Thermal cautery-assisted circumcision and principles of its use to decrease complication rates.

INTRODUCTION: Circumcision is one of the most frequently applied surgical procedures all over the world and a number of techniques and devices have been described concerning its method. Especially in developing countries where circumcision has been performed intensively under local anaesthesia, the thermocautery device developed to perform circumcisions in a short time and safely has found a widespread application. OBJECTIVE: We aim to share our experiences concerning application principles of the thermocautery device so as to be able to achieve better cosmetic results with lower complication rates. MATERIALS AND METHODS: Between the years 2009 and 2016, a total of 12,355 children between the ages of 40 days and 16 years (mean: 5.1 ± 2.0 years) were circumcised at our hospital. All circumcisions were performed by urologists under local anaesthesia using a thermocautery device (Thermo-Med TM 802B device; Thermo Medikal, Adana, Turkey). RESULTS: Bleeding that required surgical intervention did not occur in any patient. Compressive dressing was applied to 62 patients who had moderate degrees of bleeding, for haemostasis purposes. Twelve syncopes and four epileptic seizures developed secondary to local anaesthesia were managed in consultation with the Department of Children Health and Diseases. The most serious complication, trapped penis, was seen in 48 patients. All these complications were resolved using surgical interventions. Infection developed in 15 patients, and it was relieved with the administration of oral antibiotherapy. Penile adhesions were relieved in 25 cases, and anti-inflammatory treatment was organised. Meatal stenosis occurred in three cases, and two cases of inclusion cysts were treated with surgical intervention. DISCUSSION: In countries where circumcision is routinely applied, developing swift and safer methods are of the utmost importance. To this end, we prefer thermocautery, which can satisfy patient demands swiftly and safely. CONCLUSION: To reduce the complications after circumcision using thermocautery, we think that it is appropriate to pay attention to the following issues during circumcision: The cautery should be turned in a serial manner and both sides of the blade should be used for cutting, and temperature of the thermocauter should be adjusted according to the skin thickness. The cutting process should be achieved in two steps, and another method should be preferred for buried penis. If these rules are followed, we think that the thermocautery-supported method can be a very safe and fast circumcision method.

An update on percutaneous nephrolithotomy: lessons learned from the CROES PCNL Global Study.

Since its introduction in late 1970's, percutaneous nephrolithotomy (PNL) has undergone an evolution in both equipment and technique. This evolution still continues today in the era of minimally invasive treatment options, and is evidenced by the numerous publications. PNL is generally advantageous in the management of large renal stones (>1.5-2 cm) with high stone-free rates and considerable complication rates. However this technique is especially competing with retrograde intrarenal surgery and laparoscopic techniques. Therefore the CROES Global PNL Study Group prospectively collected data of over 5800 patients managed with PNL worldwide and analyzed the data in detail, producing more than 25 scientific papers. And this update focuses on the lessons learned from the CROES PCNL Global Study.

Decorin as a new treatment alternative in Peyronie's disease: preliminary results in the rat model.

The purpose of this study is to investigate the effect of decorin, a naturally occurring proteoglycan with anti-transforming growth factor beta (TGF-ß) activity, on the rat model of Peyronie's disease (PD). Twenty-five adult male Sprague-Dawley rats were divided in three groups: I) TGF-ß (0.5 µg) injected (n: 8); II) TGF-ß injected and decorin treated (n: 8); and III) controls (n: 9). Decorin (0.5 µg per day) was given with intracavernous injection on the second, third, fourth and fifth day following TGF-ß injection. All rats underwent electrical stimulation of the cavernous nerve after 6 weeks. Intracavernosal and arterial blood pressures were measured during this procedure. Cross-sections of the rat penises were examined using Mason trichrome and H&E stains. Statistical analyses were carried out using one-way anova. Histopathological examinations confirmed the Peyronie's-like condition in TGF-ß-injected rats, which exhibited a thickening of the tunica albuginea (TA), when compared to controls. Disorganisation of collagen on the TA was also prominent in TGF-ß-injected rats, but not in decorin-treated and control rats. Decorin-treated rats showed significantly higher maximal intracavernosal pressure (MIP) responses to cavernous nerve stimulation, when compared to group 1 (P < 0.05). Our results indicate that decorin antagonises the effects of TGF-ß in the rat model of PD and prevents diminished erectile response to cavernous nerve stimulation.

