The history of varicocele: from antiquity to the modern ERA

ABSTRACT Men have most likely been affected by varicocele since the assumption of the upright position. In De Medicina, written during the first century AD, Celsus credits the Greeks with the first description of a varicocele, and he recorded his own acute observation: "The veins are swollen and twisted over the testicle, which becomes smaller". Celsus himself is credited with the distinction between varicocele (dilation of surface veins) and "cirsocele" (dilation of deep veins). There has been a long history of treatment attempts and failures, some of which are remarkably strange, that have sometimes cul- minated in tragedy, as in the case of French professor Jacques-Mathieu Delpech (1772-1832). Although some questions regarding the etiopathology and treatment of varico- cele remain unanswered, a succession of more or less conservative attempts involving all medical cultures has been performed throughout history. The report by W.S. Tulloch in 1952 brought varicocele into the era of modern evidence-based medicine, and varicocele surgery finally progressed beyond the aim of merely relieving scrotal pain and swelling. From 1970 to 2000, varicocelectomies gained worldwide attention for the treatment of male infertility. Several innovative procedures to correct varicoceles began to appear in the world's literature as interventional radiology, microsurgery, laparoscopy, and robotics, while comprehensive review articles were also published on the subject of varicocelectomies. Microsurgery is nowadays used worldwide and it can be considered to be the gold standard for correcting infertility linked to varicocele.

The history of varicocele: from antiquity to the modern ERA.

Men have most likely been affected by varicocele since the assumption of the upright position. In De Medicina, written during the first century AD, Celsus credits the Greeks with the first description of a varicocele, and he recorded his own acute observation: "The veins are swollen and twisted over the testicle, which becomes smaller". Celsus himself is credited with the distinction between varicocele (dilation of surface veins) and "cirsocele" (dilation of deep veins). There has been a long history of treatment attempts and failures, some of which are remarkably strange, that have sometimes culminated in tragedy, as in the case of French professor Jacques-Mathieu Delpech (1772- 1832). Although some questions regarding the etiopathology and treatment of varicocele remain unanswered, a succession of more or less conservative attempts involving all medical cultures has been performed throughout history. The report by W.S. Tulloch in 1952 brought varicocele into the era of modern evidence-based medicine, and varicocele surgery finally progressed beyond the aim of merely relieving scrotal pain and swelling. From 1970 to 2000, varicocelectomies gained worldwide attention for the treatment of male infertility. Several innovative procedures to correct varicoceles began to appear in the world's literature as interventional radiology, microsurgery, laparoscopy, and robotics, while comprehensive review articles were also published on the subject of varicocelectomies. Microsurgery is nowadays used worldwide and it can be considered to be the gold standard for correcting infertility linked to varicocele.

Historical investigations into varicocele pathophysiology and sperm migration.

Stephenson JD, O'Shaughnessy EJ. Hypospermia and its relationship to varicocele and intrascrotal temperature. Fertil Steril 168;19(1):110-7. "There is a frequently observed, definite relationship between varicocele and hypospermia." Moghissi KS. Human and bovine sperm migration. Fertil Steril 1968;19(1):118-22. "Van Leeuwenhoek's discovery of motile spermatozoa led to the conclusion that their migration was due to their own propellant activity."

The evolution and refinements of varicocele surgery.

Varicoceles had been recognized in clinical practice for over a century. Originally, these procedures were utilized for the management of pain but, since 1952, the repairs had been mostly for the treatment of male infertility. However, the diagnosis and treatment of varicoceles were controversial, because the pathophysiology was not clear, the entry criteria of the studies varied among centers, and there were few randomized clinical trials. Nevertheless, clinicians continued developing techniques for the correction of varicoceles, basic scientists continued investigations on the pathophysiology of varicoceles, and new outcome data from prospective randomized trials have appeared in the world's literature. Therefore, this special edition of the Asian Journal of Andrology was proposed to report much of the new information related to varicoceles and, as a specific part of this project, the present article was developed as a comprehensive review of the evolution and refinements of the corrective procedures.

Scrotal asymmetry, varicocoele and the Riace Bronzes.

In 1972, a pair of remarkably attractive Greek statues, later named Riace Bronzes, were found along the Mediterranean coast in the province of Reggio Calabria, Italy. We analyse the Riace Bronzes in the context of previous research on scrotal asymmetry in Greek statues. By examining their testis, one can define a more exact time of their dating by placing them beside previous observations of scrotal asymmetry, and possibly by taking a pathological condition, varicocoele, as an influencing factor in determining the appearance of the testis. In statue A of the Riace Bronzes, the left testicle is remarkably lower compared with the right one; it also appears as it looks when under physical examination varicocoele is suspected. Being located on the left testicle (as in 90% of cases) and by sight, we feel sufficiently confident to affirm that varicocoele might be diagnosed.

