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Methods: We performed a non-randomized comparative trial that recruited infertile men with varicocele who were scheduled to undergo MSV. Eligible patients were allocated by the investigators in a 1:1 ratio to receive intraoperative Doppler (group I) or intraoperative Doppler plus hydrodissection (group II)., Results: Sixty men were included in each group. The two study groups showed a comparable number of ligated veins on the right (4.22 ±1.57 versus 4.42 ± 1.65; p = 0.49) and left side (6.77 ± 2.14 versus 6.98 ± 2.29; p = 0.59). On the contrary, group II showed a significantly higher number of preserved arteries on the right (2.42 ± 0.56 versus 1.47 ±0.5 in group I) and left side (2.6 ± 0.53 versus 1.63 ± 0.55 in group I), with p-value < 0.001. The sperm motility was significantly higher in group II than in group I (21.25 ± 13.73 versus 13.85 ± 12.25, respectively; p = 0.002). In both groups, the sperm motility increased significantly at the end of follow-up compared to the preoperative period. The postoperative sperm mortality remained significantly higher in group II than in group I (p = 0.008)., Conclusions: Intraoperative Doppler plus hydrodissection (D+IH-MSV) has advantages in preserving more arteries and enhancing the motility of sperms. Based on these findings, we strongly recommend D+IH-MSV when treating infertile men with varicocele.

Introduction: Varicocele is among the most frequently encountered, surgically correctable causes of male infertility. Since varicocele is a primary abnormality of testicular vessels, a thorough understanding of haemodynamic changes in the microcirculation of varicocele testis is needed., Objectives: To estimate changes in the microcirculation of varicocele testis and correlate them with symptomatic and semen parameters changes before and after varicocelectomy., Material and Methods: This prospective, observational study includes 47 patients of age group 18-40 years who underwent microsurgical varicocelectomy during June 2016 to April 2018 at a tertiary medical institute. Testicular haemodynamic was evaluated using a colour spectral doppler study (PSV-Peak systolic velocity/ESV-End diastolic velocity/RI-Resistive index/PI-Pulsatility index). Semen analysis parameters and testicular blood flow were compared with pre-operative values., Results: RI in the capsular artery of varicocele affected testis, which was 0.61 ± 0.11 (mean ± SD), significantly reduced to 0.56 ± 0.09 (mean ± SD) in post-operative follow-up, indicating improved perfusion. Pre-operative sperm density was noted to be 15.94 ± 7.88 (mean ± SD), which improved to 28.41 ± 10.99, Progressive sperm motility from 33.81 ± 10.88 to 38.32 ± 9.21 and morphology from 36.13 ± 10.68 to 41.43 ± 9.29 on 6-month follow-ups ( p  < 0.05)., Conclusion: Varicocele testis is associated with altered testicular haemodynamic, which insults spermatogenesis. Microsurgical varicocelectomy with testicular artery and lymphatic preservation leads to correction of this altered haemodynamic state and improves the testicular microcirculation.

Background: The influence of the number of veins that should be ligated in varicocele surgery on postoperative pain and testicular function is not clearly understood., Objective: The aim of this study was to investigate the number of Internal Spermatic Vein (ISV) ligated in postoperative pain and sperm parameters outcome., Methods: Relevant studies were collected and systematically reviewed from Medline, Scopus, and Cochrane databases. This study followed the PRISMA guideline. The mean difference (MD), odds ratio (OR), and 95% confidence intervals (CIs) were measured in the assessment of the outcome. Revman 5.4 was used in data analysis., Results: The pooled meta-analysis demonstrated that complete pain resolution was significantly higher in patients undergoing varicocelectomy procedures with more than ten vein numbers ligated with OR 1.92, 95% CI (1.03, 3.60). Improvement of sperm parameters of change in sperm concentration was also significantly observed in patients with more than ten vein numbers ligated MD 32.79, 95% CI (23.13, 42.45). However, the number of veins ligated was not associated with the change in sperm motility MD 9.69 with 95% CI (-12.32, 31.71)., Conclusion: The number of veins ligated intraoperatively determined pain relief and sperm concentration improvement. This study showed that varicocelectomy results improved with greater ISV ligation., Competing Interests: None declared., (© 2023 Ahmad Nurfakhri Syarief, Ilham Akbar Rahman, Muhammad Rifki Setiawan, Fikri Rizaldi.)

Purpose of Review: A male factor is either the primary cause or is contributory in at least half of all couples with infertility. Currently, many male factor problems may be disregarded, as reproductive technology has advanced so much that in-vitro fertilization (IVF)/Intracytoplasmic sperm injection (ICSI) allows the use of even a single sperm to achieve pregnancy., Recent Findings: Varicocele is the most commonly diagnosed correctable cause. Microsurgical repair is considered the gold standard for repair. Research has shown that varicocele repair can impact the outcome of reproductive management and upgrade male infertility from adoption or donor sperm only to IVF/ICSI and microTESE, or IVF/ICSI with ejaculated sperm, or from IVF/ICSI to intrauterine insemination (IUI) or often naturally conceived., Summary: Varicocele diagnosis and repair is an essential part of infertility evaluation. Not only does it potentially impact antiretroviral therapy choices, but it can also increase testosterone levels benefiting long-term male health., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Many questions on diagnosis of varicocele in adolescent patients have yet to be adequately answered, particularly regarding paternity outcomes after treated in comparison to conservative monitoring. There have been some promising outcomes after surgical treatment, particularly microsurgical varicocelectomy, but the results are mixed and may not be comparable because of differing variables. Future studies with robust methodologies are needed to identify which adolescents require treatment and when treatment should be initiated to avoid any detrimental effects on future fertility., (Published by Elsevier B.V.)

In this review, we tried to systematize all the evidence (from PubMed [MEDLINE], Scopus, Cochrane Library, EBSCO, Embase, and Google Scholar) from 1993 to 2021 on the predictors of microsurgical varicocelectomy efficacy in male infertility treatment. Regarding the outcomes of varicocele repair, we considered semen improvement and pregnancy and analyzed them separately. Based on the 2011 Oxford CEBM Levels of Evidence, we assigned a score to each trial that studied the role of the predictor. We systematized the studied predictors based on the total points, which were, in turn, calculated based on the number and quality of studies that confirmed or rejected the studied predictor as significant, into three levels of significance: predictors of high, moderate, and low clinical significance. Preoperative total motile sperm count (TMSC) coupled with sperm concentration can be a significant predictor of semen improvement and pregnancy after varicocelectomy. In addition, for semen improvement alone, scrotal Doppler ultrasound (DUS) parameters, sperm DNA fragmentation index (DFI), and bilateral varicocelectomy are reliable predictors of microsurgical varicocelectomy efficacy., Competing Interests: None

