Review article
Feasibility of loupe assisted subinguinal varicocelectomy in treatment of male infertility
Viabilidad de la varicocelectomía subinguinal con gafas de aumento en el tratamiento de la infertilidad masculina
Department of Urology, Government Medical College, Calicut, Kerala, India 673008.
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The x-axis indicates CK20, CD44, Ki67 and p53 markers expression and the y-axis is the standard error.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Straccia, V. Fiorentino, M. Martini, F. Pierconti" "autores" => array:4 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Straccia" ] 1 => array:2 [ "nombre" => "V." "apellidos" => "Fiorentino" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Martini" ] 3 => array:2 [ "nombre" => "F." "apellidos" => "Pierconti" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210480622001073" "doi" => "10.1016/j.acuro.2022.02.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210480622001073?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173578622000889?idApp=UINPBA00004N" "url" => "/21735786/0000004600000009/v1_202211020736/S2173578622000889/v1_202211020736/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review article</span>" "titulo" => "Feasibility of loupe assisted subinguinal varicocelectomy in treatment of male infertility" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "515" "paginaFinal" => "520" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "S. Kale, T. Rashid" "autores" => array:2 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Kale" "email" => array:1 [ 0 => "manusuper86@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "T." "apellidos" => "Rashid" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Urology, Government Medical College, Calicut, Kerala, India 673008." "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Viabilidad de la varicocelectomía subinguinal con gafas de aumento en el tratamiento de la infertilidad masculina" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2610 "Ancho" => 2507 "Tamanyo" => 278228 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">a: Comparison of sperm density before varicocelectomy and 6 months after varicocelectomy. b: Comparison of sperm motility before varicocelectomy and 6 months after varicocelectomy. c: Comparison of sperm morphology before varicocelectomy and 6 months after varicocelectomy. d: Comparison of serum testosterone level before varicocelectomy and 6 months after varicocelectomy.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Varicocele is abnormally dilated veins of the pampiniform plexus. For a long, it has been linked with male infertility. It is commonly observed in infertile men and has been associated with abnormalities in semen analyses. It is the most commonly seen, correctable cause of male infertility. It has an incidence of 4.4%–22.6% in the general population.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Varicocele causes a duration-dependent decline in semen quality and serum testosterone level.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Varicocelectomy prevents further testicular damage, improves semen quality and testosterone production.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> After varicocelectomy, semen quality is expected to improve in 60%–80% of the men.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Bilateral varicocelectomy in men who have large unilateral with small contralateral varicocele and in younger infertile men has a greater beneficial impact on semen quality and testosterone production.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Based on current evidence, it is the practice guideline of both the American Urological Association and the American Society for Reproductive Medicine that correction of varicocele should be offered to infertile men who have palpable varicocele and one or more abnormal semen parameters (except for azoospermic men).<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Also, the latest EAU guidelines recommend treatment of varicocele in infertile men with clinical varicocele, abnormal semen parameters and otherwise unexplained infertility in a couple where the female partner has a good ovarian reserve to improve fertility rates.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Varicocele can be treated surgically by retroperitoneal, inguinal, subinguinal, or laparoscopic approaches and by percutaneous embolization.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The traditional techniques for varicocele repair are associated with significant risks of hydrocele formation, ligation of the testicular artery, and varicocele recurrence. The use of surgical microscope and loupes has significantly improved the outcome of varicocelectomy.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9–12</span></a> Lower treatment cost, learning curve, and easy availability make surgical loupes a more feasible option over surgical microscopes.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> A recent study has set forth comparable outcomes by using, either of the modalities.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> We present the results of loupe assisted subingunal varicocelectomy in 102 consecutive patients.