MICROSURGICAL TREATMENT OF VARICOCELE: SELECTING MOST APPROPRIATE SHUNT GIANCARLO FLATI, M.D. BARBARA POROWSKA, M.D. DONATO FLATI, M.D. MANLIO CARBONI, M.D. From the Patologia Chirurgiea V, Policlinieo Umberto I, University of Rome "La Sapienza," Rome, Italy
•
A
CT--Microsurgical drainage of spermatic veins tailored to the hemodynamic type of vari, peqormed in 20 patients. In 14 cases the procedure was indicated as prophylaxis and in 6 ::~ treai~ment of infertility. Complete regression of varicosities was observed in 75 percent as ~ i 9 ~ six days postoperatively, in 85 percent at two weeks, and in 90 percent at twelve months. In ~ imaining 10 percent, a consistent reduction of varicocele was found. No patient experienced ~ g ! ~ s i o n of the disease. Eighty-three percent of the patients with altered seminal parameters ~ i ~ ~d an improvement of them at a mean follow-up of 9.1 months
~
cocele deserves treatment w h e n cosmetic scrotal deformities or comfort to the patient. It is also cause of male infertility. It is it 15-30 percent of young males i and twenty years old, and in 1 ats it is associated with a pathoram. 1-3 Furthermore, varicocele ~-40 percent of adult infertile or ~s. The pathologic events impli;tress pattern of seminal fluid Lly lead to subfertility or infertilrelated to testicular hypoxic staperthermia, and renospermatic al metabolites. 4 In two thirds of th varicocele, high levels of seron found. 5 Phospholipase H2 and 72~ were also elevated. 6 ',se observations, surgical eorrec~ase is advisable. The most pop'eatment of varieoeele currently re described in 1918 by Ivanisng in division of the spermatic ~*~OLOGY ....
/
FEBRUARY 1990
/
vein at the level of internal inguinal ring. This procedure is followed by normalization of seminal parameters in 20-50 pereent of the patients. Failure in obtaining eosmetic results are observed in 5 percent to 40 percent of the patients. 3.7.s Anatomic and hemodynamic factors may account for the treatment failures. Variations in the internal spermatic vein, which may in some cases be double or triple for the presence of collaterals between testicular vein and extraspermatic vessels (peri-renal veins, inferior vena eava, lumbar vessels, colie veins and portal system, prepubic right-left suprapubie and pelvic anastomoses) cast doubts on the therapeutic efficacy of the Ivanissevieh operation. Furthermore this procedure would be contraindicated w h e n the varicocele is caused by a distal "nutcracker phenomenon" resulting from compression of the left iliac vein by the right fliae artery or caused by a proximal nutcracker effect (aorto-mesenteric compression of left renal vein) (Fig. 1).
VOLUME XXXV, NUMBER 2
i21
FIGURE 1. Hemodynamic classification of varicocele according to Coolsaet: type I, proximal "nutcracker"; type H, distal "nutcracker"; type 111, type 1 + type IL In 1970 Ishigami et al. ° proposed a microsurgical drainage between the spermatic vein and the saphenous vein. Subsequently Fox, Romagnoli, and Colombo x° introduced a modification of this procedure, anastomosing 1-3 spermatic veins to the saphenous vein using a microvascular technique. Belgrano et al. n suggested an alternative drainage to the inferior epigastrie vein. Both groups reported satisfactory preliminary results. Although apparently similar, the saphenous and epigastrie systems used to drain the spermatic veins have hemodynamic differences. We report our experience with a selective mierosurgieal treatment of varieocele based on hemodynamie features. Material and Methods Twenty patients (mean age 29, years; range 17-38) with idiopathie varieoeele referred to our Institution from January, 1985, to January, 1987, underwent microsurgieal treatment. Three of them had recurrent varieoeele after the Ivanissevich procedure, and in one after bilateral ligation. Preoperative investigations include physical examination, semen analysis, scrotal thermography, ultrasound examination, 122