The objective was to assess whether men suffering from testicular retraction secondary to hyperactive cremaster muscle reflex have an anatomic difference in the thickness of the cremaster muscle in comparison to men who do not have retraction. From March 2021 to December 2021, 21 men underwent microsurgical subinguinal cremaster muscle release (MSCMR) on 33 spermatic cord units, as 12 of them had bilateral surgery, at Surgicare of South Austin Ambulatory Surgery Center in Austin, TX, USA. During that same time frame, 36 men underwent subinguinal microsurgical varicocele repair on 41 spermatic cord units, as 5 were bilateral for infertility. The thickness of cremaster muscles was measured by the operating surgeon in men undergoing MSCMR and varicocele repair. Comparison was made between the cremaster muscle thickness in men with testicular retraction due to a hyperactive cremaster muscle reflex undergoing MSCMR and the cremaster muscle thickness in men undergoing varicocele repair for infertility with no history of testicular retraction, which served as an anatomic control. The mean cremaster muscle thickness in men who underwent MSCMR was significantly greater than those undergoing varicocele repair for infertility, with a mean cremaster muscle thickness of 3.9 (standard deviation [s.d.]: 1.2) mm vs 1.0 (s.d.: 0.4) mm, respectively. Men with testicular retraction secondary to a hyperactive cremaster muscle reflex demonstrate thicker cremaster muscles than controls, those undergoing varicocele repair. An anatomic difference may be a beginning to understanding the pathology in men who struggle with testicular retraction., Competing Interests: None

The hemodynamic characteristics of venous reflux are associated with infertility in patients with varicocele; however, an effective method for quantifying the structural distribution of the reflux is lacking. This study aimed to predict surgical outcomes using a new software for venous reflux quantification. This was a retrospective cohort study of a consecutive series of 105 patients (age range: 22-44 years) between July 2017 and September 2019. Venous reflux of the varicocele was obtained using the Valsalva maneuver during scrotal Doppler ultrasonography before microsurgical varicocelectomy. Using this software, the colored reflux signals were segmented, and the gray scale of the color pixels representing the reflux velocity was comprehensively quantified into the mean reflux velocity of the green layer (MRVG) and the reflux velocity standard deviation of the green layer (RVSDG). Spontaneous pregnancy and changes from baseline in the semen parameters were assessed during a 12-month follow-up period. Data were analyzed using logistic regression analysis. An association of the high MRVG group with impaired progressive motility (odds ratio [OR] = 2.868, 95% confidence interval [CI]: 1.133-7.265) and impaired sperm concentration (OR = 2.943, 95% CI: 1.196-7.239) was found during multivariate analysis. High MRVG (OR = 2.680, 95% CI: 1.086-6.614) and high RVSDG (OR = 2.508, 95% CI: 1.030-6.111) were found to be independent predictors of failure to achieve pregnancy following microsurgical repair. In summary, intense venous reflux is an independent predictor of impaired progressive motility, sperm concentration, and pregnancy outcomes after microsurgical varicocelectomy., Competing Interests: None

Introduction: Varicocele is an abnormal dilatation of the internal spermatic veins of the spermatic cord. It has an estimated prevalence of 15% in young male adults. Even though most of them are asymptomatic, scrotal pain and testicular hypotrophy are frequent in children and adolescents. There is controversy regarding the indications and optimal approach for treatment purposes. We present the results of our 15-year series in the laparoscopic repair of pediatric varicocele., Materials and Methods: 238 patients diagnosed with varicocele and undergoing laparoscopic repair from 2006 to 2020 were reviewed. Variables collected included age, symptoms, grade, testicular atrophy, hospital stay, perioperative complications, recurrences, and formation of reactive hydrocele. Mean follow-up was 5.6 years (6 months-9 years)., Results: Mean age was 14.1 years. 188 patients had grade III varicocele. In 14 cases, varicocele was bilateral. Testicular atrophy at diagnosis was found in 42% of patients, 74% of whom were over 15 years old. 51 patients had testicular pain. All patients underwent laparoscopic treatment. Mean operating time was 36 min. Median hospital stay was 31 h. Recurrence rate was 2.1%. 43 patients (18%) developed hydrocele, but only 27 (11.2%) required hydrocelectomy according to Lord's plication at least 1 year following laparoscopy. Of the remaining 16 cases, 2 spontaneously resolved and 14 remained stable in the mean 7-year follow-up. In 7.1%, paresthesias were noted in the anterior-internal aspect of the left thigh., Conclusion: Based on our series, we believe laparoscopy should be regarded as the gold standard technique in the pediatric population. Laparoscopic varicocelectomy is technically easy and fast, causes no pain, and has a recurrence rate of 1%. The procedures involving lymphatic vessel preservation could reduce reactive hydrocele rates as a long-term complication to a minimum.

Background: Percutaneous embolisation is an effective, minimally invasive means of treating a variety of benign and malignant lesions and has been successfully used to treat varicoceles since the late 1970s, with refined and expanded techniques and tools currently offering excellent outcomes for varicocele embolisation., Purpose: This document will presume that the indication for treatment is clear and approved by the multidisciplinary team (MDT) and will define the standards required for the performance of each modality, as well as their advantages and limitations. CIRSE Standards of Practice documents are not intended to impose a standard of clinical patient care, but recommend a reasonable approach to, and best practices for, the performance of percutaneous varicocele embolisation., Methods: The writing group was established by the CIRSE Standards of Practice Committee and consisted of five clinicians with internationally recognised expertise in embolisation of male varicoceles. The writing group reviewed the existing literature on varicocele embolisation, performing a pragmatic evidence search using PubMed to search for publications in English and relating to human subjects published from 2006 to 2021. The final recommendations were formulated through consensus., Conclusion: Embolisation has an established role in the successful management of male varicoceles. This Standards of Practice document provides up-to-date recommendations for the safe performance of varicocele embolisation., (© 2022. Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE).)

Context: The benefits and harms of varicocele treatment versus observation in adult infertile males are still controversial., Objective: To systematically pool the evidence on outcomes of varicocele treatment (any surgical or radiological) versus observation in adult infertile men., Evidence Acquisition: A systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Only prospective randomized and nonrandomized studies were included until November 2021. The primary outcome was pregnancy rate; the secondary outcomes were improvements in sperm concentration, normal morphology, and progressive sperm motility after treatment compared to baseline. Men ≥18 yr of age with any-grade varicoceles were included., Evidence Synthesis: Of 557 articles identified, 12 were eligible for inclusion, involving 1357 patients. Varicoceles were treated surgically in ten and radiologically in four studies. Varicocele treatment improved pregnancy rates (odds ratio 1.29; 95% confidence interval [CI] 1.00-1.65; p = 0.048) and sperm concentration (mean difference 12.34 million/ml, 95% CI 3.49-21.18; p = 0.006) compared with observation. Proportions of spermatozoa with normal morphology and progressive motility were not statistically different from those with observation. However, considering treatment arm only, sperm concentration, progressive motility, and normal sperm morphology were improved compared with baseline. A subgroup analysis showed that the benefit of varicocele treatment is evident in men with an abnormal semen analysis. The main limitation is represented by the heterogeneity of the included studies, mostly in terms of study population, fertility of the partner, outcome evaluation, lack of long-term outcomes, and intermediate/high risk of bias., Conclusions: Treatment of any-grade varicoceles may improve pregnancy rates and sperm concentration in adult infertile men, while benefits in sperm motility and normal morphology are less clear., Patient Summary: In this systematic review and meta-analysis of all published prospective trials on varicocele treatment, significant evidence emerged on its benefit in terms of improved pregnancy rates and sperm concentration, while benefits in sperm motility and morphology are less clear., (Copyright © 2022 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

