Review article
Effect of varicocelectomy on fertility. Indications, techniques and results
Efecto de la varicocelectomía en la fertilidad. Indicaciones, técnicas y resultados
M. Caradonti
Hospital Donación Francisco Santojanni, Ciudad Autónoma de Buenos Aires, Argentina
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Indications, techniques and results" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1139 "Ancho" => 855 "Tamanyo" => 115905 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Representación de los diferentes tipos de abordaje para la corrección del varicocele. Los mismos se pueden dividir usando de reparo anatómico el trayecto inguinal. El reparo “1” representa el límite del anillo inguinal profundo o externo, siendo el abordaje próximal, el denominado RETROPERITONEAL “Tecnica de Palomo” (A), sobre este límite se encuentra el abordaje SUPRAINGUINAL “Tecnica de Ivanissevich” (B), sobre el trayecto inguinal se ubica el abordaje INGUINAL “Tecnica de Bernardi” marcado con el reparo “2” y por último se encuentra el abordaje SUBINGUINAL “Tecnica de Marmar” (C).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Caradonti" "autores" => array:1 [ 0 => array:2 [ "nombre" => "M." 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Cádiz, Spain).</p> <p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">E2: estradiol; Fragm: fragmentation; T*: testosterone; ART: assisted reproductive technology.</p> <p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">** Measured by SCSA, as there are no methods for measuring ROS levels, an indirect estimation of oxidative stress is made using DNA fragmentation levels.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "R. García-Baquero, C.M. Fernández-Ávila, J.L. Álvarez-Ossorio" "autores" => array:3 [ 0 => array:2 [ "nombre" => "R." "apellidos" => "García-Baquero" ] 1 => array:2 [ "nombre" => "C.M." "apellidos" => "Fernández-Ávila" ] 2 => array:2 [ "nombre" => "J.L." 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Indications, techniques and results" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "276" "paginaFinal" => "280" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "M. Caradonti" "autores" => array:1 [ 0 => array:3 [ "nombre" => "M." "apellidos" => "Caradonti" "email" => array:1 [ 0 => "matiascaradonti@gmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Hospital Donación Francisco Santojanni, Ciudad Autónoma de Buenos Aires, Argentina" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Efecto de la varicocelectomía en la fertilidad. Indicaciones, técnicas y resultados" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1149 "Ancho" => 855 "Tamanyo" => 195534 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Schematic diagram of the venous system showing the pampiniform venous plexus (A) and its three venous systems, (B) cremasteric artery, (C) testicular artery and (D) deferential artery.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">We define a varicocele as the dilation of the veins that make up the pampiniform plexus, which is made up of 3 systems: the internal spermatic vein group, the deferential group and the external spermatic.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">It is present in 15% of the general population. However, it prevails in 40% and 80% of men with primary and secondary infertility, respectively.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The right internal spermatic vein enters the inferior vena cava obliquely below the right renal vein, whereas the left internal spermatic vein terminates in the left renal vein at the right angle. This anatomy generates dilation on the left side.</p><p id="par0020" class="elsevierStylePara elsevierViewall">This dilation can be classified as follows: grade I, mild or asymptomatic; grade II, moderate or mildly symptomatic; and group III, severe or symptomatic. The diagnosis is based on clinical-ultrasound evaluation (color doppler).</p><p id="par0025" class="elsevierStylePara elsevierViewall">The World Health Organization (WHO) has determined that varicocele is a relevant cause of male infertility, which has been shown by different studies that have revealed this cause–effect relationship:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0030" class="elsevierStylePara elsevierViewall">Its incidence can be up to 5 times higher in infertile men than in the general population.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0035" class="elsevierStylePara elsevierViewall">The existence of a varicocele affects the functionality of the testicles, both with regard to testosterone production and spermatogenesis, reducing sperm count and motility. Also, according to more recent studies, genetic inheritance is altered.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0040" class="elsevierStylePara elsevierViewall">Once the corresponding surgery has been performed to reverse the problem, the spermogram improves significantly in 60–70% of cases, doubling the pregnancy rates.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0045" class="elsevierStylePara elsevierViewall">In the long term, untreated varicocele may cause scrotal tissue injuries and decreased testicular size.</p></li></ul></p><p id="par0050" class="elsevierStylePara elsevierViewall">Adverse effects on spermatogenesis caused by varicocele have been demonstrated, due to increased scrotal temperature, circulatory dysfunction in the testicle that generates poor oxygenation and cellular damage, and renal and spermatic vein reflux of toxic renal and adrenal metabolites.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Varicocele does not always generate infertility; many patients with varicocele are fertile, decreasing their percentage in the progression of the pathology and the association with other factors such as tobacco, marijuana, or endocrinopathies (diabetes or hypothyroidism).<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Indications</span><p id="par0060" class="elsevierStylePara elsevierViewall">In order to determine a correct medical-surgical indication, we must be clear about the following concepts; What is a varicocele? What do we mean when we refer to infertile men? What is an altered spermiogram? What parameters should we assess in order to make the right decision?