|Ahead of print publication
Commentary on “An alternative surgical technique for varicoceles: a preliminary experience of the microsurgical spermatic (distal end)-inferior or superficial epigastric vein anastomosis in symptomatic varicoceles associated with perineal pain”
Peter N Schlegel
Weill Cornell Medicine, New York, NY 10021, USA
|Date of Submission||29-Apr-2022|
|Date of Acceptance||11-May-2022|
|Date of Web Publication||17-Jun-2022|
Peter N Schlegel,
Weill Cornell Medicine, New York, NY 10021
Source of Support: None, Conflict of Interest: None
Article in PDF
|How to cite this URL:|
Schlegel PN. Commentary on “An alternative surgical technique for varicoceles: a preliminary experience of the microsurgical spermatic (distal end)-inferior or superficial epigastric vein anastomosis in symptomatic varicoceles associated with perineal pain”. Asian J Androl [Epub ahead of print] [cited 2022 Jul 2]. Available from: https://www.ajandrology.com/preprintarticle.asp?id=347733
In the article by Wan et al., the authors have described a different surgical approach limited to the treatment of men with varicoceles and pelvic floor congestion associated with perineal pain. They discuss the procedure used, which is essentially a decompression of the varicocele via anastomosis of the distal spermatic veins to the superficial epigastric veins and postoperative results. This intervention is distinctly different from the standard approach of occlusion of spermatic veins (surgically or by embolization) typically at the subinguinal, inguinal, or retroperitoneal level. The approach in the article resulted in decompression of the veins (25 of 27 men had a mean decrease in spermatic vein size in a paired comparison, with the remaining two patients showing cessation of reflux). Of note, the mean maximum venous diameter for men undergoing varicocele repair was only 2.8 mm, suggesting that some of the men had smaller veins than those typically observed for men with clinical varicoceles.
The study population underwent varicocele repair for an atypical indication for such surgeries. Varicocele repair for pain is a relatively unusual indication for surgery in our experience. Varicocele repair is most commonly indicated for men with infertility, clinical varicoceles, and abnormal semen parameters. It is critical to emphasize that the authors did not directly measure the effect of such a repair on other aspects of testicular function such as semen parameters. Testosterone levels were measured but did not change after surgery, different from what is typically observed for infertile men. In addition, there was no comparison of this surgical approach to the occlusive surgical or interventional techniques that have historically been done for men with varicoceles.
Men in this study were symptomatic with pelvic congestion and perineal/pelvic pain. Relief of pain may also be substantially affected by observer bias after a surgical procedure, so assessment of the benefits of this procedure should reasonably be evaluated only in comparison to other approaches used for pain relief such as a standard surgical varicocele repair by venous occlusion. In addition, scrotal discomfort is generally considered to be more common than perineal pain/pelvic congestion for men with symptomatic varicoceles. These observations suggest that this particular surgical approach for the stated indications may have limited clinical relevance.
It remains to be determined whether this surgical approach has a role in symptomatic varicocele repair, or even is comparable to standard microsurgical varicocelectomy. The article, as written, only provides demonstration in a small, selected group of men that the approach is feasible. As such, it should be considered and evaluated further by andrologic experts.
| Competing Interests|| |
The author declares no competing interests.
| References|| |
Wan Z, Cao HM, Yang BC, Gao Y, Ding L, et al
. An alternative surgical technique for varicoceles: a preliminary experience of the microsurgical spermatic vein (distal end)-inferior or superficial epigastric vein anastomosis in symptomatic varicoceles associated with perineal pain. Asian J Androl
2022. Doi: 10.4103/aja202232. [Online ahead of print].
Schlegel PN, Sigman M, Collura B, De Jonge CJ, Eisenberg ML, et al
. Diagnosis and treatment of infertility in men: AUA/ASRM guideline part II. J Urol
2021; 115: 62–8.
Stahl PJ, Stember DS, Schlegel PN. Interpretation of the semen analysis and initial male factor management. Clin Obstet Gynecol
2011; 54: 656–65.
Schlegel PN, Goldstein M. Alternate indications for varicocele repair: non-obstructive azoospermia, pain, androgen deficiency and progressive testicular dysfunction. Fertil Steril
2011; 96: 1288–93.