To evaluate the changes in testicular stiffness and microcirculation caused by spermatic vein ligation in patients with varicocele, we conducted a case-controlled study. A total of 27 grade III left varicocele cases were enrolled. Testicular stiffness and perfusion were evaluated by shear wave elastography and contrast-enhanced ultrasound during subinguinal microscopic varicocelectomy. The external and the internal parenchyma of bilateral testes were selected to compare the shear wave velocity of bilateral testes during the spermatic vein ligation. We mapped and compared the intensity-time curves following bolus contrast injection three times in the same region of interest. Initially, the shear wave velocity of the left internal parenchyma was higher than the right side (1.10 ± 0.06 m/s vs. 1.00 ± 0.03 m/s). It decreased (1.09 ± 0.06 m/s) (p < 0.05) after ligation. Meanwhile, the left epididymis had the higher agent peak intensity (0.90 × 10E-5 AU), the largest area under the curve (80.20 × 10E-5 AU s), and the longest washout area (54.35 × 10E-5 AU s). In addition, the left internal parenchyma presented a sharper slope (0.18 × 10E-5 AU/s) (p < 0.05). In conclusion, the spermatic vein ligation improved the perfusion of the internal testicular parenchyma, but it could temporally deteriorate the stasis of the epididymis. These changes caused softer testicular parenchyma., (© 2022 Wiley-VCH GmbH.)

Varicocele is a major entity defined within male infertility. In this report we have studied the influence of laparoscopic varicocelectomy on semen quality, biochemical parameters of seminal plasma and sperm DNA fragmentation. In this study, the semen samples from patients with left-side varicocele of grade II-III before and after laparoscopic varicocelectomy were compared to healthy individuals and separated into three groups. The volume of semen, sperm concentration (106/ml), motility (%), viability (%) and normal morphology (%) were assessed. Total antioxidant capacity (TAC), catalase (CAT), superoxide dismutase (SOD) and malondialdehyde (MDA) together with other biochemical substances in seminal plasma as alpha-glucosidase (α-Glu), fructose (Fr) and citric acid (CA) were determined by ELISA method. The spermatozoa activity including ion-transports through sodium, potassium ATPase (Na + , K + -ATPase) and calcium, magnesium ATPase (Ca 2+ , Mg 2+ -ATPase) were determined by using spectrophotometry. In addition, flow cytometry method for detection of sperm DNA fragmentation was used. The results showed, that three months after varicocelectomy such intervention led to significant postoperative improvement in volume of semen (p<0.001), total sperm count (p<0.001), sperm motility (p<0.001) and spermatozoa with normal morphology (p<0.001). We found decreased α-Glu levels due to varicocelectomy (p<0.05). There has been shown a high positive correlation between Na + , K + -ATPase and Ca 2+ , Mg 2+ -ATPase activity with total number of spermatozoa (p<0.05). The TAC levels and DNA fragmentation values after varicocelectomy can be considered as significant indicators of good prognosis after surgical intervention. It has to be emphasized that α-Glu levels and total sperm count expressed statistically significant both positive and negative predictive values for semen assessment. Varicocelectomy may lead to significant improvement of semen quality although the observations must be correlated with clinical pregnancies observed thereafter.

Varicocele is a more common male genitourinary system disease with sperm quality dysfunction or discomfort. This study was aimed to compare the clinical efficacy of sclerosing embolization with 3% polidocanol and the microsurgical subinguinal varicocelectomy in treating primary varicocele. Total of 59 patients with primary varicocele receiving a 3-month postoperative follow-up were included to analyse their biochemical parameters and clinical outcomes, including the operative time, hospitalization time, postoperative recurrence rates, and complication rate. Nineteen patients were treated with sclerosing embolization with 3% polidocanol (SE group), while 40 patients were treated with microsurgical subinguinal varicocelectomy (MSV group). For the SE group, 17 patients were treated on the left side, and two patients have treated on both without recurrences and complications during the follow-up period. For the MSV group, three patients were treated bilaterally, and 36 patients were treated separately on the left side with a total 5% recurrence rate and 10% complication rate. The duration of surgery and the hospitalization time of the SE group (46.2 ± 9.79 min and 2.53 ± 0.90 days, respectively) are significantly lower than MSV group (100.5 ± 13.76 min and 3.6 ± 1.58 days, respectively), p < 0.05. The total sperm count at 3 months was significantly higher in the SE group than in the MSV group (p < 0.05). In summary, sclerosing embolization is more effective for varicocele in improving sperm quality, shortening recovery time, and reducing recurrence rates and complications., (© 2022 Wiley-VCH GmbH.)

Varicocele is a common disease in men, with a global incidence of approximately 25%. A comprehensive and systematic analysis of the knowledge map on it will help in assessing frontier research and identify knowledge gaps. In total, 4103 articles published from 2002 to 2021 in 1066 journals were included. They represent the current research status worldwide, potential hotspots and future research directions. In the past decades, the number of publications and citations of varicocele-related studies have increased steadily. Academic institutions in the United States played a leading role in varicocele research. The country, institution, journal and author with the most publications were the United States (779), Cleveland Clinic Foundation (132), Andrologia (246) and Agarwal A (106), respectively. The most frequently used keywords were Varicocele (1620), Male Infertility (944), Varicocelectomy (288), Testis (245), Sperm (166), Oxidative Stress (144), Azoospermia (119), Semen Analysis (118), Laparoscopy (116) and Adolescent (97). Currently, the main focus of current varicocele research is its surgical treatment method and effect on sperm quality. The frontier research hotspot is the specific mechanism of varicocele-induced decrease in sperm quality., (© 2022 Wiley-VCH GmbH.)

Objectives: To study the impact of loupe assisted subinguinal varicocelectomy on semen quality, serum testosterone level, and spontaneous pregnancy rate., Methods: The data were prospectively collected for 102 infertile men with clinical varicocele. The preoperative values of semen analysis parameters and serum testosterone level were compared with postoperative values at 6 months. Spontaneous pregnancy was assessed at 6 months., Results: The mean age of patients was 31.56 ± 4.31 years. Primary infertility was reported in 86 patients, while 16 had secondary infertility. Bilateral varicocele was seen in 79 patients while 23 had a unilateral varicocele. The total sperm concentration (×10 6 /mL) before and after varicocelectomy was 12.82 ± 3.91 and 20.06 ± 2.13 respectively (P < .0001). The total sperm motility (%) before and after varicocelectomy was 37.67 ± 7.23 and 55.46 ± 4.51 respectively (P < .0001). The sperm morphology (Kruger/Strict morphology criteria, %) before and after varicocelectomy was 3.11 ± 0.80 and 3.70 ± 0.78 respectively (P < .0001). The serum testosterone level (ng/dL) before and after varicocelectomy was 323.90 ± 67.81 and 396.74 ± 40.88 respectively (P < .0001). The Spontaneous pregnancy rate in couples with primary and secondary infertility was 18.60% and 31.25% respectively. The difference in their rates was not significant (P = .251). The overall spontaneous pregnancy rate was 20.5%., Conclusion: Loupe-assisted sub-inguinal varicocelectomy is a safe and effective modality for treating infertile men, particularly when provision for microscopic surgery is unavailable. However, only large size comparative studies or multi-centric trials can confirm this., (Copyright © 2022. Published by Elsevier España, S.L.U.)

