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Effect of microsurgical subinguinal varicocele ligation to treat pain
ADULT UROLOGY
EFFECT OF MICROSURGICAL SUBINGUINAL VARICOCELE LIGATION TO TREAT PAIN ¨ NDER YAMAN, EROL O ¨ ZDI˙LER, KADRI ANAFARTA, O
AND
¨ G˘U¨S¸ ORHAN GO
ABSTRACT Objectives. The traditional treatment for a painful varicocele consists of conservative measures followed by varicocelectomy. We report our results with microsurgical subinguinal varicocele ligation to treat pain. Methods. From 1996 to 1999, a total of 119 men underwent subinguinal microsurgical varicocele ligation for painful varicocele. The diagnosis of varicocele was based on the findings of both physical examination and color Doppler ultrasound. Patients described pain with testicular discomfort as scrotal heaviness or a dull ache. While waiting for the operation (range 3 to 5 weeks), all the patients underwent a preoperative trial of conservative management for pain. Results. Of 119 men, 82 (69 %) were available for follow-up 3 months postoperatively. Of those 82 patients, 72 (88%) reported complete resolution of pain, 4 patients (5%) partial resolution, 5 patients (6%) no change, and 1 patient (1%) epididymal discomfort that resolved with conservative measures. Of the 9 patients with partial or no change, 2 patients had reflux recurrence as seen on color Doppler ultrasound. Conclusions. Subinguinal microsurgical varicocele ligation is an effective treatment for painful varicocele when performed in selected patients. UROLOGY 55: 107–108, 2000. © 2000, Elsevier Science Inc.
V
aricocele, an abnormal dilation of the spermatic vein, is found in 10% to 15% of the male population.1 Traditional indications for varicocele treatment are infertility and pain. Among the different ligation techniques, such as inguinal, subinguinal, retroperitoneal, and, recently, microsurgical inguinal/subinguinal varicocelectomy, the latter has proved a great success, with minimal complication rates.2–5 Although numerous studies have shown improved seminal parameters in patients treated with varicocelectomy, only two studies address the outcome of varicocelectomy to treat pain.6,7 We report our experience with subinguinal microsurgical varicocelectomy to treat pain. MATERIAL AND METHODS Between 1996 and 1999, a total of 230 men and boys 8 to 40 years old with varicoceles underwent 278 varicocelectomies (48 bilateral). The diagnosis of varicocele was based on the findings from both physical examination and color Doppler ultrasound. The varicoceles were assigned to one of three grades according to the criteria reported by Lyon et al.,8 during From the Department of Urology, University of Ankara School of Medicine, Ankara, Turkey Reprint requests: O¨nder Yaman, M.D., Pembe Kosk Sitesi, Sehit Ersan Caddesi, B-1 Blok Number 15, Cankaya, Ankara 06580, Turkey Submitted: May 10, 1999, accepted (with revisions): July 27, 1999 © 2000, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
an examination while the patient was in a standing position, and the criteria reported by Aydos et al.9 using color Doppler ultrasound to assess venous reflux. Of those 230 patients, 111 (48%) underwent surgery for infertility or were adolescents who had small testis associated with varicocele; 119 men (52%) underwent surgery for pain. Of these 119 men, 82 (69%) were available for follow-up 3 months postoperatively. All the patients underwent a preoperative trial of conservative management for pain (scrotal support and nonsteroidal antiinflammatory medication) for a minimum of 3 weeks (maximum 5, average 4), because our operation lists were so full. Five of the 119 patients did not undergo surgery because their scrotal pain resolved with conservative management. The varicocele was on the left side in 70 patients and bilateral in 12. The varicocele was grade III in 26, grade II in 34, grade I in 10, and left grade II and right grade I in the 12 bilateral cases. Patients described pain with testicular discomfort as a heaviness or dull ache, generally after standing all day. Our patient population was drawn mainly from police academy students. No patient had a previous history of sexually transmitted disease or inflammatory processes, including epididymitis and prostatitis. A microdissection technique through a subinguinal approach was used in all patients4 with an operating microscope; all the operations were performed by a single surgeon. Patients underwent either general or spinal anesthesia and were hospitalized for 12 to 18 hours. Our follow-up schedule for varicocele was 3, 6, and 12 months and annually thereafter.