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">The data were prospectively collected from 102 patients, who underwent varicocelectomy for infertility in our hospital, from August 2016 to August 2018. Diagnosis of varicocele was made by clinical examination and Colour Doppler. In patients with clinical varicocele, grading was done using classification proposed by Dubin and Amelar.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> Diagnosis on doppler study was based on detection of two to three venous channels with at least one >3 mm in diameter and presence of reflux during the Valsalva manoeuvre. Venous dilatation of 2.7 mm diameter or less was graded as subclinical varicoceles (grade I).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Inclusion criteria adopted were age range 20–40 years, grade II/III varicoceles, primary infertility, and secondary infertility cases of less than 3 years duration. Patients with subclinical varicoceles were excluded from the study. But those with bilateral varicocele, having grade I varicocele on one side, were included in the study and underwent bilateral varicocelectomy. Patients with unilateral varicocele of grade II or III were treated with unilateral varicocelectomy. Patients having endocrine imbalances and obstructive azoospermia were excluded from the study. The spouse of the patient was evaluated by an infertility specialist to rule out possible infertility causes for including couples within this study.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Patients were instructed to observe abstinence for one day before submitting a semen sample, as recent studies indicate that abstinence of this duration is adequate for the collection of the best possible semen sample.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a> Semen analysis was performed twice at an interval of 7 days, both before and 6 months after varicocelectomy, and the average of two values was recorded. All semen samples were analyzed using the standardization of WHO (2010 criteria). Similarly, the serum testosterone level was done at presentation and repeated postoperatively at 6 months for comparative analysis. Patients were examined clinically at 1 week and 6 months follow-up for complications. During the follow-up, scrotal ultrasound, including colour Doppler, was performed in selected patients, to rule out any complications like hydrocele, scrotal haematoma, testicular atrophy and recurrence.</p><p id="par0035" class="elsevierStylePara elsevierViewall">All the patients were treated by subinguinal varicocelectomy under spinal anaesthesia. SurgiTel micro prism (Micro EVK 350) 3.5× magnification loupes were utilized. The spermatic cord was accessed through a ∼3 cm sub-inguinal incision. Every single vein within the cord except for vassal veins were ligated (with 4-0 vicryl) and divided. The testicular artery was identified and preserved using microvascular Doppler. Patients were discharged on the next day of surgery, with instructions of not using any form of contraception and to abstain from smoking for the study duration.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical analysis</span><p id="par0040" class="elsevierStylePara elsevierViewall">Continuous variables were presented as mean ± SD. Categorical variables were expressed in frequency and percentages. Semen parameters were compared before and after varicocelectomy by performing paired <span class="elsevierStyleItalic">t</span>-test. Categorical variables were compared by performing the chi-square test. For small numbers, Fisher’s exact test was applied, wherever required. <span class="elsevierStyleItalic">P-</span>value <.05 was considered statistically significant. STATA version 14.0 (StataCorp. 2015. <span class="elsevierStyleItalic">Stata Statistical Software: Release 14</span>. College Station, TX: StataCorp LP) was used for statistical analysis.</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">Loupe assisted subinguinal varicocelectomy was successfully performed in all the patients. The mean age of 102 patients was 31.56 ± 4.31 years. Primary infertility was noted in 86 (84.31%) patients, while 16 (15.69%) patients had secondary infertility. Furthermore, unilateral varicoceles were found in 23 (22.55%) patients who were treated with unilateral varicocelectomy. While 79 (77.45%) patients had bilateral varicoceles, they were treated with bilateral varicocelectomy. After varicocelectomy, significant improvement was noted in sperm density, total progressive motility, and morphology. The mean ± SD of sperm density (×10<span class="elsevierStyleSup">6</span>/mL) before and after varicocelectomy was 12.82 ± 3.91 and 20.06 ± 2.13 respectively (<span class="elsevierStyleItalic">P</span> < .0001) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a). The mean ± SD of total motility (%) before and after varicocelectomy was 37.67 ± 7.23 and 55.46 ± 4.51 respectively (<span class="elsevierStyleItalic">P</span> < .0001) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b). The mean ± SD of sperm morphology as per Kruger/Strict morphology criteria (%) before and after varicocelectomy was 3.11 ± 0.80 and 3.70 ± 0.78 respectively (<span class="elsevierStyleItalic">P</span> < .0001) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>c). The improvement in sperm density, motility, and morphology at 6 months follow-up was by 56.45%, 47.23%, and 18.97% respectively.