Grade III Varicocele Surgical Treatment using Spermatic Vein-Superficial Abdominal Vein Shunt

Summary

Here, we present a protocol for grade III varicocele surgical treatment that aims to rebuild the venous drainage of the spermatic cord by a spermatic vein-superficial abdominal vein shunt performed under the microscope.

Abstract

Microsurgical varicocelectomy is the most commonly used method for the treatment of varicocele (VC) in recent years. However, it is technically demanding with the risk of damaging the normal anatomical structure of the spermatic cord, such as the cremaster muscle, testicular artery, and vas deferens during the pampiniform plexus ligation. Also, traditional varicocelectomy hinders the drainage of the stagnant venous blood of the affected testicle, resulting in a persistent scrotal appearance of varicose veins and slower remission of swelling sensation in postoperative patients with grade III VC. Therefore, we developed a retroperitoneal varicocelectomy with a microscopical spermatic venous-superficial vein of the abdominal wall bypass procedure. The spermatic vein was transected and ligated proximally through the retroperitoneal space. Then, the distal spermatic vein was freed and passed through the internal ring; under the skin of the groin, a microscopic vascular anastomosis was performed to build the bypass of the distal spermatic vein and proximal inferior epigastric vein. The high ligation facilitates the protection of the normal anatomy of the spermatic cord, and the venous bypass allows rapid testicular blood drainage, which can effectively improve the degree of varicocele, testicular pain, and even spermatogenic function. In conclusion, the present protocol describes a promising way to reconstruct the spermatic return through high retroperitoneal ligation of the spermatic vein and anastomosis of the spermatic vein-inferior epigastric vein, which resulted in faster and more obvious improvement in symptoms and better prognosis of grade III VC.

Introduction

The incidence of varicocele (VC) in adult males is 11.7%, and in males with abnormal semen quality, the incidence is up to 25.4%¹. Clinical manifestations include symptoms of ipsilateral testicular growth and developmental disorders accompanied by pain, discomfort, low fertility, and hypogonadism. Clinical specialist examinations can detect and grade varicocele². VC III grade shows positive for clinical palpation and ultrasonic varicocele inner diameter ≥ 3.1 mm and reflux time ≥ 6 s, often accompanied by more severe testicular pain or swelling discomfort^3,4.

Recent studies have shown that VC microsurgical varicocelectomy is considered to be the most effective way of VC repair due to its advantages of fewer complications and low recurrence rate^5,6,7. However, this procedure has some shortcomings: as in the past, scrotal, inguinal, or subinguinal incisions are often used, which easily damage the cremaster muscle, testicular artery, vas deferens artery and lymphatic vessels. Especially in grade III VC, it is more likely to be accidentally injured due to the many branches of the pampiniform plexus, and damage to the normal anatomical structure of the spermatic cord will cause postoperative complications such as testicular pain, swelling, and atrophy⁸. Additionally, traditional varicocelectomy by simple ligation of the spermatic vein hinders the drainage of the stagnant venous blood of the affected testicle, resulting in a persistent scrotal appearance of varicose veins and slower remission of swelling sensation in postoperative patients with grade III VC and the relief of testicular pain or swelling discomfort is slow or not obvious, with poor efficacy⁹. It is conducive to restoring the physiological hemodynamics of the testes by varicocele repair rather than simple varicocelectomy¹⁰. For example, microscopic internal spermatic vein-inferior epigastric vein anastomosis has also been reported to be applied to the treatment of varicocele¹¹. Here, we describe a protocol for grade III varicocele surgical treatment that aims to ligate spermatic veins at the high retroperitoneal level and rebuild the venous drainage of the spermatic cord by a spermatic vein-superficial abdominal vein (also known as superficial epigastrin vein or vena epigastrica superficialis) shunt under the microscope.

For this study, a retrospective analysis was performed on the clinical data of 96 patients in the hospital from June 2018 to August 2021 who had grade III VC and complained of testicular pain or distension discomfort, who had received spermatic vein ligation, and who had complete follow-up data. The pain score was assessed by visual scoring (VAS). They were divided into two groups according to the surgical methods: study group A was treated with high ligation of the spermatic vein under a microscope and transfer of spermatic venue-superficial abdominal vein (49 cases), and study group B was treated with low ligation of the spermatic vein under a microscope (47 cases).

Protocol

This study was approved by the ethics committee of the First Affiliated Hospital, Sun Yat-sen University (NO. 2020-478), prior to the start of the clinical study. All subjects provided informed consent before the study. The inclusion criteria for cases are (1) grade III varicocele confirmed by clinical palpation and ultrasonic examination of varicocele inner diameter ≥ 3.1 mm and reflux time ≥ 6 s; (2) Combined scrotal pain and discomfort; (3) Completed surgical treatment for varicocele in the hospital. Exclusion criteria: (1) any of the following pelvic-related histories: pelvic operation, pelvic radiotherapy, or pelvic trauma; (2) perineal skin disease; or (3) surgical contraindications.

