Staged laparoscopic orchiopexy of intra-abdominal testis: Spermatic vessels division versus traction? A multicentric comparative study.

BACKGROUND: Staged laparoscopic management of intra-abdominal testes using pedicular section is recognized as gold standard technique, successful in 85 % of cases for scrotal testicular position with less than 10 % testicular atrophy. Recently, Shehata proposed a new technique without pedicular division for these testes, using spermatic vessels traction, but did not provide a comparative study of the two techniques. OBJECTIVE: To evaluate the laparoscopic spermatic pedicular traction (Shehata technique, ST) for the treatment of intra-abdominal testis, as an alternative to gold standard pedicular section (2-stage Fowler-Stephens, FS). STUDY DESIGN: Intra-abdominal testes of 129 patients in two tertiary pediatric urology centers were managed laparoscopically (2011-2019) either by 2-stage FS orchidopexy or ST according to the surgeon preference. Testicular position and size were statistically compared. RESULTS: A total of 147 testes were pulled down by 80 ST and 67 FS, including 18 bilateral cases. Median (IQR) age at surgery was 24.2 (15.6-46.4) months (ST) and 18.3 (13.1-38.2) months (FS) (p = 0.094). Scrotal pulling-down of the testis was performed after a median (IQR) period of 2.3 (1.6-3.4) months (ST) and 6.1 (4.7-8.3) months (FS), respectively (p < 0.005). Although ST had collapsed in 17 cases (21.3 %), only one (1.3 %) redo procedure was required. After a median (IQR) follow-up of 22 (12-40) and 19 (8.75-37) months (p = 0.59), the testis was in the scrotum in 85 % and 81 % of ST and FS cases, respectively (p = 0.51). Testicular atrophy occurred in 10 % of ST and 13.4 % of FS (p = 0.61). Multivariate analysis using the propensity score analysis did not identify any difference between the two techniques. DISCUSSION: Our results seem to confirm that FS and ST achieve the same results regarding final testicular position and testicular atrophy rate, with a long-term follow-up. Our study supports pediatric surgeons to favor laparoscopic spermatic pedicular traction (ST) which preserves the testicular vascularization and may ensure better spermatogenesis after puberty. More details on the size and position of the testicle at the beginning of the first laparoscopy seem however essential to assess more accurately the outcomes of each surgical technique. Our outcomes will also be re-evaluated when our patients have reached puberty, from an exocrine and endocrine points of view. CONCLUSIONS: This study showed similar results after laparoscopic traction or section of spermatic vessels for intra-abdominal testis in a long-term follow-up, providing more evidence for the use of ST as a valuable alternative to FS.

Postvaricocele Embolization Pain Syndrome: A Case Series Report and Review of Current Treatment Strategies.

BACKGROUND: Orchialgia is not an uncommon complaint among men with varicocele, but postvaricocele embolization-related testicular pain has not been widely investigated. This study evaluates the phenomenon of postvaricocele embolization pain (PVEP) syndrome and examines the current strategies to treat this unusual complication. METHODS AND MATERIALS: A prospectively collected database of patients with PVEP who presented to a tertiary center was analyzed between January 2011 and January 2020 following internal ethics approval. Patient demographics, including other complications related to embolization, analgesic requirements, and pain scores (on a 10-point visual analog score), treatment strategies, Patient Global Impression of Improvement (PGI-I) score and overall satisfaction score (on a 5-point scale), were reviewed. All patients were reviewed for a minimum of 12 months. RESULTS: A total of 20 men with a mean age of 33.8 (18-45) years old, presented with PVEP over 10 years. Most men received embolization on an average of 26.6 (18-48) months. The reasons for varicocele embolization include either isolated or combined orchialgia (15 men), subfertility (5 men), and cosmesis (6 men). Eighteen (90%) men underwent microscopic spermatic cord denervation (MSCD) and 2 patients elected for conservative measures. The average pain scores pre-MSCD and post-MSCD were 6.9 (4-9) and 1.4 (0-4) (p<0.001) with a significant reduction in analgesia requirements. Immediate improvement in pain score was reported in all the patients and this persisted at the 12 months review. Most men reported a high satisfaction score (of 4/5) and only one patient reported no change in symptoms after MSCD. CONCLUSION: PVEP is a unique complication and patients should be counseled on the potential risk of persistent orchialgia following embolization for varicocele. The MSCD appears to be an effective treatment option with high success and satisfaction rates.

