Usefulness of indocyanine green in the laparoscopic Palomo technique: a comparative study. / Utilidad del verde de indocianina en el procedimiento de Palomo laparoscópico: estudio comparativo.

OBJECTIVE: To find out whether the use of indocyanine green for lymphatic sparing in the laparoscopic Palomo technique reduces the incidence of postoperative hydrocele. MATERIALS AND METHODS: A comparative cohort study of varicocele patients treated with the laparoscopic Palomo technique from 2008 to 2023 was carried out. Patients were divided into two groups according to whether fluorescence lymphography (intratesticular indocyanine green) had been performed or not. Epidemiological, surgical, and clinical data, as well as complications, were recorded. A hypothesis test was conducted using the SPSS software. RESULTS: 30 patients undergoing varicocele surgery through the laparoscopic Palomo technique were included. They were divided into two groups -lymphatic sparing (n= 13) vs. spermatic vessel ligation without sparing (n= 17). Mean age at surgery was 14 years. 5 cases of postoperative hydrocele were identified in the no lymphatic sparing group. 1 of them required surgery for hydrocele treatment. No hydrocele cases were noted in the lymphography group. The difference was statistically significant (p= 0.032). There were no statistically significant differences in terms of operating times or mean hospital stay. No recurrences, postoperative testicular atrophies, or indocyanine-green-related complications were recorded. Mean follow-up was 11.4 months. CONCLUSIONS: The use of indocyanine green for lymphatic sparing in the treatment of varicocele through the laparoscopic Palomo technique significantly reduces the incidence of postoperative hydrocele.

OBJETIVOS: Comprobar si el uso del verde de indocianina para la preservación linfática en la técnica de Palomo laparoscópico reduce la incidencia de hidrocele postoperatorio. MATERIAL Y METODOS: Se realizó un estudio comparativo de cohortes históricas incluyendo los pacientes tratados de varicocele mediante Palomo laparoscópico entre 2008 y 2023. Se dividieron en 2 grupos en función de la realización de linfografía con fluorescencia (verde de indocianina intratesticular). Se recogieron datos epidemiológicos, quirúrgicos, clínicos y complicaciones. Se realizó un análisis de contraste de hipótesis utilizando el programa SPSS. RESULTADOS: Se incluyeron 30 pacientes intervenidos de varicocele mediante la técnica de Palomo laparoscópico divididos en 2 grupos: en 13 se realizó preservación linfática y en 17 ligadura de vasos espermáticos sin preservación. La edad media en el momento de la cirugía fue de 14 años. Se identificaron 5 casos de hidrocele postoperatorio en el grupo sin preservación linfática. Uno requirió intervención quirúrgica para el tratamiento del hidrocele. No se identificó ningún caso de hidrocele en el grupo de la linfografía. La diferencia resultó estadísticamente significativa, p= 0,032. No hubo diferencias estadísticamente significativas en el tiempo quirúrgico ni en la estancia media. No se objetivaron recidivas, atrofias testiculares postquirúrgicas ni complicaciones asociadas al uso del verde de indocianina. El tiempo medio de seguimiento fue 11,4 meses. CONCLUSIONES: El uso del verde de indocianina para la preservación linfática en el tratamiento del varicocele mediante Palomo laparoscópico reduce significativamente la incidencia de hidrocele postoperatorio.

[Construction of a predictive model for postoperative pain relief after microscopic spermatic cord surgery for spermatic cord pain].

OBJECTIVE: To explore the relevant factors affecting the efficacy of microscopic spermatic cord surgery and build a predictive model for postoperative pain relief. METHODS: A retrospective analysis was conducted on the clinical data of 324 patients with spermatic cord pain who visited the Department of Urology at Peking University People's Hospital between October 2015 and April 2023. This cohort included 212 patients with varicocele-related spermatic cord pain and 112 patients with idiopathic spermatic cord pain. All the patients underwent microsurgical procedures: varicocele-related pain was treated with microsurgical varicocelectomy, and idiopathic pain was treated with microsurgical denervation of the spermatic cord. The patients were categorized into effective and ineffective groups based on whether their pain had decreased by more than 50% six months post-surgery compared with pre-surgery levels. Baseline data were preliminarily screened for clinical indicators using t tests and univariate analysis. Clinical predictor variables [age, duration of pain, diameter of varicocele, patient health questionnaire-9 (PHQ-9) score, generalized anxiety disorder-7 (GAD-7) score] were selected using Lasso regression. A clinical prediction model for effective pain relief following microscopic spermatic cord surgery was constructed using Logistic regression and presented as a nomogram. The model's internal validation was performed using the bootstrap method. Its predictive power and clinical utility were evaluated through the concor-dance index, the area under the receiver operating characteristic curve, and calibration plots. RESULTS: Post-microscopic varicocele ligation, 156 patients (73.58%) experienced significant pain relief, as did 94 patients (83.93%) following microscopic denervation. Independent predictors for postoperative outcomes included age, PHQ-9 score, GAD-7 score, chronic pain duration, and varicocele diameter, differing slightly between varicocele-related and idiopathic pain groups. The models demonstrated excellent predictive ability, with areas under the curve of 0.909 and 0.913 for varicocele and idiopathic groups, respectively, and high concordance indices. CONCLUSION: The postoperative efficacy prediction model based on age, pain duration, PHQ-9 score, GAD-7 score, and varicocele diameter has good predictive ability and clinical applicability, and can be used in clinical practice.