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The mean ± SD of serum testosterone level (ng/dL) before and after varicocelectomy was 323.90 ± 67.81 and 396.74 ± 40.88 respectively (<span class="elsevierStyleItalic">P</span> < .0001) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>d). Baseline serum testosterone level was noted to improve by 22.49% at 6 months after varicocelectomy.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The spontaneous pregnancy rate at 6 months follow up in couples with primary infertility and secondary infertility was 18.60% and 31.25% respectively. The difference in their rates was insignificant (<span class="elsevierStyleItalic">P</span> value .25) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Notably, the overall spontaneous pregnancy rate at 6 months follow-up was 20.5%. Concerning postoperative complications, none of our study patients had any significant complications (hydrocele, scrotal haematoma, and testicular atrophy) or recurrence following the procedure.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">Varicocele is discerned to be a bilateral vascular disease. We found that 77.45% of our study patients had a bilateral varicocele. Our finding is consonant with that of previous studies.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15–17</span></a> Treatment of clinical varicocele is recommended, in infertile men with abnormal semen parameters.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a> There are various treatment approaches available for varicocele treatment. Contemporary evidence indicates that microsurgical varicocelectomy is the most efficacious and popular modality, amongst them all.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> Despite of this fact patients are still offered treatment depending on the availability of equipment and expertise.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Recent studies have shown favourable outcomes with both loupe assisted and microscopic techniques.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,18</span></a> However, Zhang et al. reported a slightly higher complication and recurrence rate with the loupe assisted technique, possibly because of the inguinal approach and non-utilization of micro-vascular Doppler probe intra-operatively.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Whereas Alkandari et al. did not find any significant difference in the complication rates between patients undergoing varicocelectomy by either of these techniques.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> They used a tourniquet to occlude the cord at deep ring level, for dilatation and better identification of veins. We utilized micro-vascular Doppler intra-operatively to identify and spare testicular artery. There was no complication or recurrence noticed after scrutinizing our patients.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Although the microsurgical technique has the lowest complication and recurrence rates, it has the limitations of higher cost, longer operating time and learning curve.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Alkandari et al. reported the loupe assisted technique to be 33% cheaper than the microvascular technique.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">There is no recommend cut off magnification, for varicocelectomy. One study suggests that magnification by a 3× loupe is sufficient for visualisation and dissection of varicoceles in inguinal approach.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> We had utilized 3.5× magnification loupes for our study.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The principal purpose of treating varicoceles is to improve fertility outcomes in couples. We observed a spontaneous pregnancy rate of 20.5% at 6 months follow-up. This was less than that reported by previous studies, possibly because of the shorter follow-up (at 6 months) of our study compared to the other studies. Ficarra et al. in their review reported a spontaneous pregnancy rate of 36.4% in patients undergoing varicocele treatment compared with controls (20%).<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Likewise, Marmar et al. in their review reported a spontaneous pregnancy rate of 33%, in patients who underwent varicocelectomy, compared to 15% in controls, at a follow-up of 12 months.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Hsieh et al. in their study of 96 patients who underwent loupe assisted inguinal varicocelectomy reported spontaneous pregnancy rates of 39.5% at 2 years follow-up.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Besides, one study had reported a spontaneous pregnancy rate of 45.5% in patients treated with microsurgical varicocelectomy at a mean follow-up of 11.7 ± 6.2 months.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Interestingly, we found a higher spontaneous pregnancy rate in men with secondary infertility (31.25%) compared to those with primary infertility (18.60%). But the difference in rates was not significant. The empirical results reported herein should be considered considering some limitations. As previously mentioned, unfortunately, due to time constraints we had to keep a short follow-up of 6 months. Also, semen analysis is a descriptive evaluation it may not distinguish between the sperm of fertile and infertile men. It is now evident that sperm DNA damage (expressed as DNA fragmentation index) may occur in men with infertility, which may reduce the chances of natural conception.