The learning curve of bilateral laparoscopic varicocelectomy: a prospective study.

Varicocele occurs in 15% of general male population and in 35% of infertile men. Since 1992, surgical correction with laparoscopic varicocelectomy is the gold standard for treatment of symptomatic patients or patients with abnormal seminal analysis. The learning curve for this frequently performed procedure has not yet been described. In the present study, we investigated the learning curve of a single urologist in training performing his first 21 laparoscopic varicocelectomies using qualitative and quantitative tools to evaluate his performance during the process. Our results show that 14 bilateral laparoscopic varicocelectomies are enough to achieve the plateau of the learning curve.

[Ultra-remote robot-assisted laparoscopic surgery for varicocele through 5G network: Report of two cases and review of the literature].

OBJECTIVE: At present, the longest network transmission distance (NTD) for 5G remote endoscopic surgery is reportedly only about 229 km, and the NTD longer than 5 000 km has not yet been reported in clinical application. In this study, we attempted the clinical application of 5G ultra-remote robot-assisted laparoscopic surgery in spermatic vein ligation. METHODS: This retrospective study included two cases of 5G ultra-remote robot-assisted laparoscopic spermatic vein ligation using the home-made Tumai Surgical Robot System. The operation table was located in Xinjiang Kezhou People's Hospital, with an NTD of about 5 800 km (a linear distance of about 3 800 km) from the surgeon's console in the Telemedical Center of the First Affiliated Hospital of Nanjing Medical University, the apparatuses connected through the public 5G network. We observed the network connection delay, network fluctuation, and data packet loss rate of the devices at both ends of the loop through the feedback value of the Ping command by real-time monitoring. RESULTS: The total operation time of the two cases was 45 and 40 minutes respectively, with a mean blood loss of < 5 ml. The patients resumed a liquid diet and out-of-bed activity on the first day, the abdominal drainage tubes removed on the second, and both discharged from the hospital on the third day. The intraoperative average two-way network delay was 130 ms, and the average continuous data packet loss rate was 1.4%. No adverse network events, such as network interruption, occurred during the operation. CONCLUSION: Through the public 5G network and home-made Tumai Surgical Robot System, ultra-remote robot-assisted laparoscopic surgery was performed safely and successfully.

Effect of somatometric parameters on the prevalence and severity of varicocele: a systematic review and meta-analysis.

BACKGROUND: Published studies have shown contradictory results regarding the relationship between somatometric parameters and varicoceles. We performed a systematic review and meta-analysis to investigate the possible effects of age, height, weight, and body mass index (BMI) on the presence and severity of varicoceles. METHODS: Databases including EMBASE, MEDLINE, PubMed, Cochrane Library, China National Knowledge Infrastructure (CNKI), Web of Science, and Google Scholar were systematically searched to identify relevant articles published up to March 2020. Two researchers independently identified eligible articles and extracted data. Cochran's Q statistic and I2 statistics were used to assess heterogeneity. Meta-analysis was performed using StataSE 12.0 software (StataCorp LP, USA). Random-effects models were used to obtain the weighted mean differences (WMDs) and 95% confidence intervals (CIs). Publication bias was assessed using Begg's funnel plot and Egger's regression test. RESULTS: The search strategy produced 272 articles, of which 18 articles were eligible according to the inclusion/exclusion criteria. A total of 56,325 patients with varicocele and 1,334,694 patients without varicocele were included in the meta-analysis to evaluate the effect of somatometric parameters on the presence and severity of varicocele. The overall results demonstrated that the presence of varicoceles was significantly associated with height (WMD = 1.41, 95% CI = 1.07 to 1.74, P < 0.001) and inversely correlated with BMI (WMD = - 1.35, 95% CI = -1.67 to - 1.03, P < 0.001) but not with age (WMD = -0.93, 95% CI = -2.19 to 0.33, P = 0.149) or weight (WMD = 0.24, 95% CI = -2.24 to 2.72, P = 0.850). The severity of varicocele was inversely correlated with increased BMI but not with age. CONCLUSION: The presence of varicoceles was significantly associated with height and inversely correlated with BMI.