RESULTS Of the 82 patients with a follow-up visit at 3 months postoperatively, 72 patients (88%) re0090-4295/00/$20.00 PII S0090-4295(99)00374-X 107
ported complete resolution of their pain, 4 (5%) reported partial resolution and complained of a dull ache, especially after standing all day, 5 (6%) reported no change from preoperatively, and 1 (1%) reported epididymal discomfort, which resolved with conservative measures 4 months postoperatively. The preoperative and postoperative pain evaluations consisted of interviewing the pa¨ .Y.). tient (all questioned by the same surgeon, O The patients with recurrence reported no change in the character of the pain. We did not observe any complications such as wound infection, hematoma, or hydrocele. We evaluated the 9 patients with postoperative scrotal pain by color Doppler ultrasound and found 2 patients with recurrence; we offered them the option of a second operation. The resolution of pain postoperatively correlated with the preoperative varicocele grades. Of those 9 patients with persistent pain, 5 patients had grade III, 3 had grade II, and 1 had grade I varicocele preoperatively. COMMENT It is generally accepted that varicoceles can cause a marked impairment in spermatogenesis, although the exact mechanism by which varicocele alters testicular physiology is still not completely understood.5 Most urologists agree that varicocele is a treatable cause of male infertility, and many reports on this subject suggest improved seminal data and increased pregnancy rates after varicocele correction.4,10 On the other hand, treatment of a painful varicocele traditionally consists of conservative measures, followed by surgery if the conservative measures are unsuccessful. Conservative measures consist of scrotal support, nonsteroidal anti-inflammatory medications, and limitations in activity. Surgical techniques include high, inguinal, subinguinal, scrotal, laparoscopic, and microscopic ligation. The microscopic techniques are associated with the least number of complications and the lowest recurrence rates.3,11 We performed 119 varicocele ligations for pain. Patients were selected from young and physically active students of the police academy. Because activity limitations were unacceptable in this population, patients preferred surgery. We believe that the 88% rate of complete resolution of pain after surgery is a very satisfactory result in order to offer surgery to those patients in whom conservative therapy has failed. As mentioned previously, only a few studies concerning the treatment of painful varicocele have been published. The results of the study by Peterson et al.6 were similar to ours, a complete resolution of pain in 86% of a patient population of soldiers. However, Biggers et al.7 reported a rate of only 48%. 108
Those studies differ from ours at some points. We evaluated our patients both preoperatively and postoperatively by physical examination and more objectively by color Doppler ultrasound. Moreover, 2 patients of the 9 with treatment failure had recurrence as determined by color Doppler ultrasound. Since we did not observe any recurrent reflux among the other patients with failure, we believe that recurrent reflux did not play an important role in the outcome. Additionally, we did not incise the abdominal fascia, since we used the subinguinal approach, which makes for a fast and painless recovery. One of the important points of treatment of painful varicocele is defining the character of the pain. As described by Peterson et al.,6 the pain must be dull, aching, and throbbing without components of sharp or radiating pain. All our patients’ complaints fully matched these pain criteria. In conclusion, we have found that varicocele ligation for pain is successful when performed in patients who have specific complaints, an accurate diagnosis, and in whom conservative management has been tried and failed. However, a prospective, randomized study comparing conservative versus surgical therapy is required to reach a more definite conclusion. REFERENCES 1. Greenberg SH: Varicocele and male fertility. Fertil Steril 28: 699 –704, 1977. 2. Kaas EJ, and Marcol B: Results of varicocele surgery in adolescents: a comparison of techniques. J Urol 148: 694 – 696, 1992. 3. Skoog SJ, Roberts KP, Goldstein M, et al: The adolescent varicocele: what’s new with an old problem in young patients? Pediatrics 100: 112–122, 1997. 4. Marmar JL, and Kim Y: Subinguinal microsurgical varicocelectomy: a technical critique and statistical analysis of semen and pregnancy data. J Urol 152: 1127–1132, 1994. 5. Goldstein M: Varicocelectomy: general considerations, in Goldstein M (Ed): Surgery of Male Infertility. Philadelphia, WB Saunders, 1995, p 84. 6. Peterson AC, Lance RS, and Ruiz HE: Outcomes of varicocele ligation done for pain. J Urol 159: 1565–1567, 1998. 7. Biggers RD, and Soderdahl DW: The painful varicocele. Mil Med 146: 440 – 442, 1981. 8. Lyon RP, Marshall S, and Scott MP: Varicocele in childhood and adolescence: implication in adulthood infertility. Urology 19: 641– 644, 1982. 9. Aydos K, Baltacı S, Salih M, et al: Use of colour Doppler sonography in the evaluation of varicocele. Eur Urol 24: 221– 225, 1994. 10. Seftel AD, Rutchik SD, Chen H, et al: Effects of subinguinal varicocele ligation on sperm concentration, motility and Krueger morphology. J Urol 158: 1800 –1803, 1997. 11. Goldstein M, Gilbert BR, Dicker AP, et al: Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique. J Urol 148: 1808 –1811, 1982. UROLOGY 55 (1), 2000