Effects of Systolic Blood Pressure Elevation on Internal Sperm Artery Identification During Microsurgical Subinguinal Varicocelectomy.

Microsurgical subinguinal varicocelectomy (MSV) is the gold standard for treating varicoceles. Preservation of the internal spermatic arteries (ISAs) during MSV is important for sperm production. This study aimed to evaluate the safety and efficacy of elevating systolic blood pressure (SBP) using MSV. Data from 252 consecutive adult male patients were retrospectively reviewed. The patients were divided into two groups: a traditional group that underwent conventional MSV (n = 134) and a modified group that underwent MSV with a transiently elevated SBP of 140-160 mm Hg (n = 118). Arterial identification time, unilateral operative time, number of ISAs, arterial injury rate, and other postoperative indicators, including postoperative complications and sperm parameters, were compared between the groups. All the procedures were successful. The arterial identification and unilateral operative times were significantly shorter in the modified group (31.34 ± 10.44 vs. 42.94 ± 12.39 min and 61.48 ± 8.78 vs. 76.35 ± 12.33 min, p < .01, respectively). Intraoperatively, the number of preserved ISAs was significantly higher in the modified group (1.92 ± 0.53 vs. 1.45 ± 0.32, p < .01). The arterial injury rate did not differ significantly between the groups (2.74% vs. 0%, respectively). Compared with preoperative values, sperm parameters improved significantly 6 months postoperatively. Significant differences in semen parameters or postoperative complications were not observed between the groups. Elevated intraoperative SBP can be used to rapidly, safely, and effectively identify ISAs, increase the number of retained spermatic arteries, and markedly reduce the operative time for MSV.

Robotic-assisted versus conventional laparoscopic ICG-fluorescence lymphatic-sparing palomo varicocelectomy: a comparative retrospective study of techniques and outcomes.

PURPOSE: This study aimed to compare techniques and outcomes of robotic-assisted varicocelectomy (RAV) and laparoscopic varicocelectomy (LV). METHODS: The medical records of 40 patients, who received RAV and LV over a 2-year period, were retrospectively analyzed. Palomo lymphatic-sparing varicocelectomy using ICG fluorescence was adopted in all cases. Three 5-mm trocars were placed in LV, whereas four ports, three 8-mm and one 5-mm, were placed in RAV. The spermatic vessels were ligated using clips in LV and ligatures in RAV. The two groups were compared regarding patient baseline and operative outcomes. RESULTS: All patients, with median age of 14 years (range 11-17), had left grade 3 varicocele according to Dubin-Amelar. All were symptomatic and 33/40 (82.5%) presented left testicular hypotrophy. All procedures were completed without conversion. The average operative time was significantly shorter in LV [20 min (range 11-30)] than in RAV [34.5 min (range 30-46)] (p = 0.001). No significant differences regarding analgesic requirement and hospitalization were observed (p = 0.55). At long-term follow-up (30 months), no complications occurred in both groups. The cosmetic outcome was significantly better in LV than RAV at 6-month and 12-month evaluations (p = 0.001). The total cost was significantly lower in LV (1.587,07 €) compared to RAV (5.650,31 €) (p = 0.001). CONCLUSION: RAV can be safely and effectively performed in pediatric patients, with the same excellent outcomes as conventional laparoscopic procedure. Laparoscopy has the advantages of faster surgery, smaller instruments, better cosmesis and lower cost than robotics. To date, laparoscopy remains preferable to robotics to treat pediatric varicocele.

Comparing two vascular division techniques in laparoscopic varicocelectomy. A prospective study. / Comparación de dos técnicas de sección vascular en la varicocelectomía laparoscópica. Estudio prospectivo.