Do tumor volume, tumor volume ratio, type of nerve sparing and surgical experience affect prostate specific antigen recurrence after laparoscopic radical prostatectomy? A matched pair analysis.

PURPOSE: We assessed the impact of tumor volume, tumor volume ratio (tumor volume-to-prostate volume), surgical experience and type of nerve sparing procedure on biochemical recurrence after laparoscopic radical prostatectomy. MATERIALS AND METHODS: Of 1,600 laparoscopic radical prostatectomies performed between March 1999 and May 2006 we evaluated 555 patients who had at least 24 months of followup and received neither neoadjuvant nor adjuvant therapy. Of 555 patients 81 had biochemical recurrence and were match paired in 3 groups with those without recurrence. Matching decisions were based on factors such as age, preoperative prostate specific antigen, pathological stage, Gleason score, surgical margin status with localization, tumor volume, type of nerve sparing procedure, surgeon and date of operation that are related to surgical experience. We evaluated the impact of tumor volume and tumor volume ratio, type of nerve sparing procedure and surgeon on biochemical recurrence, and excluded the factor being investigated in each matched pair. RESULTS: Tumor volumes were 3.58 vs 3.3 cc and tumor volume ratios were 0.081 vs 0.071 in the biochemical recurrence and no biochemical recurrence groups, respectively (p=0.026 and p=0.040). At the second match pair the numbers of nonnerve sparing, unilateral and bilateral nerve sparing procedures were 65, 12 and 4 vs 62, 13 and 6, respectively, without statistical significance. At the last match pair the volume of cases for the first generation and the other generations were 56 and 25 vs 59 and 22, respectively, also without statistical significance. CONCLUSIONS: Although surgical experience based on an adequate training program and type of nerve sparing procedure do not have a significant impact on biochemical recurrence, tumor volume and tumor volume ratio do.

Peyronie's disease: a silent consequence of diabetes mellitus.

AIM: To investigate the clinical characteristics of patients with Peyronie's disease (PD) and diabetes mellitus (DM). METHODS: During an 8-year period, a total of 307 men seen at our outpatient clinic were diagnosed with PD. Clinical characteristics, penile deformities and the erectile status of patients with PD and DM together (n=102) were retrospectively analyzed and compared to patients with PD alone with no risk factors for systemic vascular diseases (n=97). RESULTS: The prevalence of PD among men with DM and sexual dysfunction was 10.7%. The mean age of diabetic patients with PD was (55.9+/-8.9) years; in the no risk factor group it was (48.5+/-9.0) years (P < 0.05). The median duration of DM was 5 years. The majority of diabetic patients with PD (56.0%) presented in the chronic phase (P < 0.05), and they were more likely to have a severe penile deformity (>60 degrees) than the no risk factor group (P < 0.05). In the diabetic group, the most common presenting symptom was penile curvature (81.4%), followed by a palpable nodule on the shaft of the penis (22.5%) and penile pain with erection (14.7%). A total of 19.6% of patients were not aware of their penile deformities in the diabetic group. Erectile function, provided by history and in response to intracavernosal injection and a stimulation test, was significantly diminished in patients with PD and DM (P < 0.05). CONCLUSION: DM probably exaggerates the fibrotic process in PD. Diabetic patients with PD have a higher risk of severe deformity and erectile dysfunction (ED). PD seems to be a silent consequence of DM and should be actively sought in diabetic men.

Does sexual dysfunction correlate with deterioration of somatic sensory system in diabetic women?