Functionally Silent, Giant Pheochromocytoma Presenting With Varicocele.

Adrenal incidentalomas are a known entity that have been increasing in commonality with the advent of improved diagnostic and imaging techniques. There are a vast variety of causative pathologies to which this diagnosis can be attributed. Some of these pathologies are more common than others, while many remain extremely rare. One of the distinct entities that is a unique cause of incidentalomas is the diagnosis presented herein: pheochromocytoma. Pheochromocytomas are often an exceptional subset of incidentalomas that can certainly play a major role in treatment and management plans. However, the exclusivity of a pheochromocytoma diagnosis alone is not where the uniqueness of this case rests. The uniqueness in this patient is paramount to report due to 2 additional significant factors. The first was that the patient was entirely asymptomatic aside from complaints related to scrotal swelling due to a varicocele, for which this presentation of pheochromocytoma has been scarcely reported in the literature. Second, the patient had a pathology proven diagnosis of pheochromocytoma, while lacking both symptoms and biochemical findings to support the diagnosis, making it truly a silent pheochromocytoma.

Gui-A-Gra Attenuates Testicular Dysfunction in Varicocele-Induced Rats via Oxidative Stress, ER Stress and Mitochondrial Apoptosis Pathway.

Gui-A-Gra, a commercial insect powder from Gryllus bimaculatus, is registered as an edible insect by the Korean food and drug administration. The aim of this study was to investigate the effect of Gui-A-Gra on testicular damage induced by experimental left varicocele in male Sprague Dawley rats. A total of 72 rats were randomly divided into the following six groups (12 rats in each group): a normal control group (CTR), a group administrated with Gui-A-Gra 1.63 gm/kg (G1.63), a group administrated with Gui-A-Gra 6.5 gm/kg (G6.5), a varicocele (VC)-induced control group (VC), a VC-induced group administrated with Gui-A-Gra 1.63 gm/kg (VC + G1.63), and a VC-induced group administrated with Gui-A-Gra 6.5 gm/kg (VC + G6.5). Rats were administrated 1.63 or 6.5 gm/kg Gui-A-Gra once daily for 42 days. Indicators of sperm parameters, histopathology, reproductive hormones, oxidative stress, endoplasmic reticulum (ER) stress, inflammation, and mitochondrial apoptosis were analyzed to evaluate effects of Gui-A-Gra on VC-induced testicular dysfunction. Gui-A-Gra administration to VC-induced rats significantly (p < 0.05) increased sperm count and sperm motility, Johnsen score, spermatogenic cell density, serum testosterone, testicular superoxide dismutase (SOD), glutathione peroxidase (GPx), catalase, GPx4, and steroidogenic acute regulatory protein (StAR) level. Moreover, pretreatment with Gui-A-Gra significantly (p < 0.05) decreased terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) positive cells/tubules, serum luteinizing hormone (LH), serum follicle-stimulating hormone (FSH), testicular tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), malondialdehyde (MDA), reactive oxygen species (ROS)/reactive nitrogen species (RNS) level, glucose-regulated protein-78 (Grp-78), phosphorylated c-Jun-N-terminal kinase (p-JNK), phosphorylated inositol-requiring transmembrane kinase/endoribonuclease 1α (p-IRE1α), cleaved caspase-3, and BCL2 associated X protein: B-cell lymphoma 2 (Bax: Bcl2) ratio in VC rats. These results suggest that protective effects of Gui-A-Gra on VC-induced testicular injury might be due to its antioxidant, anti-inflammatory, and androgenic activities that might be mediated via crosstalk of oxidative stress, ER stress, and mitochondrial apoptosis pathway.