Mis comienzos en laparoscopia / My first steps in laparoscopic surgery

OBJETIVO: El autor describe algo de sus comienzos en laparoscopia, de dónde le vinieron algunas de sus ideas, el porqué y los medios con que contó al empezar. Cuenta brevemente su aportación a la Urología, que puede servir de modelo para los que están empezando. MÉTODOS: Desde que el autor era un adolescente, su padre, que era urólogo, supo transmitirle el entusiasmo por su trabajo; se sentía atraído por el instrumental desde el litotritor de Freyer hasta el resector de Iglesias. También se interesó especialmente por los libros de urología antiguos. Le causaba especial admiración ver operar en directo a don José María Gil Vernet y cuenta que fue el primer urólogo al que le vio usar un laparoscopio para el diagnóstico del testículo abdominal. En 1985, mientras estaba en la universidad de Oxford, se le ocurrió diseñar un sistema de balón para disecar el espacio retropúbico, que al cabo de los años daría lugar a la cirugía extraperitoneal. Al año siguiente tras leer el manual de laparoscopia de Semm, describió la varicocelectomía laparoscópica. Entre sus trabajos destaca el haber descrito en 1993 por primera vez la técnica de la cistectomía radical con conducto ileal laparoscópico. En 1997 ideó un sistema robótico, mediante brazo maestro esclavo, concebido inicialmente para la resección transuretral. RESULTADOS/ CONCLUSIONES: Considera que una buena idea es algo valiosísimo, que no tiene precio, porque a todo aquel que tenga ambiciones y la consiga, le permitirá salir de la mediocridad

OBJECTIVES: The author describes his first steps in laparoscopic surgery and the sources of some of his ideas. He thanks his father’s influence and the technical stimuli that catalysed his scientific curiosity. For the benefit of young urologists at the beginning of their careers he shows how the frustrations of working with the early instruments became the vital challenges that inspired creative solutions. METHODS: His urological surgeon father inspired in his young son a passion for his calling. He developed an immediate and compelling interest in the shape and function of urological instruments like, for example, Freyer’s lithotripter and the Iglesias resectoscope. Books of urological history and the works of pioneer urologists fascinated him. Watching José María Gil Vernet operate particularly impressed him and he says that Gil Vernet was the first urologist he saw using a laparoscope to diagnose an abdominal testicle. While working in an Oxford University hospital in 1985, he designed a balloon device to dissect the retropubic space. This procedure was the precursor of what several years later became extraperitoneal surgery. The following year, he read the manual of Semm’s laparoscopy and later described a laparoscopic varicocelectomy. In 1993, he published the first description of a laparoscopic radical cystectomy and ileal conduit. In 1997, he adapted a surgical robotic system with a master-slave arm to carry out firstly a transurethral resection. RESULTS/CONCLUSIONS: He says that a good idea is beyond price because it helps the inspired individual to make true a long-held ambition and achieve the signal success that lifts him out of the mud of mediocrity

[Infertility and varicocele through history]. / La infertilidad y el varicocele a través de la historia.

OBJECTIVES: To perform a historical review of varicocele and male infertility with the aim to find descriptions that first related them. In parallel, we review the evolution of treatment for varicocele up to date. METHODS/RESULTS: We refer to multiple authors and their treaties on Medicine, from first to 20th Century, in which descriptions of these pathologies are found, focusing on descriptions of the surgical technique for treatment of varicocele and their application in Spain. CONCLUSIONS: Varicocele was already described in treaties from the first century having bee of n its treatment predominantly surgical from the first description to our days. Not identified as a cause of infertility until late, by the end of the 19th century, it is the main indication for treatment nowadays. The surgical technique has suffered many modifications over time, both in the approach as in the "radicality" of a vascular ligature applied.

Varicocele--a historical perspective.

Varicocele is an essential part of andrological urology. Due to its frequency and to the problems connected with it, varicocele became a subject of interest at an early stage in the history of medicine. Questions arose as to how the changes and the consequences resulting from this condition should be treated. Even today, some questions regarding the etiopathology and therapy of varicocele remain unanswered.

Varicocele and male fertility.

Over the past 25 years the association of varicocele with male subfertility has been repeatedly demonstrated and the beneficial effect of varicocele ligation in infertile men with oligoasthenospermia has been documented. Since the precise mechanisms by which a varicocele affects spermatogenesis are still unclear, the proper approach to the management of "asymptomatic" varicoceles is controversial.