INTRODUCTION: Varicocele is the abnormal dilatation of the pampiniform plexus. It occurs in 15-20% of pre-adolescent/adult males. Varicocele diagnosis is important since it can induce testicular hypertrophy and fertility issues in adulthood. The objective of this study was to assess whether complications, including varicocele recurrence, depend on the vascular occlusion technique used -clipping + division vs. vascular sealer- in the laparoscopic Palomo technique used in our institution. MATERIALS AND METHODS: A longitudinal, prospective study was carried out from 2017 to 2021. Two therapeutic groups were created according to the vascular occlusion method used during laparoscopic varicocelectomy -clipping + division vs. vascular sealer. Patients were randomly allocated to the groups in a systematic alternating consecutive manner. Variables -age, varicocele grade according to the Dubin-Amelar classification, postoperative complications, follow-up, and varicocele recurrence- were analyzed according to the method employed. RESULTS: A total of 37 boys, with a mean age of 12 years (10-15 years) and a mean follow-up of 12 months, were studied. In 20 patients (54.1%), clipping + division was used, and in the remaining 17 (45.9%), the vascular sealer was employed. 24.3% had symptomatic Grade II varicocele and 75.7% had Grade III varicocele. 32.4% of the children had postoperative complications during follow-up. 29.7% of the patients had hydrocele following surgery -8 boys from the sealing group and 3 boys from the clipping group-, with 13.5% requiring re-intervention as a result of this. None of the patients had varicocele recurrence. CONCLUSIONS: The laparoscopic Palomo technique is safe and effective, with good results in pediatric patients and few postoperative complications, regardless of the vascular occlusion device used. In our study, no statistically significant differences regarding the use of clipping or vascular sealer in this laparoscopic technique were found. However, further studies with a larger sample size are required to find potential differences.

INTRODUCCION: El varicocele es la dilatación anormal del plexo pampiniforme. Puede afectar al 15-20% de los varones preadolescentes-adultos. La importancia de su diagnóstico radica en que puede inducir hipotrofia testicular y problemas de fertilidad en la etapa adulta. El objetivo de este estudio es evaluar si existe mayor índice de complicaciones, incluyendo la recurrencia del varicocele, dependiendo de la técnica de oclusión vascular utilizada: clip y sección o sellador vascular, en la técnica de Palomo laparoscópico en nuestro centro. MATERIAL Y METODOS: Estudio longitudinal prospectivo que se realiza de 2017 a 2021. Se crean dos grupos terapéuticos según el método de oclusión vascular utilizada durante la varicocelectomía laparoscópica: clip y sección o sellador vascular. Los pacientes son incluidos en un grupo mediante asignación sistemática consecutiva alternante. Se realiza el análisis de las variables: edad, grado de varicocele según la clasificación de Dubin-Amelar, complicaciones postquirúrgicas, seguimiento y recurrencia del varicocele, según el método empleado. RESULTADOS: Se intervinieron un total de 37 niños, con edad media de 12 años (10-15 años) y una media de seguimiento de 12 meses. En 20 pacientes (54,1%), se utilizó clip y sección, y en los 17 restantes (45,9%), sellador vascular. El 24,3% presentaba varicocele Grado II sintomático y el 75,7%, Grado III. El 32,4% de los niños presentó alguna complicación postquirúrgica durante el seguimiento. El 29,7% de los pacientes presentó hidrocele tras la intervención, perteneciendo 8 niños al grupo de sellado y 3 niños al de clipaje. El 13,5% de estos precisó reintervención por este motivo. Ningún paciente presentó recurrencia del varicocele. CONCLUSIONES: La técnica de Palomo laparoscópica es una técnica segura y efectiva que presenta buenos resultados en pacientes pediátricos, ya que presenta pocas complicaciones postquirúrgicas, independientemente del dispositivo de oclusión vascular que se utilice. En nuestro estudio, no se ha demostrado que existan diferencias estadísticamente significativas en cuanto al uso de clip o sellador vascular en esta técnica laparoscópica. No obstante, es preciso realizar más estudios con mayor tamaño muestral para hallar posibles diferencias.

Video-Assisted Telescope Operating Monitor 3D System in Microsurgical Varicocelectomy: A Preliminary Report.