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> DNA fragmentation index was not taken into consideration in our study, which could have indirectly affected the fertility rates.</p><p id="par0085" class="elsevierStylePara elsevierViewall">According to the retrospective study of 272 men by Hsiao et al. microsurgical varicocelectomy resulted in a significant increase in sperm concentration and serum testosterone level in all age groups.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Recently Alkandari et al. compared the outcomes of loupe assisted and microscopic varicocelectomy prospectively, and reported commensurable improvement in sperm density and progressive forward motility, in both group.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Studies comparing outcomes of loupe assisted varicocelectomy with varicocelectomy without magnification have reported significantly better improvement in sperm concentration, sperm motility, sperm morphology and serum testosterone level in patients treated with loupe assisted technique.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a> We found the loupe assisted subinguinal varicocelectomy resulted in the highest improvement of sperm density, which improved by 56.45%, sperm motility and morphology improved by 47.23% and 18.97% respectively. Our results are like those of recent studies.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Tanrikut et al. reported a lower mean serum testosterone level in men with varicocele compared to those without varicocele.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> They observed improvement in serum testosterone from 358 ng/dL to 454 ng/dL in men who had undergone bilateral microsurgical varicocelectomy. Abdel-Meguid had reported mean serum testosterone level improvement after varicocelectomy by 44.7 ng/dL (12.9%). They also reported more significant improvement in men with hypogonadism than in eugonadal men, which were 40.1% and 2.01% respectively.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> In our study, mean serum testosterone level improvement after varicocelectomy was by 72.84 ng/dL (22.49%). Hsiao et al. reported an increase in mean serum testosterone level after varicocelectomy from 308.4 ng/dL to 417.5 ng/dL with a mean increase of 109.1 ± 12.8 ng/dL.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Likewise, Zohdy et al. reported improvement in mean serum testosterone level from 379 ± 250.8 ng/dL to 405.1 ± 170.2 ng/dL.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> In our study, the mean serum testosterone level was noted to improve from 323.90 ± 67.81 to 396.74 ± 40.88 ng/dL.</p><p id="par0095" class="elsevierStylePara elsevierViewall">As with most studies, the design of our study is subject to a limitation. Because of the absence of a comparison group, we cannot conclude that the results of the loupe assisted technique are comparable to the microsurgical technique. Only few comparative studies have compared results of the Loupe assisted technique with microsurgical technique and these were small size, single-centre studies. Although we found loupe assisted varicocelectomy safe and effective in improving semen quality in infertile men, further large volume comparative studies are needed to reach a consensus.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interests</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1795333" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1571574" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1795334" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1571573" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-04-25" "fechaAceptado" => "2021-09-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1571574" "palabras" => array:6 [ 0 => "Male infertility" 1 => "Varicocele" 2 => "Loupe assisted varicocelectomy" 3 => "Spontaneous pregnancy rates" 4 => "Semen quality" 5 => "Serum testosterone level" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1571573" "palabras" => array:6 [ 0 => "Infertilidad masculina" 1 => "Varicocele" 2 => "Varicocelectomía con lupas" 3 => "Tasas de embarazo espontáneo" 4 => "Calidad del semen" 5 => "Nivel de testosterona sérica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">To study the impact of loupe assisted subinguinal varicocelectomy on semen quality, serum testosterone level, and spontaneous pregnancy rate.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">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.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">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<span class="elsevierStyleSup">6</span>/mL) before and after varicocelectomy was 12.82 ± 3.91 and 20.06 ± 2.13 respectively (<span class="elsevierStyleItalic">P</span> < .0001). The total sperm motility (%) before and after varicocelectomy was 37.67 ± 7.23 and 55.46 ± 4.51 respectively (<span class="elsevierStyleItalic">P</span> < .0001). The sperm morphology (Kruger/Strict morphology criteria, %) before and after varicocelectomy was 3.11 ± 0.80 and 3.70 ± 0.78 respectively (<span class="elsevierStyleItalic">P</span> < .0001). The serum testosterone level (ng/dL) before and after varicocelectomy was 323.90 ± 67.81 and 396.74 ± 40.88 respectively (<span class="elsevierStyleItalic">P</span> < .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 (<span class="elsevierStyleItalic">P</span> = .251). The overall spontaneous pregnancy rate was 20.5%.