Use of indocyanine green angiography in microsurgical subinguinal varicocelectomy - lessons learned from our initial experience

ABSTRACT Microsurgical subinguinal varicocelectomy (MSV) is generally considered the gold standard nowadays in view of the lower risk of complications and recurrence. To achieve complete ligation of veins while preserving testicular artery (TA) during the procedure remains challenging despite the application of high power optical magnification and micro-Doppler ultrasonography. The use of intraoperative indocyanine green angiography (ICGA) with infrared fluorescence operative micro-scope in MSV potentially lowers the incidence of TA injury and shortens the learning curve of novice surgeons. We present our initial experience in the application of the technique in nine patients and explore the potential of the new adjunct.

Efficacy of scrotal Doppler ultrasonography with the Valsalva maneuver, standing position, and resting-Valsalva ratio for varicocele diagnosis

PURPOSE: To determine effectiveness of Valsalva maneuver and standing position on scrotal color Doppler ultrasound (CDU) for the varicocele diagnosis. MATERIALS AND METHODS: We reviewed the physical examination and CDU finding in 87 patients who visited National Police Hospital from January 2011 to April 2014. Diameters of pampiniform plexus were measured bilaterally during resting and Valsalva maneuver in the supine position and standing position. We calculated the ratio of mean of maximal vein diameter (mMVD) during resting and Valsalva maneuver (resting-Valsalva ratio) and compared in the both position. RESULTS: In the resting and supine position, mMVD of varicocele testis units were 1.8 mm, 2.1 mm, 2.6 mm (grades I, II, III, respectively), and that of normal testis units (NTU) 1.2 mm. During Valsalva maneuver in the supine position, mMVD were 3.0 mm, 3.4 mm, 4.2 mm (grades I, II, III) vs 1.8 mm (NTU) (p=0.007, p<0.001, p<0.001, respectively). Average of resting-Valsalva ratio in the supine position were 0.69, 0.74, 0.74 (grades I, II, III) and 0.67 (NTU). Whereas in the resting and standing position, mMVD were 2.8 mm, 3.3 mm, 3.8 mm (grades I, II, III) and 1.8 mm (NTU) (p=0.002, p<0.001, p<0.001). During Valsalva maneuver in the standing position, mMVD were 5.0 mm, 5.8 mm, 6.6 mm (grades I, II, III) and 2.5 mm (NTU) (p=0.002, p<0.001, p<0.001). And average resting-Valsalva ratio were 0.76, 0.90, 0.71 (grades I, II, III) and 0.26 (NTU), which showed significant differences from all grades (p<0.001, p<0.001, p<0.001). CONCLUSIONS: It is suggested that the standing position and Valsalva maneuver during CDU could improve diagnostic ability for varicocele. Resting-Valsalva ratio in the standing position could be a new diagnostic index for varicocele diagnosis using CDU.

Recurrent Varicoceles: Causes and Treatment Using Angiography and Magnification Assisted Subinguinal Varicocelectomy

PURPOSE: To investigate the causes of varicocele recurrence and assess the use of embolization and subinguinal varicocelectomy in its treatment in patients with angiography and subinguinal varicocelectomy. MATERIALS AND METHODS: The present study involved 15 patients with recurrent varicoceles. The mean patient age was 21.2 years (range: 12-42 years). Preoperative angiography was performed in 11 patients. Embolization was used in patients with patent internal spermatic veins (ISVs). Patients without patent ISVs or preoperative angiography underwent magnification-assisted subinguinal varicocelectomy which included testicular retrieval and ligation of all collateral veins except arteries and deferential veins. RESULTS: Seven among 11 patients (64%) which had preoperative angiography had patent ISVs and underwent embolization and 8 patients underwent subinguinal varicocelectomy. Of those 8 patients, 6 had dilated ISVs and external spermatic veins (ESVs), one had dilated ISVs and gubernacular veins, and one had dilated ISVs, ESVs and gubernacular veins. No patient experienced recurrence or testis atrophy. CONCLUSION: Patent ISVs or collateral veins may be the cause of recurrence after varicocelectomy. Angiographic embolization was successful in 64% of recurrent varicoceles patients with patent ISVs. However, microscope-assisted subinguinal varicocelectomy may be the best overall treatment for patients with recurrent varicoceles.

