슬라이드 1 - cmcuro.net

슬라이드 1 - cmcuro.net

Tips & Tricks: Scrotal disease - Varicocele Woo, Seung Hyo Dept. of Urology, Eulji university College of Medicine, Daejeon, Korea Introduction First description by Celsus veins that are swollen and twisted over testi cle, which becomes smaller that fellow . Prevalence Adolescent: 15% P (35-50%) / S (69-81%) : progressive

Need early intervention ! Introduction (Cont) WHO : Varicocele is ass with Decreased testicular volume Impaired sperm quality Decline in Leydig cell function Several studies results 70% of healthy palpable varicocele men Abnormal S/A Progressive & duration dependent testicular damage

Randomized, controlled, cross-over study Varicocelectomy significantly improved pregnanc y rates Anatomy Artery Internal spermatic a. : gonadal artery External spermatic a. : cremasteric a. Vasal artery Vein Internal spermatic (gonadal) v. : one in 60% External spermatic vein

Gubernacular vein Lymphatics 3.6 in spermatic cord Three compartments Vas & vasal vs. Pampiniform plexus External

spermatic vessels Pathophysiology 1. Hyperthermia 2. Reflux of metabolites 3. Hot Rock theory 37 33~34 Formula

Vol r2 , R 1/r4 , Vel 1/r2 Venous diameter Venous wall thickening Venous volume Resistance & velocity Testicular

temperature Wash out phenomenon (dilution of intratesticular testosterone) Impaired countercurrent heat exchange Impaired

spermatogenesi s Alteration of germ cell metabolism and function, induce arteriovenous shunting, decreasing activity of enzymes of DNA synthesis, increase apoptosis, induce hypoxia Prognostic indication (+) predictive value Grade III Normal FSH Lack of testicular at rophy

Motility > 60% (+) GnRH stimulati on test Total motile sper m > 5 x 106 Indication for surgery Ipsilateral growth arrest/ atrophy Multiple etiology of testi cular dysfunction

Abnormal S/A Absolu te Bilaterality Grade III Soft ipsilateral testis Pain Abnormal GnRH stimulat ion test Patient/parent anxiety Abnormal scrotal appear

ance Minor VARICOCELECTOMY Retroperitone al Inguinal Subinguinal

Management : Palomo Palomo technique Ligation of gonadal vessels Modified Palomo technique Ligation of gonaldal vein Complication Recurrence: 11-15% Hydrocele: 7% Hydrocele: 5-9% Recurrence: 5-14%

Laparoscopic varicocelecto my Management : Ivanissevich Inguinal approach Familiar region

Ease to approach to cord Recurrence rate: 9-16% ( : 5-15%) Hydrocele: 3-39% ( : 0-7%) Management : embolization Recently popularized method Not need an anesthesia Less invasive Failure rate: 27% Recurrence: 4-11% Hydrocele: 0% Cayan S, et al. J Androl

2009 Management : microsurgical Best way of varicocele management Inguinal Vs. Subinguinal Recurrence: <1% (inguinal: 1-2%) Hydrocele: nearly 0% 1994, Marmar & Kim Subinguinal approach

Less morbidity (reserve fascia & muscle) Short recovery time Less post-op pain More complex Surgical technique Comparison of different techniques used for va ricocele repair technique

Radiographic occlusion Retroperitone al Laparoscopic Conventional inguinal Microscopic inguinal Artery preserv ed

Hydrocel e (%) Failure (%) Serious morbidi ty potenti al

Yes 0 4-11 Yes No 7 15-25

No Yes No 12 3-30 5-15 5-15 Yes

No Yes 0 1 No Tips-1 Incision length Width of testis

2~3cm Incision site Inguinal Subinguinal Tips-2 Ligation of external spermatic vein & gubernacular veins Tips-3 Division into two compartments Pampiniform & vasal compartment

Zini et al. Rt : 22 min Lt : 6 min Zini et al. Urology 2006 Tips-4 Identification of arterial pulse 1. Using micro probe 2. Dripping papaverine 3. Shift downward : ext. ring prepubic Tips-4 (cont)

4. Identification of pulse by anatomy Above all, ligate bridge vessels Then, dissect large veins vertically Dont ligate large vein till isolation of artery if pos sible Tips-4 (cont) 4. Identification of pulse by anatomy Above all, ligate bridge vessels Then, dissect large veins vertically Dont ligate large vein till isolation of artery if pos sible

Tips-5 Prevention to risk of hydrocele 1. Save lymphatics 2. Prophylactic hydrocelectomy (plication) Not saved lymphatics Not identified lymphatics Conclusions

Unique purpose of varicocelectomy Optimization of testicular environment Improvement of spermatogenesis Selection of technique Higher success rate Lower complication Less invasive Microsurgery Conclusions (cont) Considerations in Microscopic varicoc electomy

Completely understanding of anatomy The Site of Incision Identification of Arterial Pulse Alter the site of incision Using papaverine or micro probe Disconnecting crossing-vessel at first Prevention of Hydrocele !

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