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Incidence of external spermatic veinsin patients undergoing inguinal varicocelectomy
ADU~
UROLOGY
INCIDENCE OF EXTERNAL SPERMATIC VEINS IN PATIENTS UNDERGOING INGUINAL VARICOCELECTOMY ERIK T. GOLUBOFF, M.D. DAVID T. CHANG, B.A. ANDREWJ. KIRSCH, M.D. HARRY FISCH, M.D. From the Department of Urology and Squier Urological Clinic, Columbia University College of Physicians and Surgeons, New York, New York
ABSTRACT--Objectives. To determine the incidence of external spermatic veins at inguinal varicocelectomy. Methods, A prospective study was performed by" making intraoperative observations on 78 varicocelectomies (47 patients) performed by a single surgeon. All patients were referred for evaluation of male infertility and had a palpable varicocele present when examined while performing a Valsalva maneuver in the upright position. Varicocelectomies were performed via the inguinal approach using ×2.5 loupe magnification. Presence of external spermatic veins was defined as visualization (with ×2.5 Ioupe magnification) of veins on the floor of the inguinal canal traveling posterolateral to the spermatic cord that then subsequently exited the spermatic cord before passing through the internal inguinal ring. Age, anesthetic technique, and need for incision of the external inguinal ring were also recorded for each patient. Results. One third of patients had undergone left-sided varicocelectomies, while two thirds had undergone bilateral procedures. External spermatic veins were identified in 15% of left-sided varicoceles and 19% of right-sided ones. Of 31 patients undergoing bilateral varicocelectomies, 19% had at least 1 external spermatic vein. Of these patients, only 2 (7%) had a unilateral right external spermatic vein, none had a unilateral left external spermatic vein, and 4 (13%) had bilateral external spermatic veins. Overall, of all patients studied, 16% had at least 1 external spermatic vein. Follow-up at 1 year showed no evidence of clinical recurrence in any patient. Conclusions. These results emphasize the importance of distal gonadal venous anatomy in the surgeon's choice of the proper approach to varicocele repair, since external spermatic veins are only accessible via an inguinal approach.
Varicoceles, which are found in approximately 15% of the general population and in as many as 40% of infertile men,~,2 are caused by abnormal retrograde venous flow to the testicle. Varicocele therapy aims to occlude the involved venous channels, with common indications for intervention including male infertility, pain or discomfort, undesirable cosmetic appearance, and, in the adolescent, discrepancy in testicular size. Successful varicocele repair leads to improved semen parameters in 60% Submitted: March 31, 1994, accepted (with revisions): July 8, 1994
UROLOGY~ / DECEMBER1994 / VOLUME44, NUMBER6
of infertile patients. 3 Recent work has addressed the inherent advantages offered by the various surgical and percutaneous embolization treatment options, each of which have reported postoperative recurrence rates between 5% and 20%. 4-8 The outcome of any varicocele repair is highly dependent upon the gonadal venous anatomy, which is complex and can have many variations T M (Fig. 1). Testicular venous drainage occurs primarily through the internal spermatic veins, but collateral channels often exist both proximal and distal to the inguinal rings. Proximally, collaterals to the spermatic vein from the renal vein, the capsular
89S
the upright position. Observations of presence or absence of external spermatic veins were made in a prospective manner by this surgeon expressly for study purposes and were recorded in each patient's operative report. Collateral V. to Lumbar ;ollateral V. Branch :ric V. ,al Ring I via 'matic V. nal Ring
FIGURE 1.
Collateral complexity of gonadal venous
anatomy.