INTRODUCTION: Video-assisted telescope operating monitor (VITOM®) with 3D Visualization technology was developed and has been used with favorable results by several surgical specialties. Our study aims to be a preliminary report for initial experience using the VITOM® 3D system for microsurgical varicocelectomy on varicocele patients. METHODS: We performed 35 microsurgical varicocelectomy procedures using the VITOM® 3D system on varying types and grades of varicoceles. The surgeon had the option of using either a 2.5 or 3.5 magnifying loupe in addition to the exoscope for each operation evaluated. The exoscope is a standalone camera head with an integrated 3D telescope and remote control with zoom and focus functions. It is connected to the 3D monitor via a mechanical holding arm. During the procedure, surgeons, assistants, and observers were able to view the 3D high-definition stream displayed on a 26-inch 3D monitor at a convenient viewing angle and distance. The varicocele ligation was performed using a Carl Zeiss Meditec AG microscope. RESULTS: There were 35 patients with varicocele aged 31.51 years old on average, which were included in this report. Most patients had grade 3 bilateral varicocele (n = 13, 37.1%). All procedures were performed without any intraoperative complications. After the procedures, only a few patients suffered from postoperative complications. Three patients suffered scrotal edema (8.6%), while another had hydrocele (2.9%). The postoperative pain results were also very minimal from .89 1 day after the operation to .26 3 days after the operation. CONCLUSION: The VITOM® 3D system showed promise in microsurgical varicocelectomy.

Microsurgical varicocelectomy efficacy in treatment of men with primary and secondary infertility (retrospective study).

INTRODUCTION AND OBJECTIVES: Varicocele is the most common treatable cause of male infertility. The study aimed to compare varicocelectomy efficacy in men with primary (PI) and secondary infertility (SI). PATIENTS AND METHODS: Medical records of 100 men suffering from PI and SI and having varicocelectomy at the Republican Specialized Scientific-Practical Medical Center of Urology were retrospectively selected and analyzed. Patients were divided into 2 groups. Group I included 58 men with PI and Group II 42 men with SI. Preoperative clinical characteristics and semen parameters before and after varicocelectomy were analyzed and compared between groups. RESULTS: Analysis revealed that the mean age of patients of group I was significantly lower (p<0.001) and the duration of infertility was accurately shorter (p<0.01) than those of group II. Main semen parameters increased significantly in group I (e.g., sperm concentration increased by 50%, from 62.2 ± 8.7 to 93.5 ± 10.0 M/ml, and total motile sperm count increased by 113%, from 76.7±17.1 to 163.4±27.8 M p<0.05), while in group II only rate of progressive motile sperm increased significantly (by 107%, from 13.5± .6 to 28.0±5.2% p<0.05). We identified a significant difference in varicocelectomy efficacy between group I and group II in change of total motile sperm count (by 113% vs 74% respectively, p<0.01). We also revealed a discrepancy between groups in correlation ratio (r) between initial and post-surgical percent of progressive motile sperm. CONCLUSIONS: Patients with SI were older and had longer infertility period. Varicocelectomy resulted in significant semen parameters improvement in patients with PI. In patients with SI, only a percent of progressively motile sperm improved significantly. It indicates that advanced male age and long infertility duration may have a negative impact on varicocelectomy success.

Significant reduction in left testicular volume shown by ultrasonography in infertile patients with left-side grade 2-3 varicocele as compared to less than grade 2: An evidence for indication of varicocelectomy.

PURPOSE: Testicular volume (TV) is known to be one of the main parameters for testicular function (TF). This study was conducted to re-evaluate the indications of a varicocelectomy based on a survey of preoperative TV results in left-side varicocele patients considered to reflect the detrimental effects of a varicocele on TF. METHODS: TV results of infertile patients determined using ultrasonography by a single expert physician were retrospectively evaluated. RESULTS: Of 590 examined patients, 424 had no varicocele findings (Group A), while 148 had a left-side varicocele (Group B). Group B was subdivided based on varicocele grade into Group B0 (subclinical), B1 (grade 1), B2 (grade 2), and B3 (grade 3). Comparisons of left-side TV showed no significant differences for grade among Group A, B0, and B1, whereas that for Group B2 and B3 was significantly lower as compared with Group A (p < 0.01, 0.02, respectively). The median TV of Group B I (composed of Groups B0 and B1) was 9.8 cm3, while that of Group B II (Groups B2 and B3) was significantly lower at 8.4 cm3 (p < 0.05). In contrast, a comparison of right TV values identified no significant differences among the groups (p = 0.918). CONCLUSION: A varicocelectomy should be performed for patients with a grade 2 and 3 varicocele for ameliorating testicular function.

The effect untreated right subclinical varicocele on the outcomes of contralateral left clinical varicocelectomy in infertile patients.