Background: Varicocoele is the most common correctable cause of male infertility; however, predicting varicocoelectomy outcomes is difficult. "Omics" techniques have been increasingly used to develop new diagnostic and prognostics tools for several male infertility causes, and could be applied to study varicocoele., Objectives: The objective is to create metabolomics models capable of segregating men who improved semen analysis (SA) parameters or achieved natural pregnancy after microsurgical varicocoelectomy (MV) from those who did not, using hydrogen-1 nuclear magnetic resonance ( 1 H NMR) spectra of seminal plasma of pre-operative samples., Material and Methods: We recruited 29 infertile men with palpable varicocoele. 1 H NMR spectra of seminal plasma were obtained from pre-operative samples and used to create metabonomics models. Improvement was defined as an increase in the total motile progressive sperm count (TMC) of the post-operative SA when compared to the baseline, and pregnancy was assessed for 24 months after MV., Results: Using linear discriminant analysis (LDA), we created a model that discriminated the men who improved SA from those who did not with accuracy of 93.1%. Another model segregated men who achieved natural pregnancy from men who did not. We identified seven metabolites that were important for group segregation: caprylate, isoleucine, N-acetyltyrosine, carnitine, N-acetylcarnitine, creatine, and threonine., Discussion: We described the use of metabonomics model to predict with high accuracy the outcomes of MV in infertile men with varicocoele. The most important metabolites for group segregation are involved in energy metabolism and oxidative stress response, highlighting the pivotal role of these mechanisms in the pathophysiology of varicocoele., Conclusions: 1 H NMR spectroscopy of seminal plasma can be used in conjunction with multivariate statistical tools to create metabonomics models useful to segregate men with varicocoele based on the reproductive outcomes of MV. These models may help counseling infertile men with varicocoele regarding their prognosis after surgery., (© 2022 American Society of Andrology and European Academy of Andrology.)

Many therapies are effective in treating varicoceles, including dilation of the pampiniform plexus in males. The most common method of treatment is varicocelectomy. We aimed to assess an alternative technique (microsurgical spermatic [distal end]-superficial or inferior epigastric vein anastomosis) that preserves the normal blood flow pattern for varicocele treatment. We retrospectively analyzed 27 men with varicocele between October 2019 and July 2020. All patients underwent microsurgical spermatic (distal end)-superficial or inferior epigastric vein anastomosis. The prognosis was reviewed retrospectively with an additional survey conducted 3 months after surgery. The mean ± standard deviation of the age was 26.1 ± 7.3 years in patients with microsurgical spermatic (distal end)-superficial or inferior epigastric vein anastomosis. The maximum diameter of the varicocele vein, perineal pain score, sperm density, and forward movement of sperm improved over 3 months after surgery. Microsurgical spermatic (distal end)-superficial or inferior epigastric vein anastomosis is a safe and efficient surgical treatment for varicoceles., Competing Interests: None

Competing Interests: None

The aim of this systematic review and meta-analysis was to assess whether oral antioxidant supplementation improves sperm quality in men with infertility and varicocele (VCL) who have not undergone surgical repair. In men with infertility and VCL who had not undergone surgical repair oral antioxidant supplementation significantly increased sperm concentration (WMD +5.86 × 10 6 /ml 95% CI: +1.47 to +10.24, p < 0.01; random effects model, six studies, 213 patients), total motility (WMD + 3.76%, 95% CI: +0.18 to +7.34, p = 0.04; random effects model, three studies, 93 patients), progressive motility (WMD + 6.38%, 95% CI: +3.04 to +9.71, p < 0.01; random effects model, three studies, 84 patients) and seminal volume (WMD +0.55 ml, 95%CI: +0.06 to +1.04, p = 0.03; random effects model, four studies, 120 patients). On the other hand, no significance difference was observed in sperm morphology (WMD +3.89%, 95% CI: -0.14 to +7.92, p = 0.06; random effects model, five studies, 187 patients). In conclusion, limited evidence suggests that the use of oral antioxidants in men with infertility and VCL, who have not undergone surgical repair improves their seminal volume, sperm concentration, total and progressive motility., (© 2022 Wiley-VCH GmbH.)

Background: Previously, we highlighted the benefits of magnified subinguinal varicocelectomy over conservative treatment on the semen of a small group of adolescents with varicoceles. In this report, we presented changes of semen parameters of 47 adolescents who underwent magnified subinguinal varicocelectomy (MSV) and followed-up for 6 months., Methods: The present prospective controlled study was conducted on 47 adolescents with varicocele who underwent MSV and were followed up for 6 months. In addition, age and sex-matched patients were added as control group. The primary outcome of this study was to assess the postoperative change in semen analysis parameters., Results: A significant increase in sperm volume from 2.5 (1.9-3) to 3.2 (2.6-4) mL at the end of the sixth month of follow-up. Likewise, the sperm count increased from 10.8 (3.51-21.6) to 20.3 (9.6-35) million. Notably, the percentage of rapid and slow sperms increased significantly from a median of 5% (0%-10%) and 15% (10 -20%) to a median of 10% (5%-15%) and 17.5% (15%-25%), respectively. The percentage of sperm with progressive movement increased from 35% (30%-40%) to 59% (45%-69%). The vitality of the sperms increased significantly as well. While the percentage of sperms with abnormal morphology decreased significantly at the end of follow-up., Conclusion: Our findings support the safety and efficacy of MSV in patients with clinically detectable varicocele. MSV has improved the semen parameters of the included patients, including sperm motility, volume, count, and total progressive motility, which may positively impact their fertility potential.

Introduction: The current challenge for the treatment of varicocele is identifying patients who could benefit the most from surgery. We aimed to develop and validate a nomogram for predicting spontaneous pregnancy following microscopic varicocelectomy in infertile men, based on a large cohort., Methods: Two hundred eighty-two consecutive patients who underwent microscopic varicocelectomy from January 2018 to December 2020 were enrolled as participants in the study. Xiang Hua center (206 patients) as a development cohort. Hu Nan center (76 patients) as a validation cohort. Patient clinicopathologic data were recorded. Multivariate logistic regression was used to build a predictive model with regression coefficients. Then, backward stepwise selection was applied, and the likelihood ratio test with Akaike's information criterion was used as the stopping rule. The performance of this predictive model was assessed for discrimination, calibration, and clinical usefulness., Results: Predictors of this model included the age of female partners, diameter of veins, initial and increased total progressively motile sperm count. The model demonstrated good discrimination with an AUROC of 0.925 (p < 0.001) and calibration (Unreliability test, p = 0.522) in the validation cohort. Furthermore, the model was clinically useful, according to decision curve analysis., Conclusions: Our findings indicated that younger female partners, larger diameter of veins, higher initial and increased total progressively motile sperm count were significant predictors of spontaneous pregnancy in infertile men, post microscopic varicocelectomy. This nomogram may assist in individual decision-making on the treatment strategy of varicocele preoperatively and improve the treatment outcome., (© 2022. The Author(s).)

