Microanatomy of the left and right spermatic cords at subinguinal microsurgical varicocelectomy: comparative study of primary and redo repairs.

OBJECTIVES: To examine and compare the left and right spermatic cord arterial and lymphatic anatomy identified at primary and redo microsurgical subinguinal varicocelectomy. METHODS: We reviewed the operative reports of 335 consecutive microsurgical varicocelectomies performed by a single surgeon: 325 primary repairs and 10 reoperations. We recorded number of testicular arteries (internal and external spermatic) and lymphatic channels preserved at subinguinal microsurgical varicocelectomy, and evaluated the relationship between the right and left vascular anatomy at bilateral varicocelectomy. RESULTS: A total of 235 left-sided and 90 bilateral primary repairs were performed. A mean (+/-standard deviation) number of 2.4+/-1.0 arteries and 4.6+/-1.5 lymphatics were identified during the left-sided repairs. For bilateral repairs, there were 2.4+/-0.9 arteries and 4.4+/-1.2 lymphatics on the left and 2.2+/-0.9 arteries and 4.2+/-1.3 lymphatics on the right with a significant correlation between the number of right and left internal spermatic arteries (r=0.42). For the cohort of secondary (redo) varicocelectomies, we identified 2.3+/-0.6 arteries and 4.8+/-1.6 lymphatic channels (not significantly different from the primary varicocelectomy cohorts). CONCLUSIONS: The number of arteries and lymphatics preserved at microsurgical varicocelectomy is highly variable, but there is some similarity in the microanatomy of the right and left spermatic cords at the level of the external inguinal ring. The data also suggest that the number of arteries and lymphatic channels identified at a redo varicocelectomy is comparable to that observed during a primary varicocelectomy.

Microsurgical varicocelectomy for infertile men with oligospermia: differential effect of bilateral and unilateral varicocele on pregnancy outcomes.

OBJECTIVES: To evaluate the pregnancy outcomes of two groups of oligospermic men with varicocele, one having a varicocelectomy (group 1) and the other electing not to have surgery (group 2), as varicocele represents the most common factor associated with male infertility and most reports indicate that varicocelectomy has a beneficial effect on male fertility and pregnancy outcome. PATIENTS AND METHODS: We retrospectively reviewed consecutive oligospermic men who had microsurgical varicocelectomy (233, group 1) between September 1996 and January 2002 and a consecutive group of oligospermic men with varicoceles who elected not to have surgery (127, group 2). The outcome measures included changes in semen variables, partner pregnancy rates (assisted and unassisted) and use of assisted reproductive technologies (ART). RESULTS: The mean sperm concentration and motility increased significantly after varicocelectomy (P < 0.05). The natural pregnancy rate in group 1 (38%) was higher than in group 2 (30%). The use of ART was significantly greater in group 2 than group 1. In the subset of couples with bilateral varicocele, the natural pregnancy rate was significantly higher in group 1 than group 2 (48% vs 15%, respectively, P = 0.008). CONCLUSIONS: This study suggests that the natural pregnancy rate is higher after varicocelectomy than in those not having surgery, although the difference was not statistically significant. However, in the subset of couples with bilateral varicocele, the spontaneous pregnancy rates were significantly higher after surgery.

Microsurgical varicocelectomy for isolated asthenospermia.

PURPOSE: Varicocele represents the most common cause of male infertility, and most reports indicate that varicocelectomy has a beneficial effect on male fertility and pregnancy outcome. We evaluated the clinical outcomes of infertile couples with varicocele and isolated asthenospermia who chose to undergo varicocelectomy as well as those who chose not to undergo the procedure. MATERIALS AND METHODS: We performed a retrospective review of 118 consecutive infertile couples in whom the man presented with clinical varicocele and isolated asthenospermia (less than 50% motile sperm). All couples were presented with possible treatment options (observation, varicocelectomy, assisted reproductive technologies). The clinical characteristics and outcomes of 2 subgroups of men--those who elected to undergo surgery (varicocelectomy, 69) and those who did not (49)--were examined and compared. RESULTS: Mean male and female patient age, duration of infertility and baseline total motile sperm count were not significantly different in the control and surgery groups. The mean total motile sperm count increased significantly after varicocelectomy (29.6 million preoperatively vs 39.0 million postoperatively, p <0.05). The spontaneous pregnancy rate was significantly higher in the surgery group compared to the control group (65% vs 32%, respectively, p <0.01). The combined spontaneous and intrauterine insemination pregnancy rate was also significantly higher in the surgery group compared to the control group (74% vs 36%, respectively, p <0.01). Use of in vitro fertilization/intracytoplasmic sperm injection was significantly higher in the control group compared to the surgery group (32% vs 11%, respectively, p <0.05). CONCLUSIONS: Our data support the practice of varicocelectomy for the treatment of clinical varicocele and isolated asthenospermia.

Natural history of varicocele management in the era of intracytoplasmic sperm injection.