vein of the kidney, and the inferior vena cava have been described. Distally, communications to the internal spermatic vein can occur from the external spermatic vein, which drains into the external iliac vein, and from the deferential veins, which travel with the vas and drain into the hypogastric vein. External spermatic veins exit the spermatic cord distal to the internal inguinal ring, and are not accessible by retroperitoneal or laparoscopic approaches to varicocele repair. 9 n Their reported incidence, however, has varied from 12% to 7 4 % . 12-14 This inconsistency may be due in part to differing methods of external spermatic vein identification, with previous studies utilizing criteria such as minimal dilation 12 or presence of the vein after extensive microdissection. 14 In the present study, we prospectively examined 78 consecutive varicocelectomies in 47 patients to determine the incidence of visible (by x2.5 loupe magnification) external spermatic veins during inguinal varicocelectomy. MATERIAL AND METHODS PATIENTS
Seventy-eight consecutive varicocelectomies were performed on 47 patients by a single surgeon (H.E). All patients were referred for evaluation of male infertility and a palpable varicocele was present when examined during the Valsalva maneuver in 894
SURGICAL PROCEDURE
Varicocelectomies were performed via the inguinal approach as modified by Ivanessivich with loupe magnification. B Operative microscopy was not used in any patient. Patients received either local anesthesia with sedation or general anesthesia, based primarily on patient choice. An inguinal skin incision was made in a skin crease beginning 1 cm above the symphysis pubis and 2 cm lateral to the midline, in line with the lateral edge of the scrotum, extending for approximately3 cm. The spermatic cord was mobilized. Any distended veins along the spermatic cord were ligated. Elevation of the spermatic cord with a Babcock clamp allowed visualization, by x2.5 loupe magnification, of any veins on the floor of the inguinal canal traveling posterolateral to the spermatic cord. These veins, if they exited the cord before passing through the in, ternal inguinal ring, were defined as external sper-: matic veins and their presence or absence was noted in the patient's operative report. Although the number of these veins in a given patient was noted in: each operative report, for the purposes of this study categories included only presence or absence of external spermatic veins. Size of external spermatic veins was not recorded. All of these veins were ligated. The testicular artery was identified and preserved in all cases, and artery patency was confirmed with the use of an intraoperative Doppler probe. Lymphatic channels were also carefully maintained. The testis was not mobilized in any patient. The wound was closed in a standard fashion, covered with Steristrips, and patients were discharged home the same day. Age, anesthetic technique, need for incision of the external inguinal ring, and presence of externa! spermatic veins, as defined above, were recorded for each patient. RESULTS A total of 78 varicoceles was repaired in 47 men. Twenty-five patients (53%) chose to have local anesthesia with sedation, while the remaining 47% were given general anesthesia. Mobilization of the spermatic cord required incision of the external inguinal ring in 44% of the cases; patients who were obese, had local anesthesia with sedation, or who were concerned about the size of the skin incision were more likely to require incision of the external UROLOGY~ /
DECEMBER 1994 / VOLUME44, NUMBER6
FIGURE 2. Intraoperative photograph shows grossly dilated external spermatic vein (arrow) in characteristic position posterolateral to the sperrnatic cord (arrowhead) on the floor of the inguinal canal, demonstrated by elevation of the sperrnatic cord.
inguinal ring for proper mobilization of the spermatic cord. Sixteen patients (34%) had only left-sided varicocelectomies, while the remaining 31 patients (66%) had bilateral procedures, and no patient had a unilateral right-sided varicocelectomy. External spermatic veins were visually identified by x2.5 loupe magnification in 16% of the 78 varicoceles (Fig. 2). They were present in 18% of men undergoing left-sided varicocelectomy alone, while 19% of men undergoing bilateral procedures were found to have at least one external spermatic vein. External spermatic veins were seen in 15% of the 47 total leftsided varicoceles, and they were present in 19% of the 31 right-sided ones. Of the 31 patients undergoing bilateral varicocelectomies, only 2 (7%) had a unilateral right external spermatic vein, none had a unilateral left external spermatic vein, and 4 (13%) had bilateral external spermatic veins. At 1 year follow-up, no clinical recurrences, determined by physical examination, have been detected in any patient. COMMENT Testicular venous drainage occurs primarily via the internal spermatic veins, which empty into the renal vein on the left side and the inferior vena cava on the right. However, collateral vessels often join this system; external spermatic veins are the most common and empty into the external iliac system. 9-1i Distal collaterals are of particular interUROLOGY~ / DECEMBER1994 / VOLUME44, NUMBER 6