EFFECT OF MICROSURGICAL SUBINGUINAL VARICOCELE LIGATION TO TREAT PAIN ¨ NDER YAMAN, EROL O ¨ ZDI˙LER, KADRI ANAFARTA, O
AND
¨ G˘U¨S¸ ORHAN GO
ABSTRACT Objectives. The traditional treatment for a painful varicocele consists of conservative measures followed by varicocelectomy. We report our results with microsurgical subinguinal varicocele ligation to treat pain. Methods. From 1996 to 1999, a total of 119 men underwent subinguinal microsurgical varicocele ligation for painful varicocele. The diagnosis of varicocele was based on the findings of both physical examination and color Doppler ultrasound. Patients described pain with testicular discomfort as scrotal heaviness or a dull ache. While waiting for the operation (range 3 to 5 weeks), all the patients underwent a preoperative trial of conservative management for pain. Results. Of 119 men, 82 (69 %) were available for follow-up 3 months postoperatively. Of those 82 patients, 72 (88%) reported complete resolution of pain, 4 patients (5%) partial resolution, 5 patients (6%) no change, and 1 patient (1%) epididymal discomfort that resolved with conservative measures. Of the 9 patients with partial or no change, 2 patients had reflux recurrence as seen on color Doppler ultrasound. Conclusions. Subinguinal microsurgical varicocele ligation is an effective treatment for painful varicocele when performed in selected patients. UROLOGY 55: 107–108, 2000. © 2000, Elsevier Science Inc.
V
aricocele, an abnormal dilation of the spermatic vein, is found in 10% to 15% of the male population.1 Traditional indications for varicocele treatment are infertility and pain. Among the different ligation techniques, such as inguinal, subinguinal, retroperitoneal, and, recently, microsurgical inguinal/subinguinal varicocelectomy, the latter has proved a great success, with minimal complication rates.2–5 Although numerous studies have shown improved seminal parameters in patients treated with varicocelectomy, only two studies address the outcome of varicocelectomy to treat pain.6,7 We report our experience with subinguinal microsurgical varicocelectomy to treat pain. MATERIAL AND METHODS Between 1996 and 1999, a total of 230 men and boys 8 to 40 years old with varicoceles underwent 278 varicocelectomies (48 bilateral). The diagnosis of varicocele was based on the findings from both physical examination and color Doppler ultrasound. The varicoceles were assigned to one of three grades according to the criteria reported by Lyon et al.,8 during From the Department of Urology, University of Ankara School of Medicine, Ankara, Turkey Reprint requests: O¨nder Yaman, M.D., Pembe Kosk Sitesi, Sehit Ersan Caddesi, B-1 Blok Number 15, Cankaya, Ankara 06580, Turkey Submitted: May 10, 1999, accepted (with revisions): July 27, 1999 © 2000, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
an examination while the patient was in a standing position, and the criteria reported by Aydos et al.9 using color Doppler ultrasound to assess venous reflux. Of those 230 patients, 111 (48%) underwent surgery for infertility or were adolescents who had small testis associated with varicocele; 119 men (52%) underwent surgery for pain. Of these 119 men, 82 (69%) were available for follow-up 3 months postoperatively. All the patients underwent a preoperative trial of conservative management for pain (scrotal support and nonsteroidal antiinflammatory medication) for a minimum of 3 weeks (maximum 5, average 4), because our operation lists were so full. Five of the 119 patients did not undergo surgery because their scrotal pain resolved with conservative management. The varicocele was on the left side in 70 patients and bilateral in 12. The varicocele was grade III in 26, grade II in 34, grade I in 10, and left grade II and right grade I in the 12 bilateral cases. Patients described pain with testicular discomfort as a heaviness or dull ache, generally after standing all day. Our patient population was drawn mainly from police academy students. No patient had a previous history of sexually transmitted disease or inflammatory processes, including epididymitis and prostatitis. A microdissection technique through a subinguinal approach was used in all patients4 with an operating microscope; all the operations were performed by a single surgeon. Patients underwent either general or spinal anesthesia and were hospitalized for 12 to 18 hours. Our follow-up schedule for varicocele was 3, 6, and 12 months and annually thereafter.