PURPOSE: The management of infertile patients with unilateral subclinical varicocele (SCV) and contralateral clinical varicocele (CV) remains controversial. We aimed to evaluate the effect of untreating SCV on the outcome of contralateral clinical varicocelectomy in infertile patients with oligoasthenozoospermia (OA). MATERIALS AND METHODS: Infertile patients with the diagnosis of OA who underwent left varicocelectomy were retrospectively evaluated. While all patients in the study had left clinical varicocele (LCV), some patients had concomitant right SCV. Patients were divided into two groups according to the presence or absence of a right SCV accompanying LCV as group 1; (LCV n = 104) or group 2; (LCV with right SCV, n = 74). Patients were evaluated with spermiogram parameters, pregnancy rates and serum levels of follicle stimulating hormone, luteinizing hormone, total testosterone at the first year of the follow-up. RESULTS: The mean sperm concentration increased significantly in both groups. However, group 1 showed significantly greater improvement than group 2. The ratio of progressive motile sperm in group 1 was increased significantly whereas no significant change was shown in group 2. Both the spontaneous pregnancy rate and the pregnancy rate with ART were statistically lower in the group of patients with right SCV. No statistically significant difference was detected in serum hormone levels in both groups after varicocelectomy operations. CONCLUSIONS: Untreated right SCV may have adverse impact on the outcomes of left clinical varicocelectomy. In this context, the right testis can be considered in terms of treatment in patients with right SCV accompanying left CV.

Clinical management of nonobstructive azoospermia: An update.

Approximately 1% of the general male population has azoospermia, and nonobstructive azoospermia accounts for the majority of cases. The causes vary widely, including chromosomal and genetic abnormalities, varicocele, drug-induced causes, and gonadotropin deficiency; however, the cause is often unknown. In azoospermia caused by hypogonadotropic hypogonadism, gonadotropin replacement therapy can be expected to produce sperm in the ejaculate. In some cases, upfront varicocelectomy for nonobstructive azoospermia with varicocele may result in the appearance of ejaculated spermatozoa; however, the appropriate indication should be selected. Each guideline recommends microdissection testicular sperm extraction for nonobstructive azoospermia in terms of successful sperm retrieval and avoidance of complications. Sperm retrieval rates generally ranged from 20% to 70% but vary depending on the causative disease. Various attempts have been made to predict sperm retrieval and improve sperm retrieval rates; however, the evidence is insufficient. Further evidence accumulation is needed for salvage treatment in cases of failed sperm retrieval. In Japan, there is inadequate provision on the right to know the origin of children born from artificial insemination of donated sperm and the rights of sperm donors, as well as information on unrelated family members, and the development of these systems is challenging. In the future, it is hoped that the pathogenesis of nonobstructive azoospermia with an unknown cause will be elucidated and that technology for omics technologies, human spermatogenesis using pluripotent cells, and organ culture methods will be developed.

Effects of smoking on varicocelectomy outcomes: a retrospective cohort study.

PURPOSE: To evaluate the effects of smoking on semen parameters and spontaneous pregnancy development by comparing smoker and non-smoker varicocelectomy patients. METHODS: This study included 63 male patients with primary infertility for at least one year, and underwent microscopic subinguinal varicocelectomy at the Erzurum City Hospital urology clinic between 2020 and 2023. Patient files were retrospectively evaluated, and 27 patients were assigned to smoker group, whereas 36 patients were assigned to non-smoker group. Demographic data, semen parameters, spontaneous pregnancy development and timing were compared between two groups. RESULTS: No statistically significant differences were observed in age, partner's age, BMI, clinical presentation, varicocele grade, side of varicocele, testicular volume, or testicular vein diameters (p > 0.05). The mean age of the study group was determined to be 30.7 ± 4.9 years. In the non-smoker group, 27 patients (75%) had only subfertility complaints, while 9 patients (25%) also experienced scrotal pain. Progressive motility was significantly higher in the non-smoker group at the 3rd month (28.11 ± 5.78 vs. 24.51 ± 4.24, p < 0.05) and 6th month (29.61 ± 5.16 vs. 26.22 ± 4.14, p < 0.05) evaluations. When comparing the rates of pregnancy development, the non-smoker group was determined to have a higher rate (53%), but this comparison was not statistically significant. (p < 0.05) Regarding the timing of pregnancy, the non-smoker group was associated with earlier spontaneous pregnancy. (5.84 ± 2.26 vs. 9.20 ± 2.30, p < 0.05). CONCLUSION: Smoking negatively affects the outcomes of varicocelectomy in terms of semen parameters, spontaneous pregnancy development and timing. Prospective, randomized, and larger sample-sized studies are required on this subject. TRIAL REGISTRATION: This study was approved by the Ataturk University Local Ethics Committee (approval number: B.30.2.ATA.0.01.00/234).