est because these vessels are not accessible by retroperitoneal or laparoscopic approaches. The presence of external spermatic veins has been documented radiographically in patients with varicocele, il but their incidence and role in the-pathogenesis of varicocele recurrence remain speculative. Using a conventional inguinal operative approach with loupe magnification, we found external spermatic veins in 16% of the 78 varicoceles in this study. This figure is lower than recently reported incidences of 49.5% i4 and 74%, i2 and is more consistent with a previous value of 12% found by intraoperative venography. 13 Such differences reflect the many methods used to identify external spermatic veins. These range from visualization with routine dissection used in the present study to intraoperative venography, 13 and also include minimal dilation during conventional varicocelectomy i4 or even presence alone during microscopic varicocelectomy with delivery of the testis.12 Uncertainty exists regarding the contributions of external spermatic veins to the pathogenesis of varicocele recurrence after repair. Uncertainty also exists as to the optimal technique for detection of varicocele recurrence (ie, physical examination [this report], Doppler, thermography, or venography), and the significance of such recurrence. With external spermatic vein ligation in this report, no clinical recurrences were detected at I year. At a rate of 15% to 19%, the incidence of these collateral vessels is significant. Because pathologic reflux through the external spermatic vein has been documented, i5 dilated external spermatic veins should remain a surgical consideration until their specific role in varicocele formation is better defined. Such 4xternal spermatic veins are not accessible by either a retroperitoneal or transabdominal laparoscopic repair approach since they exit the spermatic cord '~distal to the internal inguinal ring. These anatomic findings support the use of the inguinal surgical approach for greatest certainty in addressing all potential collateral vessels when performing varicocele repair. Erik T. Goluboff, M.D. Male Reproductive Center Department of Urology Columbia-Presbyterian Medical Center 944 Park Avenue New York, New York 10028 REFERENCES 1. Saypol DC: Varicocele. J Androl 2: 61-71, 1981. 2. Dubin L, and Amelar RD: Varicocelectomy: 986 cases in a twelve-year stud)~ Urology 10: 446-449, 1977. 3. Fisch H: The surety of surgical repair of varicoceles.
895
Contemp Urol 3: 68-74, 1991. 4. Thomas AJJr, and Geisinger M.A: Current management of varicoceles. Urol Clin North Am 17: 893-907, 1990. 5. Sayfan J, Softer Y, and Orda R: Varicocele treatment: prospective randomized trial of 3 methods. J Urol 148: 1447-1449~ 1992. 6. Cvitanic OA, Cronan JJ, Sigman M, and Landau ST: Varicoceles: postoperative prevalence--a prospective study with color Doppler US. Radiology 187: 711-714, 1993. 7. Ralph DJ, Timoney AG, Parker C, and Pryor JP: Laparoscopic varicocele ligation. BrJ Urol 72: 230-233, 1993. 8. JarowJP, Assimos DG, and Pittaway DE: Effectiveness of laparoscopic varicocelectomy. Urology 42: 544-547, 1993. 9. Murray RRJr, Mitchell S, Kadir S, Kaufman SL, Chang R, Kinnison ML, SmythJW, and White RIJr: Comparison of recurrent varicocele anatomy following surgery and percutaneous balloon occlusion. J Urol 135: 286-289, 1986. 10. Morag B, Rubenstein ZJ, Goldwasser B, Yerushalmi A,
896
and Lunnenfeld B: Percutaneous venography and occlusion in the management of spermatic varicoceles. AJR Am J Roentgenol 143: 635-640, 1984. 11. Levitt S, Gill B, Katlowitz N, Kogan S, and Reda E: Routine intraoperative post-ligation venography in the treat: ment of the pediatric varicoeele. J Urol "137: 716-7t8, 1987. 12. Beck EM, Schlegel PN, and Goldstein M: Intraoperative varicocele anatomy: a macroscopic and microscopic study j Urol 148: 1190--1194, 1992. 13. SayfanJ, and Adam YG: Intraoperative internal spermatic vein phlebography in the subfertile male with varicocelel Fertil Steri129: 669-675, 1978. 14. Chehval MJ, and Purcell MH: Varicocelectomy: inci-, dence of external spermatic vein involvement in the clinical varicocele. Urology 39: 573-575, 1992, 15. Belgrano E, Puppo P, Quattrini S, Trombetta C, and Giuliani L: The role of venography and sclerotherapy in the management of varicocele. Eur Urol 10: 124-129, 1984.
