow, and maintain the viability and spermatogenic function of the testicle. The veins of the spermatic cord emerge from the mediastinum of the testicle to form the extensive pampiniform plexus, which consists of 3 groups of veins that freely anastomose. 1) The internal spermatic vein group emerges from the testis and accompanies the internal spermatic artery to enter the renal vein on the left or the vena cava on the right. A varicocele results when there is reflux or retrograde flow of blood down the internal spermatic vein. 2) The deferential group accompanies the vas deferens to veins within the pelvis. 3) The external spermatic or cremasteric group follows a

367

course along the posterior aspect of the spermatic cord and empties in the region of the external inguinal ring into branches of the superficial and deep inferior epigastric veins, and into the superficial external and deep pudendal veins. Thus, the deferential and cremasteric groups of veins provide collateral circulation for the return of blood from the testes after the internal spermatic vein is ligated during varicocelectomy, just as the deferential and cremasteric arteries can accommodate and maintain satisfactory arterial flow in the event of inadvertent or purposeful ligation of the internal spermatic artery. Dr. Marc Goldstein, who routinely performs varicocelectomy using an operating microscope, recently reported that he has certain knowledge that he inadvertently ligated the internal spermatic artery during varicocelectomy on 18 occasions and in none of these patients was there a decrease in sperm count, any pain or any atrophy of the involved testicle as a result of his unintentional ligation of the internal spermatic artery while using the operating microscope.14 Thus, Goldstein has clearly demonstrated that, when during inguinal varicocelectomy the internal spermatic vein is intentionally ligated and the internal spermatic artery should then be inadvertently ligated, the preserved deferential arteries and veins in association with the cremasteric arteries and veins are adequate to maintain testicular circulation and prevent atrophy or spermatogenic depletion. In my experience using 4⫻ to 6⫻ ocular loupe magnification during varicocelectomy the most effective measure for avoiding vascular compromise of the testis during inguinal or subinguinal varicocelectomy is to take care to stay away from the vas with its own closely adherent artery and vein, which serve as a collateral supply. It is best accomplished by isolating the vas and its vessels as a first step in spermatic cord dissection. If the vein adherent to the vas is noted to be dilated, resist the temptation to ligate it. It is the deferential vein, not the spermatic vein. While I have found that the use of 4⫻ to 6⫻ ocular loupe magnification is helpful in this dissection, I do not believe that it is necessary to use an operating microscope. Use of an operating microscope during varicocelectomy is not the standard of care. Rather, the use of more easily accessible high power ocular loupes, such as those used during cardiovascular surgery, should be encouraged. VARICOCELE RECURRENCE

With this meticulous approach to varicocele ligation the rate of persistent or recurrent varicocele has been extremely low. However, I have reported a recurrence in one of my patients.2 I found that in dealing with varicocele recurrence following inguinal varicocelectomy a subinguinal approach is useful for finding and ligating the culprit, namely a persistently patent spermatic vein tributary. A word of advice to any of my colleagues consulted by an unhappy patient because of a persistent or recurrent varicocele following varicocelectomy by another surgeon: this patient should be referred to an interventional radiologist for transvenous balloon occlusion.15 Everyone would be more satisfied than if you should perform another operation to correct it: the patient because he would not need another operation, the surgeon who performed the first operation because he may now consider you a true gentleman, and finally the radiologist because you have referred the patient to him. UNUSUAL COMPLICATIONS

My most dramatic complication occurred when, in making an inguinal incision, I inadvertently incised into an unsuspected inguinal bladder hernia, releasing a large amount of clear urine into the operating field, to my great surprise and consternation. This case required exposing and repairing the

368

EARLY AND LATE VARICOCELECTOMY COMPLICATIONS

Composite drawings show slight similarity in appearance of spermatic cord at external inguinal ring and femoral vein at fossa ovalis

bladder rent and hernia before continuing with varicocelectomy.16 My patient had an indwelling urethral Foley catheter draining his bladder for 1 week while he healed. Fortunately, his wife became pregnant within the year and happily delivered twins. The most memorable complication that I have encountered occurred during varicocelectomy in a patient whom I saw in consultation some weeks after he experienced inadvertent ligation of the femoral vein, which had been mistaken for the internal spermatic vein by a urologist! How this disaster could have happened can be understood by examining the accompanying illustrations from Sobotta and Uhlenhuth’s Atlas of Descriptive Human Anatomy (see figure)17 and by appreciating the slight similarity of the appearance of the femoral fossa ovalis, which lies below the inguinal ligament, and of the external inguinal ring lying just above the inguinal ligament. One can perhaps appreciate how such a horrendous mistake can occur if you consider that an inguinal skin incision placed a bit too low and an assistant retracting a bit too hard can expose the fossa ovalis with its penetrating femoral vessels rather than the external inguinal ring. When the femoral vein was clamped, cut and tied, the patient lower extremity was jeopardized, requiring 2 major emergency revascularization procedures with considerable long-term lower extremity swelling and disability. Fortunately, horren-

dous complications such as femoral vein ligation are so rare as to be anecdotal. PARTING ADVICE