Hypertension and Unilateral Varicoceles in a Young Male: Harbinger of a Sinister Finding.

A 26-year-old young male presented with recent onset hypertension and left-sided varicocele. On physical examination, his blood pressure was elevated and varicoceles were visible. On evaluation with computed tomography of abdomen, a large left-sided para-aortic mass was seen. His 24-hour urinary metanephrines and normetanephrines levels were within normal limits. Subsequently, the mass was excised. Tumor was excised completely after carefully dissecting it from left kidney and final histopathology revealed paraganglioma and postoperatively varicoceles disappeared.

Nutcracker Syndrome-A Rare but Important Cause of Varicocele in Adolescent Boys.

Nutcracker syndrome is a complex of clinical symptoms due to compression of the left renal vein between abdominal aorta and superior mesenteric artery. Hematuria and pelvic or back pain are the most common presenting symptoms with varicocele being an uncommon clinical finding in these patients especially in children. Doppler ultrasound, computed tomography and selective left renal vein phlebography are useful to confirm the diagnosis. Treatment can be conservative or surgical depending on the severity of symptoms. Here, we report a 13-year-old boy with left flank pain and varicocele on examination who on evaluation was found to have nutcracker syndrome as the etiology.

Localized solitary left renal vein thrombus complicating nutcracker syndrome: a case report and review of the literature.

Nutcracker syndrome (NCS) refers to compression of the left renal vein (LRV) between the abdominal aorta and the superior mesenteric artery (SMA). The clinical presentation of NCS includes hematuria, abdominal and left flank pain, gonadal varices, and varicocele formation. Theoretically, thrombosis can occur in the LRV in patients with NCS. However, an isolated solitary left renal vein thrombus (LRVT) complicating NCS is rare. In addition, the clinical features of an LRVT complicating NCS remain unclear. We describe a 43-year-old woman presenting with an asymptomatic LRVT complicating NCS. She was referred to our hospital for investigation of dysfunctional uterine bleeding, and detailed examination revealed endometrial cancer. Computed tomography angiography (CTA) and Doppler ultrasonography revealed compression of the LRV between the aorta and the SMA, as well as an LRVT. CTA performed 4 months after the administration of an anticoagulant showed complete disappearance of the LRVT. We have also included a review of published reports describing LRVT complicating NCS and discussed the clinical features of such a presentation.

Sertoli Cell Alterations in Peripubertal Varicocelized Rats: Evidence of Primary Damage on Spermatogenesis.

Idiopathic varicocele is closely associated with male infertility or subfertility. Sertoli cell is a very important regulator of spermatogenesis. We investigated the morphofunctional alterations in the Sertoli cell and its possible involvement in the establishment of testicular primary lesion in experimental left-sided varicocele, induced from peripuberty. Twenty-five male peripubertal rats (44 days postpartum [dpp]) were distributed into two groups: control (C) and varicocele (V). Experimental left varicocele was induced in rats through the partial ligature of the left renal vein. Euthanasia was performed at 100 dpp. Testicular histopathology and testosterone plasmatic level were evaluated. Transferrin and vimentin proteins were, respectively, used as immunomarkers of Sertoli cell function and structure. Significant reductions in vimentin and transferrin expressions were noticed in androgen-dependent stages (VII and VIII) of the seminiferous epithelium cycle in V rats; testosterone plasmatic level was also reduced. Bilateral testicular histopathological alterations were found in V rats, mainly massive germ cell desquamation. The histological damage and changes in protein expressions occurred bilaterally. The relevant impairment of the functional and structural characteristics of the Sertoli cell, together with the typical massive germ cell desquamation, indicates that Sertoli cell changes can primarily contribute to the significant testicular dysfunction associated with varicocele.

