Lundy, S. D., & Sabanegh, E. S., Jr. (2018). Varicocele management for infertility and pain: A systematic review. Arab journal of urology, 16(1), 157-170. https://doi.org/10.1016/j.aju.2017.11.003
Lundy SD, Sabanegh ES Jr. Varicocele management for infertility and pain: A systematic review. Arab journal of urology. 2018;16(1):157-170. doi:10.1016/j.aju.2017.11.003
Lundy, Scott D., and Edmund S. Sabanegh, Jr. "Varicocele management for infertility and pain: A systematic review." Arab journal of urology, vol. 16, no. 1, 2018, pp. 157-170.
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Microsurgical varicocele repair appears to have lowest complications
Microsurgical repair through a small cut below the groin appeared to have the lowest complication and failure rates in a 2018 review of 112 studies of men with varicoceles. Varicoceles are swollen veins above the testicle. The summarized risk of fluid around the testicle with this repair was 0.6%.
Key Findings
The review included 112 studies in its qualitative synthesis and used 56 for a quantitative analysis of outcomes by indication and by surgical approach.
Hydrocele (fluid around the testicle) risk appeared lowest with the microsurgical subinguinal approach (0.6%), then open inguinal (5.3%), laparoscopic (6.7%), and retroperitoneal (7.5%).
Recurrence and/or technical failure was lowest with microscopic subinguinal repair (1.2% of cases) and highest with retroperitoneal repair (12.6%).
With microscopic subinguinal repair, which appears to convey the greatest benefit, 41% of postoperative patients achieved spontaneous pregnancy (Table 2).
In studies of men with chronic testicular pain, varicocelectomy success approaches 90%. The data seem to suggest robust improvement in most carefully selected men who had not improved with conservative management.
Interpretation
This systematic review searched PubMed and the Cochrane Library for studies published from 1995 to 2017, then reported outcomes by surgical approach. The authors note that only a minority of men who have varicocelectomy go on to father a pregnancy without further treatment. The findings support larger studies comparing surgical approaches head to head.
RRM Context
Restorative reproductive medicine checks both partners. Male factor contributes in many couples. A doctor can find a varicocele on exam. The review cites an AUA statement. It limits treatment to men with a varicocele a doctor can feel and abnormal semen test results. The statement also asks that the partner have normal fertility, or a fertility problem that can be treated.
Our editorial summary of this paper, not the article's abstract.
Abstract
Despite being first described two thousand years ago, the varicocele remains a controversial multifaceted disease process with numerous biological consequences including infertility, hypogonadism, and chronic orchidalgia. The underlying mechanisms remain poorly understood and likely include hypoxia, oxidative stress, hyperthermia, anatomical aberrations, and genetics as primary components. Despite a high prevalence amongst asymptomatic fertile men, varicoceles paradoxically also represent the most common correctable cause for male infertility. In this systematic review we discuss the rich historical aspects of the varicocele and the contemporary data regarding its clinical manifestations. We performed a systematic literature review with the goal of comparing outcomes and complication rates of each of the major surgical approaches as they relate to infertility and pain. We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)-compliant systematic literature review for manuscripts focused on varicocele and its biological consequences. We identified 112 studies suitable for qualitative analysis and included 56 of these for quantitative analysis, with an emphasis on infertility and chronic pain outcomes. Taken together, the clinical work to date suggests that the highest fertility rates and the lowest complication rates are associated with the microsurgical subinguinal surgical approach to varicocelectomy. In all, 26-40% of patients undergoing varicocelectomy will successfully achieve short-term spontaneous pregnancy, and up to 90% of all patients undergoing varicocelectomy for pain will have improvement and/or resolution of their symptoms. Taken together, the data support an ongoing role for varicocelectomy in both of these clinical arenas.
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