Be wary of requests for vasectomy after your patient with bilateral varicocelectomy and his wife have had all the children that they desire. Remember that the deferential artery and vein may be the only remaining source of blood supply to the testis following varicocelectomy if the internal spermatic artery has been inadvertently ligated. With the requested vasectomy you then sever the remaining testicular blood supply and you have performed castration instead of sterilization. Bilateral vasectomy performed after unilateral varicocelectomy may only result in hemicastration. In either case you will have an unhappy patient! By the same token, be cautious of performing a bilateral vasectomy-reversal procedure or epididymovasostomy combined with a varicocelectomy at the same time. REFERENCES

1. Amelar, R. D.: Philadelphia: 2. Amelar, R. D., Philadelphia: 3. Stewart, B. H.:

Infertility in Men, Diagnosis and Treatment. F. A. Davis Co., 1966 Dubin, L. and Walsh, P. C.: Male Infertility. W. B. Saunders Co., 1977 Infertility and vas reconstruction. In: Urologic

EARLY AND LATE VARICOCELECTOMY COMPLICATIONS

4. 5. 6.

7. 8. 9. 10.

Surgery, 3rd ed. Edited by J. F. Glenn. Philadelphia: J. B. Lippincott Co., pp. 1094 –1096, 1983 Marmar, J. L., DeBenedictis, T. J. and Praiss, D.: The management of varicoceles by microdissection of the spermatic cord at the external inguinal ring. Fertil Steril, 43: 583, 1985 Dubin, L. and Amelar, R. D.: Varicocelectomy: 986 cases in a twelve-year study. Urology, 10: 446, 1977 Dubin, L. and Amelar, R. D.: Varicocele in male infertility: 25 years experience. In: Current Therapy of Infertility-3. Edited by C.-R. Garcı´a, L. Mastroianni, Jr., R. D. Amelar and L. Dubin. St. Louis: The C. V. Mosby Co., pp. 212–217, 1988 Szabo, R. and Kessler, R.: Hydrocele following internal spermatic vein ligation: a retrospective study and review of the literature. J Urol, 132: 924, 1984 Walsh, P. C. and White, R. I., Jr.: Balloon occlusion of the internal spermatic vein for the treatment of varicoceles. JAMA, 246: 1701, 1981 Huggins, C. B. and Entz, F. H.: Absorption from normal tunica vaginalis testis, hydrocele and spermatocele. J Urol, 25: 447, 1931 Murray, J. E. and Harrison, J. H.: Surgical management of 50 patients with kidney transplants, including 18 pairs of twins.

369

Am J Surg, 105: 205, 1958 11. Penn, I., Mackie, G., Halgrimson, C. G. and Starzl, T. E.: Testicular complications of renal transplantation. Ann Surg, 176: 697, 1972 12. Starzl, T. E., Groth, C. G., Putnam, C. W., Penn, I., Halgrimson, C. G., Flatmark, A. et al: Urological complications in 216 human recipients of renal transplants. Ann Surg, 172: 1, 1970 13. Smith, R. B. and Ehrlich, R. M.: The surgical complications of renal transplantation. Urol Clin North Am, 3: 621, 1976 14. Chan, P. T., Wright, E. J. and Goldstein, M.: Incidence and post-operative outcomes of accidental ligation of the testicular artery during microsurgical varicocelectomy. Fertil Steril, suppl., 76: S49, abstract 0 –128, 2001 15. Pryor, J. L. and Howards, S. S.: Varicocele. Urol Clin North Am, 14: 499, 1987 16. Bell, E. D. and Witherington, R.: Bladder hernias. Urology, 15: 127, 1980 17. Sobotta, J. and Uhlenhuth, E.: Atlas of Descriptive Human Anatomy, 7th ed. New York: Hafner Publishing Co., Inc., vol. I, pp. 216 and 276, 1957