Fragmentación del ADN espermático en parejas tratadas por fertilización in vitro / Sperm DNA fragmentation in couplestreated by in vitro fertilization

RESUMEN Introducción: Se estudian los factores que afectan el ADN espermático en la actualidad y en qué medida influyen en la aplicación de las técnicas de reproducción asistida de alta tecnología. La fertilización in vitro es un tema de interés que ha motivado a muchos investigadores. Objetivo: Determinar la relación que existe entre el índice de fragmentación del ADN de la cromatina espermática y los resultados de la técnica de fertilización in vitro en parejas infértiles. Métodos: Se realizó un estudio descriptivo transversal en 107 parejas infértiles remitidas del Programa Nacional de Atención a la pareja infértil, donde se precisó la asociación entre el potencial fertilizante y las variables de resultados: tasa de fertilización, calidad embrionaria y embarazo. Se estudiaron, además, algunos factores que pueden influir en el grado de fragmentación del ADN. Resultados: El potencial fertilizante no se relacionó con la tasa de fertilización, ni con el embarazo clínico, pero sí con la calidad embrionaria (P= 0.036). La edad paterna resultó ser estadísticamente significativa en relación con el potencial fertilizante (P= 0.032). La presencia de varicocele se asoció con el bajo potencial fertilizante (OR= 5,27; IC 95 por ciento [1.34 - 24.09]). Conclusiones: El índice de fragmentación del ADN de la cromatina espermática afecta negativamente la calidad de los embriones a transferir. La edad y el varicocele se relacionan positivamente con el grado de fragmentación del ADN espermático. El consumo de alcohol, el hábito de fumar y la exposición a agentes físicos y químicos no se relacionaron con el índice de fragmentación del ADN espermático en este estudio(AU)

ABSTRACT Introduction: The factors that affect the spermatic DNA are being studied at present and in what extent they affect the implementation of high technology assisted reproduction techniques. In vitro fertilization is a topic of interest that has motivated many researchers. Objective: To determine the relationship between the rate of DNA fragmentation of sperm chromatin and the results of in vitro fertilization technique in infertile couples. Methods: A descriptive cross-sectional study was conducted in 107 infertile couples referred to the National Program of Attention to the Infertile Couple, where it was specified the association between the potential fertilizer and outcome variables: rate of fertilization, embryo quality and pregnancy. In addition, there were studied some factors that may influence the degree of DNA fragmentation. Results: The fertilizing potential was not related to the rate of fertilization, or with the clinical pregnancy, but it did with the embryo quality (p= 0.036). The paternal age proved to be statistically significant in relation to the fertilizing potential (p= 0.032). The presence of varicocele was associated with the low fertilizing potential (OR = 5.27; CI 95 percent [1.34 - 24.09]). Conclusions: The rate of DNA fragmentation of sperm chromatin negatively affects the quality of the embryos to be transferred. The age and varicocele are positively related with the degree of sperm DNA fragmentation. The consumption of alcohol, the smoking habit and the exposure to chemical and physical agents were not associated with the rate of sperm DNA fragmentation in this study(AU)

The association between high-grade varicocele and endothelial dysfunction.

Varicocele is determined as dilatation of veins in the pampiniform plexus of the spermatic cord. Although various factors have been implicated in the pathophysiology of varicocele, the underlying aetiological cause is not fully understood. Endothelial dysfunction is a precursor of vascular pathologies that may develop gradually and a substantial inducer in atherosclerosis aetiology. Brachial artery flow-mediated dilatation (FMD) measurement with sensitive brachial artery ultrasonography for assessing endothelial function is the most common noninvasive method. Similarly, carotid intima-media thickness (CIMT), measured using noninvasive ultrasonographic methods, is a tool for evaluating subclinical atherosclerosis and gives information on early changes in the vessel wall structure. Totally, 128 patients met the criteria were evaluated in this study. FMD was significantly lower in the varicocele group compared with the control group (9.16 ± 3.34 vs.7.96 ± 1.88, p = .013). CIMT measurements were similar between the groups (p = .091). Multivariate logistic regression revealed that FMD was independently associated with varicocele [odds ratio (OR): 0.814; 95% confidence interval (CI): 0.697-0.950; p = .009]. We suggest that endothelial dysfunction may have a role in the varicocele. Therefore, we recommend that every patient with symptomatic varicocele should be evaluated and followed up regularly for cardiovascular pathologies.