Internal Spermatic Vein to Superficial Epigastric Vein Microsurgical Bypass in Varicocele Treatment.

INTRODUCTION: Identification and preservation of testicular artery and lymphatic vessels during microsurgical varicocelectomy can be tedious if adhered encompassing venous network is encountered. A venous bypass from internal spermatic to saphenous or inferior epigastric vein, that have been described for varicocele treatment, may be used in such situations. This paper describes a simplified modification of the venous bypass technique that reroutes the testicular blood to the superficial epigastric vein, which can easily be found in the incisional wound. Surgical technique and anastomotic patency test are described, and indications and results are discussed. MATERIALS AND METHODS: During 2020 and 2021, 32 adolescent patients underwent microsurgical varicocelectomy. In eight patients additional microsurgical testicular vein-superficial epigastric vein microvascular bypass was done. The indication for bypass was difficult identification of testicular artery and/or lymphatic vessels due to adhered venous plexus. RESULTS: Varicocele resolution was noted in all eight patients with clinical and/or semen analysis improvement. There were no complications or recurrences. Average length of procedure was 65 minutes. All patients were discharged within 24 hours and no antiplatelet or anticoagulant therapy was used. CONCLUSION: Testicular vein to superficial epigastric vein anastomosis is a useful and simplified venous bypass technique that reroutes the blood from the pampiniform plexus to the femoral vein. It can be done as an adjunct to microsurgical varicocelectomy in selected patients through a standard incision.

Preliminary experience with 3D digital image microscope system on the treatment of varicocele.

The three-dimension digital image microscope system (3D-DIM) with a better ergonomic design and equipment characteristics can contribute to the achievement of good results during microsurgery. In this study, the safety and efficiency of 3D-DIM assisted varicocelectomy was evaluated. From July 2019 to November 2019, fifteen cases with varicocele (20 sides of varicocele in total) were included, seven cases underwent 3D-DIM-assisted modified microsurgical subinguinal varicocelectomy, and eight cases underwent modified microsurgical subinguinal varicocelectomy under standard operating microscope (SOM). The mean operative time of 3D-DIM group (67 ± 12.3 min) was a little longer than that of SOM group (55 ± 12.9 min) (p < 0.05). There was no significant difference between the two groups in the number of internal spermatic arteries, internal spermatic vein, lymphatics, gubernacular vein, external spermatic vein and post-operation complications. The 3D-DIM showed a significant difference in image definition for nurse (p < 0.01) and in doctor-nurse cooperation (p < 0.05) over SOM. The 3D-DIM with better ergonomic design and image definition can be applied to perform microsurgical subinguinal varicocelectomy, and could improve the surgeon's fatigue and doctor-nurse cooperation. We believe that the 3D-DIM would be widely used in the field of male infertility microsurgery in the near future.

Ultrasound evaluation of testicular vein diameter in suspected cases of varicocele: Comparison of measurements in supine and upright positions.