1. High ligation of spermatic veins

1. Administer intravenous-inhalational anesthesia and assess depth by disappearance of the patient's consciousness and pain response, as well as skeletal muscle relaxation.
2. Make an external oblique incision parallel to the groin through the internal ring with a length of 3 cm. Cut the skin and subcutaneous tissue with a scalpel, and use a unipolar electric scalpel combined with blunt separation to separate the aponeurosis of the external oblique and internal oblique muscles. Then, on the outside of the incision, forceps is applied through the internal obliquus into the retroperitoneum.
3. Push open the peritoneal tissue with saline wet gauze and find the flexed and thickened spermatic vein in front of the psoas major muscle and behind the peritoneum while paying attention to protecting the artery.
4. The spermatic cord sheath was opened bluntly with a vascular clamp to carefully free a spermatic vein of about 6-8 cm in length to the proximal end. Lift the vascular sling, ligate the proximal end with a non-absorbable 2-0 suture, and cut. Lift the distal end knot and free it to the vicinity of the peritoneal junction. Use the spermatic vein with a larger diameter for subsequent spermatic vein-inferior epigastric vein shunt (Figure 1).
5. Ligate other branches of the spermatic vein with a non-absorbable 2-0 suture.

2. Releasing the inferior epigastric vein

1. On the medial aspect of the incision, identify and retract the spermatic cord. The inferior epigastric vein was located beneath the fascia surrounding the spermatic cord left to the internal ring.
2. Lift the vascular sling, free inferior epigastric vein with a sufficient length of about 3cm towards its distal end and observe the direction of blood flow. After ligation with a non-absorbable 3-0 suture, the distal end was excised and the proximal end was dissected for subsequent anastomose with the distal end of the spermatic vein with a vascular clamp (Figure 2).

3. Anastomosis of spermatic vein - inferior epigastric vein

1. Relying on the manipulation of bending forceps, the spermatic vein was carefully guided through the inner ring opening to the abdominal incision and secured with a vascular clamp in preparation for subsequent anastomosis with inferior epigastric vein.
2. Check that there is no tension in connection with the free spare superficial vein of the abdominal wall, and then suture 6-8 stitches with 8-0 Polypropylene suture (Figure 3).
3. Release the vascular clamp to ensure that the vein is full, the blood flow is smooth, and there is no blood leakage when pressing the testicle.

4. Closing the incision

1. To close the incision layer by layer, use 2-0 absorbable sutures to suture the external oblique aponeurosis and subcutaneous tissue. Use 3-0 absorbable sutures to suture the skin.

5. Postoperative management

1. Ask the patient to pay attention to rest and avoid strenuous exercise. After surgery, administer a subcutaneous injection of 40 mg Enoxaparin Sodium, and the next day, switch to oral Rivaroxaban, 10 mg daily for 1 month.

Representative Results

For this study, the 96 patients were divided into two groups: study group A, treated with high ligation of the spermatic vein under a microscope and transfer of spermatic vein-inferior epigastric vein (49 cases), and study group B, treated with low ligation^{9,12,13,14,15} of the spermatic vein under a microscope (47 cases). The basic data, operation time, hospital stay, postoperative scrotal edema, testicular pain or swelling discomfort score, and the remission of varicocele were compared between the two groups for 1 month after the operation. The measurement data were expressed as mean ± standard deviation, and an independent sample t-test was used for comparison. Count data is expressed as percentages (%) and compared using the chi-square test with p <0.05, indicating a statistically significant difference.

There were no significant differences in age, BMI, varicosity degree, and testis pain score between the 2 groups (p>0.05; Table 1). There was no significant difference in the length of hospital stay between group A and group B, 5.32 ± 0.42 days vs. 5.16 ± 0.28 days (p>0.05; Table 2). However, the operation time of group A was significantly longer than that of group B, 146.26 ± 14.33 min vs. 92.27 ± 8.66 min, and the difference was statistically significant (p<0.01; Table 2). The incidence of postoperative scrotal edema or hydrocele of testis and acute epididymitis in group A was lower than those in group B (0% vs.5.1%, 0% vs.6.0%, 0.9% vs.7.7%, respectively; p<0.05; Table 2). The relief rates of testicular pain or distention discomfort in group A and group B, 1 month after surgery, were 91.8% and 61.78%, respectively (Table 2). The decrease in varicocele was 0.16 ± 0.06 mm vs. 0.08 ± 0.04 mm for group A and group B, respectively, and the difference was statistically significant (p<0.05; Table 2).

Figure 1: Dissociation of a spermatic vein of sufficient length. Selection of a spermatic vein with a larger diameter for subsequent spermatic vein-superficial abdominal vein shunt. Please click here to view a larger version of this figure.

Figure 2:  Dissociation of inferior epigastric vein of sufficient length. Ensure that the length and diameter is to the reserved spermatic vein. Please click here to view a larger version of this figure.

Figure 3: Reconstruction of the bypass. Reconstructed bypass between spermatic vein and superficial abdominal wall vein under microscope. Please click here to view a larger version of this figure.