and Doppler velocimetry. In 1 . . . . . varicocele, transcrotal phh deemed neeessary. Aecordinl dynamic classification propo,, (Fig. 1) 14 patients had type I tients had type II, and 2 parle Sixteen patients had a varicoc~ ble and palpable without a V~ (grade III), and 4 had varic~ palpable but not visible withol neuver (grade II). Six patient.. grade II) had severe fertility d creased seminal parameters < 20 mil/cc, 1 hour motility crosurgical techniques were etiopathogenetic type of varlet I group (proximal nutcrackel saphenous shunt was performe ble shunt between two sperma collaterals of the saphenous formed in 13. In 2 teenage pat; and particularly voluminous v drainage (total shunting) into gastric vein (end to side) and collaterals (end to end) were patients with type III, a prox epigastrie drainage was perforl affected by left varicocele ar hernia spermatico-saphenous shunts plus hernioplasty were Operative Techniques Spermatico-saphenous coil (Figs. 2 and 3) The skin incision is exter the hemiscrotum to a point is felt. This incision allows spermatic cord up to the e~ Saphenous vein and a] carefully dissected and isc luminous spermatic veins sected and freed from any, crosurgieal technique and, (Zeiss 6X) or loops (2.5 X) of the vessels. Usually it is 1 the external inguinal ring, ciated groin hernia is presc vessels have been isolated fi they can be anastomosed nous collaterals. They ar~ while the distal stumps are mosed in end-to-side or p fashion to the medial or sl the saphenous vein using . . . . . . tinuous sutures.
UROLOGY
/ FEBRUARY!990
/ VOLUME
XXXV, N U ~
r
/ J
4 t
~/}i~ i2 Double drainage between two sperco~issels(sv 1, sv 2), saphenous veto (sa.v), and ~ ~oilaterals (sc), respectively.
%
Spermatico-epigastric shunts: (1) endto-side, (2) distal end, to-end, and (3) proximal end, to-end. FIcumz 4.
Spermatic epigastAc shunt (Figs. 4 and 5) An inguino-pubie skin incision is performed on the anterior wall of the inguinal channel. The external obliquis fascia is opened in order to isolate the funiculus spermatieus. At the level of the internal inguinal orifice, the inferior epigastric vein is isolated for a 2 to 3-cm segment. The longest spermatic vein is isolated as well and a spermatic-epigastric anastomosis is performed according to the hemodynamic type of varicocele: end-to-end proximal shunt (type II), end-to-end distal shunt (type I), and end-to-side shunt (type III or type I). In teenagers with uncertain hemodynamic pattern a total drainage is obtained performing an end-to-side spermatieo-epigastric shunt and a spermaticosaphenous shunt (Fig. 6). All shunted patients are treated with intraoperative and early postoperative infusion of dextran followed by antisludging treatment for six days. Results
~e~-
tgh
F E B R U A R Y 1990
/
All patients experienced a postoperative course without any significant complication. Within one week, a complete disappearance of the varicosities was observed in 75 percent of the cases; in 20 percent the size of the varices was consistently reduced, while in 5 percent it
V O L U M E XXXV, N U M B E R 2
123
FICUaE 5. (A) Operative view o~ spermatic vein (sv) and inferior epigastric vein (iev) after dissectNh:~N Proximal end-to-end spermatico-epigastric shunt (arrow).
o J ¢
J
J t Z
/J f
f
i
jJ j
s
was unchanged (Fi: of the patients w, point of view, wh: tients, after single there was a consiste eosities still could findings were conf: aminations perfon months postoperatJ alterations of semi sults were obtaine was documented, rameters returned thirty-eight-year-ol ment observed at varicosities had dis reduction occurred Comment Several sur g ical P rocedures for v a r i e ~ have been proposed since 1918 when ! ~ ! ! ~ sevieh deseribe~t his procedure of dividl either to epigastric vein (end-to-end shunt, 1; en~'l to-side shunt, la) or to sapheno~ vein (2).