To evaluate genital and extragenital somatic sensory system in diabetic women using biothesiometry and investigate the relation with sexual dysfunction. A total of 30 diabetic women and 20 normal sexually active women as a control group were evaluated with a detailed medical and sexual history including Index of Female Sexual Function (IFSF) questionnaire. Somatic sensory system of all women enrolled to the study was assessed by biothesiometry and threshold sensory values of nine genital sites and 14 extragenital sites were analyzed. The IFSF score in diabetic women was 23.6 while it was 38.3 in the control group (&<0.0005). For each genital as well as extragenital sites, the mean biothesiometric values were significantly higher in diabetics. The sensation of introitus vagina, labium minora and clitoris were found to be the most deteriorated genital sites in diabetic women. The difference between diabetic women with or without female sexual dysfunction (FSD) was not significant for biothesiometric values. Our data indicate that, somatic sensory system is affected by diabetes however sexual dysfunction does not always manifest.

Hydatid disease of the kidney caused by Echinococcus multilocularis: a rare clinical entity.

Hydatid disease of the urinary tract is extremely rare and constitutes approximately 4% of all cases of hydatid disease. The Echinococcus multilocularis is a relatively rare form of echinococcus as the cause of renal hydatid disease. We describe a patient who had renal hydatidosis which is rarely caused by the E. multilocularis.

Is selective internal spermatic venography necessary in detecting recurrent varicocele after surgical repair?

OBJECTIVES: Surgical varicocele repair can be complicated by postoperative recurrence. The aim of this study is to evaluate the diagnostic value of scrotal color Doppler ultrasonography (SCDU) and selective internal spermatic venography (SISV) in detecting recurrent venous reflux after conventional varicocelectomy. MATERIALS AND METHODS: A total of 36 men (mean age 30.1 +/- 4.3 years) with a persisting left unilateral varicocele and abnormal semen parameters more than 12 months after conventional varicocele repair were evaluated with physical examination, semen analyses, SCDU and SISV. RESULTS: The median interval between primary varicocelectomy and presentation was 13 (range 12-16) months. Physical examination at that time revealed a grade- I left varicocele in 22 and a grade-II left varicocele in 14 patients. Semen analyses showed oligoasthenozoospermia in 30 patients (83%), asthenozoospermia in 4 (11%) and oligozoospermia in 2 (6%). Although all patients had reflux on SCDU, SISV confirmed reflux in 8 (22%) cases. SISV was not able to document recurrence in 28 cases (78%) that were detected by SCDU. CONCLUSIONS: Considering clinical findings, confirmed with SCDU, and semen parameters as the reference point in the diagnosis of recurrent varicocele, the sensitivity of SISV in the radiological documentation of recurrence was 22%. SISV was unable to document the recurrence in 78% of cases implying that reflux was not through internal spermatic veins. Thus, we conclude that SISV is neither necessary nor sufficient in the evaluation of recurrent varicocele.

Does response to treatment of ejaculatory duct obstruction in infertile men vary with pathology?

OBJECTIVE: To describe the pathology-specific response to transurethral resection of ejaculatory ducts (TURED) in patients with complete or partial ejaculatory duct obstruction and to evaluate the role of TURED in light of powerful assisted reproductive technologies. DESIGN: Retrospective clinical study. SETTING: University hospital. PATIENT(S): Thirty-eight infertile men with obstruction of the ejaculatory ducts. INTERVENTION(S): Diagnosis by transrectal ultrasonography or magnetic resonance imaging, and treatment with TURED. MAIN OUTCOME MEASURE(S): Changes in semen variables, pregnancy outcomes, and complication rates were analyzed before and after surgery. RESULT(S): Improvement in semen variables was significantly better in patients with partial obstruction (94%) of ducts than in those with complete obstruction (59%) (P=.04). Cystic obstruction, especially midline and eccentric cysts, responded best to TURED. Before surgery, all patients were candidates for IVF/ICSI; after surgery, 32% of azoospermic men and 81% of oligospermic men conceived spontaneously or were referred for IUI instead of IVF/ICSI. CONCLUSION(S): Ejaculatory duct obstruction due to cysts appears to respond best to TURED. In addition, TURED may decrease the need for IVF/ICSI as primary treatment in many cases. Finally, TURED may allow IVF/ICSI to be performed with ejaculated rather than surgically retrieved sperm.