Fertility, a social, cultural, and medical issue, has aroused public attention because of its potential to predict future health. In recent years, the incidence of male infertility has increased significantly, and various risk factors, such as congenital factors, acquired factors, and idiopathic factors, have led to this situation. Male infertility causes substantial psychological and social distress in patients. With the implementation of the two-child policy, male infertility has brought enormous psychological and social pressure and huge economic burden to patients and the healthcare system. This has attracted the attention of not only men of childbearing age but also many male experts. The conventional therapeutic approaches for treating male infertility, including drugs, varicocele surgery, intrauterine insemination, in vitro fertilization, and intracytoplasmic sperm injection, can restore fertility to a certain extent, but their efficacy is far from satisfactory, not to mention some adverse events. Therefore, acupuncture has been chosen by many men to treat their infertility and produced significant effects. In the present paper, the efficacy and mechanism of acupuncture in the treatment of male infertility were analyzed from different perspectives such as regulating hormone secretion, reducing inflammation, and improving semen parameters. The existing literature shows that acupuncture can effectively treat male infertility., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Feng, He, Wang, Zhang, Zhang, Zhang, Zhu, Wu and Zhang.)

The aim of this study was to evaluate the effect of inflammation on the success of varicocelectomy by using some inflammatory markers. Adult male patients aged ≥18 years who were evaluated for infertility, had abnormal parameters in at least two preoperative semen analyses and underwent subinguinal microscopic varicocelectomy were retrospectively evaluated. The patients were divided into two groups; those showing improvement in semen parameters were determined as Group A and those without improvement as Group B and compared with each other. A total of 102 patients were included in this study. Group A contained 32 (31.4%) patients while Group B had 70 (68.6%) patients. Monocyte/lymphocyte ratio (MLR) and neutrophil/lymphocyte ratio (NLR) were found to be statistically significantly higher in Group B (p = 0.014 and p = 0.028 respectively). Although preoperative sperm concentration and total motile sperm count were higher in Group B, postoperative all semen parameters were significantly higher in Group A. The cutoff points that were determined using the Youden test were <2.02 for NLR (AUC = 0.636, CI = 0.519-0.754; p = 0.028) and <0.22 for MLR (AUC = 0.652, CI = 0.531-0.773; p = 0.014). Pre-varicocelectomy low NLR and MLR values were found to be significant parameters in predicting the success of the surgery., (© 2022 Wiley-VCH GmbH.)

Mean platelet volume, platelet, varicocele, varicocele surgery Our meta-analysis demonstrated that varicocele patients had higher MPV values and the varicocele surgery could normalise the pre-operatively elevated MPV levels. Keywords: mean platelet volume; platelet; varicocele; varicocele surgery EN mean platelet volume platelet varicocele varicocele surgery 1 2 2 04/05/21 20210501 NES 210501 Dear editor, We appreciate the opportunity to response to the comments by Beyan et al. regarding our published meta-analysis clarifying the relationship between varicocele and platelet indices (Zhang et al., 2020). [Extracted from the article]

Background: Varicocele is known to have impacts in infertility cases and sperm quality. This review aimed to evaluate the effects of microsurgical varicocelectomy on sperm DNA fragmentation index (DFI) and sperm parameters., Methods: Open full English text articles from January 2017 to October 2021 were searched from online database including PubMed, EMBASE, Scopus, Cochrane Library and Google Scholar., Results: Systematic search resulted in 277 potential papers. After throughout paper analysis, 5 studies were included in this review. From all five analyzed studies, microsurgical varicocelectomy was statistically proven to reduce DNA fragmentation index by 5.46% (mean difference -5.46; 95% CI: -4.79, -6.13; p < 0.00001). Moreover, the procedure also significantly improved other sperm parameters (sperm concentration +8.23%, sperm motility +7.17%, sperm progressive motility +2.77%, sperm morphology +0.64%)., Conclusion: Microsurgical varicocelectomy significantly improves spermatogenesis as reflected by biomarkers of infertile men including semen parameters and sperm DNA fragmentation (SDF).

To analyse spermatic vein parameters and post-varicocelectomy diagnostic ultrasound methods by comparing pre- and post-operative ultrasound parameters and semen quality in patients undergoing varicocelectomy. Ultrasound and semen analyses were performed within 1 week before surgery and 3 months after surgery in 125 patients who underwent varicocelectomy for infertility. Patients were divided into three groups according to the post-operative internal diameter of the spermatic vein and reflux: recovery, dilatation, and reflux. Changes in semen quality before and after surgery were compared between groups. Sperm concentration, motility, and morphology were significantly improved (p < 0.05); however, semen volume did not improve (p > 0.05) in patients in the recovery and dilatation groups compared to those in patients before surgery. Sperm concentration, motility, and semen volume did not improve in patients in the reflux group compared with those in patients before surgery (p > 0.05). Logistic regression analysis revealed that the internal diameter of the spermatic vein and reflux duration were risk factors for post-operative spermatic vein dilatation without reflux. Ultrasonography after varicocelectomy should primarily be used to observe reflux, and should not be used as a diagnostic criterion for varicocele based on the internal diameter of the spermatic vein alone., (© 2022 Wiley-VCH GmbH.)

We aimed to systematically review complications, and recurrence rate of varicocele treatment by comparing the surgical ligature versus sclero-embolization techniques in children, adolescents and adults. The secondary outcomes were the evaluation of semen parameters and spontaneous pregnancy rate in adults. The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework. Continuous variables were pooled using the inverse variance of the mean difference (MD) with a fixed effect, and 95% confidence interval (CI). The incidences of complications were pooled using the Cochran-Mantel-Haenszel Method with the random effect model and reported as Odds Ratio (OR), and 95% CI. Statistical significance was set two-tail p-value < 0.05. Twenty studies were included. Incidence of postoperative hydrocele was significantly higher in the surgical ligation group (OR 3.06 95% CI 1.06-8.88, p = 0.04). Incidence of postoperative orchiepidydimitys was significantly higher in sclero-embolization group (OR 0.26 95% CI 0.08-0.85, p = 0.02). Presence of normal spermatozoa was significantly higher sclero-embolization group compared with the surgical ligature group (MD 2.54% 95% CI 0.43-4.65, p = 0.02). No difference was found in overall complications, wound infection, testis pain, surgical site hematoma, total sperm count, sperm motility, pregnancy and recurrence rate. This review confirms that current data does still not support the superiority of one type of treatment over other ones., (© 2022 Wiley-VCH GmbH.)

The three-dimension digital image microscope system (3D-DIM) with a better ergonomic design and equipment characteristics can contribute to the achievement of good results during microsurgery. In this study, the safety and efficiency of 3D-DIM assisted varicocelectomy was evaluated. From July 2019 to November 2019, fifteen cases with varicocele (20 sides of varicocele in total) were included, seven cases underwent 3D-DIM-assisted modified microsurgical subinguinal varicocelectomy, and eight cases underwent modified microsurgical subinguinal varicocelectomy under standard operating microscope (SOM). The mean operative time of 3D-DIM group (67 ± 12.3 min) was a little longer than that of SOM group (55 ± 12.9 min) (p < 0.05). There was no significant difference between the two groups in the number of internal spermatic arteries, internal spermatic vein, lymphatics, gubernacular vein, external spermatic vein and post-operation complications. The 3D-DIM showed a significant difference in image definition for nurse (p < 0.01) and in doctor-nurse cooperation (p < 0.05) over SOM. The 3D-DIM with better ergonomic design and image definition can be applied to perform microsurgical subinguinal varicocelectomy, and could improve the surgeon's fatigue and doctor-nurse cooperation. We believe that the 3D-DIM would be widely used in the field of male infertility microsurgery in the near future., (© 2022 Wiley-VCH GmbH.)