124
UROLOGY
/ FEBRUARY1990 / VOLUME XXXV, N U M ~
Na~nE 7 Young patient ~aricocele (A) before ~a~lon, and (B) one week ~ total drainage.
level of internal inas the first attempt for Lof varieocele assumeflux was the cause of this etiopathogenetic ;nged recently because tom the procedure and the complex anatomic tures of the varico,olsaet 18 classification, ~y a distal nutcracker ;in compressed by right ~terized by an iliacovaricoeele type III is a ~roximal and distal reIt appears that only in ae spermatic vein may ercent of the patients, ly be present, and in them are found at the rnal inguinal ring. The aight be incomplete alaim that preoperative the risk. We do think tportant but may give especially w h e n perIn any ease the interlumn too distally may, owed by recurrence of a some authors suggest ao) or even a ligature presuming that at this trunk is usually found. erruption might be by.... ~ _~ . . . . . . important anastomosis
~l~.OLOGy,
FEBRUARY 1990
between different levels of the spermatic vein and a true network of collaterals of other venous systems. Anastomosis of the spermatie system with renal veins, with inferior vena eava, with intercostal veins, with ureteral veins, with lumbar and perivertebral veins, with epigastric veins, along with vertical anastomosis between different spermatie vein segments, with iliac system, with contralateral spermatie vein, or with eontralateral spermatie plexus have been well d o c u m e n t e d by Chatet et al. 17 These authors also demonstrated a very high incidence of anastomosis between the left spermatic vein and the portal system (45.4%). All these considerations substantiate the rationale for microsurgieal drainage of the spermatic system tow a r d a lower pressure system such as the saphenous or epigastric vein. The high number of infertile patients among those affected by varicocele reinforces the necessity of treating the disease to reverse the seminal alterations or prevent them at an early stage of the disease. Ivanissevich or Palomo procedures do not represent as logical approach as prophylaxis to infertility in a young patient with varicocele since in a number of cases they w o u l d be h e m o d y n a m i e a l l y i n a d e q u a t e . Furthermore, since the functional successes of varicoeele surgical correction are inversely" related to age, it follows that a more effective operation should be done as early as possible after puberty. We believe that drainage procedures are advisable in prophylactic treatment of infertility in varieoeele provided that the type of shunt is hemodynamically tailored to the individual patient.19 Following this program we observed at
VOLUME XXXV, NUMBER 2
125
twelve months that 90 percent of the patients were cured from a cosmetic point of view and the remaining 10 percent experienced size reduction of the varices. In 83.3 percent of patients with alterations of seminal parameters, a satisfactory improvement was observed. The most surprising result was the disappearance of serotal varieosities as early as two weeks in 85 percent of the patients. In conclusion, we believe that hemodynamie and anatomic guidelines of the testieular and scrotal venous system should be the basis for selecting a suitable mierosurgieal drainage for varicoeele. Patologia Chirurgiea V Policlinico Umberto I University of Rome "La Sapienza" 00161 Rome, Italy (DB. FLATI) References 1. Aafjes JH, and Van Der Vijver JCM: Fertility of men with and without waricocele, Fertil Steril 43" 901 (1985). 2. Coekett ATK, Takihnara H, and Cosentino MJ: The varicoe,ele, Fcrtil Steril 41:5 (1984). 3. Poizat R~ and Steg A: Varicocele and infertility, facts, ineertitudes and hypotheses, Sere HSp Paris 59:1341 (1983). 4. Harrison RG: Effect of temperature on the mammalian testis, in Hamilton DW, and Greep RO (Eds): Handbook of Physiology, Baltimore,, Williams & Wflkins, vol 5, 1975, p 64.