BACKGROUND: Scrotal ultrasonography has high sensitivity in the detection of intra-scrotal abnormalities. Various ultrasonographic parameters such as the spermatic cord diameter, venous diameter, and venous retrograde flow in either supine or upright positions with or without Valsalva maneuver have been investigated to assess patients suspected of having varicocele. AIMS: This study aimed at comparing testicular vein diameter in supine and upright positions using ultrasonography. METHODOLOGY: This is a prospective multicenter study conducted between September 2018 and June 2019. Eighty-two consenting suspected cases of varicocele, 20 years and above, referred for scrotal ultrasonography were included in this study. RESULTS: The study population had a mean age of 42.9 + 14.89 (SD) with a range of 20-96 years. The highest number of participants fell within the age range of 30-39 years 23 (28%). Varicocele was demonstrated in 96.3% of the patients. More patients showed sonographic evidence of varicocele in the upright position, on the right 50 (61%) as well as left 50 (61%). Bilateral varicocele had a higher frequency in the upright position 45 (54.9%), while supine was 23 (28%). Upright position had the widest diameter in 72% of participants on the right and 82% on the left. The upright position also showed higher average vein diameter of 2.6 mm and 2.9 mm on the right and left, respectively, while it was 2.2 mm and 2.3 mm for right and left in the supine position. CONCLUSION: The upright position is more predictive of varicocele in scrotal ultrasound examination for suspected cases of varicocele. We recommend an upright position where one position is to be used.

The effect of experimental varicocele on the apelin and APJ expressions in rat testis tissue.

Varicocele, which is one of the causes of infertility in men, can be defined as the expansion of spermatic cord veins. The presence of apelin and apelin receptor (APJ) in many tissues and the effects of apelin have been reported in several studies. There is no study showing apelin and APJ protein expressions in normal and varicocele-induced testicular tissues. In this study, we aimed to demonstrate varicocele-induced changes in apelin and APJ expressions in testicular tissue by immunohistochemical and western blotting techniques. In our study, Wistar male rats were randomly divided into three groups as control, varicocele, and sham. While the control group rats were not subjected to any treatment, the unilateral varicocele model was created under anesthesia in the varicocele group. In the sham group, the left abdominal region was opened and closed to exclude the effect of the surgical procedure. At the 13th postoperative week, the left testes were obtained under anesthesia in all groups, and the immunohistochemistry and Western blotting techniques were used to detect apelin and APJ expressions. In our study; apelin and APJ were significantly expressed in control group's testicular tissue; apelin in testicular tissues of varicocele groups increased compared to the control group, whereas APJ expression decreased. In conclusion, the presence of apelin/APJ system in normal testis and the increased expression of apelin in varicocele-induced testicular tissue suggested that apelin may have a role in the varicocele etiopathogenesis.

Spontaneous spermatic vein thrombosis in pediatric patients: A condition to be considered. / Trombosis espontánea de la vena espermática en la edad pediátrica: una entidad a tener en cuenta.

Spermatic vein thrombosis is a very rare pathology, with 25 cases published only, 6 of which in patients under 15 years of age. We present the case of a male patient, as well as a review of the literature. A 12-year old boy presented at emergency with 3-day progressive testicular pain. Following abdominal Doppler ultrasound imaging, he was diagnosed with left spermatic vein thrombosis and nutcracker syndrome. Admission and enoxaparin treatment were decided upon. Patient evolution was satisfactory, with subsequent ultrasound imaging demonstrating the absence of thrombus. The patient is currently under follow-up and without treatment. Various treatments are mentioned in the literature, with conservative management being the treatment of choice.

La trombosis de la vena espermática es una patología muy poco frecuente, con solo 25 casos publicados, 6 de los cuales menores de 15 años. De esta manera presentamos el caso de un varón, así como la revisión de la literatura. Un paciente de 12 años de edad acudió a Urgencias por dolor testicular de aumento progresivo, de 3 días de evolución. Mediante ecografía doppler abdominal se diagnosticó de trombosis de la vena espermática izquierda y síndrome de cascanueces. Se decidió ingreso y tratamiento con enoxaparina. La evolución del paciente fue satisfactoria, en la ecografía posterior se observó la desaparición del trombo. El paciente se encuentra en seguimiento y sin tratamiento. Existen varios tratamientos reflejados en la literatura, siendo el de elección el manejo conservador.