</p><p id="par0065" class="elsevierStylePara elsevierViewall">Varicocele is a pathology of frequent presentation in adolescents and young males, characterized by the dilatation and tortuosity of the veins of the spermatic cord (pampiniform plexus), consisting of 3 venous systems: the internal spermatic vein group, the deferential group and the external spermatic. It may include inverted blood flow (reflux) during physical effort, caused by increased intra-abdominal pressure, producing deleterious disorders to the testicle over time. <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows the pampiniform plexus and its venous systems.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">According to the WHO, “Infertility is the inability of a sexually active, non-contracepting couple to achieve pregnancy in one year”. On my daily practice, I determine it as any sexually active couple with no successful conception within 6 months.</p><p id="par0075" class="elsevierStylePara elsevierViewall">A factor associated with male infertility along with abnormal seminal parameters is identified in 50% of couples who do not have children against their will.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Idiopathic male infertility may be explained by several factors, including endocrine disorders as a consequence of environmental pollution, reactive oxygen species, or genetic abnormalities.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The WHO established in 2010 that the following values should be considered to determine a “normal” spermiogram:</p><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">pH:</span> the semen sample must have a pH between 7.2 and 8.0.</p><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Semen volume:</span> values that exceed 1.5<span class="elsevierStyleHsp" style=""></span>ml of semen are considered normal in terms of volume.</p><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Sperm concentration</span>: a concentration of more than 15 million per ml is considered normal.</p><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Total sperm</span><span class="elsevierStyleItalic">count</span>: 39 million per ejaculate is considered acceptable.</p><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Sperm motility</span>: at least 40% motile and more than 32% progressively motile are recommended.</p><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Morphology</span>: it is essential that it has a proper shape in relation to its head, neck and tail. A sample with more than 4% of sperm is considered normal.</p><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Vitality</span>: more than 58% of sperm cells must be alive.</p><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Leukocytes</span>: a sample with more than a million leukocytes/ml usually indicates infection which can affect the seminal quality.</p><p id="par0130" class="elsevierStylePara elsevierViewall">When several parameters are altered, we must know how to assess them for a correct diagnosis and treatment; according to the different alterations, they are defined as oligospermia or oligozoospermia when the sperm sample has a sperm concentration less than 15<span class="elsevierStyleHsp" style=""></span>million/ml. Cases of extremely low concentration, less than 100,000<span class="elsevierStyleHsp" style=""></span>sperm/ml, imply cryptozoospermia.</p><p id="par0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Asthenospermia or asthenozoospermia:</span> it is diagnosed when sperm motility does not reach the reference values.</p><p id="par0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Teratospermia or teratozoospermia:</span> when more than 96% of his sperm are morphologically abnormal.</p><p id="par0145" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Azoospermia</span>: it is a male pathology that appears when sperm are not observed in the ejaculate.</p><p id="par0150" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Hypospermia</span>: it is indicated if there is low semen volume.</p><p id="par0155" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Aspermia</span>: it is diagnosed when men cannot ejaculate, that is, when the semen volume is zero.</p><p id="par0160" class="elsevierStylePara elsevierViewall">An altered spermiogram should be confirmed with a second test performed 3 months apart.</p><p id="par0165" class="elsevierStylePara elsevierViewall">Several studies have highlighted the deleterious effect of varicocele on the testicle over time.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">7,8,14</span></a> Considering these concepts, concerns have been raised about the possible early treatment of varicocele in order to prevent testicular disorders. Different parameters have been evaluated that can be correlated with testicular damage and consequently with the decision of surgical correction.<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">(a)</span><p id="par0170" class="elsevierStylePara elsevierViewall">Testicular volume</p><p id="par0175" class="elsevierStylePara elsevierViewall">The presence of testicular hypotrophy is an indication of gonadal distress. Hence, this is an indication of treatment and there lies the relevance of its assessment. Some authors consider that there should be no more than 2<span class="elsevierStyleHsp" style=""></span>ml difference in the volume of both testicles.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">9</span></a> Steeno et al. find that a third of adolescents with moderate varicocele have changes in testicular ipsilateral volume and/or consistency, a value that increases to 80% in cases of large varicoceles.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">10</span></a> Kass and Belman reported that 16 of 20 adolescents with varicocele and testicular hypotrophy recovered testicular volume after surgical correction of varicocele.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">9</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Based on these data, we could conclude that moderate and large varicocele are accompanied by a delay in testicular growth in puberty, a process that can be reversed by surgical correction.