nutcracker syndrome: an underdiagnosed cause for high grade varicocele

The nutcracker syndrome represents a clinical condition caused by compression of the left renal vein [LRV] between the superior mesenteric artery [SMA] and the aorta. One of its manifestations is left-sided varicocele. The aim of this study is to determine the prevalence of nutcracker syndrome in patients with primary and recurrent high grade left-sided varicocele. Fifty patients with primary and recurrent high grade left-sided varicocele were enrolled in this study. Color Doppler ultra-sonography [US] of renal vessels was done and diameter of LRV and peak systolic velocity [PSV] were measured in renal hilum and in site of compression of LRV be-tween SMA and the aorta and then magnetic resonance angiography [MRA] of renal vessels was done. Thirty six patients [72%] had primary high grade varicocele and 14 patients [28%] had recurrent high grade varicocele. Twelve patients [33%] with primary high grade varicocele and seven patients [50%] with recurrent varicocele had evidences of NCS in color Doppler US and MRA. The differences of LRV diameter in NCS group and in patients without NCS were statistically significant [P<0.001]. The differences of PSV in the LRV at the hilar portion in the NCS group and in the patients without NCS were not statistically significant. The differences of PSV in the LRV at the aortomesenteric portion in the NCS group and in the patients without NCS were statistically significant [P< 0.001]. In all patients with NCS, MRA showed dilatation and compression of LRV at site of passage between aorta and SMA. NCS should be suspected in patients with high grade primary and recurrent varicocele

Adolescent varicocele: the role of laparoscopic ligation and colour doppler ultrasonography

The objective of this study was to report the results of laparoscopic varicocelectomy and the role of color Doppler ultrasonography [CDU] in adolescent varicocele. Twenty-two laparoscopic varicocelectomies and CDU were performed for 18 patients. In the postoperative follow up period, symptoms disappeared in 17 patients, three patients had pneumoscrotum, one patient had vaginal hydrocele and one patient had recurrent varicocele. Ultrasonography showed the testicular growth in 15 patients within 12 months of surgery. CDU was an easy, effective and noninvasive modality for the pre and postoperative assessment of these patients

Role of varicocele recurrence in male subfertility

This study was carried out on 49 patients who did varicocele ligation by different approaches without correction of semen parameters, Doppler or duplex scan were used for examination of all patients, which showed that, from the 23 patients who did bilateral varicocele ligation, 18 cases recur also bilateral- and 5 unilateral, the 10 patients who did right side ligation all recur again and the 61 patients who did left side ligation 42 recur again, 3 in the left and 16 in the right alone. The study showed also that the incidence of recurrence was 34.6% in high ligation, 28.2% in inguinal, 19.2% in scrotal neck, 103 in scrotal, 7.6% in laparoscopic approachs and that 17% of the total as persistent not recurrent. Operative findings were dilated anterior group, posterior group, cremastric or tunical veins which show reflux with surgical Doppler which also showed injury of 36 testecular artery. It was concluded that, surgical Doppler is very important in surgery of varicocele and helpn selective varicocele ligation, high and laparoscopic approaches has a high recurrence rate than low approaches

Spermatic vein doppler examination: use and abuse

Varicoceles have been shown to be detrimental to spermatogenesis and to cause male infertility. Patients with infertility referred for spermatic vein Doppler ultrasound evaluation were studied prospectively to correlate the findings on physical examination and those on Doppler ultrasound evaluation. Twelve out of thirty four spermatic veins [35%] with no evidence of varicocele on physical examination were found to have definite reflux on Doppler ultrasound examination, while all the unoperated spermatic veins with clinically evident varicoceles had reflux on Doppler ultrasound examination. In the absence of newer methods of diagnosis like high resolution real-time scrotal ultrasonography or scrotal colour Doppler duplex ultrasonography, our results support the use of Doppler ultrasound to detect subclinical varicoceles in patients with infertility but we do not recommend its use in patients with clinically evident varicoceles

Diagnosis and impact on fertility of subclinical varicocele: a series of 6 cases

The varicocele is the most common and identifiable cause of subfertility in men. Its subclinical form is underestimated. Its impact on male fertility is not well known. Doppler sonography is a non invasive and reliable mean of diagnosis. It enabled us to detect subclinical varicocele in six subfertile men. After ligation of the internal spermatic vein, the semen analysis was improved in two cases and pregnancy was achieved in one. Therefore, doppler sonography is the correct procedure in men unexplained subfertility