Trombosis espontánea de la vena espermática en la edad pediátrica: una entidad a tener en cuenta / Spontaneous spermatic vein thrombosis in pediatric patients: A condition to be considered

La trombosis de la vena espermática es una patología muy poco frecuente, con solo 25 casos publicados, 6 de los cuales menores de 15 años. De esta manera presentamos el caso de un varón, así como la revisión de la literatura. Un paciente de 12 años de edad acudió a Urgencias por dolor testicular de aumento progresivo, de 3 días de evolución. Mediante ecografía doppler abdominal se diagnosticó de trombosis de la vena espermática izquierda y síndrome de cascanueces. Se decidió ingreso y tratamiento con enoxaparina. La evolución del paciente fue satisfactoria, en la ecografía posterior se observó la desaparición del trombo. El paciente se encuentra en seguimiento y sin tratamiento. Existen varios tratamientos reflejados en la literatura, siendo el de elección el manejo conservador

Spermatic vein thrombosis is a very rare pathology, with 25 cases published only, 6 of which in patients under 15 years of age. We present the case of a male patient, as well as a review of the literature.A 12-year old boy presented at emergency with 3-day progressive testicular pain. Following abdominal Doppler ultrasound imaging, he was diagnosed with left spermatic vein thrombosis and nutcracker syndrome. Admission and enoxaparin treatment were decided upon. Patient evolution was satisfactory, with subsequent ultrasound imaging demonstrating the absence of thrombus. The patient is currently under follow-up and without treatment. Various treatments are mentioned in the literature, with conservative management being the treatment of choice

Microstructures of the spermatic cord with three-dimensional reconstruction of sections of the cord and application to varicocele.

The aim of the study was to investigate the micro-structures of the spermatic cord using histological examination with three-dimensional (3D) reconstruction of the serial tissue sections of the cord for clinical application in microscopic varicocelectomy. Human spermatic cord specimens obtained from 13 adult male cadavers were used to prepare serial transverse sections. The sections were stained to allow observation of the spermatic cord microstructures. The 3D reconstruction was performed with digitized serial sections by Mimics software. The microscopic varicocelectomy was performed based on the anatomical results of 3D reconstruction of the spermatic cord. The results showed the number of small spermatic veins, large spermatic veins, arteries, lymphatics or nerves were not markedly different between the subinguinal and inguinal regions or between the right and left sperm cord. The number of medium spermatic veins in the subinguinal region was obviously higher than at the inguinal level. The internal spermatic vessels and the vas deferens together with other associated vessels within the cremaster were separately enclosed by two thin and translucent sheaths, the internal spermatic fascia and the vas deferens fascia. We conclude that internal spermatic vessels and the vas deferens together with the associated neurovascular vessels are wrapped by two distinct sheaths separating them from the surrounding tissues. Microscopic varicocelectomy based on the anatomical results of 3D reconstruction of the spermatic cord is feasible. ABBREVIATIONS: 3D: three-dimensional; ISF: internal spermatic fascia; ESF: external spermatic fascia; MHIV: High inguinal microsurgical varicocelectomy; MSIV: subinguinal microsurgical varicocelectomy; CAAD: computer-assisted anatomic dissection; HE: hematoxylin-eosin.

The predictive value of the platelet volume parameters in evaluation of varicocelectomy outcome in infertile patients.

The aim of this study was to evaluate the role of platelet count (PLT) and platelet volume indices (PVI) such as mean platelet volume (MPV), platelet distribution width (PDW) and plateletcrit (PCT) as a clinical biomarker in 64 infertile males with varicocele and 45 controls. In addition, semen parameters, serum total testosterone, FSH and testicular volume were measured before and at 6 months after varicocelectomy. The mean PLT, MPV, PDW and PCT were 231 ± 42 × 103/µl, 9.6 ± 1.8 fl, 16.2 ± 2.5 fl and 0.18% in the patient group respectively. When the patient and control groups were compared, there was a significant increase in mean MPV, PDW and PCT (p < .0001), while platelet count was lower in patients than control group, but with no significant relationship. MPV had a significant negative correlation with total testosterone (p < .03). No significant correlations were found between PVI and testicular volume. After follow-up of 37.1 ± 1.9 months, a significant negative correlation was found between the preoperative MPV and varicocelectomy outcome in terms of semen values (p < .007). So, the increase in MPV and low total testosterone in men with varicocele may be a feature of high risk of infertility.