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">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.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Evaluar el impacto de la varicocelectomía subinguinal con gafas de aumento sobre la calidad del semen, el nivel de testosterona sérica y las tasas de embarazo espontáneo.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Se recogieron datos de forma prospectiva de 102 hombres infértiles con varicocele clínico. Se compararon los valores preoperatorios de los parámetros de análisis de semen y el nivel de testosterona sérica con los valores postoperatorios a los 6 meses. Se evaluó la tasa de embarazo espontáneo a los 6 meses.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">La edad media de los pacientes era de 31,56 ± 4,31 años. Se registró infertilidad primaria en 86 pacientes e infertilidad secundaria en 16. Se observó varicocele bilateral en 79 pacientes y varicocele unilateral en 23. La concentración total de espermatozoides (×10<span class="elsevierStyleSup">6</span>/mL) antes y después de la varicocelectomía fue de 12,82 ± 3,91 y 20,06 ± 2,13, respectivamente (<span class="elsevierStyleItalic">P</span> < ,0001). La motilidad espermática total (%) pre y postvaricocelectomía fue de 37,67 ± 7,23 y 55,46 ± 4,51 respectivamente (<span class="elsevierStyleItalic">P</span> < ,0001). La morfología espermática (criterios estrictos de morfología Kruger, %) antes y después de la varicocelectomía fue de 3,11 ± 0,80 y 3,70 ± 0,78, respectivamente (<span class="elsevierStyleItalic">P</span> < ,0001). El nivel de testosterona sérica (ng/dL) antes y después de la varicocelectomía fue de 323,90 ± 67,81 y 396,74 ± 40,88 respectivamente (<span class="elsevierStyleItalic">P</span> < ,0001). La tasa de embarazo espontáneo en las parejas con infertilidad primaria y secundaria fue de 18,60% y 31,25%, respectivamente. La diferencia de tasas no fue significativa (<span class="elsevierStyleItalic">P</span> = ,251). La tasa global de embarazo espontáneo fue del 20,5%.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">La varicocelectomía subinguinal con gafas de aumento es una modalidad segura y eficaz para el tratamiento de varones infértiles, especialmente cuando no se dispone de medios para la cirugía microscópica. Sin embargo, sólo los estudios comparativos de gran tamaño o los ensayos multicéntricos pueden confirmarlo.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2610 "Ancho" => 2507 "Tamanyo" => 278228 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">a: Comparison of sperm density before varicocelectomy and 6 months after varicocelectomy. b: Comparison of sperm motility before varicocelectomy and 6 months after varicocelectomy. c: Comparison of sperm morphology before varicocelectomy and 6 months after varicocelectomy. d: Comparison of serum testosterone level before varicocelectomy and 6 months after varicocelectomy.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Values are represented as mean ± standard deviation.</p>" "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Before Varicocelectomy \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">6 Months after varicocelectomy \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">t-value \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>-values \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">% Improvement \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sperm density (millions/mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.82 ± 3.91 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20.06 ± 2.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23.14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.0001<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">56.45 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total Sperm motility (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37.67 ± 7.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">55.46 ± 4.51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28.50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.0001<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">47.23 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sperm Morphology (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.11 ± 0.80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.70 ± 0.78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.0001<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.97 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Serum Testosterone level (ng/mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">323.90 ± 67.81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">396.74 ± 40.88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.0001<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22.49 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0005"><span class="elsevierStyleItalic">P</span> < .05, statistically significant.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Sperm density, total sperm motility, sperm morphology, and serum testosterone level before and 6 months after varicocelectomy (Paired <span class="elsevierStyleItalic">t</span>-test).</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Values are represented as a number (%).