Peyronie's disease in men under age 40: characteristics and outcome.

Peyronie's disease is most commonly seen in the fifth decade of life. However, a wide range of age (20-83 y) is reported. During a 6-year period, men with Peyronie's disease presenting under the age of 40 were reviewed retrospectively and followed-up. The prevalence of Peyronie's patients presenting under age 40 was 8.2%. Their mean age was 32.47 +/- 5.37 (range: 23-39) y and 78.9% of them presented during the acute phase of the disease. Pain on erection was a part of presenting symptom complex in 52.6% and the majority (84%) had a degree of penile curvature < 60 degrees. Erectile dysfunction (ED) was present in 21% of patients, who responded well to intracavernous injection test. After a minimal 2-year follow-up, improvement in penile deformity was observed in 36.8%, and 42.1% had stable disease while 21% experienced deterioration of the penile curvature. The onset of Peyronie's disease is clinically more noisy and acute in patients presenting under age 40 and this forces the physicians to treat them more vigorously.

Honeymoon impotence: psychogenic or organic in origin?

OBJECTIVES: Honeymoon impotence is the inability to perform successful sexual intercourse during the initial experience, especially during the first nights of marriage, and it is relatively frequent in Turkey. We investigated the underlying penile vascular abnormalities in patients presenting with honeymoon impotence and sought to differentiate between psychogenic and organic etiologies. METHODS: Between 1989 and 1999, 90 patients sought urologic help for honeymoon impotence. Patient age ranged from 18 to 39 years (mean 28.06 +/- 3.4). All patients were given an intracavernous injection of 60 mg papaverine combined with self-manual genital stimulation (CIS test) to assess the degree of tumescence. Patients with a positive response to the CIS test were later evaluated with nocturnal penile tumescence (NPT) monitoring. Patients with a negative response to the CIS test and/or NPT monitoring were evaluated further using penile color Doppler ultrasound. RESULTS: A psychogenic etiology was found in 61 patients (67.7%), 50 (55.5%) of whom achieved satisfactory sexual intercourse after intracavernous injection. Twenty-five patients (27.7%) exhibited penile vascular abnormalities by color Doppler ultrasound. Neurogenic erectile dysfunction was considered in the remaining 4 patients (4.4%) with a positive response to the CIS test, abnormal findings on NPT monitoring, and a normal vascular system with color Doppler ultrasound. CONCLUSIONS: The present study is the first to report penile vascular abnormalities in patients presenting with honeymoon impotence, which was previously believed to be exclusively psychogenic in origin. The evaluation of the penile vascular system in patients with honeymoon impotence may reveal underlying penile vascular abnormalities, allowing the choice of the appropriate therapeutic option.

Microsurgical inguinal varicocele repair in azoospermic men.

OBJECTIVES: To evaluate the efficacy of microsurgical inguinal varicocele repair in nonobstructive azoospermic men with palpable varicocele and to determine predictive parameters of outcome. METHODS: After standard diagnostic evaluation, 24 pellet (-) completely azoospermic men and 14 pellet (+) virtually azoospermic men underwent microsurgical inguinal varicocele repair. Testicular core biopsy was also performed perioperatively in all patients. The outcome was assessed in terms of improvement in semen parameters and spontaneous pregnancy. RESULTS: After a mean follow-up of 13.4 +/- 4.7 months, motile sperm in the ejaculate could be identified in 5 (21%) of the completely azoospermic patients, and these patients were rescued from invasive sperm extraction techniques when referred to intracytoplasmic sperm injection. Testicular histopathology of these patients with postoperative improvement revealed maturation arrest at spermatid stage (n = 3), Sertoli-cell-only (SCO) pattern with focal spermatogenesis (n = 1), and hypospermatogenesis (n = 1). None of the patients with pure SCO pattern or maturation arrest at spermatocyte stage had improvement after varicocele repair. However, improvement in semen parameters was observed in 12 (85.7%) patients with virtual azoospermia, 4 (28.6%) achieved a total motile sperm count greater than 5 million, and spontaneous pregnancy occurred with 3 (21.4%) of them. CONCLUSIONS: Microsurgical inguinal varicocele repair offers completely azoospermic men the chance to provide motile sperm via ejaculate in 21%. Moreover, 28.6% of virtually azoospermic men are rescued from ICSI procedures as an initial treatment modality. Results of varicocele repair in azoospermic men also reveal that a certain threshold of spermatogenesis, requiring the presence of at least spermatids, is necessary for effective varicocele repair.