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">22</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">(b)</span><p id="par0185" class="elsevierStylePara elsevierViewall">Spermiogram</p><p id="par0190" class="elsevierStylePara elsevierViewall">In a patient with varicocele, the presence of a pathological spermiogram makes us suppose, after ruling out other factors, that the varicocele is responsible for the pathology. Hence, the presence of semen abnormalities is currently one indication for surgical correction of varicocele in adults.</p><p id="par0195" class="elsevierStylePara elsevierViewall">However, there are some difficulties when dealing with adolescents. It is not easy to obtain a semen sample in the initial stages of puberty (Tunner I, II), and semen matures as the organism does; hence, there are no normal values during this stage.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">12</span></a> Therefore, the spermiogram is useful in the patient with complete pubertal development (Tunner V).</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">(c)</span><p id="par0200" class="elsevierStylePara elsevierViewall">Hormonal study</p><p id="par0205" class="elsevierStylePara elsevierViewall">It is accepted that elevated gonadotropin (FSH and/or LH) levels indicate testicular injury. Likewise, gonadotropins hyperresponsiveness to the administration of LH–RH evidences testicular damage. Kass and Belman, in a study of 104 adolescents with varicocele, showed an abnormal response to LH–HR in 30% of patients with varicocele, allowing identification of individuals with evidence of testicular dysfunction.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">9</span></a> As the hypothalamic-pituitary unit matures while patients grow up, hormone study is useful in the advanced stages of puberty.</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Surgical therapeutics</span><p id="par0210" class="elsevierStylePara elsevierViewall">Surgery is indicated in cases of grade 3 varicocele (when seen through the scrotal skin and palpated as a “worm bag” without Valsalva maneuver),<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">9</span></a> cases of atrophy or testicular growth arrest with differences in volume of more than 2<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span> between both testicles, when accompanied by pain and alterations in the spermiogram in young patients.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">17</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Inguinal approaches are preferable as they are simpler and obtain better outcomes. The retroperitoneal access has a lower incidence of hydrocele (due to ligation of lymphatic vessels) but higher recurrence rates (attributed to the inability to ligate periarterial and collateral inguinal veins). It is generally used in specific cases of recurrent varicocelectomy or extensive inguinal surgery.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">15,16</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">The determination of the surgical approach depends on the surgeon's preference. There are three approaches following the inguinal canal: subinguinal (Marmar technique), inguinal (Bernardi technique) and suprainguinal (Ivanissevich technique). Following the inguinal line at the level of the iliac crest, at about 7–10<span class="elsevierStyleHsp" style=""></span>cm, appears the retroperitoneal approach (Palomo technique). These are shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Discussion</span><p id="par0225" class="elsevierStylePara elsevierViewall">Varicocele is a pathology that must be resolved when male patients want to conceive, are unable to do so and have an altered spermiogram.</p><p id="par0230" class="elsevierStylePara elsevierViewall">Varicocele repair is known to be associated with a significant improvement in sperm concentration, as well as total and progressive motility; in turn, it reduces seminal oxidative stress and DNA damage (deoxyribonucleic acid), thereby improving morphology.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">6,12</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">Data extracted from the literature indicate that varicocelectomy can improve the spermiogram results.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">13,17,18</span></a> In different series, the percentage of improvement in the spermiogram is around 60–80% after the surgical procedure.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">10,11</span></a> Variables are the different associations with cofactors related to normal spermatogenesis (hormonal alteration, time since onset, tobacco, drug use, diabetes, hypothyroidism, among others).</p><p id="par0240" class="elsevierStylePara elsevierViewall">Onozawa et al.,<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">23</span></a> in a study conducted in Japan, demonstrated an increased total sperm count in more than 50% and a spontaneous pregnancy rate of 37%, achieved after laparoscopic ligation of the spermatic vein.</p><p id="par0245" class="elsevierStylePara elsevierViewall">Clearly, the normality of the spermiogram becomes null in those patients who present oligoasthenoteratozoospermia syndrome (OAT) with associated varicocele.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">4,19–21</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conclusion</span><p id="par0250" class="elsevierStylePara elsevierViewall">All patients with a stable partner, unable to conceive in a period of more than 6 months should be evaluated with spermiogram, physical examination and imaging tests (color doppler ultrasonography). The presence of varicocele is a determining factor for the performance of varicocelectomy, with inguinal access as the preferred approach, in its 3 areas, leaving the laparoscopic approach for specific cases.