</p>" "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total cases \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Spontaneous pregnancies 6 months after varicocelectomy \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P-</span>values \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Primary infertility</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">86 (84.31%)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 (18.60%)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chi<span class="elsevierStyleSup">2</span> = 1.3194 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#tblfn0010">*</a><span class="elsevierStyleItalic">P</span> = .251, NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Secondary infertility \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 (15.69%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (31.25%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0010"><span class="elsevierStyleItalic">P</span> > .05, statistically insignificant; NS, Not significant.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Spontaneous pregnancy rates at 6 months after varicocelectomy (Chi-square test).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:27 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Varicoceles: prevalence and pathogenesis in adult men" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.I. Clavijo" 1 => "R. Carrasquillo" 2 => "R. Ramasamy" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.fertnstert.2017.06.036" "Revista" => array:6 [ "tituloSerie" => "Fertil Steril." "fecha" => "2017" "volumen" => "108" "paginaInicial" => "364" "paginaFinal" => "369" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28865534" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Elevation of intratesticular and scrotal skin surface temperature in men with varicocele" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Goldstein" 1 => "J.F. Eid" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0022-5347(17)38874-2" "Revista" => array:6 [ "tituloSerie" => "J Urol." "fecha" => "1989" "volumen" => "142" "paginaInicial" => "743" "paginaFinal" => "745" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2769853" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Correlation of ultrasound-measured venous size and reversal of flow with Valsalva with improvement in semen-analysis parameters after varicocelectomy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.D. Schiff" 1 => "P.S. Li" 2 => "M. Goldstein" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.fertnstert.2005.12.038" "Revista" => array:6 [ "tituloSerie" => "Fertil Steril." "fecha" => "2006" "volumen" => "86" "paginaInicial" => "250" "paginaFinal" => "252" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16764870" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Best practice policies for male infertility" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "I.D. Sharlip" 1 => "J.P. Jarow" 2 => "A.M. Belker" 3 => "L.I. Lipshultz" 4 => "M. Sigman" 5 => "A.J. Thomas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0015-0282(02)03105-9" "Revista" => array:6 [ "tituloSerie" => "Fertil Steril." "fecha" => "2002" "volumen" => "77" "paginaInicial" => "873" "paginaFinal" => "882" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12009338" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Varicocele and male factor infertility treatment: a new meta-analysis and review of the role of varicocele repair" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Baazeem" 1 => "E. Belzile" 2 => "A. Ciampi" 3 => "G. Dohle" 4 => "K. Jarvi" 5 => "A. Salonia" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.eururo.2011.06.018" "Revista" => array:6 [ "tituloSerie" => "Eur Urol." "fecha" => "2011" "volumen" => "60" "paginaInicial" => "796" "paginaFinal" => "808" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21733620" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impact of surgical varicocele repair on pregnancy rate in subfertile men with clinical varicocele and impaired semen quality: a meta-analysis of randomized clinical trials" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K.H. Kim" 1 => "J.Y. Lee" 2 => "D.H. Kang" 3 => "H. Lee" 4 => "J.T. Seo" 5 => "K.S. Cho" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4111/kju.2013.54.10.703" "Revista" => array:5 [ "tituloSerie" => "Korean J Urol." "fecha" => "2013" "volumen" => "54" "paginaInicial" => "703" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24175046" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Surgery or embolisation for varicocele in subfertile men" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.L. Evers" 1 => "J. Collins" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Cochrane Database Syst Rev." "fecha" => "2004" ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reassessing the value of varicocelectomy as a treatment for male subfertility with new meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.L. Marmar" 1 => "A. Agarwal" 2 => "S. Prabakaran" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.fertnstert.2006.12.008" "Revista" => array:6 [ "tituloSerie" => "Fertil Steril." "fecha" => "2007" "volumen" => "88" "paginaInicial" => "639" "paginaFinal" => "648" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17434508" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Varicocelectomy: modified loupe-assisted versus microscopic technique–a prospective comparative study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.H. Alkandari" 1 => "A. Al-Hunayan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.aju.2016.12.002" "Revista" => array:6 [ "tituloSerie" => "Arab J Urol." "fecha" => "2017" "volumen" => "15" "paginaInicial" => "74" "paginaFinal" => "77" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28275523" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Outcome of loupe-assisted sub-inguinal varicocelectomy in infertile men" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.S. Abdelrahman" 1 => "B.I. Eassa" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.5812/numonthly.1623" "Revista" => array:5 [ "tituloSerie" => "Nephrourol Mon." "fecha" => "2012" "volumen" => "4" "paginaInicial" => "535" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23573481" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A prospective randomized comparative trial between open subinguinal and loupe assisted subinguinal varicocelectomy: a single centre experience" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "H.G. Vyas" 1 => "V. Bhandari" 2 => "A. Kumar" 3 => "B. Nanda" 4 => "H. Singh" 5 => "S. Bhowmick" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/0974-7796.198899" "Revista" => array:5 [ "tituloSerie" => "Urol Ann." "fecha" => "2017" "volumen" => "9" "paginaInicial" => "13" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28216922" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Loupe-assisted high inguinal varicocelectomy for sub-fertile men with varicoceles" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.L. Hsieh" 1 => "P.L. Chang" 2 => "S.T. Huang" 3 => "T.M. Wang" 4 => "K.H. Tsui" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chang Gung Med J." "fecha" => "2003" "volumen" => "26" "paginaInicial" => "479" "paginaFinal" => "484" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14515970" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Relationship between the duration of sexual abstinence and semen quality: analysis of 9,489 semen samples" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. Levitas" 1 => "E. Lunenfeld" 2 => "N. Weiss" 3 => "M. Friger" 4 => "I. Har-Vardi" 5 => "A. Koifman" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.fertnstert.2004.12.045" "Revista" => array:6 [ "tituloSerie" => "Fertil Steril." "fecha" => "2005" "volumen" => "83" "paginaInicial" => "1680" "paginaFinal" => "1686" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15950636" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Time-to-ejaculation and the quality of semen produced by masturbation at a clinic" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "S. Elzanaty" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.urology.2007.12.009" "Revista" => array:6 [ "tituloSerie" => "Urology." "fecha" => "2008" "volumen" => "71" "paginaInicial" => "883" "paginaFinal" => "888" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18374400" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Induction of spermatogenesis and achievement of pregnancy after microsurgical varicocelectomy in men with azoospermia and severe oligoasthenospermia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G.J. Matthews" 1 => "E.D. Matthews" 2 => "M. Goldstein" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0015-0282(98)00108-3" "Revista" => array:6 [ "tituloSerie" => "Fertil Steril." "fecha" => "1998" "volumen" => "70" "paginaInicial" => "71" "paginaFinal" => "75" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9660424" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adolescent varicocele: is it a unilateral disease?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Y. Gat" 1 => "Z.V. Zukerman" 2 => "G.N. Bachar" 3 => "D.O. Feldberg" 4 => "M. Gornish" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0090-4295(03)00793-3" "Revista" => array:6 [ "tituloSerie" => "Urology." "fecha" => "2003" "volumen" => "62" "paginaInicial" => "742" "paginaFinal" => "746" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14550455" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Varicocele, hypoxia and male infertility. Fluid Mechanics analysis of the impaired testicular venous drainage system" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Y. Gat" 1 => "Z. Zukerman" 2 => "J. Chakraborty" 3 => "M. Gornish" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Human Reprod." "fecha" => "2005" "volumen" => "20" "paginaInicial" => "2614" "paginaFinal" => "2619" ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Loupe-assisted versus microscopic varicocelectomy: is there an intraoperative anatomic difference?" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H. Zhang" 1 => "X.P. Liu" 2 => "X.J. Yang" 3 => "W.T. Huang" 4 => "X.X. Ruan" 5 => "H.J. Xiao" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/1008-682X.122189" "Revista" => array:5 [ "tituloSerie" => "Asian J Androl." "fecha" => "2014" "volumen" => "16" "paginaInicial" => "112" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24369142" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0095" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment of varicocele in subfertile men: the Cochrane review–a contrary opinion" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "V. Ficarra" 1 => "M.A. Cerruto" 2 => "G. Liguori" 3 => "G. Mazzoni" 4 => "Minucci" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.eururo.2005.11.023" "Revista" => array:6 [ "tituloSerie" => "Eur