Item	Group A	Group B	T value	P value
Number of cases	47	49
Age (years)	32. 6±5. 4	30. 8±5. 1	1.16	0.14
BMI	20.64±3.34	20.09±3.91	0.83	0.38
Course of disease (years)	3.8±1.3	4.3±1.4	-1.682	0.078
Width of spermatic vein (cm)	3.62±0.41	3.67±0.35	– 0. 665	0.512
Testicular pain VAS score	3.6±1.5	3.4±1.7	0.186	0.398

Table 1: Comparison of preoperative baseline data of patients. The measurement data are expressed as mean ± standard deviation, and an independent sample t-test is used for comparison. Count data is expressed as percentages (%) and compared using the chi-square test with p <0.05, indicating a statistically significant difference.

Item		Group A	Group B	T value	P value
Operation time		146.26±14.33	92.27±8.66	6.5	0.015
Length of stay		5.32±0.42	5.16±0.28	1.7	0.093
1 month after surgery for narrowing the width of the spermatic vein (cm)		0.16±0.06	0.08±0.04	-1.7	<0.01
Rate of relief from testicular pain or discomfort		91.80%	61.78%		0.047
Complication	Scrotal edema	1	3
(Number of cases)	Epididymitis	0	1
	Hydrocele	0	1
	Atrophy of testis	0	0

Table 2: Comparison of perioperative indexes. The measurement data are expressed as mean ± standard deviation, and an independent sample t-test is used for comparison. Count data is expressed as percentages (%) and compared using the chi-square test with p <0.05, indicating a statistically significant difference.

Discussion

Increasing evidence has shown that microsurgical varicocelectomy has more advantages than open or laparoscopic varicocelectomy for the surgical management of VC^5,6. The surgical microscope can magnify the anatomical details with a clear field of vision, and the arteriovenous, lymphatic vessels and nerves can be discerned more readily. In contrast, it is difficult to distinguish the arteries and veins clearly in other surgical procedures. They may miss venous vessels for ligation or accidentally injure the accompanying lymphatic vessels and nerves, which leads to postoperative complications such as scrotal pain, testicular edema, and recurrence. Moreover, a sublingual or intralingual incision is usually adopted in microsurgical varicocelectomy, which is convenient for exposing the spermatic veins^12,13. However, the internal spermatic veins in the inguinal canal are in the form of the pampiniform plexus with more complex branches in lower levels^14,15. It is still challenging to avoid potential damage to the anatomy of the spermatic cord. Another fact that cannot be ignored is that varicocelectomy has not restored the normal venous drainage of the spermatic cord, which causes persistent testicular edema¹⁰.

Recently, microscopic varicocele repair using internal spermatic vein-inferior epigastric vein anastomosis has also been applied to the treatment of varicocele11. However, their primary focus is on diverting the blood from renal venous reflux to alleviate the burden on the kidneys, whereas our objective is to reinstate normal blood flow to the testicles. Similarly, we selected the grade III varicocele patients as study subjects, adopted a high ligation of the spermatic vein with fewer branches, and constructed the bypass from the spermatic vein to inferior epigastric vein under a microscope, which not only retained some of the advantages of varicocelectomy but also recovered the venous drainage of the spermatic cord to restore the testicular venous reflux. In this way, the stagnant venous blood in the testis can be drained after surgery, which is conducive to the vanishing of varicose veins on the surface of the scrotum. 

In order to achieve successful surgery, it is necessary to separate veins of sufficient free length and ensure tension-free anastomosis. Moreover, searching for inferior epigastric vein is challenging and requires extensive anatomical knowledge.

There are some limitations that need to be addressed. The surgical protocol adds more surgical steps, although as time goes on, our surgical techniques continue to mature, and the surgical time continues to shorten. These steps might bring potential complications like bleeding and obstruction during anastomosis. It demands higher requirements for microsurgical techniques and postoperative management, including the application of anticoagulant drugs. Moreover, the protocol makes it impractical to ligate the external spermatic vein and the gubernaculum vein, which are inferred as the most common recurrence routes. Also, it is important to note that due to the short follow-up period, we need to further understand the evaluation of long-term outcomes such as semen quality and pregnancy rate. In addition, the operation time of group A was relatively long, which may bring the risks associated with the long operation time, such as anesthesia risk¹⁶. Moreover, verifying and ensuring long-term patency of the spermatic vein is also a subject that requires follow-up.

Materials

Clexan (Enoxaparin Sodium Injection)	Sanofi (Beijing) Pharmaceutical Co., LTD
CROWNJUN (Nylon suture)	Kono Seisakusho Co., Ltd., Japan
Doppler ultrasonography	Mindray, Shenzhen, China	Resona R9
Microscope	Zeiss, Jena, Germany	OPMI PENTERO 800
Non-absorbable suture	Johnson, (Shanghai) Medical Equipment Co., LTD
Rivaroxaban	Bayer Healthcare GMBH
VICRYL (absorbable surgical suture)	Johnson, (Shanghai) Medical Equipment Co., LTD