UROLOGY* / DECEMBER1994 / VOLUME44, NUMBER 6
UROLOGY
INCIDENCE OF EXTERNAL SPERMATIC VEINS IN PATIENTS UNDERGOING INGUINAL VARICOCELECTOMY ERIK T. GOLUBOFF, M.D. DAVID T. CHANG, B.A. ANDREWJ. KIRSCH, M.D. HARRY FISCH, M.D. From the Department of Urology and Squier Urological Clinic, Columbia University College of Physicians and Surgeons, New York, New York
ABSTRACT--Objectives. To determine the incidence of external spermatic veins at inguinal varicocelectomy. Methods, A prospective study was performed by" making intraoperative observations on 78 varicocelectomies (47 patients) performed by a single surgeon. All patients were referred for evaluation of male infertility and had a palpable varicocele present when examined while performing a Valsalva maneuver in the upright position. Varicocelectomies were performed via the inguinal approach using ×2.5 loupe magnification. Presence of external spermatic veins was defined as visualization (with ×2.5 Ioupe magnification) of veins on the floor of the inguinal canal traveling posterolateral to the spermatic cord that then subsequently exited the spermatic cord before passing through the internal inguinal ring. Age, anesthetic technique, and need for incision of the external inguinal ring were also recorded for each patient. Results. One third of patients had undergone left-sided varicocelectomies, while two thirds had undergone bilateral procedures. External spermatic veins were identified in 15% of left-sided varicoceles and 19% of right-sided ones. Of 31 patients undergoing bilateral varicocelectomies, 19% had at least 1 external spermatic vein. Of these patients, only 2 (7%) had a unilateral right external spermatic vein, none had a unilateral left external spermatic vein, and 4 (13%) had bilateral external spermatic veins. Overall, of all patients studied, 16% had at least 1 external spermatic vein. Follow-up at 1 year showed no evidence of clinical recurrence in any patient. Conclusions. These results emphasize the importance of distal gonadal venous anatomy in the surgeon's choice of the proper approach to varicocele repair, since external spermatic veins are only accessible via an inguinal approach.
Varicoceles, which are found in approximately 15% of the general population and in as many as 40% of infertile men,~,2 are caused by abnormal retrograde venous flow to the testicle. Varicocele therapy aims to occlude the involved venous channels, with common indications for intervention including male infertility, pain or discomfort, undesirable cosmetic appearance, and, in the adolescent, discrepancy in testicular size. Successful varicocele repair leads to improved semen parameters in 60% Submitted: March 31, 1994, accepted (with revisions): July 8, 1994
UROLOGY~ / DECEMBER1994 / VOLUME44, NUMBER6
of infertile patients. 3 Recent work has addressed the inherent advantages offered by the various surgical and percutaneous embolization treatment options, each of which have reported postoperative recurrence rates between 5% and 20%. 4-8 The outcome of any varicocele repair is highly dependent upon the gonadal venous anatomy, which is complex and can have many variations T M (Fig. 1). Testicular venous drainage occurs primarily through the internal spermatic veins, but collateral channels often exist both proximal and distal to the inguinal rings. Proximally, collaterals to the spermatic vein from the renal vein, the capsular
89S
the upright position. Observations of presence or absence of external spermatic veins were made in a prospective manner by this surgeon expressly for study purposes and were recorded in each patient's operative report. Collateral V. to Lumbar ;ollateral V. Branch :ric V. ,al Ring I via 'matic V. nal Ring
FIGURE 1.
Collateral complexity of gonadal venous
anatomy.