RESULTS Of the 82 patients with a follow-up visit at 3 months postoperatively, 72 patients (88%) re0090-4295/00/$20.00 PII S0090-4295(99)00374-X 107
ported complete resolution of their pain, 4 (5%) reported partial resolution and complained of a dull ache, especially after standing all day, 5 (6%) reported no change from preoperatively, and 1 (1%) reported epididymal discomfort, which resolved with conservative measures 4 months postoperatively. The preoperative and postoperative pain evaluations consisted of interviewing the pa¨ .Y.). tient (all questioned by the same surgeon, O The patients with recurrence reported no change in the character of the pain. We did not observe any complications such as wound infection, hematoma, or hydrocele. We evaluated the 9 patients with postoperative scrotal pain by color Doppler ultrasound and found 2 patients with recurrence; we offered them the option of a second operation. The resolution of pain postoperatively correlated with the preoperative varicocele grades. Of those 9 patients with persistent pain, 5 patients had grade III, 3 had grade II, and 1 had grade I varicocele preoperatively. COMMENT It is generally accepted that varicoceles can cause a marked impairment in spermatogenesis, although the exact mechanism by which varicocele alters testicular physiology is still not completely understood.5 Most urologists agree that varicocele is a treatable cause of male infertility, and many reports on this subject suggest improved seminal data and increased pregnancy rates after varicocele correction.4,10 On the other hand, treatment of a painful varicocele traditionally consists of conservative measures, followed by surgery if the conservative measures are unsuccessful. Conservative measures consist of scrotal support, nonsteroidal anti-inflammatory medications, and limitations in activity. Surgical techniques include high, inguinal, subinguinal, scrotal, laparoscopic, and microscopic ligation. The microscopic techniques are associated with the least number of complications and the lowest recurrence rates.3,11 We performed 119 varicocele ligations for pain. Patients were selected from young and physically active students of the police academy. Because activity limitations were unacceptable in this population, patients preferred surgery. We believe that the 88% rate of complete resolution of pain after surgery is a very satisfactory result in order to offer surgery to those patients in whom conservative therapy has failed. As mentioned previously, only a few studies concerning the treatment of painful varicocele have been published. The results of the study by Peterson et al.6 were similar to ours, a complete resolution of pain in 86% of a patient population of soldiers. However, Biggers et al.7 reported a rate of only 48%. 108
Those studies differ from ours at some points. We evaluated our patients both preoperatively and postoperatively by physical examination and more objectively by color Doppler ultrasound. Moreover, 2 patients of the 9 with treatment failure had recurrence as determined by color Doppler ultrasound. Since we did not observe any recurrent reflux among the other patients with failure, we believe that recurrent reflux did not play an important role in the outcome. Additionally, we did not incise the abdominal fascia, since we used the subinguinal approach, which makes for a fast and painless recovery. One of the important points of treatment of painful varicocele is defining the character of the pain. As described by Peterson et al.,6 the pain must be dull, aching, and throbbing without components of sharp or radiating pain. All our patients’ complaints fully matched these pain criteria. In conclusion, we have found that varicocele ligation for pain is successful when performed in patients who have specific complaints, an accurate diagnosis, and in whom conservative management has been tried and failed. However, a prospective, randomized study comparing conservative versus surgical therapy is required to reach a more definite conclusion. REFERENCES 1. Greenberg SH: Varicocele and male fertility. Fertil Steril 28: 699 –704, 1977. 2. Kaas EJ, and Marcol B: Results of varicocele surgery in adolescents: a comparison of techniques. J Urol 148: 694 – 696, 1992. 3. Skoog SJ, Roberts KP, Goldstein M, et al: The adolescent varicocele: what’s new with an old problem in young patients? Pediatrics 100: 112–122, 1997. 4. Marmar JL, and Kim Y: Subinguinal microsurgical varicocelectomy: a technical critique and statistical analysis of semen and pregnancy data. J Urol 152: 1127–1132, 1994. 5. Goldstein M: Varicocelectomy: general considerations, in Goldstein M (Ed): Surgery of Male Infertility. Philadelphia, WB Saunders, 1995, p 84. 6. Peterson AC, Lance RS, and Ruiz HE: Outcomes of varicocele ligation done for pain. J Urol 159: 1565–1567, 1998. 7. Biggers RD, and Soderdahl DW: The painful varicocele. Mil Med 146: 440 – 442, 1981. 8. Lyon RP, Marshall S, and Scott MP: Varicocele in childhood and adolescence: implication in adulthood infertility. Urology 19: 641– 644, 1982. 9. Aydos K, Baltacı S, Salih M, et al: Use of colour Doppler sonography in the evaluation of varicocele. Eur Urol 24: 221– 225, 1994. 10. Seftel AD, Rutchik SD, Chen H, et al: Effects of subinguinal varicocele ligation on sperm concentration, motility and Krueger morphology. J Urol 158: 1800 –1803, 1997. 11. Goldstein M, Gilbert BR, Dicker AP, et al: Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique. J Urol 148: 1808 –1811, 1982. UROLOGY 55 (1), 2000