Surgical treatment of varicocele

SURGICAL TREATMENT

OF VARICOCELE

ROBERT ALEXANDER PRICE, M.D. Phoenix, Arizona

0

NE of the anatomic

weaknesses of the human organism is the emptying of the Ieft interna spermatic vein into the left renaI vein at right angIes. When the valves of the interna spermatic vein are incompetent, venous stasis in the pampiniform pIexus resuIts causing the scrotal veins to enlarge and the testicle to become more dependent. The condition is rare on the right side because the right internal spermatic vein empties obIiqueIy into the inferior vena cava and rareIy is incompetent. The incidence of this defect is high in the young maIe population aIthough most cases are without disabling symptoms. However, when discomfort and pain are present, the condition often requires surgery for aIIeviation. Varicocelectomy has long been an unsatisfactory surgical procedure, carrying with it numerous pitfaIIs. The cIassic procedure of dissection and excision of the distended veins in the scrotum is technicaIIy a difficult undertaking, often failing to relieve symptoms and frequentIy resulting in undesirable complications such as hemorrhage, atrophy of the testicle and hydrocele formation. AccordingIy, many uroIogists and surgeons have been reluctant to advise operation in cases of symptomatic varicoceIe. Ivanissevich over twenty years ago described accurateIy the venous drainage system of the testicIe and recommended high ligation of the interna spermatic vein as treatment of later described painfu1 varicoceIes. 1 Bernardi a new technic utilizing an inguina1 incision and dissecting out a11 veins within the inguina1 canal. It remained, however, for Javert and CIark3 to describe a modification which simplifies Bernardi’s operation and promises to repIace a11 other surgical procedures for the correction of varicocele. Their operation is known as Iigation of the interna spermatic vein. Anatomy. The pampiniform pIexus of testicular veins is drained by deep and superficia1 venous systems. The deep system is made up of the internal spermatic vein, the vein of the ductus deferens (a tributary of the hypogastric 330

vein) which anastomoses with the internal spermatic vein within the epididymis and testicIe, and the external spermatic veins (Ieading to the inferior epigastric vein) which anastomose with the internal spermatic in the cord. The superficial system is composed of the superticia1 and deep epigastric veins, the superficial interna circumflex vein, and the scrota1 tributaries of the superficia1 and deep externa1 pudendals (a11 Ieading to the femoral vein) and the internal pudenda1 vein. AI1 of these anastomose with each other and the externa1 spermatic vein near the externa1 inguina1 ring within the cord.3l4 Understanding the circulation of the testicIe and surrounding regions, the IogicaI operation is to reIieve the back pressure caused by the anatomic weakness of the interna spermatic vein by Iigation of this vesse1 above the points of anastomosis of the various components of the venous system in the pampiniform plexus. Operation. An incision is made as for a herniorrhaphy except that the Iength rarely needs to be more than 6 cm. unIess a concurrent hernia is present. If an unsuspected hernia is encountered, extension of the incision wiI1 be necessary. The aponeurosis of the external obIique muscIe is incised down to or through the externa1 inguina1 ring, being carried IateraIly to expose the abdominal inguina1 ring. The cremasteric muscIe and fascia are incised IongitudinaIIy at the proxima1 end of the inguinal canal, and the interna spermatic vein is dissected free for a distance of about 3 cm. The vein is secureIy ligated at the interna ring and at the dista1 portion of the dissection. The vein is excised between the Iigatures, the proxima1 end being aIIowed to retract into the abdomina1 cavity. In some instances the interna spermatic vein is formed inside the abdomina1 inguina1 ring and there are two Iarge branches instead of a singIe vein in the cord at the Iateral end of the inguinal canaI. Both veins are Iigated in such cases. This occurred three times in the ten patients reported in this series. The Iongitudinal incision in the cremasteric muscIe and fascia is closed

American

Journal of Surgery

Price-Treatment transversely with a running suture. The dista1 end of the Iigated interna spermatic vein may be incIuded in this cIosing stitch. CIosure of the cord in this manner causes eIevation of the dependent left testicIe. CarefuI search of the cord for possibIe indirect herniation should be done in al1 cases.

of Varicocele either the varicoceIe or his symptoms of discomfort. Eight of the ten patients were reIieved of their symptoms before discharge from the hospital on the tenth or eleventh postoperative day. Of the two not relieved, one was the patient previously mentioned who had the TABLE ,I

TABLE ,NC,DENCE

OF

“ERKIA

Series

Javert-CIark. ..... Riba ............. Price, ............

’

RESULTSOr; LLGATION

I

1X CASES

OI-

Hernia Suspected

32

32

10

1950

SPERMATIC

Hernia (p~~~~t,

Series

Patients Operated upon

Varicocele Cured (Per cent)

VEl,,’

3

3

2

Symptoms Relieved (Per cent)

Total

32

?

SmaII hernias were found in two of the author’s ten cases. (TabIe I.) In such instances high Iigation of the sac and repair of the posterior waI1 of the inguina1 cana are necessary. Further cIosure of the wound shouId be done in Iayers. PostoperativeIy the patient should wear a scrota1 support for about one week. He is aIIowed bathroom privileges on the first postoperative day and gradua1 ambuIation thereafter. HospitaIization is usuaIIy unnecessary after three or four days in cases in which herniorrhaphy is not done. Results. This series consisted of ten cases of symptomatic varicoceIe, in which a11 of the patients compIained of a feeIing of heaviness in the scrotum and a duI1 ache in the left groin made worse by increased physica exertion and most distressing in the afternoon and evening hours. In addition a few of the patients complained of occasiona sharp pains in the groin of varying intensity and usuaIIy of short duration. AI1 of these patients were given extensive trial with scrota1 suspensories without relief before surgery was recommended. In nine of the ten patients the varicoceIe was dramatically reduced in size within seventytwo hours and in most of these cases it was imperceptible to inspection within ten days. (Table II.) The tenth patient had previousIy undergone a Ieft inguina1 herniopIasty and the cord was scarred to such an extent that the veins could not be accurately indentified and dissected. This patient was not relieved of

September,

lNTERNAL

VAKICOCELE

Patients Operated upon

23

OF THE

Javert-Clark. Riba. Price.

22 23

100

I0

90

I 00 (smaller)

I00 87 80

scarred cord and had undergone unsuccessful dissection. The other patient (cured of his varicoceIe) stiI1 complained of duI1 aching in the testicIe and groin aIthough to a sIighter degree than before surgery. He was Iast seen three weeks postoperativeIy. The resuIts of this series compare favorably with the series of twenty-two cases reported by Javert and CIark and the twenty-three cases reported by Riba. (Table IL) No complications were encountered.

The high incidence of postoperative comptications previousIy seen foIlowing varicocelectomy have been Iargely eliminated and operative success greatIy enhanced in treating symptomatic varicoceIes with Iigation of the internal spermatic vein and simultaneous herniorrhaphy in cases in which this defect is aIs present. REFERENCES

I. RIBA, W. R. Excision of the internat spermatic vein for varicoceIe. J. Ural., 57: 889-893, 1947. 2. BERNARDI, R. A new incision for the surgical treatment of varicocele; SymptomatoIogicaI and surgiCaI Concepts. Bol. Inst. din. rmir., 18: 323, 1942. 3. JAVERT, C. T. and CLARK, R. L. A combined operation for varicoceIe and inguinal hernia. Surg., @MC. @Y Oh., 79: 644-650, 1944. 4. LEWIS, W. B. Gray’s Anatomy of the Human Body. z3rd ed., pp. 668-675. Philadelphia, 1936. Lea & Febiger.