126
5. Caldamone AA, A1-Juburi A, an, cele: elevated serotonin and infertilit) 6. Hudson RW, Perez-Marrero tL4 Kay DE: Hormonal parameters of rr and after varicocelectomy, Fertfl Ster 7. Ross LS, Lipson S, and Dritz S: cocele, Urology 19:179 (1982). 8. Tinga DJ, et ah Factors related fertility after varicocele operation, Fc 9. Ishigami K, Yoshida Y, Hiraoke operation for varicocele: use of micr~ gery 67:620 ( 1 9 7 0 ) . . -~4~ ';~v~ 10. Fox U, Romagnoli G, and Colombo F: The mmr0sui:~ drainage of the varicocele, Fertil Sterfl 41:475 (1984). : : ~ ! 11. Belgrano E, e t a h Microsurgicalspermatieoepigastri~ 5:44 '(,~~~ e~s~ tomosis for treatment of varicocele, Microsurgery tecnica nella 12. Contessini-Avesani E, et ah Variante :~::~:;z~ zione chirurgica del varicocele, Min Chir 40:29 (1985)i :::.:~J~ 13. Erembourg L, Pricolo VE, Ronchi F, and Orena C: A ~ i ~ orientamenti nella terapia 'ebhrurgica del varieocele m a i ~ idiopatieo, Min Chir 38:187 (1983), i'.~,~i~ {-~'~ 14. Marmar JL, DeBenedictis TJ, and Prmss DE: The m a ~ . ment of varicoceles by microdissection of the spermatic c ~ the external inguinal ring, Fcrtfl Steril 43:583 (1985). :~,~ :~ 15. Mvrag B, et ah Percutaneous venography aI'1d occlas~0l the management of spermatic varicocetes, AJR 142:635 ~ ( ~ 16. Sayfan J~ Adam YG, and Softer Y: A new entity in ~it~.~ cele subfertility: the "cremasteric reflux," Fertil Steril ~!': 17. Chatel A, Bigot JM, Dectot H, and Helenon C: Ana[5~ radiologique des veines spermatiques. Apropos de 152 phie~j~
raphiesspermatiquesretrograde,J Chir i15:443 (1978):~i~!~ 18. Coolsaet BLRA: The varieocele syndrome: v e n o g r a p h ~ termining the optimal level for surgical management, J U ~ 833 (1980). t:~ 19. Flati G, Flati D, Porowska B, and Carboni M: I s ~ surgical drainage of varie,ocele a logical treatment? Urbi~'~!~ 463 (1987).
UROLOGY
/
FEBRUARY1990
/ VOLUME XXXV, N U M ~
•
A
CT--Microsurgical drainage of spermatic veins tailored to the hemodynamic type of vari, peqormed in 20 patients. In 14 cases the procedure was indicated as prophylaxis and in 6 ::~ treai~ment of infertility. Complete regression of varicosities was observed in 75 percent as ~ i 9 ~ six days postoperatively, in 85 percent at two weeks, and in 90 percent at twelve months. In ~ imaining 10 percent, a consistent reduction of varicocele was found. No patient experienced ~ g ! ~ s i o n of the disease. Eighty-three percent of the patients with altered seminal parameters ~ i ~ ~d an improvement of them at a mean follow-up of 9.1 months
~
cocele deserves treatment w h e n cosmetic scrotal deformities or comfort to the patient. It is also cause of male infertility. It is it 15-30 percent of young males i and twenty years old, and in 1 ats it is associated with a pathoram. 1-3 Furthermore, varicocele ~-40 percent of adult infertile or ~s. The pathologic events impli;tress pattern of seminal fluid Lly lead to subfertility or infertilrelated to testicular hypoxic staperthermia, and renospermatic al metabolites. 4 In two thirds of th varicocele, high levels of seron found. 5 Phospholipase H2 and 72~ were also elevated. 6 ',se observations, surgical eorrec~ase is advisable. The most pop'eatment of varieoeele currently re described in 1918 by Ivanisng in division of the spermatic ~*~OLOGY ....