Relation of nitric oxide synthase gene (NOS3) polymorphisms to varicocele risk and post-varicocelectomy seminal oxidative stress reduction.

The pathophysiology of varicocele remains to be unknown. Several genetic factors have been implicated in varicocele etiopathogenesis. We studied the relationship between NOS3 c.894G>T, c.786T>C and 4b/a polymorphisms to varicocele risk and their prognostic value as regards improvement of the post-operative seminal parameters &/or seminal malonaldehyde levels. The three NOS3 polymorphisms were evaluated in 100 patients with varicocele and 100 healthy subjects by RT-PCR. Seminal plasma MDA level was measured pre-operatively and 3 months after varicocelectomy by the thiobarbituric acid method. The GT, TT, TC and bb genotypes of NOS3 polymorphism were more commonly observed in varicocele patients (30%, 9%, 28% and 70% respectively) compared to normal controls (12%, 0%, 10% and 50% respectively). The mean percentage of post-varicocelectomy seminal MDA reduction was highest with the GT genotype (p < .001). Genotypes GT+TT, TC and bb were associated with varicocele occurrence in our patients. The T (c.894G>T), C (c.786T>C) and b (NOS3 intron 4 VNTR) alleles were significantly associated with varicocele occurrence in our cohort of patients. We also report a better response regarding the reduction of seminal MDA after varicocelectomy with the GT and ba genotypes.

The change in Thiol-Disulphide Homeostasis levels as an oxidative stress marker after varicocelectomy: Is there a relationship with sperm parameters?

One of the most important causes of varicocele-related infertility is oxidative stress (OS). One of the markers considered as an indicator of OS is thiol-disulphide homeostasis (TDH). Based on the hypothesis that OS should decrease after varicocelectomy in the light of this information, in our current study, we investigated the relationship between TDH levels and sperm parameters. The data of 56 infertile varicocele men were prospectively analysed. The post-operative total and native thiol levels were significantly higher than those pre-operative total and native thiol levels (477.7 & 436.7 nmol/L, 417.6 & 372.1 nmol/L). Positive correlation was found between total thiol change and change in semen volume (ρ: .277, p: .039), ratio of spermatozoa with normal morphology (ρ: .342, p: .01), progressive (ρ: .334, p: .012) and nonprogressive motility (ρ: .385, p: .003). Positive correlation was also found between native thiol change and semen volume (ρ: .349, p: .008), ratio of spermatozoa with normal morphology (ρ: .362, p: .006), progressive (ρ: .297, p: .026) and nonprogressive motility (ρ: .368, p: .005). Change in the level of TDH was found as positively correlated with progressive and nonprogressive motility change. According to these results, OS decreases with varicocelectomy in infertile patients and TDH can be used as a useful method for measuring OS.

Thiol-disulphide balance in infertility secondary to varicocele.

Oxidative stress plays an important role in the development of infertility secondary to varicocele. We aimed to investigate the dynamic thiol-disulphide homeostasis as an oxidative stress marker in the spermatic vein of infertility secondary to varicocele. Sixty-one patients with varicocele were included in the study. Blood was drawn from the median cubital vein and the testicular venous return side before the spermatic vein was separated during surgery. Total thiol, native thiol, disulphide, ischaemia modified albumin (IMA) and albumin values were measured from both the dilated spermatic vein and the median cubital vein. The disulphide/native thiol, disulphide/total thiol and native thiol/total thiol ratios were determined. The mean age of the patients was 27.0 ± 6.68 (15-50) years. While the albumin, native thiol and total thiol values and the native thiol/total thiol ratio were significantly lower (p = 0.004, p < 0.001, p < 0.001, p < 0.001 respectively), the IMA value and the disulphide/native thiol and disulphide/total thiol ratios were significantly higher (p < 0.001, p < 0.001, p < 0.001 respectively) in the samples taken from spermatic venous blood. Thiol-disulphide balance had deteriorated towards disulphide formation in the spermatic vein compared with the peripheral vein. Abnormal thiol-disulphide balance may be an independent risk factor for infertility secondary to varicocele.