OBJECTIVE: To evaluate the outcomes of infertile couples with varicocele. DESIGN: Retrospective study. SETTING: University infertility clinic. PATIENT(S): Six hundred ten consecutive infertile couples in whom the man was found to have a clinical varicocele. INTERVENTION(S): Microsurgical varicocelectomy and assisted reproductive technologies (ARTs; intrauterine insemination and intracytoplasmic sperm injection). MAIN OUTCOME MEASURE(S): Clinical characteristics, pregnancy rates, and ART utilization in two subgroups of couples (those who elected to undergo varicocelectomy and those who did not). RESULT(S): Sixty percent of the couples (363/610) opted for varicocele repair. The surgical and nonsurgical groups had comparable ages and duration of infertility. However, sperm concentration and motility were significantly lower in the surgical group, compared with in the observation one. As well, the surgical group had a significantly higher prevalence of primary infertility (80% vs. 71%) and had significantly smaller testicles bilaterally. Utilization of ART was significantly higher in the observation group compared with the surgical group (54% vs. 38%). Overall pregnancy rates (spontaneous + assisted pregnancies) in the observation and surgical group were not significantly different. CONCLUSION(S): This study suggests that men with poorer baseline characteristics are more likely to opt for varicocele repair. Furthermore, couples electing not to repair the varicocele are more likely to undergo ART procedures to improve their chances of conception.

Beneficial effect of microsurgical varicocelectomy is superior for men with bilateral versus unilateral repair.

PURPOSE: Varicocele represents the most common correctable cause of male infertility, and most reports indicate that varicocelectomy has a beneficial effect on male fertility and pregnancy outcome. Little is known about the differential effect of bilateral, compared to unilateral varicocelectomy, on male fertility potential. MATERIALS AND METHODS: A total of 369 consecutive varicocelectomies were performed for male factor infertility between July 1996 and July 2002. The outcomes measured include postoperative changes in semen parameters, pregnancy rates (assisted and unassisted) and use of assisted reproductive technology (intrauterine insemination and in vitro fertilization with intracytoplasmic sperm injection). RESULTS: There were 157 men who underwent bilateral and 212 who underwent unilateral left varicocelectomy. Both groups had comparable male and female ages, and baseline semen parameters. Semen parameters improved significantly after surgery in the bilateral and unilateral groups. Moreover, the improvement in percent motility was significantly greater in the bilateral compared to the unilateral group (8.0% +/- 1.7% compared to 4.4% +/- 1.5% improvement, respectively, p <0.01). In addition, the spontaneous pregnancy rate was significantly higher in the bilateral compared to the unilateral group (49% vs 36%, respectively, p <0.05). Assisted reproductive technology was comparable in the unilateral and bilateral groups (64% vs 51%, respectively, p >0.05). CONCLUSIONS: Our data indicate that bilateral varicocelectomy (for clinically palpable bilateral varicoceles) is associated with a significantly greater improvement in sperm quality (motility) and male fertility potential than unilateral varicocelectomy. The greater improvement in semen parameters and pregnancy outcome associated with bilateral varicocelectomy support the concept of a detrimental dose-effect of varicocele on male fertility potential.

The use of a suprascrotal or 'wink' incision for placing a testicular prosthesis.

OBJECTIVE: To describe a suprascrotal technique of testicular prosthesis insertion that obviates the difficulties and complications associated with either the inguinal or scrotal approach, as although the insertion of a testicular prosthesis is common there are few reports of the various techniques of insertion, associated complication rates, and patient satisfaction. PATIENTS AND METHODS: Eight males (aged 14-26 years) who had had a previous orchidectomy, had a testicular prosthesis inserted using a suprascrotal incision. A 2-cm semilunar incision is made just above the scrotum, 2-3 cm lateral to the penis ('wink' incision). The prosthesis is inserted after developing the intrascrotal space with blunt dissection. All patients tolerated the procedure well and all were outpatient procedures. RESULTS: After a median follow-up of 12 months, all patients were satisfied with the aesthetics of the prosthesis. Incisions were hidden by pubic hair. There were no wound infections at the incision site, and no reports of any pain or discomfort associated with the prosthesis. CONCLUSION: The 'wink' incision is an attractive alternative for inserting a testicular prosthesis; the advantages of the suprascrotal approach include: (i) the incision is hidden by pubic hair; (ii) no difficult dissection through fibrotic tissue in patients who have had previous inguinal surgery; and (iii) avoidance of direct contact between the prosthesis and suture line, minimizing the risk of infection, erosion and postoperative pain, while maintaining a pouch of adequate size.

Feasibility of microsurgical reconstruction of the male reproductive tract after percutaneous epididymal sperm aspiration (PESA).

For obstructive azoospermia, surgical sperm retrieval from the epididymis for IVF/ICSI is an established management. However, various recent studies have established that surgical reconstruction with vasovasostomy or vasoepididymostomy remains a more cost-effective treatment option than upfront assisted reproduction. After epididymal sperm retrieval, fibrosis and scarring of the punctured epididymal tubule can lead to complete epididymal obstruction. The feasibility of surgical reconstruction after surgical epididymal sperm retrieval has not been established. We describe two cases of bilateral microsurgical vasoepididymostomy, using a new 2-suture longitudinal intussusception technique we previously described, after previous successful bilateral percutaneous epididymal sperm aspiration (PESA). In both cases, motile sperm were found in ejaculate in the first post-operative semen analysis at 6 weeks and 2 months. We conclude that even in men with previous epididymal sperm retrieval, surgical reconstruction remains a feasible management option for fertility.