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ORIGINAL ARTICLE
Year : 2015  |  Volume : 28  |  Issue : 1  |  Page : 1-4

Study of inguinal versus retroperitoneal approach in the treatment of varicocele


1 Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of General Surgery, Omm Elmisryeen General Hospital, Giza, Egypt

Date of Submission07-May-2014
Date of Acceptance10-Jul-2014
Date of Web Publication29-Apr-2015

Correspondence Address:
Mohamed Samir Aboulfotoh
Flat 304, 3rd Floor, 101 Khatam Almorsaleen St, Giza
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.155897

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  Abstract 

Objective
The aim of the study was to assess the efficacy of the inguinal approach versus the retroperitoneal approach in the treatment of varicocele.
Background
Published results have shown that the inguinal approach has several advantages over the retroperitoneal approach in terms of lower incidence of recurrence, easier applicability, and greater safety.
Patients and methods
This prospective study was conducted from April 2013 to February 2014 in Menoufia University hospitals on 40 patients with primary varicocele and subfertility.
The patients were randomly allocated into two groups of 20 patients each. Patients in group I underwent inguinal varicocelectomy, and patients in group II underwent retroperitoneal varicocelectomy.
Results
The ages of the 40 patients with suspected appendicitis ranged from 16 to 40 years. The mean age was 25.24 years in group I and 27.15 years in group II. Improvement in semen characteristics was seen in 80% of patients (16 in each group). Hematoma formation was observed in two (10%) cases in group I and in no cases in group II. One (5%) patient of group I had hydrocele formation. No testicular atrophy was noticed in the immediate postoperative period in either group. In two (10%) patients of group II there was no symptomatic relief. In group II there was no patient with symptomatic persistence.
Conclusion
The inguinal approach is superior to the conventional retroperitoneal approach in the treatment of varicocele, especially with respect to recurrence rate. Using inguinal approach varicocelectomy, identification and preservation of the testicular artery can be easily carried out. However, semen characteristics improved in both groups.

Keywords: Inguinal, retroperitoneal varicocelectomy, subfertility


How to cite this article:
Omar AA, Greda HS, Aboulfotoh MS. Study of inguinal versus retroperitoneal approach in the treatment of varicocele. Menoufia Med J 2015;28:1-4

How to cite this URL:
Omar AA, Greda HS, Aboulfotoh MS. Study of inguinal versus retroperitoneal approach in the treatment of varicocele. Menoufia Med J [serial online] 2015 [cited 2019 Sep 20];28:1-4. Available from: http://www.mmj.eg.net/text.asp?2015/28/1/1/155897


  Introduction Top


Varicocele is an abnormal dilatation of the pampiniform plexus within the spermatic cord [1]. Varicocele is seen in 15% of the normal male population and in up to 35-40% of patients with male infertility [2]. A varicocele is an underlying cause in ~70-81% of patients with secondary infertility [3]. It is a disease that occurs during puberty and is only rarely detected in boys younger than 10 years of age [4].

The diagnosis of varicocele is based on clinical examination and duplex scanning. Duplex scanning can detect the venous reflux and categorize the reflux site. There are five grades of varicocele according to duplex classification: grade I is characterized by a prolonged reflux in vessels in the inguinal channel only during Valsalva's maneuver; grade II is characterized by a small posterior varicosity that reaches the superior pole of the testis; grade III is characterized by vessels that appear enlarged to the inferior pole of the testis; grade IV is diagnosed if vessels appear enlarged; and grade V is characterized by an evident venous ectasia even in an upright position [5].

Varicocele remains the most common specific cause of male infertility, and varicocelectomy is the most frequently performed surgery for male infertility [6]. The WHO investigated the influence of varicocele on fertility in men presenting at infertility clinics and concluded that it is clearly associated with a duration-dependent decline in testicular function and in infertility [7].

The indications for varicocele treatment include scrotal pain, testicular atrophy, and infertility [8].

The treatment options for varicocele can be divided into three major categories:

  1. conservative treatment including testicular suspending wear, venotonics, and avoiding prolonged standing;
  2. percutaneous occlusion by intravenous injection of various materials to occlude the varicoceles; and
  3. surgical repair by ligation or clipping of the varicocele to prevent venous reflux [9].


The most common approaches for surgical repair are inguinal (groin), retroperitoneal (abdominal), which can be achieved either by an open or a laparoscopic approach, and infrainguinal (below the groin) [10].

However, the extent of improvement in semen parameters correlates with the grade of the varicoceles treated, with the biggest improvement seen in men treated for grade III varicocele [11].


