Bassi R, Radice F, Bergami G, De Grazia F, Papa B
Divisione di Chirurgia Generale, Ospedale S. Marta, Rivolta d'Adda, Cremona.
Minerva Chir. 1996 Jul-Aug;51(7-8):533-6.
Varicocele means a varicose dilatation with stretching of the veins in the pampiniform plexus. In the last years the problem of varicocele has emerged again in all its importance for the increasing of couple sterility which, in Italy, is certified to 13%. It is known that this problem is connected to anomalies of the spermiogram, even in the subclinical forms located with the ultrasound method, and that the surgical operation allows to correct in a high percentage of cases.
For treatment of varicocele we use a technique with inguinal approach of 5-6 cm and isolation of all the dilated veins intra- and extrafunicular. After their ligation and section we transpose the funiculus proximally with a little traction on the testicle and we fix it to the great oblique muscle fascia, using margin of cremasteric muscle prepared in advance and distal stumps of resected veins. This manoeuvre forms a short ansa of the funiculus that, in the orthostatic position, helgs to stop the hematic column which weighs on the testicle. This operation has been performed in 54 patients. In 18 (60%), oligoastenospermia was present and 10 (33%) had consulted their physician for sterility problems (4 of them with a sub-clinical varicocele). The patients have been recalled for clinical and echo-doppler control as well qualitative evaluation of the sperm. The follow-up goes from 8 months to 7 years.
We have noticed the presence of six relapses (13.3%) so divided: 4 relapses with a first grade reflux; 1 relapse with a second grade reflux and 1 relapse with a third grade reflux. Only in two patients with first grade reflux was the spermiogram normal, while in all the others oligoastenospermia persisted. Seric evaluation of testosterone and androstenedione have excluded hormonal causes of sterility. Among the 10 sterile patients 6 (60%), had a normalization of the spermiogram and 4 of them (2 of which with preceding subclinical varicocele), had a partner pregnancy in periods within 7 and 18 months after the operation.
On the basis their experience, the authors confirm the validity of the selective varicocelectomy by inguinal approach, with probable further advantage using funicular transposition. To agree with other authors there isn't any very important advantage, in the cost/benefit ratio, between microsurgical diversion and laparoscopic surgery, and traditional varicocelectomy in local anesthesia. The incidence of relapses noticed (13.3%), lower than that rated at the high ligature (29%), is the expression of the anatomic complexity of the spermatic venous drainage, in such a way to think right a phlebographic anterograde intraoperative evaluation. We also confirm the importance of ultrasonographic and ecographic methods in the pre and postoperative evaluation, we underline that, in the subclinical cases, it is possible to verify spermiogram alteration corrected, in a high percentage, by varicocelectomy.
精索静脉曲张指蔓状静脉丛中静脉的曲张性扩张伴伸长。近年来，精索静脉曲张问题因其在夫妻不育症增加方面的重要性再次凸显，在意大利，夫妻不育症的确诊率为13%。众所周知，即使是超声检查发现的亚临床型精索静脉曲张，该问题也与精液分析异常有关，且手术治疗在很大比例的病例中可起到纠正作用。
对于精索静脉曲张的治疗，我们采用经腹股沟5 - 6厘米切口的技术，分离精索内和精索外所有扩张的静脉。在结扎并切断这些静脉后，我们将精索向近端移位，对睾丸稍作牵引，并利用预先准备好的提睾肌边缘和切除静脉的远端残端将其固定于腹外斜肌腱膜。这一操作形成了精索的短袢，在直立位时有助于阻止压迫睾丸的血柱。该手术共对54例患者实施。其中18例（60%）存在少弱精子症，10例（33%）因不育问题前来就诊（其中4例为亚临床型精索静脉曲张）。患者被召回进行临床、超声多普勒检查以及精液质量评估。随访时间从8个月至7年不等。
我们注意到有6例复发（13.3%），具体情况如下：4例为一级反流复发；1例为二级反流复发；1例为三级反流复发。仅2例一级反流患者的精液分析正常，其他所有患者均持续存在少弱精子症。睾酮和雄烯二酮的血清学评估排除了不育的激素原因。在10例不育患者中；6例（60%）精液分析恢复正常，其中4例（2例之前为亚临床型精索静脉曲张）在术后7至18个月内其配偶怀孕。
基于他们的经验，作者证实了经腹股沟入路选择性精索静脉结扎术的有效性，精索移位可能具有进一步的优势。与其他作者观点一致，在成本效益比方面，显微外科分流术、腹腔镜手术和局部麻醉下的传统精索静脉结扎术之间没有非常显著的优势。所观察到的复发率（13.3%）低于高位结扎术报道的复发率（29%），这体现了精索静脉引流的解剖复杂性，因此术中进行静脉造影顺行评估是合理的。我们还证实了超声检查和超声心动图方法在术前和术后评估中的重要性，强调在亚临床病例中，精索静脉结扎术在很大比例上可纠正精液分析的改变。