vein of the kidney, and the inferior vena cava have been described. Distally, communications to the internal spermatic vein can occur from the external spermatic vein, which drains into the external iliac vein, and from the deferential veins, which travel with the vas and drain into the hypogastric vein. External spermatic veins exit the spermatic cord distal to the internal inguinal ring, and are not accessible by retroperitoneal or laparoscopic approaches to varicocele repair. 9 n Their reported incidence, however, has varied from 12% to 7 4 % . 12-14 This inconsistency may be due in part to differing methods of external spermatic vein identification, with previous studies utilizing criteria such as minimal dilation 12 or presence of the vein after extensive microdissection. 14 In the present study, we prospectively examined 78 consecutive varicocelectomies in 47 patients to determine the incidence of visible (by x2.5 loupe magnification) external spermatic veins during inguinal varicocelectomy. MATERIAL AND METHODS PATIENTS
Seventy-eight consecutive varicocelectomies were performed on 47 patients by a single surgeon (H.E). All patients were referred for evaluation of male infertility and a palpable varicocele was present when examined during the Valsalva maneuver in 894
SURGICAL PROCEDURE
Varicocelectomies were performed via the inguinal approach as modified by Ivanessivich with loupe magnification. B Operative microscopy was not used in any patient. Patients received either local anesthesia with sedation or general anesthesia, based primarily on patient choice. An inguinal skin incision was made in a skin crease beginning 1 cm above the symphysis pubis and 2 cm lateral to the midline, in line with the lateral edge of the scrotum, extending for approximately3 cm. The spermatic cord was mobilized. Any distended veins along the spermatic cord were ligated. Elevation of the spermatic cord with a Babcock clamp allowed visualization, by x2.5 loupe magnification, of any veins on the floor of the inguinal canal traveling posterolateral to the spermatic cord. These veins, if they exited the cord before passing through the in, ternal inguinal ring, were defined as external sper-: matic veins and their presence or absence was noted in the patient's operative report. Although the number of these veins in a given patient was noted in: each operative report, for the purposes of this study categories included only presence or absence of external spermatic veins. Size of external spermatic veins was not recorded. All of these veins were ligated. The testicular artery was identified and preserved in all cases, and artery patency was confirmed with the use of an intraoperative Doppler probe. Lymphatic channels were also carefully maintained. The testis was not mobilized in any patient. The wound was closed in a standard fashion, covered with Steristrips, and patients were discharged home the same day. Age, anesthetic technique, need for incision of the external inguinal ring, and presence of externa! spermatic veins, as defined above, were recorded for each patient. RESULTS A total of 78 varicoceles was repaired in 47 men. Twenty-five patients (53%) chose to have local anesthesia with sedation, while the remaining 47% were given general anesthesia. Mobilization of the spermatic cord required incision of the external inguinal ring in 44% of the cases; patients who were obese, had local anesthesia with sedation, or who were concerned about the size of the skin incision were more likely to require incision of the external UROLOGY~ /
DECEMBER 1994 / VOLUME44, NUMBER6
FIGURE 2. Intraoperative photograph shows grossly dilated external spermatic vein (arrow) in characteristic position posterolateral to the sperrnatic cord (arrowhead) on the floor of the inguinal canal, demonstrated by elevation of the sperrnatic cord.
inguinal ring for proper mobilization of the spermatic cord. Sixteen patients (34%) had only left-sided varicocelectomies, while the remaining 31 patients (66%) had bilateral procedures, and no patient had a unilateral right-sided varicocelectomy. External spermatic veins were visually identified by x2.5 loupe magnification in 16% of the 78 varicoceles (Fig. 2). They were present in 18% of men undergoing left-sided varicocelectomy alone, while 19% of men undergoing bilateral procedures were found to have at least one external spermatic vein. External spermatic veins were seen in 15% of the 47 total leftsided varicoceles, and they were present in 19% of the 31 right-sided ones. Of the 31 patients undergoing bilateral varicocelectomies, only 2 (7%) had a unilateral right external spermatic vein, none had a unilateral left external spermatic vein, and 4 (13%) had bilateral external spermatic veins. At 1 year follow-up, no clinical recurrences, determined by physical examination, have been detected in any patient. COMMENT Testicular venous drainage occurs primarily via the internal spermatic veins, which empty into the renal vein on the left side and the inferior vena cava on the right. However, collateral vessels often join this system; external spermatic veins are the most common and empty into the external iliac system. 9-1i Distal collaterals are of particular interUROLOGY~ / DECEMBER1994 / VOLUME44, NUMBER 6