Assessing safety and efficacy of microscopic and laparoscopic varicocoelectomy for varicocoele treatment: A comparative cohort study.

BACKGROUND: Surgical is appropriate for 35-40% of varicocoele-induced infertility. This comparative observational study presents a comparative assessment of microscopic or laparoscopic varicocoelectomy (grade II varicocoele; n = 132 cases). METHODS: Sperm count, density, total motility, and forward motility rate (preoperative and postoperative 6 months), operation duration, pain at 1 month, testicular atrophy (by scrotal ultrasound at 3 months), recurrence (angiography at 6 months), and scrotal edema (at 12 months) were measured. RESULTS: The preoperative semen parameters were comparable between groups (P > 0.05), as were certain postoperative results (total sperm count [median 162 (range 100-242) compared with median 182 (range 84-253)]; sperm density [median 47 (range 38-83) compared with median 42 (range 27-88)]; forward motility (37.18 ± 4.14 compared with 34.13 ± 7.79); P > 0.05). However, sperm motility was higher in the microscope group (52.79 ± 8.21 compared with 46.64 ± 10.04; t = 2.304, P = 0.040). Within the microscope group, postoperative sperm density [median 47 (range 38-83)], total sperm motility (53.79 ± 8.25), and forward motility sperm rate (37.19 ± 4.14) demonstrated significant improvements compared with preoperative values (Z = -2.679, P = 0.005; t = -4.548, P < 0.001; t = -5.029, P < 0.001). In contrast, the postoperative forward motility sperm rate (34.13 ± 7.78) displayed substantial improvements compared with preoperative values (27.74 ± 14.42) within the laparoscopic group (t = -3.895, P = 0.001). Testicular atrophy occurred in neither group. CONCLUSIONS: Microscopic varicocoelectomy may be safer and more effective.

Inter-disciplinary provider development of an online, interactive adolescent varicocele decision aid prototype.

BACKGROUND: Decision-making regarding varicocele management can be a complex process for patients and families. However, to date, no studies have presented ways to mitigate the decisional conflict surrounding varicoceles. OBJECTIVE: To facilitate a discussion among physicians in order to develop a framework of the decision-making process regarding adolescent varicocele management, which will inform the development of the first online, interactive decision aid. MATERIALS AND METHODS: Semi-structured interviews with pediatric urologists and interventional radiologists were conducted to discuss their rationale for varicocele decision-making. Interviews were audio recorded, transcribed, and coded. Key themes were identified, grouped, and then qualitatively analyzed using thematic analysis. Utilizing the common themes identified and the Ottawa Decision Support Framework, a decision aid prototype was developed and transformed into a user-friendly website: varicoceledecisionaid.com. RESULTS: Pediatric urologists (n = 10) and interventional radiologists (n = 2) were interviewed. Key themes identified included: (1) definition/epidemiology; (2) observation as an appropriate management choice; (3) reasons to recommend repair; (4) types of repair; (5) reasons to recommend one repair over another; (6) shared decision-making; and (7) appropriate counseling. With this insight, a varicocele decision aid prototype was developed that engages patients and parents in the decision-making process. DISCUSSION AND CONCLUSIONS: This is the first interactive and easily accessible varicocele decision aid prototype developed by inter-disciplinary physicians for patients. This tool aids in decision-making surrounding varicocele surgery. It can be used before or after consultation to help families understand more about varicoceles and their repair, and why intervention may or may not be offered. It also considers a patient and family's personal values. Future studies will incorporate the patient and family perspective into the decision-making aid as well as implement and test the usability of this decision aid prototype in practice and in the wider urologic community.

[Varicocele and male infertility]. / Varicocèle et infertilité masculine.

BACKGROUND: Varicocele is the most common correctable cause of male infertility. It was the subject of recent Association française d'urologie (AFU) Comité d'andrologie et de médecine sexuelle (CAMS) recommendations. Since then, the literature has provided additional information. This review will comprehensively reassess current indications for the treatment of varicocele, and revisit contemporary issues in the light of current advances. METHODS: Update of the literature search carried out as part of the CAMS recommendations for the period between 2020 and 2023. RESULTS: Microsurgical sub-inguinal varicocelectomy remains the surgical treatment of choice for infertile men with clinical varicocele and abnormal sperm parameters. It offers recurrence rates of less than 4%. It significantly improves both natural and in vitro fertilization live birth and pregnancy rates, as well as sperm count, total and progressive motility, morphology and DNA fragmentation rates. All in all, it modifies the MPA strategy in around one in two cases. Varicocele grade and bilaterality are predictive of improved sperm parameters and pregnancy rate. Treatment of subclinical varicocele is not recommended. Complications are rare, notably hydroceles (0.5%), unilateral testicular atrophy due to arterial damage (1/1000), hematomas, delayed healing and postoperative pain. Retrograde embolization is an alternative to surgery. CONCLUSION: Whenever possible, the urologist should present and discuss treatment options for varicocele with the MPA team and the patient, taking a personalized approach.