/
FEBRUARY 1990
/
vein at the level of internal inguinal ring. This procedure is followed by normalization of seminal parameters in 20-50 pereent of the patients. Failure in obtaining eosmetic results are observed in 5 percent to 40 percent of the patients. 3.7.s Anatomic and hemodynamic factors may account for the treatment failures. Variations in the internal spermatic vein, which may in some cases be double or triple for the presence of collaterals between testicular vein and extraspermatic vessels (peri-renal veins, inferior vena eava, lumbar vessels, colie veins and portal system, prepubic right-left suprapubie and pelvic anastomoses) cast doubts on the therapeutic efficacy of the Ivanissevieh operation. Furthermore this procedure would be contraindicated w h e n the varicocele is caused by a distal "nutcracker phenomenon" resulting from compression of the left iliac vein by the right fliae artery or caused by a proximal nutcracker effect (aorto-mesenteric compression of left renal vein) (Fig. 1).
VOLUME XXXV, NUMBER 2
i21
FIGURE 1. Hemodynamic classification of varicocele according to Coolsaet: type I, proximal "nutcracker"; type H, distal "nutcracker"; type 111, type 1 + type IL In 1970 Ishigami et al. ° proposed a microsurgical drainage between the spermatic vein and the saphenous vein. Subsequently Fox, Romagnoli, and Colombo x° introduced a modification of this procedure, anastomosing 1-3 spermatic veins to the saphenous vein using a microvascular technique. Belgrano et al. n suggested an alternative drainage to the inferior epigastrie vein. Both groups reported satisfactory preliminary results. Although apparently similar, the saphenous and epigastrie systems used to drain the spermatic veins have hemodynamic differences. We report our experience with a selective mierosurgieal treatment of varieocele based on hemodynamie features. Material and Methods Twenty patients (mean age 29, years; range 17-38) with idiopathie varieoeele referred to our Institution from January, 1985, to January, 1987, underwent microsurgieal treatment. Three of them had recurrent varieoeele after the Ivanissevich procedure, and in one after bilateral ligation. Preoperative investigations include physical examination, semen analysis, scrotal thermography, ultrasound examination, 122
and Doppler velocimetry. In 1 . . . . . varicocele, transcrotal phh deemed neeessary. Aecordinl dynamic classification propo,, (Fig. 1) 14 patients had type I tients had type II, and 2 parle Sixteen patients had a varicoc~ ble and palpable without a V~ (grade III), and 4 had varic~ palpable but not visible withol neuver (grade II). Six patient.. grade II) had severe fertility d creased seminal parameters < 20 mil/cc, 1 hour motility crosurgical techniques were etiopathogenetic type of varlet I group (proximal nutcrackel saphenous shunt was performe ble shunt between two sperma collaterals of the saphenous formed in 13. In 2 teenage pat; and particularly voluminous v drainage (total shunting) into gastric vein (end to side) and collaterals (end to end) were patients with type III, a prox epigastrie drainage was perforl affected by left varicocele ar hernia spermatico-saphenous shunts plus hernioplasty were Operative Techniques Spermatico-saphenous coil (Figs. 2 and 3) The skin incision is exter the hemiscrotum to a point is felt. This incision allows spermatic cord up to the e~ Saphenous vein and a] carefully dissected and isc luminous spermatic veins sected and freed from any, crosurgieal technique and, (Zeiss 6X) or loops (2.5 X) of the vessels. Usually it is 1 the external inguinal ring, ciated groin hernia is presc vessels have been isolated fi they can be anastomosed nous collaterals. They ar~ while the distal stumps are mosed in end-to-side or p fashion to the medial or sl the saphenous vein using . . . . . . tinuous sutures.
UROLOGY
/ FEBRUARY!990
/ VOLUME
XXXV, N U ~
r
/ J
4 t
~/}i~ i2 Double drainage between two sperco~issels(sv 1, sv 2), saphenous veto (sa.v), and ~ ~oilaterals (sc), respectively.
%
Spermatico-epigastric shunts: (1) endto-side, (2) distal end, to-end, and (3) proximal end, to-end. FIcumz 4.