  Patients and methods Top


This prospective study was conducted from April 2013 to Febuary 2014 in Menoufia University hospitals on 40 patients with primary varicocele and subfertility. The patients were randomly allocated into two groups of 20 patients each: the patients in group I underwent inguinal varicocelectomy and the patients in group II underwent retroperitoneal varicocelectomy.

Inclusion criteria

Patients aged 16-40 years with primary varicocele and subfertility were included in the study.

Exclusion criteria

Patients with secondary varicocele, those with normal semen characteristics, and recurrent varicocele patients were excluded.

The patients were examined in supine and standing position, and the grade of the varicocele was recorded. Varicoceles were graded as follows: grade I, palpable with the aid of Valsalva's maneuver; grade II, palpable without the aid of Valsalva's maneuver; and grade III, visible without palpation.

All patients underwent preoperative laboratory tests, semen analysis, and scrotal duplex and 6 months' postoperative follow-up semen analysis and scrotal duplex.

Inguinal varicocelectomy is carried out through inguinal incision of about two-finger breadth above the line between the anterior superior iliac spine and the symphysis pubis; the cord is delivered vas and its artery is separated; dilated veins are ligated and the wound is closed in layers. The retroperitoneal approach is through an incision of 3-4 cm medially to the anterior superior iliac spine two fingers above the internal ring cutting the external oblique aponeurosis. The internal oblique and transversus abdominus muscles are dissected, the spermatic artery is separated, the veins are ligated, and then the wound is closed in layers.


  Results Top


The ages of the 40 patients with primary varicocele and subfertility ranged from 16 to 40 years. The mean age was 25.24 years in group I and 27.15 years in group II [Table 1].
Table 1: Comparison between the two groups with respect to clinical features

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The mean preoperative sperm count was 23.5 × 10 6 /ml and 24.65 × 10 6 /ml in groups I and II, respectively. The mean spermatic motility after 1 h was 43.30 and 43.25% in groups I and II, respectively (P = 0.990); the mean spermatic motility after 2 h was 29.70 and 29.75% in groups I and II, respectively (P = 0.988); and the mean spermatic motility after 3 h was 21.30 and 20.80% in groups I and II, respectively (P = 0.865). The mean proportion of abnormal forms was 43.05 and 43.50% in groups I and II, respectively (P = 0.922), and the mean liquefaction time was 39.25 and 40.50 in groups I and II, respectively [Table 2]. There was significant increase in the mean spermatic count from 23.50 × 10 6 /ml to 36.11 × 10 6 /ml in group I (P < 0.001) and from 24.65 × 10 6 /ml to 36.39 × 10 6 /ml in group II (P < 0.001). The improvement in spermatic count shows no significant difference between the two groups [Table 3]. There was a slightly significant improvement in sperm motility postoperatively in both groups [Table 4].
Table 2: Preoperative semen characters in both groups

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Table 3: Effect of surgery on sperm count in both groups

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Table 4: Effect of surgery on sperm motility in both groups

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The operative time was not significantly different in the two groups (25.5 and 26.2 min for groups I and II, respectively) (P = 0.889). The mean duration of hospital stay in the two groups was 1.2 ± 0.32 days in group I and 1.1 ± 0.28 days in group II (P = 0.870) [Table 5].
Table 5: Operative time, postoperative pain, and hospital stay in both groups

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Out of 40 patients, 5% (one patient) in group I had an infected wound, whereas no infected wounds were seen in group II; one (5%) patient in group I had hydrocele formation, whereas no hydrocele formation was observed in group II; recurrence or persistent symptoms were 10% (two patients) in group II, whereas there was no recurrence in group I [Table 6] [Figure 1],[Figure 2] and [Figure 3].
Figure 1: Incision of inguinal approach.

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Figure 2: Spermatic cord extraction.

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Figure 3: Separation of vas from dilated veins.

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Table 6: Postoperative complications in both groups

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  Discussion Top


Varicocele is an abnormal dilation of the pampiniform plexus that constitutes the primary drainage of the testis. It is found in ~15% of male adolescents and in 70-80% of men with secondary infertility [12].

Varicocele most frequently appears at the age of 15-25 years and rarely develops after the age of 40 [13].

Several treatment options are available, including spermatic vein sclerotherapy or embolization and open surgical ligation of the varix through a retroperitoneal or inguinal approach. Laparoscopic varicocelectomy has been introduced as an alternative surgical procedure for the repair of varicocele [14].

In our study, there was no significant difference in mean age between the two groups (25.24 and 27.15 years for group I and II, respectively) (P = 0.291), denoting good matching of patients.

