Varicocele is an abnormal dilatation of the veins of the pampiniform plexus.

It occurs in 6% of children at age 10, 13% of adolescents, 15 percent of males in the general population. However, varicocele has been observed in 35 percent of men with primary infertility and up to 80 percent of men with secondary infertility. Although many men with varicocele can father children, varicocele causes a progressive time-dependent decline in semen quality. It is more common on the left side. The primary factor in testicular dysfunction secondary to varicocele suggested being abnormal retrograde blood flow within the gonadal veins. The etiology of varicocele is unclear and the most common theories include: 1. Anatomic differences in left and right internal spermatic vein. 2. Incompetent or absent valves in the spermatic vessels with blood backflow. 3. Compression of left renal vein between aorta and superior mesenteric artery with high pressure transmitted to the left internal spermatic vein (so called nutcracker phenomenon) The exact mechanism of impaired testicular function in patients with varicocele is not known. The most widely accepted concept presently is a varicocele-related increase of testicular temperature. It has been established that normally the difference between the intraabdominal and scrotal temperature averages 2.20C. Varicocele can cause an increase in scrotal temperature by 2.60C, neutralizing the required temperature gradient. The varicocele-associated pathology mainly includes changes in testicular size, histology, function of Leydig cells, sperm characteristics and testicular steroidogenesis. The WHO study reported that varicocele (most of which were on the left side) was associated with relative left testicular atrophy compared to the contralateral testis. In contrast, right and left testicular size was not significantly different in men without varicocele. Decrease of testicular volume was associated with increasing varicocele grade. Varicocele is a clinical diagnosis established by physical exam performed in the warm room. 78% of varicocele are left-sided, 1-2% are right- sided and up to 20% are bilateral. Unilateral right varicocele is rare and should alert the physician of possible association with right renal mass. Varicocele may be graded in severity as follows: Grade I: present only with Valsalva Grade II: present without Valsalva

Grade III: visible through the skin ("bag of worms") Laparoscopic varicocelectomy has been proposed as an alternative surgical procedure with reported benefits of better convalescence, minimal invasiveness, less analgesic requirement postoperatively. Recent studies revealed no advantage of laparoscopic varicocelectomy (with significantly longer operating time and need of naso-gastric suction and Foley catheter) compared with subinguinal approach operating time. Laparoscopic varicocelectomy has been recommended in the context of concurrent laparoscopic procedure, such as hernia repair. Open surgical correction of the varicocele traditionally include inguinal (Ivanissevich), subinguinal and retroperitoneal (Palomo) procedures. Retroperitoneal The retroperitoneal approach involves incision at the level of the internal inguinal ring, splitting of the external and internal oblique muscles, and exposure of the internal spermatic artery and vein retroperitoneally near the ureter. The approach has the advantage of isolating the internal spermatic vein proximally, at a level where only one or two large veins are present. In addition, the testicular artery has not yet branched at this level, and is distinctly separate from the internal spermatic veins. The major disadvantage of the retroperitoneal approach is the high incidence of varicocele recurrence secondary to the presence of parallel inguinal and retroperitoneal collateral vessels that may bypass area of ligation and rejoin the internal spermatic vein proximal to the site of ligation. It may be difficult to identified and, therefore, preserve the testicular artery and lymphatics because the they cannot be delivered into the wound at this level

The advantages of inguinal (and subinguinal) approach are that it enables the surgeon to easily identify the spermatic cord structures, and if necessary, access the testis, epididymis, and the external spermatic and gubernacular veins. Use of magnification is strongly recommended (preferably, an operating microscope) Inguinal approach Inguinal approach is the modification of the technique described by Ivanissevich and Gregorini in 1918. The inguinal approach involves a 5 to 10 cm incision over the inguinal canal, opening of the external oblique

aponeurosis, delivery of the spermatic cord and ligation of all dilated internal spermatic veins. The vas deferens and vasal vessels are preserved. An attempt is made to preserve the testicular artery and, as many lymphatic channels as possible. In addition, the cord is elevated and any external spermatic veins that are running parallel to the spermatic cord or perforating the floor of the inguinal canal are identified and ligated. Inguinal approach lowers the incidence of varicocele recurrence but do not alter the incidence of hydrocele formation (4 - 15% with an average incidence of 7%). or testicular artery injury. The incidence of testicular artery injury after inguinal varicocelectomy is unknown but may be more than is generally realized . Subinguinal approach The major advantage of this approach is more direct approach to the spermatic cord, external spermatic veins. The small incision (corresponding to the length of the testis) is more comfortable for the patient with less postoperative pain since there is no incision of aponeurosis. The delivery of the testis is recommended to isolate and divide gubernacular veins and external spermatic perforators. Gubernacular veins have been demonstrated radiographically to be the cause of up to 10% of varicocele recurrences. After testis is returned to the scrotum, spermatic cord is elevated on the Penrose drain and ligation and division of dilated internal spermatic veins is performed under the operating microscope with 8-15 power magnification. Subtle pulsation will usually reveal the location of the testicular artery. One percent papaverine solution irrigation may help to identify the artery by potentiate the pulsation. The artery is dissected free of all surrounding veins and encircled with a 0-silk ligature for identification. Unidentified periarterial vein may be the important source of recurrence. The vas deferens is inspected for any abnormally dilated veins. Veins measuring 3 mm or greater should be divided as these can also lead to postoperative recurrences. Two sets of vessels usually accompany the vas deferens in the spermatic cord and at least one of these sets must be preserved to ensure venous return following varicocelectomy. The majority of lymphatics have to be preserved as these can contribute to hydrocele formation postoperatively when divided. At the completion contain only the deferens with the (with its veins lymphatics. of varicocelectomy, the cord should testicular artery or arteries, vas vasal vessels, cremasteric muscle ligated and artery preserved), and Several passes "through" the

spermatic cords may be necessary to ensure the complete ligation of all dilated internal spermatic veins. Use of the operating microscope allows for reliable identification of spermatic cord lymphatics, internal spermatic veins and venous collaterals, and the testicular artery or arteries so that the incidence of these complications can be reduced significantly. Delivery of the testis through a small subinguinal incision provides direct visual access to all possible avenues of testicular drainage. In addition, men with larger varicocele have poorer preoperative semen quality, but repair of varicocele results in greater improvement than repair of small varicocele. Microsurgical varicocelectomy provides a safe and effective approach to varicocele with preservation of testicular function, improvements in semen quality, and improvements in pregnancy rates in a significant number of men. Complications following varicocelectomy include hydrocele formation, epididymitis, injury to the internal spermatic artery and persistent or recurrent scrotal varicocele. Fortunately, this occurs in less than 3-5% of patients. Results The results of varicocele repair are often difficult to interpret since most of these studies are not controlled, different techniques of varicocelectomy were applied and no information provided regarding fertility status and age of the spouse. Limited reports compared pregnancy rates among patients treated by varicocele repair and patients with varicocele who declined surgical treatment. These studies indicated a marked increase in pregnancy rates among the group treated by varicocele repair. Reports indicate significant improvement in pregnancy rates up to 43% one year after varicocele repair and 62% 2 years after artery sparing microsurgical procedure. This is two-to three times higher than that for men with varicocele who do not have surgery