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflicts of interest</span><p id="par0255" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1362028" "titulo" => "Abstract" "secciones" => array:3 [ 0 => array:1 [ "identificador" => "abst0005" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Surgical therapeutics" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1252165" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1362027" "titulo" => "Resumen" "secciones" => array:3 [ 0 => array:1 [ "identificador" => "abst0020" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Terapéuticas quirúrgicas" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1252164" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Indications" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Surgical therapeutics" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-09-10" "fechaAceptado" => "2019-10-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1252165" "palabras" => array:4 [ 0 => "Varicocelectomy" 1 => "Fertility" 2 => "Varicocele" 3 => "Spermiogram" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1252164" "palabras" => array:4 [ 0 => "Varicocelectomía" 1 => "Fertilidad" 2 => "Varicocele" 3 => "Espermograma" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We define varicocele as the dilation of the veins that make up the pampiniform plexus, which is made up of three branches, the internal spermatic, deferential and external spermatic. The World Health Organization (WHO) has determined that varicocele is an important cause of male infertility. This has been acknowledged by several studies that have shown this cause–effect relationship. Varicocele does not always generate infertility. In fact, many patients with varicocele are fertile, decreasing their percentage in the progression of the pathology and the association with other factors such as tobacco, marijuana or endocrine disorders (diabetes or hypothyroidism). Infertility is a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse (WHO).</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Surgical therapeutics</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Surgery is indicated in cases of grade 3 varicocele (when seen through the scrotal skin and palpable as a ‘bag of worms’ without Valsalva maneuver), cases of atrophy or growth arrest with volume differences of more than 2<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span> between testes, when accompanied by pain and alterations in the spermiogram in young patients.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conclusion</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The presence of varicocele determines the performance of varicocelectomy, with the inguinal approach in its three branches being the approach of preference. The laparoscopic approach will be used in specific cases.</p></span>" "secciones" => array:3 [ 0 => array:1 [ "identificador" => "abst0005" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Surgical therapeutics" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El varicocele lo definimos como la dilatación de las venas que conforman el plexo pampiniforme, el cual está constituido por 3 sistemas: el espermático, el deferencial y el funicular. La Organización Mundial de la Salud (OMS) ha determinado que el varicocele es una causa importante de infertilidad masculina, lo que se ha constatado a raíz de diferentes estudios que han puesto en evidencia esta relación causa-efecto. No siempre el varicocele genera infertilidad; muchos pacientes con varicocele son fértiles, disminuyendo su porcentaje en la progresión de la patología y la asociación con otros factores como el tabaco, la marihuana o endocrinopatías (diabetes o hipotiroidismo). La infertilidad es la incapacidad de una pareja sexualmente activa que no emplea métodos anticonceptivos de lograr el embarazo en el plazo de un año (OMS).</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Terapéuticas quirúrgicas</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La cirugía está indicada en casos de varicocele de grado 3 (cuando se observa a través de la piel del escroto y se palpa como «bolsa de gusanos» sin maniobra de Valsalva), casos de atrofia o detención en el crecimiento testicular con diferencias de volumen de más de 2<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span> entre ambos testículos, cuando se acompaña de dolor y existencia de alteraciones en el espermograma en pacientes jóvenes.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusión</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La presencia de varicocele es un determinante para la realización de la varicocelectomía, siendo el abordaje de preferencia a nivel inguinal, en sus 3 sectores. El abordaje laparoscópico se reserva para casos puntuales.</p></span>" "secciones" => array:3 [ 0 => array:1 [ "identificador" => "abst0020" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Terapéuticas quirúrgicas" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Caradonti M. Efecto de la varicocelectomía en la fertilidad. Indicaciones, técnicas y resultados. Actas Urol Esp. 2020;44:276–280.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1149 "Ancho" => 855 "Tamanyo" => 195534 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Schematic diagram of the venous system showing the pampiniform venous plexus (A) and its three venous systems, (B) cremasteric artery, (C) testicular artery and (D) deferential artery.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1139 "Ancho" => 855 "Tamanyo" => 116375 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Representation of the different surgical approaches for varicocele correction following the inguinal canal. “1” represents the limit of the deep or external inguinal ring, being the proximal approach, the so-called RETROPERITONEAL “Palomo technique” (A), the SUPRAINGUINAL approach is over this limit “Ivanissevich Technique” (B), the INGUINAL approach “Bernardi Technique” is located on the inguinal path, marked as “2” and finally the SUBINGUINAL approach “Marmar technique” (C).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0115" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anatomo fisiopatología del varicocele" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "N. 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