Left spermatic vein reflux after varicocele repair predicts pregnancies and live births in subfertile couples.

PURPOSE: Varicocele repair (VR) is proposed to improve fertility in subfertile couples with a poor semen quality. We explored whether the disappearance of a left continuous spermatic venous reflux (SVR) at scrotal colour-Doppler ultrasound (CDUS), an objective evidence for a VR, is predictive for improved fertility outcome in subfertile couples. METHODS: VR was performed by left internal spermatic vein sclero-embolisation in 88 males seeking a consultation for subfertility. Semen analysis and scrotal CDUS were evaluated before and 6 months after VR. Serum levels of FSH and total testosterone (TT) were obtained at baseline. Telephone interview was used to obtain information about fertility outcome. Significant predictors of pregnancy and live births, selected by univariate analyses, were included into multiple logistic regression models to assess independent associations. RESULTS: At the adjusted model, independent significant predictors of pregnancy after VR were a disappeared SVR at CDUS (OR = 5.5, 97.5% CI 2.01-15.4; p = 0.0009) and an improved sperm total motile count (TMC) (OR = 5.5, 97.5% CI 1.4-27.9; p = 0.02). Even live births were independently associated with both disappeared left SVR at CDUS (OR = 4.3, 97.5% CI = 1.6-11.8; p = 0.003) and improved TMC after VR (OR = 4.8, 97.5% CI 1.3-24.2; p = 0.02). CONCLUSION: The still controversial effect of varicocele repair on fertility in subfertile couples may reside on the undefined objective methods to document a successful VR and its effect on couple fertility. The disappearance of a continuous left SVR at CDUS after VR was the objective best predictor for subsequent improved fertility in subfertile couples.

Anatomic mapping of the internal spermatic vein via subinguinal varicocelectomy with intraoperative vascular Doppler ultrasound.

BACKGROUND: Varicocele is believed to be a dilated vein of the pampiniform plexus along the spermatic cord. Surgical treatment should be considered in men with a symptomatic varicocele. To date, microsurgical varicocelectomy is the most effective method among various varicocelectomy techniques, according to the current evidence. This study aimed to evaluate the effectiveness of subinguinal varicocelectomy with intraoperative vascular Doppler for symptomatic varicocele and map the distributional trend of spermatic content simultaneously. METHODS: A total of 24 male patients underwent subinguinal varicocelectomy with intraoperative vascular Doppler ultrasound between March 2016 and October 2017, because of symptomatic varicocele or infertility. The numbers, sizes, and location of spermatic vessels in each site were recorded during operation. The visual analogue scale (VAS) score of scrotal pain was also obtained before and after surgery. RESULTS: The mean number of spermatic veins that were ligated in each spermatic unit was 4.70 (±2.06). The predominant distributional zone of spermatic veins was the medial upper zone on an axial view of the spermatic cord. Fifty-six (44.1%) spermatic veins were found in this zone. Normally, each spermatic cord has 1.33 (±0.61) spermatic arteries. The average VAS score prior to surgery was 1.95 (±0.89) and it decreased to 0.05 (±0.21) after the surgery. Complete resolution of pain was observed in almost all symptomatic patients (95.23%). A significant positive relationship between the number of veins ligated and improvement of VAS score was also noted (p < 0.05). CONCLUSION: Subinguinal varicocelectomy with intraoperative vascular Doppler ultrasound is an effective treatment for symptomatic varicocele. The more the internal spermatic veins are ligated, the more the VAS scores are improved. Determining the distributional trend of spermatic content is of great importance in the prevention of iatrogenic injury to the spermatic vessels and vas deferens.