Evaluation of Transforming Growth Factor Beta-1 in the vein wall of males with varicocele.

OBJECTIVE: This study aims to investigate potential differences in the presence of Transforming Growth Factor-Beta 1 (TGF-ß1) between the vein walls of patients with varicocele and those of healthy individuals. PATIENTS AND METHODS: The study comprised a total of 40 participants, divided into two groups. The control group (Group 1) consisted of 20 patients who underwent coronary bypass surgery, while the varicocele group (Group 2) included 20 patients scheduled for varicocelectomy. The cytoplasmic and nuclear staining patterns of TGF-ß1 immunohistochemistry were assessed in tissue samples under light microscopy, identifying any differences in TGF-ß1 presence between varicocele patient vein walls and normal (saphenous) veins. RESULTS: The varicocele group demonstrated lower nuclear and cytoplasmic TGF-ß1 staining rates compared to the control group. After controlling for the independent factor of age, significantly lower nuclear and cytoplasmic staining was still observed in the varicocele group. CONCLUSIONS: This study is the first of its kind to compare TGF-ß1 staining in the vein walls of varicocele patients and healthy individuals. Previous studies focusing on varicose veins reported elevated TGF-ß1 expression. Contrarily, our study observed lower TGF-ß1 expression in varicocele patient veins, marking a unique contribution to the field.

A systematic review and meta-analysis on the efficacy of internal spermatic artery ligation during laparoscopic varicocelectomy in children and adolescents: Is it safe?

INTRODUCTION: Challenges in identifying small testicular arteries and lack of microscopic experience have led to a rising trend in the use of laparoscopic technique for pediatric and adolescent varicocele. The controversy over artery ligation (AL) and artery preservation (AP) during laparoscopic varicocelectomy (LV) is still debatable. This study investigates the effectiveness of AL and AP during LV in pediatric and adolescent varicocele cases. METHODS: The systematic searches based on PRISMA guideline were conducted in PubMed, Scopus, ScienceDirect, Web of Science and ProQuest databases with pre-defined keywords. Both quantitative and qualitative analyses were performed to assess catch-up growth, persistence, recurrence, hydrocele, operative time, post-operative testicular volume, and sperm analysis. RESULTS: A total of 1512 patients from 9 eligible studies were included. There were no significant differences in catch up growth (OR 0.89; 95%CI 0.53, 1.51; p = 0.68) or hydrocele incidence (OR 0.59; 95%CI 0.28, 1.24; p = 0.16). The recurrence rate and persistence rate in AP group is significantly higher compared to AL group (OR 2.95; 95%CI 1.53, 5.68; p = 0.001 and OR 5.13; 95% CI 2.04, 12.88; p = 0.0005, respectively). The mean operative time during laparoscopic varicocelectomy is significantly longer when arteries are preserved as opposed to when they are ligated (OR 5.33; 95%CI 2.05, 8.60; p = 0.001). AL and AP both improved testicular volume and post-operative sperm analysis. CONCLUSIONS: AL showed higher efficacy and comparable safety to AP. We recommend using AL with lymphatic sparing to minimize hydrocele complications.

Bilaterality of varicocele: The overlooked culprit in male infertility. Case series study.

OBJECTIVES: Varicocele is the most common correctable cause of male infertility that always has been a debatable subject as regards how it affects fertility and the best way to treat it. Proper assessment of the disease bilaterality is crucial not to miss one side and not to jeopardize treatment outcome. This study aimed to objectively assess varicocele bilaterality in infertile men aiming to improve treatment outcome in this cohort of patients. METHODS: This prospective study was conducted between January 2019 and January 2022 including infertile males with varicoceles. Assessment of missed concomitant contralateral varicocele done pre-operatively by Color Doppler Ultrasound and intraoperatively by intraoperative Doppler device and measurement of maximal vein diameter of contralateral side. RESULTS: A total of 329 cases completed the study. A hundred cases (30.4%) were initially referred as unilateral varicoceles and 229 (69.6%) as bilateral varicoceles. After reassessment of the study population, bilaterality of varicocele was found to be as high as 98.5% (324/329). Repeat CDUS strongly correlated with the intraoperative measured varicocele diameter (r = 0.9, p < 0.001). Moreover, sperm parameters showed significant improvement 3 and 6 months post varicocelectomy. Normal pregnancy after 1 year of surgery occurred in 118 cases (35.9%). CONCLUSIONS: Varicocele bilaterality in infertile men is underreported. Thorough assessment by expert radiologists and andrologists is of paramount importance not to miss significant pathology or hazard treatment outcome.