Objective: At present, the longest network transmission distance (NTD) for 5G remote endoscopic surgery is reportedly only about 229 km, and the NTD longer than 5 000 km has not yet been reported in clinical application. In this study, we attempted the clinical application of 5G ultra-remote robot-assisted laparoscopic surgery in spermatic vein ligation., Methods: This retrospective study included two cases of 5G ultra-remote robot-assisted laparoscopic spermatic vein ligation using the home-made Tumai Surgical Robot System. The operation table was located in Xinjiang Kezhou People's Hospital, with an NTD of about 5 800 km (a linear distance of about 3 800 km) from the surgeon's console in the Telemedical Center of the First Affiliated Hospital of Nanjing Medical University, the apparatuses connected through the public 5G network. We observed the network connection delay, network fluctuation, and data packet loss rate of the devices at both ends of the loop through the feedback value of the Ping command by real-time monitoring., Results: The total operation time of the two cases was 45 and 40 minutes respectively, with a mean blood loss of < 5 ml. The patients resumed a liquid diet and out-of-bed activity on the first day, the abdominal drainage tubes removed on the second, and both discharged from the hospital on the third day. The intraoperative average two-way network delay was 130 ms, and the average continuous data packet loss rate was 1.4%. No adverse network events, such as network interruption, occurred during the operation., Conclusion: Through the public 5G network and home-made Tumai Surgical Robot System, ultra-remote robot-assisted laparoscopic surgery was performed safely and successfully.

Varicocele has been hypothesized to lead to seminal inflammation, which in turn interferes with sperm function. Thus, the aim of this study was to investigate the role of inflammatory cytokines in the pathogenesis of decreased semen quality observed in adult men with varicocele, and to determine if varicocelectomy corrects these potential alterations. A prospective study was carried out including fifteen control men without varicocele and with normal semen quality and 15 men with varicocele with surgical indication. Men with varicocele grades II or III underwent microsurgical subinguinal varicocelectomy. Controls collected one semen sample and men with varicocele collected one before and one 6 months after the surgery. Semen analysis, sperm function, and seminal lipid peroxidation levels were assessed. Seminal plasma inflammasome activity was evaluated by ELISA assays for IL-1β, IL-18 and caspase-1 and by Western blotting for ASC (apoptosis-associated speck-like protein). Groups were compared by an unpaired Student's T test. Varicocelectomy samples were compared using a paired Student's T test ( α  = 5%). Men with varicocele had decreased semen quality, and increased seminal IL-1β levels, when compared to control men. Varicocelectomy decreased levels of caspase-1, IL-18, and IL1β. Thus, varicocelectomy improves sperm morphology and decreases seminal plasma inflammatory activity, after a six-month post-operative period.

Purpose: To conduct a systematic review and meta-analysis to assess the relative efficacy of endovascular and surgical treatments for varicocele., Materials and Methods: PubMed and Embase databases were systematically searched to identify studies reporting on the outcomes associated with surgical or endovascular treatments of varicoceles. The studies that assessed the relative efficacy of surgical and endovascular treatments for patients with clinical varicocele were eligible for inclusion. Pooled data analyses were performed., Results: A total of 16 studies incorporating 2,138 patients were included in the present meta-analysis. The pooled risk ratio (RR) values suggested that rates of adverse events were lower among patients who underwent endovascular treatment than those who underwent surgical treatment (RR, 0.63; 95% confidence interval (CI), 0.42-0.93; P = .02). Both treatments were associated with similar rates of recurrence (RR, 1.03; 95% CI, 0.78-1.36; P = .82) and pregnancy (RR, 1.03; 95% CI, 0.85-1.25; P = .82)., Conclusions: These data demonstrate that endovascular treatment for varicocele is associated with similar rates of recurrence and subsequent pregnancy outcomes compared with surgical treatment but with lower rates of adverse events., (Copyright © 2022 SIR. Published by Elsevier Inc. All rights reserved.)

Objective: To assess whether varicocele repair improves oxidative stress (OS) measured by the MiOXSYS system., Methods: A prospective clinical trial was performed on male patients ages 18 and older who had not fathered a child within the previous 12 months, with a clinically palpable varicocele, who completed all aspects of the study who were enrolled through a couple's fertility center with on-site andrology laboratory testing. Men that met inclusion criteria were offered enrollment in the clinical trial and signed informed consents to participate, after having a history and physical examination. Semen analysis with OS measurement was obtained preoperatively and repeat semen analysis with OS measurement obtained 3 months following varicocele repair. Changes in postoperative semen analysis parameters, static oxidation reduction potential (sORP), and sperm DNA fragmentation (SDF) indices when available were compared to these values preoperatively., Results: Of the 177 subjects, 49 subjects met inclusion criteria. The data of OS suggests negative correlations with major semen parameters. Semen parameters and OS revealed statistically significant improvements following varicocele repair from baseline. Of the 49 subjects included, 22 completed all aspects of testing postoperatively. Subgroup analysis shows statistically significant negative correlations between OS and semen parameters. Forward progressive motility, SDF, and sORP demonstrated statistically significant improvements 3 months following varicocele repair in comparison to preoperatively., Conclusion: Varicocele repair in infertile men improved sORP as measured by the clinically useful MiOXSYS system., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: To compared the traditional Chinese medicine Danhong Tongjing Prescription (DTP) and microsurgery in the treatment of varicocele (VC)-induced infertility and investigate the factors influencing the recovery of semen parameters of the patients., Methods: We retrospectively analyzed the clinical data on 218 cases of VC-induced infertility with qi-deficiency and blood-stasis treated with DTP (n = 86) or by microsurgery (n = 132) in our hospital from January 2017 to July 2019, and compared the semen parameters between the two groups of patients after treatment. With age, course of disease, degree of VC, change of the testis volume, estrogen/testosterone (E/T) ratio and levels of FSH and LH as independent variables, and increased semen parameters after treatment as dependent variables, we constructed a multivariate linear regression model and identified statistically significant independent variables., Results: After treatment, sperm concentration and the percentages of progressively motile sperm (PMS) and morphologically normal sperm (MNS) were obviously improved in both the DTP and microsurgery groups, with statistically significant difference between the two groups in sperm concentration and MNS, but not in PMS. Linear regression analysis showed that the severity of VC was an influencing factor for the recovery of sperm concentration after treatment in the DTP group (r = －11.599, Ra2 = 0.044 9) and the course of VC infertility was a factor affecting the recovery of sperm count in the microsurgery group (r = －1.837, Ra2 = 0.035 7)., Conclusion: DTP is comparable to microsurgery in improving sperm motility while microsurgery is more effective in increasing the percentage of MNS in the treatment of VC-induced infertility. Early surgery is recommended for the treatment of infertility induced by severe bilateral VC, and DTP can be selected for infertility caused by mild or moderate bilateral VC if the patient is unwilling to accept surgery or microsurgery is inaccessible in the hospital.