Urol." "fecha" => "2006" "volumen" => "49" "paginaInicial" => "258" "paginaFinal" => "263" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16426727" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0100" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spontaneous pregnancy rates in Chinese men undergoing microsurgical subinguinal varicocelectomy and possible preoperative factors affecting the outcomes" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Peng" 1 => "Z. Zhang" 2 => "W. Cui" 3 => "Y. Yuan" 4 => "W. Song" 5 => "B. Gao" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.fertnstert.2014.12.091" "Revista" => array:6 [ "tituloSerie" => "Fertil Steril." "fecha" => "2015" "volumen" => "103" "paginaInicial" => "635" "paginaFinal" => "639" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25624191" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0105" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sperm DNA fragmentation: consequences for reproduction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L. Simon" 1 => "B. Emery" 2 => "D.T. Carrell" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/978-3-030-21664-1_6" "Revista" => array:6 [ "tituloSerie" => "Adv Exp Med Biol." "fecha" => "2019" "volumen" => "1166" "paginaInicial" => "87" "paginaFinal" => "105" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31301048" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0110" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Older age is associated with similar improvements in semen parameters and testosterone after subinguinal microsurgical varicocelectomy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "W. Hsiao" 1 => "J.S. Rosoff" 2 => "J.R. Pale" 3 => "E.A. Greenwood" 4 => "M. Goldstein" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.juro.2010.09.114" "Revista" => array:6 [ "tituloSerie" => "J Urol." "fecha" => "2011" "volumen" => "185" "paginaInicial" => "620" "paginaFinal" => "625" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21168880" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0115" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Varicocele as a risk factor for androgen deficiency and effect of repair" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C. Tanrikut" 1 => "M. Goldstein" 2 => "J.S. Rosoff" 3 => "R.K. Lee" 4 => "C.J. Nelson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1464-410X.2010.10030.x" "Revista" => array:6 [ "tituloSerie" => "BJU Int." "fecha" => "2011" "volumen" => "108" "paginaInicial" => "1480" "paginaFinal" => "1484" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21435152" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0120" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effects of varicocele on serum testosterone and changes of testosterone after varicocelectomy: a prospective controlled study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "T.A. Abdel-Meguid" 1 => "H.M. Farsi" 2 => "A. Al-Sayyad" 3 => "A. Tayib" 4 => "H.A. Mosli" 5 => "A.H. Halawani" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.urology.2014.05.029" "Revista" => array:6 [ "tituloSerie" => "Urology." "fecha" => "2014" "volumen" => "84" "paginaInicial" => "1081" "paginaFinal" => "1087" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25214202" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0125" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Varicocelectomy is associated with increases in serum testosterone independent of clinical grade" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "W. Hsiao" 1 => "J.S. Rosoff" 2 => "J.R. Pale" 3 => "J.L. Powell" 4 => "M. Goldstein" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.urology.2013.01.060" "Revista" => array:6 [ "tituloSerie" => "Urology." "fecha" => "2013" "volumen" => "81" "paginaInicial" => "1213" "paginaFinal" => "1218" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23561709" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0130" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impact of varicocelectomy on gonadal and erectile functions in men with hypogonadism and infertility" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "W. Zohdy" 1 => "S. Ghazi" 2 => "M. Arafa" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1743-6109.2010.01974.x" "Revista" => array:6 [ "tituloSerie" => "J Sex Med." "fecha" => "2011" "volumen" => "8" "paginaInicial" => "885" "paginaFinal" => "893" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20722780" "web" => "Medline" ] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0135" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Varicocelectomy: 986 cases in a twelve-year study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "L. Dubin" 1 => "R.D. Amelar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/0090-4295(77)90132-7" "Revista" => array:6 [ "tituloSerie" => "Urology." "fecha" => "1977" "volumen" => "10" "paginaInicial" => "446" "paginaFinal" => "449" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/919135" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735786/0000004600000009/v1_202211020736/S2173578622000129/v1_202211020736/en/main.assets" "Apartado" => array:4 [ "identificador" => "6275" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Review article" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735786/0000004600000009/v1_202211020736/S2173578622000129/v1_202211020736/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173578622000129?idApp=UINPBA00004N" ]
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