The Influence of Number of Ligated Veins in Varicocele Patients Undergoing Microsurgical Varicocelectomy in Postoperative Pain and Sperm Parameters Outcome.

Background: The influence of the number of veins that should be ligated in varicocele surgery on postoperative pain and testicular function is not clearly understood. Objective: The aim of this study was to investigate the number of Internal Spermatic Vein (ISV) ligated in postoperative pain and sperm parameters outcome. Methods: Relevant studies were collected and systematically reviewed from Medline, Scopus, and Cochrane databases. This study followed the PRISMA guideline. The mean difference (MD), odds ratio (OR), and 95% confidence intervals (CIs) were measured in the assessment of the outcome. Revman 5.4 was used in data analysis. Results: The pooled meta-analysis demonstrated that complete pain resolution was significantly higher in patients undergoing varicocelectomy procedures with more than ten vein numbers ligated with OR 1.92, 95% CI (1.03, 3.60). Improvement of sperm parameters of change in sperm concentration was also significantly observed in patients with more than ten vein numbers ligated MD 32.79, 95% CI (23.13, 42.45). However, the number of veins ligated was not associated with the change in sperm motility MD 9.69 with 95% CI (-12.32, 31.71). Conclusion: The number of veins ligated intraoperatively determined pain relief and sperm concentration improvement. This study showed that varicocelectomy results improved with greater ISV ligation.

Increased intraoperative vein ligation in microsurgical varicocelectomy is associated with pain improvement.

Varicocele is a major cause of male infertility. However, few studies have discussed the potential associations between the pain caused by varicocele and preoperative and intraoperative factors. The aim of this study was to evaluate factors potentially associated with changes in pain score after microsurgical varicocelectomy. This retrospective study was conducted between August 2020 and August 2022 at China Medical University Hospital in Taichung, Taiwan. Patient characteristics including age, body mass index, semen analysis, testicular volume, and the number of veins ligated were collected. Preoperative and intraoperative factors were analyzed to determine if they were correlated with changes in numeric rating scale (NRS) after microsurgical varicocelectomy. A total of 44 patients with clinical varicocele underwent subinguinal microsurgical varicocelectomy and were analyzed. The overall pain resolution rate was 91%, and the average satisfaction score after surgery was 9.2 according to their subjective feelings. Multivariate analysis revealed that severe varicocele grade (odds ratio [OR] 16.5, 95% confidence interval [CI] 3.01-90.47; P = .018) and the number of veins ligated (OR 6, 95% CI 1.6-22.48; P = .013), were significantly associated with changes in NRS after surgery. In addition, the area under the receiver operating characteristic curve for changes in NRS and the total number of veins ligated was 0.869. Microsurgical varicocelectomy had a high success rate for scrotal pain and satisfaction. Severe varicocele grade and the number of veins ligated in microsurgical varicocelectomy were associated with postoperative pain improvement.

Effects of Varicocele Surgical Repair on Serum Hormone and Inhibin B Levels for Patients With Varicocele: A Systematic Review and Meta-Analysis.

Varicocele surgical repair can improve the function of the testis for patients with varicocele. We carried out a systematic review and meta-analysis to assess the effects of varicocele surgical repair on serum hormones and inhibin B levels in patients with varicocele. A literature search was performed in August 2022, and no language or geographic region restrictions were applied. The search included the following databases: PubMed, Embase, and Medline. A literature review was performed to identify all published clinical trials assessing serum hormone and inhibin B levels before and after varicocele surgical repair. The reference lists of retrieved studies were also investigated. A systematic review and meta-analysis were conducted. Eight articles were selected from 162 articles, including 452 patients. The combined analysis showed that after surgical treatment, mean serum testosterone, inhibin B, and sperm concentration levels increased compared with preoperative levels (p < .05). After surgical treatment, mean serum follicle-stimulating hormon (FSH), and Luteinizing hormone (LH) levels decreased compared with preoperative levels (p < .05). This meta-analysis demonstrates that varicocele surgical repair can improve testicular function, increase serum testosterone, and inhibin B levels and decrease serum FSH and LH levels in patients with varicocele. This might be related to the improvement of infertility. A large-scale multicenter randomized controlled study is needed for further confirmation.