Spermatic vein aneurysm: a report of a unique case and review of the literature.

A spermatic vessel aneurysm is a rare entity, described only a few times in the literature. In most cases, it is caused by trauma or inflammation and appears as a painful mass in the scrotum or the inguinal area. We present a case of a 22-year-old man who came to our Surgical Department with a painful, palpable mass in the right inguinal area. A spermatic vein aneurysm was diagnosed with the use of ultrasonography and it was surgically excised. The findings were confirmed by pathological examination. The patient is well, four months after surgery. A spermatic vessel aneurysm, though rare, should always be included in the differential diagnosis of a scrotal or inguinal mass. The lesion can be cured by surgical resection.

[A CASE OF THROMBOSIS OF THE PAMPINIFORM PLEXUS TREATED WITH ANTICOAGULANT THERAPY].

We describe a patient with thrombosis of the pampiniform plexus cured using heparin. A 40-year-old man was referred to our hospital with pain in the left scrotum. A physical examination revealed a painful, 20-mm long, beaded mass in the upper left paratesticular region. Magnetic resonance imaging and ultrasonography revealed 10-mm long thrombosis in the left pampiniform plexus, so intravenous heparin was started. The patient recovered well and was discharged on oral anticoagulation therapy after five days of hospitalization. The patient was completely asymptomatic, and ultrasonographic findings of the left testicle were normal at six months after starting treatment. We found 19 patients with thrombosis of the pampiniform plexus including the present patient, in the English and Japanese literature to date. Here, we review these 19 patients and discuss their clinical features.

Pattern of varicocele vein blood gases in patients undergoing microsurgical Varicocelectomy.

BACKGROUND: Varicocele is known to be associated with infertility and sperm disorders. The exact cause of this ailment is not fully understood. There are limited numbers of studies where venous blood gases (VBGs) of varicocele veins were determined with conflicting results. Therefore, we have investigated the pattern of VBGs in both internal spermatic and external spermatic varicocele veins and correlation with semen quality parameters in infertile individuals who underwent left microsurgical varicocelectomy. METHODS: Patients (n = 27) undergoing left microsurgical varicocelectomy at a tertiary care hospital, were included in the study. Before surgery, semen parameters and scrotal color Doppler ultrasonography was performed. During surgery, blood sample was drawn from varicocele veins (internal spermatic and external spermatic veins) and a peripheral arm vein of the same patient as a control. The VBGs of all veins under study were estimated and compared with each other. The VBGs were also correlated with various semen quality parameters. Data, expressed as Mean ± SD, regarding VBGs in three veins were analyzed using one-way ANOVA. The correlation between VBGs and semen quality parameters was determined using Pearson's correlation. Differences were considered significant at p < 0.05. RESULTS: The pH was found to be higher (p < 0.01) in the internal spermatic vein compared with the external spermatic and the peripheral veins. Partial pressure of oxygen (pO2) and oxygen saturation (sO2) were higher (p < 0.01) in the internal spermatic vein compared with the peripheral vein. However, concentration of bicarbonate (HCO3) was lower (p < 0.01) in both veins compared with the peripheral vein. Partial pressure of carbon dioxide (pCO2) was also lower (p < 0.01) in the varicocele veins compared with the control vein. CONCLUSION: The internal spermatic veins had higher pH and oxygen tension, but lower HCO3 and pCO2 levels compared with the control peripheral veins. External spermatic veins had lower pCO2 and HCO3 but other VBGs were similar to the peripheral veins. The shift of VBGs of internal spermatic vein toward arterial blood pattern may be a missing link to understand the pathophysiology of varicocele.