Treatment of Peyronie's disease with oral colchicine: long-term results and predictive parameters of successful outcome.

As recent clinical and animal studies have indicated, colchicine, with its anti-fibrotic, anti-mitotic and anti-inflammatory activities, has suppressive effects in the pathogenesis of Peyronie's disease. Oral colchicine treatment was initiated in 60 Peyronie's patients during their acute phase (mean duration of disease: 5.7 +/- 4.3 months). Long-term results, based on changes of subjective and objective criteria, were assessed and predictive factors of successful outcome were investigated. After a mean follow-up of 10.7 +/- 4.7 months, the penile deformity improved in 30%, remained unchanged in 48.3% and deteriorated in 21.7%. Pain resolved in 95%. Best results were obtained in those with no risk factor for vascular disease, presenting during the initial 6 months of disease, degree of curvature <30 degrees, no erectile dysfunction by history and positive response to combined injection and stimulation test. In conclusion since tunica albuginea is affected as a whole in Peyronie's disease, systemic oral agents, such as colchicine, may be preferred in the early phase of the disease.

The role of reactive oxygen species in testicular dysfunction associated with varicocele.

OBJECTIVE: To determine the level of malondialdehyde (MDA), an indirect indicator of lipid peroxidation-induced injury by reactive oxygen species, in testicular biopsy specimens from infertile patients with and without varicocele. PATIENTS AND METHODS: Levels of MDA were measured in the testicular biopsy specimens from 25 infertile men (15 with varicocele, mean age 30.0 years, SD 5.7, range 23-45, and 10 without, mean age 28.7 years, SD 4.2, range 21-34). All patients were evaluated by a detailed history, physical examination, semen analysis (at least twice), serum follicle-stimulating hormone and free testosterone levels, testicular biopsy and contact imprint. Scrotal colour Doppler ultrasonography was used to confirm suspected varicocele. The level of MDA in testicular biopsy specimens was measured using the thiobarbituric acid test and the results expressed per unit tissue weight. RESULTS: As a causal factor for infertility, varicocele was identified in 15 men (60%), testicular failure in four (16%), idiopathic infertility in four (16%) and obstruction in two (8%). Of the 15 patients with varicocele, eight had bilateral varicocele and it was subclinical in three; the varicocele was grade I in four, grade II in six and grade III in two. The mean (SD) MDA level in the men with a subclinical varicocele was 15.7 (3.1) pmol/mg tissue, while in those with grade I-III varicocele it was 32.9 (12.25), 37.1 (12.25) and 86.9 (2.89) pmol/mg tissue, respectively. The levels in patients with grade III varicocele were significantly greater than in the other groups (P < 0.05). The mean MDA level in patients with or without varicocele was 38.3 (22.92) and 33.5 (18.93) pmol/mg tissue, respectively (P > 0.05). CONCLUSION: These results suggest that increasing levels of MDA are associated with higher grades of varicocele and support a possible rationale for controlled trials in infertile men with varicocele.

Delayed repair of post-traumatic posterior urethral distraction injuries: long-term results.

