Post Date April, 15 2023
The incidence rate of varicocele is about 10%~15% in male population, of which 21%~41% patients seek medical advice due to infertility, which is an important reason for abnormal sperm quality in men. Since Palomo first reported in 1949, the surgical treatment of varicocele has been improved for many times, including inguinal and retroperitoneal ligation, internal spermatic vein embolization, spermatic vein bypass, etc., from the use of magnifying glass and microscope to the use of celioscope. As a basic treatment method, ligation of internal spermatic vein has definite curative effect and rare complications. At present, there is no special literature to analyze, study and summarize its complications. This article takes the transinguinal operation as an example, involving several modified methods at present, and summarizes the complications and possible causes of ligation of varicocele.
1 scrotal edema and hydrocele of testicular sheath
The most common complications after operation are scrotal edema and hydrocele of testicular sheath, with the incidence of 3%~40%. Edema is more likely to occur under the following conditions: ① ligation of bilateral varicocele; ② Postoperative edema was also obvious in patients with a history of inguinal surgery; ③ Deliberately separating the vas deferens may increase the incidence of edema. Severe edema will lead to hydrocele of the testicular sheath. Edema can begin immediately after operation and disappear about 12 months after operation, or it can be maintained for more than 12 months; It has also been reported that edema occurred after 6 months of operation, with an average of 22 months, even 3 years after operation [1]. Therefore, there is a possibility of potential edema at the end of follow-up 1, 3 or 6 months after operation. Edema generally can naturally subside without special treatment, and the average time to subside is about 12 months from the time of emergence. A few patients need puncture and drainage or open surgery.
Compared with open surgery and minimally invasive surgery (including the use of magnifying glass, microscope and laparoscopy), the incidence of edema is reported differently. Many studies believe that the incidence of edema in endoscopic surgery is high [3]. The retrospective study of a single center believes that the incidence of edema in laparoscopic Palomo surgery is increased, but its sample is limited (41 cases). The European multi-center pediatric surgery study showed that the incidence of edema in 278 children undergoing surgery (187 cases of minimally invasive surgery and 91 cases of open surgery) was 12.2%. The time of occurrence ranged from 1 week to 44 months after surgery, with an average of 24 months. The time of edema regression averaged 12 months. About half of the children underwent re-treatment after edema, while there was no difference between open surgery and minimally invasive surgery. However, most literatures believe that there is a difference in the incidence of edema between minimally invasive surgery and open surgery, and even improved minimally invasive surgery can reduce the incidence of edema to zero. The author believes that minimally invasive surgery can reduce the incidence of postoperative edema, which may be related to the pathogenesis of postoperative edema.
At present, it is widely believed that the mechanism of scrotal edema is related to lymphatic injury. The lymphatic vessels accompanying the spermatic cord artery and vein were damaged during the operation, resulting in lymph extravasation and obvious local edema, while the vein had been ligated and the reflux was blocked, and in severe cases, hydrocele of the testicular sheath could occur. Further research [8] pointed out that the average number of lymphatic vessels on each side was 3.2 (0~8), and these lymphatic vessels could be damaged when the mass was ligated. It is easy to separate the testicular artery and lymphatic vessels under the microscope, which is conducive to reducing the incidence of scrotal edema. Therefore, many scholars have improved the operation method, or operated under a magnifying glass/microscope to avoid ligation of lymphatic vessels and reduce or avoid edema [8]; Alternatively, the lymphatic vessel separation under laparoscopy [9] or the marking of lymphatic vessels with dye such as isoprosulan during operation, and the spermatic vein ligation for lymphatic vessel separation [6] have achieved good results, effectively reducing the incidence of postoperative edema. The effect of edema on testicular function and sperm quality is still unclear.
Edema can cause hydrocele of the tunica vaginalis of the testis, and can also cause edema of the testis (parenchyma). Kocvara et al. However, some authors believe that testicular edema on the operative side has no effect on semen parameters and pregnancy rate after operation, and the specific effect needs further study.
2 Vascular injury and testicular atrophy
Testicular artery injury is an unavoidable aspect of Palomo operation. The blood supply of the testis mainly comes from three aspects: the internal spermatic artery (testicular artery), the vas deferens artery and the levator muscle artery, all of which are accompanied by the same vein, which constitutes the spermatic vein. Palomo surgery often ligates the internal spermatic cord artery and vein at the same time, and the spermatic cord artery can be separated during the inguinal surgery. Chan et al. made statistics on the postoperative situation of patients who had accidentally ligated the testicular artery during the operation, and found that in 2102 cases of minimally invasive surgery, 19 cases (0.9%) confirmed that unilateral testicular artery was ligated unintentionally, and the natural pregnancy rate after the operation was only 14%, far lower than the 46% reported in the literature; In 19 cases, 1 case (5%) had testicular atrophy; The risk of testicular artery being ligated by mistake is higher in small testicles; The protection of the levator muscle artery can help reduce the incidence of such adverse events. It is recommended to try to protect the blood supply of the testicular artery to the testis.
However, most scholars believe that there are abundant anastomotic branches between the internal spermatic artery, the vas deferens artery and the levator muscle artery. Even if the testicular artery is ligated by mistake, the latter two branches are enough to provide sufficient blood supply for the testicle, without serious consequences. Riccabona et al. compared four surgical methods of spermatic vein ligation: standard Palomo operation (via retroperitoneal mass ligation), laparoscopic Palomo operation, inguinal operation (separation of testicular artery) and modified Palomo operation (via inguinal and retroperitoneal ligation of artery and vein, and marking and separation of lymphatic vessels with blue dye). After an average of 52 months of follow-up, there was no testicular atrophy, and the testicular volume increased significantly after surgery, which also proved this view laterally. Grober et al. studied the changes of FSH, LH, testicular volume and postoperative semen analysis parameters in patients with testicular artery preservation, and believed that there was no correlation between testicular artery preservation during operation and postoperative semen analysis parameters.