Is inguinal hernia a risk factor for varicocele in the young male population? / ¿Es la hernia inguinal un factor de riesgo para varicocele en el varón joven?

Objectives: The aim of this study is to investigate the role of the inguinal hernia over the development of varicocele, in cases with accompanying inguinal hernia. Methods: The continuous variables were calculated from mean and standard deviation, and intermittent variables were calculated over percentage and frequency. Normality testing was performed on continuous variables using the Kolmogorov-Smirnov test. Univariate analyses were performed using the unpaired Mann-Whitney U test and Chi-squared test was used for proportions. Kendall's tau-b correlation coefficient was used for correlition coefficient. Logistic regression modeling were used to identify the impact of inguinal hernias on selected cases. The data were analyzed with SPSS(TM) for Windows 22 (SPSS,Chicago, IL). Results: Twelve cases (23.1%) in the inguinal hernia group also had varicocele, which was relatively high, whereas 12 cases with inguinal hernia in the varicocele group corresponded to only were 4.02% (12/52 (23.1%) vs 12/298 (4.02%) ). On the other hand, as a result of the binary logistic regression, we found statistically significant difference in the probability of being diagnosed varicocele among the patients with inguinal hernia as 1.94 times. Conclusions: We think that in addition to the direct compression of some of the inguinal hernias on testicular veins, the potential for a combination of common enzymatic and biochemical disorders in some of the cases involving these two disorders may be play role

Objetivos: La finalidad de este estudio es investigar el rol de la hernia inguinal respecto al desarrollo de varicocele, en casos con acompañamiento de hernia inguinal. MÉTODOS: Las variables continuas fueron calculadas a partir de media y desviación standard, y las variables discontinuas se calcularon con porcentaje y frecuencia. Se desarrollaron pruebas de normalidad para variables continuas utilizando el test de Kolmogorov-Smirnov. Se realizó análisis univariante usando el test U de Mann-Whitney sin emparejamiento y para proporciones y utilizó el test de Chi cuadrado. Se aplicó el coeficiente de correlación tau-b de Kendall para los coeficientes de correlación. Se usaron modelos de regresión logística para identificar el impacto de la hernia inguinal en casos seleccionados. La información fue analizada con SPSS™ 22 para Windows (SPSS, Chicago, IL). RESULTADOS: Doce casos (23,1%) en el grupo de hernia inguinal tenían también varicocele, incidencia relativamente alta, mientras que solo había 12 casos con hernia inguinal en el grupo de varicocele, que correspondían a un 4,02 % [12/52 (23,1%) vs 12/298 (4,02%)]. Por otro lado, como resultado de la regresión logística binaria, descubrimos una diferencia estadísticamente significativa en la probabilidad de ser diagnosticado varicocele en los pacientes con hernia inguinal (1,94 veces). CONCLUSIONES: Pensamos que además de la compresión directa de algunas de las hernias inguinales de las venas testiculares, el potencial para una combinación de alteraciones comunes enzimáticas y bioquímicas en algunos de los casos, implicando estas dos anomalías, podría desempeñar un papel importante/clave

Hernia inguinal de contenido vesical: hallazgo cistoscópico / Inguinal bladder hernia: Cystoscopy finding

No disponible

Ultrasound-assisted microsurgical left spermatic-inferior epigastric vein anastomosis for treating nutcracker syndrome-associated varicocele.