OBJECTIVES: There is still controversy regarding the treatment of post-traumatic posterior urethral distraction injuries. Initial suprapubic cystostomy and delayed perineal urethral reconstruction has been considered the reference standard. In this report, we review our experience with delayed perineal urethral reconstruction, with a focus on the long-term outcome and complications. METHODS: A total of 77 men with posterior urethral distraction injury due to pelvic trauma underwent reconstruction with delayed perineal approach. In all cases, the area of fibrosis was aggressively excised, the corpus spongiosum was mobilized, and a tension-free, spatulated end-to-end anastomosis was achieved by splitting the corporeal bodies in 66.2% and by an additional perineally performed inferior pubectomy in 49.3% of the patients. The median time from injury to surgical repair was 12 months. The preoperative evaluation consisted of combined antegrade and retrograde cystourethrograms and cystourethrography. A detailed sexual history was obtained in 58 patients (75.3%). RESULTS: After a mean follow-up of 47 months (range 15 months to 14 years), the urethral continuity was adequate in 94. 8%; however, 2 patients required a perineal surgical revision (total of 79 operations). Postoperative incontinence was observed in 7 (9. 1%) of 77 patients. Postoperative erectile dysfunction was noted in 16.2% of patients who were known to be potent by history before surgery. CONCLUSIONS: Our results support the belief that delayed perineal reconstruction with extensive excision of fibrosis and a tension-free, spatulated end-to-end anastomosis is a successful treatment alternative for posterior urethral distraction defects, with acceptable morbidity.

Comparison of results and complications of high ligation surgery and microsurgical high inguinal varicocelectomy in the treatment of varicocele.

OBJECTIVES: To prospectively compare sperm parameters, pregnancy and recurrence rates, and complications after randomized high ligation surgery versus microsurgical high inguinal varicocelectomy (MHIV). METHODS: Varicocele was diagnosed by physical examination and color Doppler ultrasound in 468 patients who underwent one of two procedures: high ligation surgery (n = 232) or MHIV (n = 236). The high ligation surgery was left unilateral in 142 and bilateral in 90. The MHIV was left unilateral in 128 and bilateral in 108. The patients were postoperatively evaluated by spermiograms and physical examination. The pregnancy rate was monitored for 2 years. RESULTS: One year after surgery, 34.05% in the high ligation group and 46.61% in the MHIV group had a more than 50% increase in their total motile sperm count (P = 0.000). The increase in sperm count was not statistically different between the two groups (P = 0.1), but the difference in the increase in sperm motility in the MHIV group was statistically significant (P = 0.000). Pregnancy rates at the end of 2 years reached 33.57% in the high ligation group and 42.85% in the MHIV group, not a statistically significant difference (P = 0.0571). The postoperative recurrence as detected by physical examination was markedly different between the two techniques. The recurrence rate was 15.51% in the high ligation group and 2.11% in the MHIV group (P = 0.000). Also, the incidence of postoperative hydrocele was significantly different between the two groups (9.09% in the high ligation group and 0.69% in the MHIV group; P = 0.000). CONCLUSIONS: MHIV has lower recurrence and hydrocele rates, a higher increase in sperm motility, and results in higher pregnancy rates. Therefore, it should be the preferred technique for varicocelectomy.

Urologic complications of extravesical ureteroneocystostomy in renal transplantation from living related donors.

INTRODUCTION: Reconstruction of the urinary system during renal transplantation is usually performed with antirefluxive ureteroneocystostomy techniques and extravesical methods are usually preferred. MATERIAL AND METHODS: Between 1983 and 1997, 241 renal transplantations from living donors were performed at our institution. A variation of the Lich-Gregoir technique was used as the ureteroneocystostomy method in all cases. RESULTS: A total of 12 (4.9%) urologic complications were observed. Urinary fistula developed in 5 (2%) cases and were explored surgically during the early postoperative period. Postoperative vesicoureteral reflux (VUR) to the transplanted kidney was identified in 7 (2.9%) cases. Either endoscopic or surgical interventions resolved VUR in 4 cases while the other 3 did not need further treatment. No ureteral stenosis was observed. There was no loss of graft due to urologic complications. CONCLUSIONS: Urologic complications after renal transplantation are reported to be about 7% and ischemia is blamed as the major contributing factor. Preparation of the native ureter during donor nephrectomy and preservation of distal periureteral fatty tissue, anastomosis technique variations in vascular anatomy, rejections and medications are the major factors determining the ischemia.

