[Varicocele and its repercussion on infertility. Indications and limitations of surgical intervention]

According to different Authors, varicocele incidence in unselected population fluctuates from 8 to 22% but in selected population affected by sterility incidence ranges from 21 to 39%. However other Authors have demonstrated that about 50% of patients suffering from varicocele have semen alterations. Various mechanisms have been suggested for testicular dysfunction associated with varicocele: intrascrotal hyperthermia, reflux of renal and adrenal metabolites from the renal vein and hypoxia. The most important semen alterations are observed in patients suffering from grade 2 and 3 varicocele and especially these patients must undergo surgical operation. According to recent findings, better results about the improvement of semen quality are obtained by operating children in puberal age. This clinical approach allows a prevention of testicular hypotrophy or, when this is already present, its reversibility. Varicocele surgical treatment makes use of traditional techniques microsurgical or not and mininvasive techniques. After renouncing of intrascrotal varicocelectomy, traditional techniques provide ligature and section of ectasic spermatic veins, after a surgical high (at level of the internal inguinal ring) or low (over inguinal canal) skin incision. Microsurgery allows recognition and protection of lymphatic and arterial vessels and execution of microsurgical anastomosis between venous spermatic and ileo-femoral circle vessels, when this is necessary. Internal spermatic vessels and vas deferens can be visualized through the laparoscope and so laparoscopic varicocele treatment was suggested. These new techniques and traditional operation are burdened with the same percentage of relapses but in laparoscopic procedure complications are more important. Recently radiographic occlusion techniques are also utilized (internal spermatic vein retrograde scleroembolization); the percentage of relapses is between 4 and 11%, with no risk of postvaricocelectomy hydrocele but with risk of loss of kidney (migration of the ballon or coil into the renal vein). Surgical treatment of varicocele produces a significant improvement in semen analysis in 60 to 80 per cent of patients affected by testicular dysfunction. Pregnancy rates after varicocelectomy are including from 20 to 60 per cent with most series averaging about 35 per cent.