OBJECTIVES: The study summarizes the effectiveness of ultrasound-assisted microsurgical left spermatic-inferior epigastric vein anastomosis for treating nutcracker syndrome (NCS)-associated varicocele. METHODS: Cases of NCS-associated varicocele were recruited between December 2012 and December 2018. Prior to the operation, all patients were tested for the internal diameter and blood flow velocity of left renal vein, testicular volume, maximum venous diameter and venous retrograde flow in the pampiniform plexus of veins during the Valsalva maneuver by Color Doppler ultrasound. Moreover, the direction of left spermatic and inferior epigastric vein was marked. RESULTS: All patients underwent ligation of the internal spermatic veins and left spermatic-inferior epigastric vein anastomosis under microscopy. Color Doppler ultrasound, urinary and semen analysis (above age 18 years old) were reviewed during the follow-up period. 53 patients (94.6%) underwent spermatic-inferior epigastric vein anastomosis with the mean operation time of 78.4 ± 14.2 min. The hospital stay was 4-7 days. Scrotal hydrocele, wound infection and testicular atrophy did not occur after operation. However, there were 5 cases of left varicocele recurrence and 2 cases of vascular anastomotic thrombosis. 51 cases had decrease in blood peak flow rate of left renal vein and improvement in nutcracker syndrome while scrotal bulge symptoms resolved in 26 cases. 10 cases had microscopic hematuria disappearance with symptom improvement in 2 cases. 19 cases of left testicular hypotrophy experience no further deterioration after surgery, of which 16 cases had catch-up testicular growth. CONCLUSION: Ultrasound-assisted microsurgical left spermatic-inferior epigastric vein anastomosis assisted is safe, easy and effective for treating nutcracker syndrome-associated varicocele.

Five veins at the deep inguinal ring: can they reduce the chances of indirect inguinal hernia and increase the chances of varicocele? / Cinco venas en el anillo inguinal profundo. ¿pueden reducir las probabilidades de una hernia inguinal indirecta y aumentar las posibilidades de varicocele?

Complete duplication of testicular veins is a rare phenomenon. However, a few cases of duplication of gonadal veins have been reported. Here, I report a case of unusual formation and termination of the right testicular vein in an adult male cadaver. Five veins arose from the pampinniform plexus and entered the abdomen through the deep inguinal ring. The most medial among the five was large (3 mm in diameter) and it continued as a testicular vein and opened into the right edge of the inferior vena cava, 1 cm above the union of the common iliac veins. The other four veins were about 1 mm in diameter and they united to form two veins in front of the lower part of the right psoas and iliacus muscles (about 2 cm above the deep inguinal ring) and the two veins united to form upper testicular vein, 4 cm above the deep inguinal ring. This testicular vein was 3 mm in diameter and it opened into the inferior vena cava, 4 cm above the union of common iliac veins. Having five veins at deep inguinal ring might increase the chances of varicocele and decrease the chances of indirect inguinal hernia.

La duplicación completa de las venas testiculares es un fenómeno raro. Sin embargo, se han reportado algunos casos de duplicación de venas gonadales. En el presente trabajo se informa un caso de formación y terminación inusual de la vena testicular derecha en un cadáver de un hombre adulto. Cinco venas surgieron del plexo pampiniforme y penetraron en el abdomen a través del anillo inguinal profundo. El más medial entre los cinco fue de gran tamaño (3 mm de diámetro) y continuó como una vena testicular y se abrió hacia el margen derecho de la vena cava inferior, 1 cm por encima de la unión de las venas ilíacas comunes. Las cuatro venas restantes eran de 1 mm de diámetro aproximadamente, y se unieron para formar dos venas frente a la parte inferior de los músculos psoas e ilíaco derechos (aproximadamente 2 cm por encima del anillo inguinal profundo). Se unieron dos venas para formar la vena testicular superior, la cual medía 3 mm de diámetro y se abría hacia la vena cava inferior, 4 cm por encima de la unión de las venas ilíacas comunes. Cinco venas en el anillo inguinal profundo podrían aumentar las posibilidades de varicocele y disminuir las posibilidades de una hernia inguinal indirecta.