Color Doppler ultrasound assessment of penile vascular system in men with Peyronie's disease.

The purpose of this study was to evaluate the penile vascular function by color Doppler ultrasonography (CDU) in patients with Peyronie's disease. A total of 136 men with Peyronie's disease were stratified according to their potency by history as Group I consisting of potent patients and Group II consisting of patients with erectile dysfunction. They were all evaluated by penile CDU. Overall, 70.6% had erectile dysfunction by history. CDU revealed penile vascular abnormalities in 76.5%. In Group I, veno-occlusive dysfunction (VOD) was observed in 40% while mixed (arterial + venous) vascular disease was diagnosed in 10%. Penile vascular disease was detected in 87.5% patients in Group II (ie VOD in 28%, arterial disease in 9.3% and mixed vascular disease in 50%). The prevalence of arterial disease on CDU among Peyronie' patients with erectile dysfunction (59.3%) was significantly (P < 0.05) higher then it was among potent patients (10%). The prevalence of pure VOD was almost similar for patients with or without erectile dysfunction (P < 0.05). We conclude that penile vascular abnormalities can be observed in 76.5% on cases with Peyronie's disease by CDU and this ratio significantly increases to 87.5% among cases with erectile dysfunction by history. Our data also indicate that arterial disease, accounts for much of the diminished rigidity in men with Peyronie's disease.

The effect of microsurgical varicocelectomy on serum follicle stimulating hormone, testosterone and free testosterone levels in infertile men with varicocele.

OBJECTIVES: To analyse the effects of varicocelectomy on serum follicle-stimulating hormone (FSH), testosterone and free testosterone levels, and to investigate the interrelationships between seminal and hormonal variables. PATIENTS AND METHODS: The records were retrospectively evaluated for 78 infertile patients who underwent microsurgical inguinal varicocelectomy, with documented serum FSH, testosterone, free testosterone levels, sperm concentration and sperm motility before and after surgery. Left and bilateral varicoceles were detected in 40 and 38 patients, respectively. In addition, serum hormonal values of 10 fertile men in whom physical examinations and Doppler ultrasonography revealed no evidence of varicocele were recorded and used as a control group. RESULTS: The mean (sd) serum FSH levels of all patients decreased from 15.21 (3.34) before surgery to 10.82 (2.93) mIU/mL afterward (P=0.01), and serum testosterone levels increased from 5.63 (1.40) to 8.37 (2.2) ng/mL (P=0.01), whereas free testosterone levels increased from 23.13 (3.19) to 32.83 (4.37) pg/mL (P<0.001). In contrast to the significant difference in sperm motility before and after surgery of all patients (P<0.01), the difference in sperm count was insignificant (P>0.05). Thirty-six patients with high serum FSH levels before surgery had significantly lower levels afterward (P=0.001). In this group, the sperm concentration and motility also increased, from 17.66 (4.35) to 20.76 (4.37) million/mL (P=0.05) and from 30.9 (4.4)% to 37.5 (4.34)%, respectively (P=0.01). In the remaining 42 patients who had normal preoperative serum FSH levels, there was a slight decrease after surgery (P=0.02). Their sperm concentration increased slightly (P=0. 04), and motility also increased (P=0.001). Sixty patients had a significantly higher testosterone level after surgery; in this group the sperm concentration and motility increased (P=0.01). CONCLUSION: Varicocelectomy promotes Sertoli and Leydig cell function. The significant increase in serum free testosterone level results in a significant improvement in sperm concentration and motility.