Objectives: To investigate clinical outcomes, radiation exposure and procedural costs associated with percutaneous varicocoele embolization using coils and sclerosing agents (SAs) in a cohort of young-adult men., Materials and Methods: Data from consecutive men treated with percutaneous varicocoele embolization using coils and SA between 2017 and 2021 were analyzed. The allocation was based on a change of policy occurred in June 2020 with the substitution of coils with SA (before and after study). Semen analysis values were based on 2010 WHO reference criteria. Anatomic variants of gonadal veins were categorized according to Jargiello et al. Intraoperative radiation dose and procedural costs were collected for each patient. Descriptive statistics and linear regression models were used to describe the association between clinical parameters with procedural costs and radiation exposure., Results: One hundred sixteen men were included, of whom 76 (65.5%) received coils, and 40 (34.5%) received SA. Baseline characteristics of the two study groups did not differ. A type 3 Jargiello anatomic variation of left gonadal vein was found in 45.7% of cases. Radiation dose was lower in the SA group as compared to the coils one (13.2 [7-43] vs. 19.8 [12-57] Gy/cm 2 ; p < 0.001). Similarly, procedural costs were lower for the SA group (169.6 [169-199] € vs. 642.5 [561-775] €; p < 0.001). At follow-up, pain and sperm variables significantly improved in both groups (p < 0.01), without differences among the embolic materials. Linear regression model revealed that coils use was associated with higher radiation exposure (beta 8.8, p = 0.02) than SA after accounting for anatomic variation of gonadal vein, body mass index, and vascular access., Conclusions: SA and coils for varicocoele embolization are equally safe and effective. The use of SA was associated with lower radiation exposure and procedural costs than coils. These results should be considered in terms of public health cost and patient's safety., (© 2022 The Authors. Andrology published by Wiley Periodicals LLC on behalf of American Society of Andrology and European Academy of Andrology.)

Abstract: Although many studies suggest that varicocelectomy leads to improvement in semen parameters and morphology, its clinical efficacy remains controversial. The detailed morphological parameters described in the World Health Organization guidelines are important in terms of showing the effect of microsurgical subinguinal varicocelectomy on morphological changes.An observational, retrospective clinical cohort study was conducted with patients followed up from January 2018 to August 2021. This study included the data of 79 patients who met the criterion of undergoing at least 2 detailed morphological evaluations before and after surgery. All operations were performed by the same surgical team using the microsurgical subinguinal varicocelectomy technique.The mean age of the patients was 30.25 years. Of the patients, 63 underwent left-sided varicocelectomy and 16 underwent bilateral surgery. The sperm analysis revealed statistically significant increases in sperm volume (P = .006), sperm concentration (P = .003), total sperm count (P = .001), progressive sperm motility (P < .001), and normal morphology (P < .001). In the detailed morphological evaluation, except for the elongated head anomaly (P = .037), no other statistically significant changes were found in relation to sperm head, tail, and neck anomalies after surgery.This study makes an important contribution to the literature, being the first to use the subinguinal microscopic varicocelectomy technique in detailed morphological semen evaluation. We consider that detailed morphology examination in the selection and treatment of infertile patients may be useful in evaluating the efficacy of varicocelectomy., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Competing Interests: The authors have disclosed no conflict of interest.

Introduction: Paediatric varicocele embolization has many benefits over surgical ligation, but lacks published long-term data. We investigated technical and clinical outcomes in this under reported patient group., Objective: To evaluate technical success, complications and recurrence rates following varicocele embolization in paediatric patients., Materials and Methods: A single-centre retrospective review of procedural data and electronic notes of consecutive patients referred for varicocele embolization over a 10-year period was performed (February 2010-March 2020). The primary outcomes were technical success and clinical efficacy (lack of symptom recurrence). Secondary outcomes included complications, testicular vein size reduction and procedural parameters including radiation exposure. Chi-square analysis was used to identify predictors of clinical success. Follow-up involved outpatient clinical assessment and telephone interview., Results: 40 patients (median age 15) were referred for left-sided symptomatic varicocele. Technical embolization success was achieved in 36/40 patients (90%), with 4 procedures abandoned (inaccessible vein). Embolization technique was platinum-based coils ± sclerosant. There were no immediate or long-term procedural complications. 32/36 patients completed short term follow-up at a median interval of 2.8 months. 30/32 (93.78%) experienced early clinical success. We found a significant reduction in peritesticular vein size following embolization (pre-3.70 vs post-2.56 mm, p = 0.00017) and a significant relationship between varicocele grade and early clinical success (χ2 = 4.2, p = 0.04), but not pre-treatment peritesticular vein size (χ2 = 0.02, p = 0.88). 33/36 patients completed long-term follow-up (median 4.2 years, range 0.36-9.9 years) producing a late clinical success rate of 93.9% (31/33). No post procedural complications including hydroceles were identified., Discussion: This study demonstrates technical success, matching rates described in adult patients which is reassuring and in support of embolization in the younger patient cohort. More importantly, the overall clinical success rate is comparable with previous embolization studies. Reassuringly, all symptom recurrences occurred early in follow-up, and there is a cogent argument for a single follow-up appointment at this juncture. Our long-term average follow-up duration, primarily gained via telephone interview, exceeds other studies. Although our study has the longest follow-up for varicocele embolization in children, it is limited by a few patients being lost to early and long-term follow-up. This is a recognised issue faced by studies attempting to follow-up benign conditions with a high clinical success rate., Conclusion: Paediatric varicocele embolization is a successful alternative to surgical ligation, with no complications and good clinical outcomes over a long-term follow-up., Competing Interests: Conflict of interest None., (Copyright © 2021 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Introduction and Objective: It is generally considered that artery sparing suprainguinal varicocelectomy is associated with a higher risk of persistence in comparison with the non-sparing (Palomo) procedure. Artery sparing is desirable in specific conditions. Based on our 21-year long experience, this study aims to describe technical details and standard steps of the procedure, leading to a comparatively low recurrence rate., Material and Method: 336 patients, prospectively collected, who underwent laparoscopic lymphatic and artery-sparing microsurgical varicocelectomy as a primary operation between March 1999 and February 2020, were retrospectively evaluated. Patient age was 7-21.5 years (mean 15.4). The left side was involved in 313 (93.2%), both sides in 23 (6.8%) patients. In total 359 varicoceles were repaired, in which 281 cases were grade III, 65 grade II and 13 cases were grade I. The most common indications for surgery were left testicle hypotrophy, demonstrated in 167 (49.7%) patients, an abnormal spermiogram in 48 (14.2%), pain in 28 (8.3%) and bilateral involvement in 23 (6.8%) of patients. The technique has been standardized into four steps: early artery identification; peeling the network of small veins off the artery; peeling the lymphatic vessels off medium and large size veins and division of all veins; check of residual vascular bundle containing the artery and lymphatics only (video - Appendix A). Mean postoperative followup was 27.1 (range 0.5-174) months. Complications were recorded. Persistent varicocele was defined as clinically significant varicocele accompanied by renotesticular reflux on Doppler ultrasound. Ultrasound was used to rule out hydrocele formation and testicular atrophy., Results: Persistent varicocele was recorded in 15 of 359 (4.2%) cases; secondary hydrocele was detected in 1 case (0.3%). Testicular atrophy was not detected in any of the operated patients. Most complications were recorded in the first 3 years after the introduction of the method; 5 recurrences of 290 (1.7%) cases were detected over the last 18 years (Table)., Discussion: The method meets all requirements of subinguinal microscopic repair. The artery preservation is desirable in previous (and for future) inguinal and subinguinal surgery cases where collaterals could be compromised. Artery sparing allows for a future vasectomy. Boys with a varicocele on a solitary testicle may be good candidates for this procedure as well. We consider the method as alternative for experienced laparoscopic surgeons., Conlusion: The laparoscopic lymphatic and artery sparing microsurgical varicocelectomy is safe and effective method with a low recurrence rate like the non-sparing suprainguinal repairs., Competing Interests: Conflict of interest None., (Copyright © 2022 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

