Kaltsas Aris, Dimitriadis Fotios, Chrisofos Michael, Sofikitis Nikolaos, Zachariou Athanasios
Third Department of Urology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece.
Laboratory of Spermatology, Department of Urology, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece.
Medicina (Kaunas). 2024 Dec 13;60(12):2056. doi: 10.3390/medicina60122056.
Varicocele repair in men with non-obstructive azoospermia (NOA) remains a subject of debate due to inconsistent outcomes. This study aimed to evaluate the impact of microsurgical varicocelectomy on sperm recovery rates in men with NOA and to assess the role of varicocele grade and testicular histopathology in predicting postoperative outcomes. A retrospective cohort study was conducted of 78 men diagnosed with NOA and clinical varicocele who underwent microsurgical subinguinal varicocelectomy with simultaneous diagnostic and therapeutic testicular biopsy at the Department of Urology of the University of Ioannina between September 2013 and December 2021. Varicoceles were graded I to III based on physical examination and Doppler ultrasound. Histopathological patterns were classified as hypospermatogenesis (HYPO), early maturation arrest (EMA), late maturation arrest (LMA), or Sertoli cell-only syndrome (SCOS). Patients were followed postoperatively at 3, 6, 9, and 12 months, with semen analyses performed according to World Health Organization guidelines to assess sperm presence. At the 12-month follow-up, spermatozoa were detected in the ejaculate of 26 out of 78 patients, resulting in an overall sperm return to ejaculate rate of 33.3%. Varicocele grade significantly influenced outcomes: patients with Grade II varicoceles had the highest sperm return to ejaculate rate (45.2%, 14/31), followed by Grade III (39.1%, 9/23) and Grade I (12.5%, 3/24) (-value < 0.05). The sperm retrieval rate (SRR) from testicular biopsies also varied with varicocele grade: Grade II had the highest SRR (54.8%, 17/31), followed by Grade III (47.8%, 11/23) and Grade I (33.3%, 8/24). Histopathological findings were significant predictors of sperm retrieval: patients with HYPO had an SRR of 84.8% (28/33) and a sperm return to ejaculate rate of 66.7% (22/33); those with LMA had an SRR of 47.1% (8/17) and a sperm return rate of 23.5% (4/17). No sperm retrieval was observed in patients with EMA (0%, 0/4) or SCOS (0%, 0/24) (-value < 0.01). Multivariate logistic regression identified varicocele grade and histopathology as independent predictors of sperm retrieval, with higher grades and favorable histopathology associated with increased likelihood of success. Microsurgical varicocelectomy can induce spermatogenesis in a significant proportion of men with NOA, particularly those with higher-grade varicoceles and favorable histopathological patterns such as HYPO or LMA. Varicocele grade and histopathological findings are important predictors of postoperative outcomes and should inform patient selection and counseling. These findings provide valuable insights for optimizing fertility treatments in men with NOA undergoing varicocele repair.
由于治疗结果不一致，非梗阻性无精子症（NOA）男性的精索静脉曲张修复术仍是一个有争议的话题。本研究旨在评估显微外科精索静脉结扎术对NOA男性精子恢复率的影响，并评估精索静脉曲张分级和睾丸组织病理学在预测术后结果中的作用。对2013年9月至2021年12月在约阿尼纳大学泌尿外科接受显微外科腹股沟下精索静脉结扎术并同时进行诊断性和治疗性睾丸活检的78例诊断为NOA和临床精索静脉曲张的男性进行了一项回顾性队列研究。根据体格检查和多普勒超声将精索静脉曲张分为I至III级。组织病理学模式分为生精低下（HYPO）、早期成熟停滞（EMA）、晚期成熟停滞（LMA）或唯支持细胞综合征（SCOS）。术后对患者进行3、6、9和12个月的随访，根据世界卫生组织指南进行精液分析以评估精子存在情况。在12个月的随访中，78例患者中有26例在射精中检测到精子，总体精子恢复到射精率为33.3%。精索静脉曲张分级对结果有显著影响：II级精索静脉曲张患者的精子恢复到射精率最高（45.2%，14/31），其次是III级（39.1%，9/23）和I级（12.5%，3/24）（P值<0.05）。睾丸活检的精子获取率（SRR）也随精索静脉曲张分级而变化：II级的SRR最高（54.8%，17/31），其次是III级（47.8%，11/23）和I级（33.3%，8/24）。组织病理学结果是精子获取的重要预测因素：HYPO患者的SRR为84.8%（28/33），精子恢复到射精率为66.7%（22/33）；LMA患者的SRR为47.1%（8/17），精子恢复率为23.5%（4/17）。EMA（0%，0/4）或SCOS（0%，0/24）患者未观察到精子获取（P值<0.01）。多因素逻辑回归确定精索静脉曲张分级和组织病理学是精子获取的独立预测因素，较高分级和良好的组织病理学与成功可能性增加相关。显微外科精索静脉结扎术可在相当比例的NOA男性中诱导精子发生，特别是那些患有较高分级精索静脉曲张和具有良好组织病理学模式如HYPO或LMA的男性。精索静脉曲张分级和组织病理学结果是术后结果的重要预测因素，应指导患者选择和咨询。这些发现为优化接受精索静脉曲张修复的NOA男性的生育治疗提供了有价值的见解。