Spermatic epigastAc shunt (Figs. 4 and 5) An inguino-pubie skin incision is performed on the anterior wall of the inguinal channel. The external obliquis fascia is opened in order to isolate the funiculus spermatieus. At the level of the internal inguinal orifice, the inferior epigastric vein is isolated for a 2 to 3-cm segment. The longest spermatic vein is isolated as well and a spermatic-epigastric anastomosis is performed according to the hemodynamic type of varicocele: end-to-end proximal shunt (type II), end-to-end distal shunt (type I), and end-to-side shunt (type III or type I). In teenagers with uncertain hemodynamic pattern a total drainage is obtained performing an end-to-side spermatieo-epigastric shunt and a spermaticosaphenous shunt (Fig. 6). All shunted patients are treated with intraoperative and early postoperative infusion of dextran followed by antisludging treatment for six days. Results
~e~-
tgh
F E B R U A R Y 1990
/
All patients experienced a postoperative course without any significant complication. Within one week, a complete disappearance of the varicosities was observed in 75 percent of the cases; in 20 percent the size of the varices was consistently reduced, while in 5 percent it
V O L U M E XXXV, N U M B E R 2
123
FICUaE 5. (A) Operative view o~ spermatic vein (sv) and inferior epigastric vein (iev) after dissectNh:~N Proximal end-to-end spermatico-epigastric shunt (arrow).
o J ¢
J
J t Z
/J f
f
i
jJ j
s
was unchanged (Fi: of the patients w, point of view, wh: tients, after single there was a consiste eosities still could findings were conf: aminations perfon months postoperatJ alterations of semi sults were obtaine was documented, rameters returned thirty-eight-year-ol ment observed at varicosities had dis reduction occurred Comment Several sur g ical P rocedures for v a r i e ~ have been proposed since 1918 when ! ~ ! ! ~ sevieh deseribe~t his procedure of dividl either to epigastric vein (end-to-end shunt, 1; en~'l to-side shunt, la) or to sapheno~ vein (2).
124
UROLOGY
/ FEBRUARY1990 / VOLUME XXXV, N U M ~
Na~nE 7 Young patient ~aricocele (A) before ~a~lon, and (B) one week ~ total drainage.
level of internal inas the first attempt for Lof varieocele assumeflux was the cause of this etiopathogenetic ;nged recently because tom the procedure and the complex anatomic tures of the varico,olsaet 18 classification, ~y a distal nutcracker ;in compressed by right ~terized by an iliacovaricoeele type III is a ~roximal and distal reIt appears that only in ae spermatic vein may ercent of the patients, ly be present, and in them are found at the rnal inguinal ring. The aight be incomplete alaim that preoperative the risk. We do think tportant but may give especially w h e n perIn any ease the interlumn too distally may, owed by recurrence of a some authors suggest ao) or even a ligature presuming that at this trunk is usually found. erruption might be by.... ~ _~ . . . . . . important anastomosis
~l~.OLOGy,
FEBRUARY 1990
between different levels of the spermatic vein and a true network of collaterals of other venous systems. Anastomosis of the spermatie system with renal veins, with inferior vena eava, with intercostal veins, with ureteral veins, with lumbar and perivertebral veins, with epigastric veins, along with vertical anastomosis between different spermatie vein segments, with iliac system, with contralateral spermatie vein, or with eontralateral spermatie plexus have been well d o c u m e n t e d by Chatet et al. 17 These authors also demonstrated a very high incidence of anastomosis between the left spermatic vein and the portal system (45.4%). All these considerations substantiate the rationale for microsurgieal drainage of the spermatic system tow a r d a lower pressure system such as the saphenous or epigastric vein. The high number of infertile patients among those affected by varicocele reinforces the necessity