The influence of varicocele and microsurgical varicocelectomy on semen quality remains unclear. Few studies have investigated the relationship between semen metabolism and the abnormalities in reproductive function caused by varicocele, however, there is no study on the changes of semen metabolism after microsurgical varicocelectomy. Here, we used the non-targeted and targeted metabolic analysis to investigate the different metabolites in seminal plasma within normal, varicocele, and varicocelectomy groups. We clearly showed that varicocele significantly affects semen metabolism, and microsurgical varicocelectomy can reverse this metabolic abnormality. Moreover, we characterized the landscape of three dipeptides in the seminal plasma of patients with varicocele that have not been identified previously in human tissues or biofluids. Interestingly, the levels of these three dipeptides decreased after microsurgical varicocelectomy coincident with an improvement in semen quality. Western blotting confirmed the downregulation of DPEP3 (dipeptidase 3) in the varicocele group and the upregulation of DPEP3 in the varicocelectomy group. Furthermore, we found that eight metabolites may be helpful to distinguish varicocele patients from normal subjects. Our results may be applied to earlier diagnosis or to predict the outcome of microsurgery for varicocele., (© 2022. The Author(s).)

Varicocele is one of the main causes of male infertility and microsurgical varicocelectomy (MV) seems to be the best procedure for its repair and to reduce testicular oxidative stress (ROS). As ROS causes guanine modifications, we postulated that DNA damage could be more intense in telomeres due to their G-rich nature. We studied the effect of MV on sperm telomere length (TL), single- and double-strand DNA fragmentation (ssSDF and dsSDF) and seminal parameters. Sperm telomeres from 12 fertile donors and 20 varicocele patients before and nine months after MV were labelled using FITC-PNA qFISH (a new method to obtain absolute TL from relative fluorescence intensity using FITC-fluorescent spheres). Both ssSDF and dsSDF were analysed using the alkaline and neutral Comet assays, respectively. The results showed that varicocele and MV had no effect on TL. Seminal parameters, ssSDF and dsSDF of varicocele patients were altered. Although these parameters improved after MV, values did not reach those seen in fertile donors. A good estimation of absolute TL was developed based on FITC-fluorescent spheres. The results showed that TL is not affected by varicocele or surgery. However, MV is able to partially reduce altered seminal parameters, ssSDF and dsSDF values in varicocele patients.

Varicocele has been raised as a contributor to male infertility supported by the improvement of sperm parameters after varicocelectomy. Cystatin C (Cys C) has been linked to several cellular changes that are common in male infertility cases associated with varicocele such as apoptosis and autophagy. This preliminary study aimed to assess the seminal levels of Cys C in infertile oligoasthenoteratozoospermic (OAT) men associated with varicocele that have been shown to have spermatic vein vasodilation and active death pathway. Overall, 60 men were investigated being divided into two equivalent groups-infertile OAT men with varicocele who underwent varicocelectomy and healthy fertile men as a control group. These men were subjected to history taking, clinical examination, semen analysis and assessment of seminal Cys C pre and 6 months post-varicocelectomy. The results showed a significant increase of seminal Cys C in infertile OAT men with varicocele than the fertile control (55.57 ± 25.6 ng/ml versus 10.78 ± 1.88 ng/ml, p = .001). Seminal Cys C was a significantly decreased post-operative than its pre-operative level (34.69 ± 14.02 versus 55.57 ± 25.6 ng/ml, p = .01). These results show a potential role of Cys C in varicocele-induced infertility., (© 2021 Wiley-VCH GmbH.)

Background: There is paucity of literature comparing varicocelectomy to observant management amongst adolescent boys with hormonal and semen abnormalities resulting from high grade unilateral varicoceles and consequent testicular volume loss. Furthermore, it is not known whether surgical correction in such adolescents improves paternity rates in future compared to their non-operated cohort., Objective: The primary objective was to compare adolescent boys with unilateral high grade varicocele with associated ipsilateral testicular volume loss who were operated versus those who were not, in relation to their fertility markers (hormonal, semen parameters, and testicular volume) over a 5 year follow up period. The secondary objective was to compare the paternity rates in the respective groups over long term., Study Design: This was a single center, retrospective study of a prospectively maintained database conducted from 2010 to 2020, based on a standardized protocol. All adolescent boys >15 years of age (middle and late adolescence), with grade II or III unilateral varicoceles with abnormal fertility markers, who were operated (Group A) and not operated (Group B) were included. The changes in hormonal assay, sonographic assessment, semen analysis at presentation, 1st year and the 5th year follow up amongst both the groups were collated and analysed. Primary paternity rates amongst both the groups was documented by telephonic or email conversations., Results: Of the 182 boys referred for varicocele management, 110 boys (Group A -70 boys and Group B - 40 boys) satisfied our inclusion criteria and were analysed. Mean age at presentation amongst Group A boys was 16.5 years (15-18 years) and Group B boys was 16 years (15-18 years). Grade III varicoceles were more predominant amongst both the groups. There was a significant improvement in all Group A boys (operated) in the fertility markers from the time at presentation to the 5th year follow up (p < 0.001). In Group B, (boys not operated) there was no significant improvement in the above parameters. The testicular catch up growth was 92% at the 5th year follow-up in Group A and 42% in Group B. At long term follow-up, the paternity rate was 80% and 36% in Group A and B respectively., Discussion and Conclusion: In adolescent boys in whom hormonal assay, testicular volumes and semen characteristics are negatively affected by high grade unilateral varicoceles, surgical correction could normalize these values, thereby safeguarding their fertility in the long term., Competing Interests: Conflicts of interest None declared., (Copyright © 2021 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Background: The suitability of laparoscopic varicocelectomy for assisted reproductive technology depends on the improvement of semen parameters. The present study analyzed the improvement of semen parameters following laparoscopic varicocele ligation., Material and Methods: A retrospective study of the laparoscopic varicocele clippings at the Department of Urology of University Hospital of Kiel between the years 2007 and 2019 was conducted. The semen analyses according to WHO standards (sperm count, density, motility and morphology) were conducted before and 12 months after surgery. Screening for surgical complications took place at the time of the follow-up seminal analysis. Included were patients with oligozoospermia, asthenozoospermia and/or teratozoospermia (group 1, OAT) or with nonobstructive azoospermia (group 2, NOA)., Results: This study included data of 27 patients and 22 patients presented preoperative OAT (81%, group 1). Another 5 patients showed NOA (19%, group 2). Data of group 1 showed that semen parameters normalized in 32% of the patients after surgery. Significant improvement in total sperm count (p < 0.005), sperm density (p < 0.005) and total motile sperm count (p < 0.005) was observed. No deterioration of semen parameters was observed. In group 2 we detected spermatozoa in 1 case in the postoperative ejaculate. None of the patients showed complications according to the Clavien-Dindo classification, postoperative hydrocele formation or recurrence of varicocele at the time of control spermiogram., Conclusion: Laparoscopic varicocelectomy is a valid therapeutic approach to improve semen parameters for further assisted reproductive techniques. Spermatogenesis may be induced for patients with NOA. Normalization of semen parameters can be achieved for patients with OAT., (© 2021. The Author(s).)