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Rasulov Z. D., Kayumkhodzhaev A. A., State Institution of the Republican Specialized Scientific Practical Center of Surgery named after Academician V. Vakhidov E-mail: mbshakur@mail.ru
SURGICAL TREATMENT OF RECURRENT VARICOCELE
Abstract: Determining the hemodynamic varicocele type by Doppler ultrasound and intraoperative fleboto-nometry in the spermatic vein system allows to choose the best way of operation and to prevent the development of recurrence. Using microsurgical techniques allows to ligate not only the collateral spermatic vein, but also periarterial trunks excluding intraoperative damage to testicular artery and lymph collectors. Worked out method comprising the use of microsurgery in combination with the formation of an "internal" jockstrap, is an effective method of treatment of varicocele and prevent its recurrence, complicated with infertility.
Keywords: varicocele, infertility, microsurgery.
Introduction Varicocele is the cause of male infertility in 40% of cases and is quite widespread in 15-19% of young men of working age. Clinically manifested varicocele is diagnosed in 35% of men with primary infertility and 70-81% of men with secondary infertility, while being detected in 15% of the male population [1; 3]. Currently, most researchers believe that "correction of varicocele is a necessary operational tool for the prevention and normalization of spermatogenesis [5].
The generally accepted way of treating varicocele is the Ivanisevich operation - the ligation of the seminal vein ("high ligation") in the retroperitoneal section, which is considered the most justified. However, a large percentage of relapses after this operation led to the search for new, modified methods.
According to the European Association of Urologists, the recurrence rate for varicocele ranges from 2% to 29.5%, depending on the method of surgical intervention [4]. The result largely depends on the correct choice of the method of operation, depending on the degree and type of varicocele. The latter speaks of the need to develop a single standard procedure for intraoperative diagnosis of the degree and type of varicocele with the definition of indications for a particular type of intervention. In this regard, the development and improvement of the indications for the choice of the method of re-operation in the recurrence of varicocele is relevant and not fully solved the problem.
Purpose of the study. To improve the results of surgical treatment of recurrent varicocele by developing methods using microsurgical techniques.
Materials and methods. The clinical material for this work was the results of the examination and surgical treatment of 60 patients with recurrent varicocele. 36 out of them, were patients of the first group with varicocele who underwent ligation of the inner and outer spermatic veins according to the
method developed by us and Group II - 24 patients who underwent ligation of the spermatic vein in the traditional way. The age ofpatients ranged from 12 to 41 years, the average age was 20.88 ± 0.51 years.
In the main group, all operations were performed by inguinal access under local anesthesia. In the compared group -pararectal access under general intravenous anesthesia.
The distribution of patients according to the degree of varicocele in both groups was homogeneous.
Patients performed general clinical examinations (comprehensive blood and urine analysis, blood biochemistry, ECG, chest roentgenoscopy), ultrasound dopplerography of the spermatic veins and cutaneous electrothermometry of the scrotum, intraoperative phlebotonometry of the spermatic veins were performed to determine the extent and type of varicocele and evaluate the effectiveness of surgical treatment.
In sexually mature patients of the compared groups, before and in the control periods after the operation, spermatogenesis studies were performed. In the first (main) group, a study of spermograms was carried out in 18, of which 6 showed abnormalities of spermatogenesis of varying degrees involving infertility. In the second (compared) group, the spermogram was performed in 14 patients, where it was noted that the pathological change in spermograms was observed in 7 patients and was accompanied by infertility in two patients.
Microsurgical inspection of the elements of the spermatic cord allowed to determine the anatomical types of BCB. Thus, the trunk type VSV was found out in 24(38.7%) patients, the loose type - in 5(8%) and mixed type - in 33(53.3%) patients. Scatter type VSV was an indication for microsurgical vein ligation due to the inability to perform microvascular anastomosis.
Medical science
In 36 cases (group I), the trunks of the inner and outer spermatic vein were ligated using microsurgical techniques according to the method developed in the clinic (patent for the invention "Method for the surgical treatment of varicocele complicated by infertility" No. IAP 04683 dated April 08, 2013).
The use of microsurgical techniques allows you to:
- to identify and protect from damage the vas deferens with its accompanying vessels, the internal testicular artery, the main lymphatic vessels of the spermatic cord;
- identify and evaluate the external seed artery and vein, save the artery during vein ligation;
- isolate and bandage the periarterial trunks of the BCB;
- to isolate and bandage all the veins of the spermatic cord, with the exception of the veins of the vas deferens and one vein, which is used to form the anastomosis (if indicated).