of treating the disease to reverse the seminal alterations or prevent them at an early stage of the disease. Ivanissevich or Palomo procedures do not represent as logical approach as prophylaxis to infertility in a young patient with varicocele since in a number of cases they w o u l d be h e m o d y n a m i e a l l y i n a d e q u a t e . Furthermore, since the functional successes of varicoeele surgical correction are inversely" related to age, it follows that a more effective operation should be done as early as possible after puberty. We believe that drainage procedures are advisable in prophylactic treatment of infertility in varieoeele provided that the type of shunt is hemodynamically tailored to the individual patient.19 Following this program we observed at
VOLUME XXXV, NUMBER 2
125
twelve months that 90 percent of the patients were cured from a cosmetic point of view and the remaining 10 percent experienced size reduction of the varices. In 83.3 percent of patients with alterations of seminal parameters, a satisfactory improvement was observed. The most surprising result was the disappearance of serotal varieosities as early as two weeks in 85 percent of the patients. In conclusion, we believe that hemodynamie and anatomic guidelines of the testieular and scrotal venous system should be the basis for selecting a suitable mierosurgieal drainage for varicoeele. Patologia Chirurgiea V Policlinico Umberto I University of Rome "La Sapienza" 00161 Rome, Italy (DB. FLATI) References 1. Aafjes JH, and Van Der Vijver JCM: Fertility of men with and without waricocele, Fertil Steril 43" 901 (1985). 2. Coekett ATK, Takihnara H, and Cosentino MJ: The varicoe,ele, Fcrtil Steril 41:5 (1984). 3. Poizat R~ and Steg A: Varicocele and infertility, facts, ineertitudes and hypotheses, Sere HSp Paris 59:1341 (1983). 4. Harrison RG: Effect of temperature on the mammalian testis, in Hamilton DW, and Greep RO (Eds): Handbook of Physiology, Baltimore,, Williams & Wflkins, vol 5, 1975, p 64.
126
5. Caldamone AA, A1-Juburi A, an, cele: elevated serotonin and infertilit) 6. Hudson RW, Perez-Marrero tL4 Kay DE: Hormonal parameters of rr and after varicocelectomy, Fertfl Ster 7. Ross LS, Lipson S, and Dritz S: cocele, Urology 19:179 (1982). 8. Tinga DJ, et ah Factors related fertility after varicocele operation, Fc 9. Ishigami K, Yoshida Y, Hiraoke operation for varicocele: use of micr~ gery 67:620 ( 1 9 7 0 ) . . -~4~ ';~v~ 10. Fox U, Romagnoli G, and Colombo F: The mmr0sui:~ drainage of the varicocele, Fertil Sterfl 41:475 (1984). : : ~ ! 11. Belgrano E, e t a h Microsurgicalspermatieoepigastri~ 5:44 '(,~~~ e~s~ tomosis for treatment of varicocele, Microsurgery tecnica nella 12. Contessini-Avesani E, et ah Variante :~::~:;z~ zione chirurgica del varicocele, Min Chir 40:29 (1985)i :::.:~J~ 13. Erembourg L, Pricolo VE, Ronchi F, and Orena C: A ~ i ~ orientamenti nella terapia 'ebhrurgica del varieocele m a i ~ idiopatieo, Min Chir 38:187 (1983), i'.~,~i~ {-~'~ 14. Marmar JL, DeBenedictis TJ, and Prmss DE: The m a ~ . ment of varicoceles by microdissection of the spermatic c ~ the external inguinal ring, Fcrtfl Steril 43:583 (1985). :~,~ :~ 15. Mvrag B, et ah Percutaneous venography aI'1d occlas~0l the management of spermatic varicocetes, AJR 142:635 ~ ( ~ 16. Sayfan J~ Adam YG, and Softer Y: A new entity in ~it~.~ cele subfertility: the "cremasteric reflux," Fertil Steril ~!': 17. Chatel A, Bigot JM, Dectot H, and Helenon C: Ana[5~ radiologique des veines spermatiques. Apropos de 152 phie~j~
raphiesspermatiquesretrograde,J Chir i15:443 (1978):~i~!~ 18. Coolsaet BLRA: The varieocele syndrome: v e n o g r a p h ~ termining the optimal level for surgical management, J U ~ 833 (1980). t:~ 19. Flati G, Flati D, Porowska B, and Carboni M: I s ~ surgical drainage of varie,ocele a logical treatment? Urbi~'~!~ 463 (1987).
UROLOGY
/
FEBRUARY1990
/ VOLUME XXXV, N U M ~