On comparing the preoperative semen parameters, no statistically significant differences were found with respect to the mean preoperative spermatic count between the two groups (23.50 × 10 6 /ml and 24.65 × 10 6 /ml in groups I and II, respectively) (P = 0.766). On comparing the postoperative semen parameters, significant increase was found in the mean spermatic count in group I (from 23.50 × 10 6 /ml to 36.11 × 10 6 /ml) (P < 0.001) and in group II (from 24.65 × 10 6 /ml to 36.39 × 10 6 /ml) (P < 0.001). The improvement in spermatic count showed no significant difference between the two groups.

No significant difference was found in the operative time between the first and second groups (25.5 and 26.2 min for groups I and II, respectively) (P = 0.889).

Patients in the two groups showed no difference with respect to the frequency and dosage of postoperative analgesics.

Hospital stay was not significantly different between the two study groups (1.2 ± 0.32 days in group I and 1.1 ± 0.28 days in group II) (P = 0.870).

The persistence or recurrence rate was 10% in the retroperitoneal group, whereas there were no cases of persistence or recurrence in the inguinal group. There was one case with hydrocele formation in group I and no such cases in group II. There were two cases with hematoma formation in group I and no such cases in group II.

The use of inguinal approach varicocelectomy is better than the retroperitoneal approach especially with respect to recurrence rate. With inguinal approach varicocelectomy, identification and preservation of the testicular artery can be easily carried out. However, hydrocele formation was more in inguinal varicocelectomy.


  Conclusion Top


The inguinal approach is superior to the conventional retroperitoneal approach in the treatment of varicocele, especially with respect to recurrence rate. Using inguinal approach varicocelectomy, identification and preservation of testicular artery can be easily carried out.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Mustafa Arian G, Awan WS, KarmF. Biomedica 2009; 25 :10-13.  Back to cited text no. 1
    
2.
Negler HM, Martinis FG. In: Lipshultz LI, Howards SS, editors. Varicocele. Infertility in the male. 3rd ed. St Louis: Mosby Year Book; 1997. 336-359.  Back to cited text no. 2
    
3.
Witt MA, Lipshultz LI. Varicocele: a progressive or static lesion?. Urol J 1993; 42 :541-543.  Back to cited text no. 3
    
4.
Paul JT. In: Tanagho EA, McAninch J Weditors. Male infertility. Smith′s general urology. 17th ed. McGraw Hill; 2008. 704-705.  Back to cited text no. 4
    
5.
Liguori G, Trombetta C, Garaffa G, et al. Color Doppler ultrasound investigation of varicocele. World J Urol 2004; 22 :378-381.  Back to cited text no. 5
    
6.
Goldstein: Varicocele. Options for management. AUA news, Jan/Feb. 2001; 6 : Front page.  Back to cited text no. 6
    
7.
Gorelick JI, Goldstein M. Loss of fertility in men with varicocele. Fertil Steril 1993; 42 : 541-543.  Back to cited text no. 7
    
8.
Williams DH, Karpman E, Lipshultz LI. Varicocele: surgical techniques in 2005. Canadian J Urol 2006; 13 :31-31.  Back to cited text no. 8
    
9.
Costanza M, Policha A, Amankwah K, Gahtan V. Treatment of bleeding varicose veins of the scrotum with percutaneous coil embolization of the left spermatic vein: a case report. J Vasc Endovasc Surg 2007; 41 :73-76.  Back to cited text no. 9
    
10.
Steckel J, Dicker AP, Goldstein M. Relationship between varicocele size and response to varicocelectomy. J Urol 1993; 149 :769-771.  Back to cited text no. 10
    
11.
Hsu GL, Ling PY, Hsieh CH, et al. Outpatient varicocelectomy performed under local anesthesia. Asian J Androl 2005; 7 :439-444.  Back to cited text no. 11
    
12.
Fretz PC, Sandlow JI. Current concepts in pathophysiology, diagnosis and treatment. Urol Clin J North Am 2002; 29 :921-937.  Back to cited text no. 12
    
13.
Rudloff U, Holmes RJ, Prem JT, et al. Mesoaortic compression of the left renal vein (nutcracker syndrome): case reports and review of the literature. Ann Vasc Surg 2006; 20 :120-129.  Back to cited text no. 13
    
14.
Kass EJ, Stork BR, Steinert BW. Varicocele in adolescence induces left and right testicular volume loss. Intl Br J Urol 2001; 87 :499-501.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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Abstract
Introduction
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