est because these vessels are not accessible by retroperitoneal or laparoscopic approaches. The presence of external spermatic veins has been documented radiographically in patients with varicocele, il but their incidence and role in the-pathogenesis of varicocele recurrence remain speculative. Using a conventional inguinal operative approach with loupe magnification, we found external spermatic veins in 16% of the 78 varicoceles in this study. This figure is lower than recently reported incidences of 49.5% i4 and 74%, i2 and is more consistent with a previous value of 12% found by intraoperative venography. 13 Such differences reflect the many methods used to identify external spermatic veins. These range from visualization with routine dissection used in the present study to intraoperative venography, 13 and also include minimal dilation during conventional varicocelectomy i4 or even presence alone during microscopic varicocelectomy with delivery of the testis.12 Uncertainty exists regarding the contributions of external spermatic veins to the pathogenesis of varicocele recurrence after repair. Uncertainty also exists as to the optimal technique for detection of varicocele recurrence (ie, physical examination [this report], Doppler, thermography, or venography), and the significance of such recurrence. With external spermatic vein ligation in this report, no clinical recurrences were detected at I year. At a rate of 15% to 19%, the incidence of these collateral vessels is significant. Because pathologic reflux through the external spermatic vein has been documented, i5 dilated external spermatic veins should remain a surgical consideration until their specific role in varicocele formation is better defined. Such 4xternal spermatic veins are not accessible by either a retroperitoneal or transabdominal laparoscopic repair approach since they exit the spermatic cord '~distal to the internal inguinal ring. These anatomic findings support the use of the inguinal surgical approach for greatest certainty in addressing all potential collateral vessels when performing varicocele repair. Erik T. Goluboff, M.D. Male Reproductive Center Department of Urology Columbia-Presbyterian Medical Center 944 Park Avenue New York, New York 10028 REFERENCES 1. Saypol DC: Varicocele. J Androl 2: 61-71, 1981. 2. Dubin L, and Amelar RD: Varicocelectomy: 986 cases in a twelve-year stud)~ Urology 10: 446-449, 1977. 3. Fisch H: The surety of surgical repair of varicoceles.
895
Contemp Urol 3: 68-74, 1991. 4. Thomas AJJr, and Geisinger M.A: Current management of varicoceles. Urol Clin North Am 17: 893-907, 1990. 5. Sayfan J, Softer Y, and Orda R: Varicocele treatment: prospective randomized trial of 3 methods. J Urol 148: 1447-1449~ 1992. 6. Cvitanic OA, Cronan JJ, Sigman M, and Landau ST: Varicoceles: postoperative prevalence--a prospective study with color Doppler US. Radiology 187: 711-714, 1993. 7. Ralph DJ, Timoney AG, Parker C, and Pryor JP: Laparoscopic varicocele ligation. BrJ Urol 72: 230-233, 1993. 8. JarowJP, Assimos DG, and Pittaway DE: Effectiveness of laparoscopic varicocelectomy. Urology 42: 544-547, 1993. 9. Murray RRJr, Mitchell S, Kadir S, Kaufman SL, Chang R, Kinnison ML, SmythJW, and White RIJr: Comparison of recurrent varicocele anatomy following surgery and percutaneous balloon occlusion. J Urol 135: 286-289, 1986. 10. Morag B, Rubenstein ZJ, Goldwasser B, Yerushalmi A,
896
and Lunnenfeld B: Percutaneous venography and occlusion in the management of spermatic varicoceles. AJR Am J Roentgenol 143: 635-640, 1984. 11. Levitt S, Gill B, Katlowitz N, Kogan S, and Reda E: Routine intraoperative post-ligation venography in the treat: ment of the pediatric varicoeele. J Urol "137: 716-7t8, 1987. 12. Beck EM, Schlegel PN, and Goldstein M: Intraoperative varicocele anatomy: a macroscopic and microscopic study j Urol 148: 1190--1194, 1992. 13. SayfanJ, and Adam YG: Intraoperative internal spermatic vein phlebography in the subfertile male with varicocelel Fertil Steri129: 669-675, 1978. 14. Chehval MJ, and Purcell MH: Varicocelectomy: inci-, dence of external spermatic vein involvement in the clinical varicocele. Urology 39: 573-575, 1992, 15. Belgrano E, Puppo P, Quattrini S, Trombetta C, and Giuliani L: The role of venography and sclerotherapy in the management of varicocele. Eur Urol 10: 124-129, 1984.
UROLOGY* / DECEMBER1994 / VOLUME44, NUMBER 6