If we take into account that the majority of the examined patients had a loose scrotum (64.5%), which also contributed to the development of relapse, it became necessary to develop a method of forming an "internal" suspension, using the capabilities of microsurgical techniques. The combination of the developed method with the main stage of the operation contributed to the prevention of relapse.
The method consists in microsurgical ligation of the trunks of the spermatic vein, discharge of the spermatic cord below the external inguinal ring, without additional access, pulling up of the testicle to the level of the / 3 scrotum with fixation of the spermatic cord to the inguinal ligament with separate interrupted sutures.
Distinctive features of the developed method are:
1. Isolation of the spermatic cord and fixation to the inguinal ligament with 1-2 sutures to create an "internal" suspensor.
2. Ligation of the trunks ofVSV and NSV using microsurgical techniques, in view of the complete "destruction" of the Reno - testicular and oro - testicular pathological circulation.
3. Restoring the integrity of the cremasteric muscle throughout the inguinal canal.
Upon completion of the main stage of the operation, the aponeurosis of the external oblique abdominal muscle was com-ducted with interrupted sutures and wound closure layered.
The results of microsurgical dressings for the development method in group I (n = 36) were analyzed in comparison with the control group of patients (group II - n = 24) who underwent Ivanissevich surgery for varicocele.
Results and its discussion.
An indicator of skin thermometry of the scrotum is an indirect sign of impaired blood flow. In the control periods, the temperature gradient between the left and right halves of the scrotum in I group significantly decreased from 1.22 °C
to 0.26 °C in the upper third of the scrotum, at the level of the lower third of the scrotum from 0.82 °C to 0.19 °C and in group II from 1.32 °C to 0.37 °C, from 0.67 °C to 0.25 °C, respectively, which indicates the adequacy of the operation and the reduction of venous stagnation.
With ultrasound doppler, there is a decrease in the diameter of the seminal vein from 0.47 ± 0.04 cm to 0.28 ± 0.02 cm in group I and from 0.52 ± 0.05 cm to 0.30 ± 0.01 cm in group II. An assessment of the dynamics of changes in the ultrasound parameters of the blood flow of the operated patients of the two compared groups during the year showed that the difference between the obtained data is statistically significant (p <0.05), which indicates the preservation of the achieved positive result of surgical intervention in both groups. However, in the long-term period, one patient in the control group (group II) had a reflux of blood through the seed vein and a recurrence of the disease was recorded.
In the first (main) group, in 4 patients, the spermogram remained unchanged after surgery. After surgery, 2 patients showed a deterioration in the quantitative and qualitative indicators of the spermogram, in 2 patients a deterioration in the quantitative, but improved quality indicators, in 9 patients showed a positive dynamics of the spermogram indicators.
In the II (compared) group, in the long-term postoperative period, three patients were under observation, and all showed a positive increase in the quantitative parameter. But one patient showed a deterioration in the quality parameter of the spermogram, and in two patients there was a positive change in the quality parameters of the spermograms.
In the observation period of 6-12 months. after the operation, there was an improvement in the qualitative and quantitative parameters of the spermogram in both groups, but in the main group (I) the concentration of spermatozoa was 1 ml. increased 1.59 times, while in the compared group (II) increased to 1.38 times; the number of live spermatozoa in the main group increased to 1.28 times, while in the compared group it increased to 1.02 times; pathological forms of spermatozoa decreased 4.36 times in group I, respectively 1.74 times in group II. The onset of pregnancy was noted in the wives of patients of group I in 11.7%, and in the patients of group II, in 6.7% of cases within a year.
Discomfort and pain in the scrotum in the postoperative period was observed in all patients in both groups, but in the comparison group in the first two days after the operation all patients (100%) needed analgesics, in the main group in the early postoperative period only anesthesia was needed 20 patients (55.6%).
In the long term, recurrence of varicocele in group I was not canceled; in group II, varicocele recurred in 5.3% of cases.
Thus, the method of ligation of the trunks of the seed vein developed by us has several advantages over the tradi-
tional operation. The main ones are the following: the use of a microsurgical revision of the elements of the spermatic cord and ligation of the venous trunks with the formation of an "internal" suspensor.
Findings:
1. Recurrence of the disease in 51.6% of cases was associated with technical faults in the performance of the primary intervention (left main trunk untied, additional venous trunks, collaterals, periarterial collaterals).
2. Determination of the hemodynamic type of varicocele by ultrasound-doppler sonography and intraoperative phlebo-tonometry in the spermatic vein system allows choosing the optimal method of operation and preventing the development of a relapse of the disease.
3. The use of microsurgical techniques eliminates intraoperative damage to the testicular artery and lymphatic collectors of the spermatic cord, allows ligation not only of the collateral seminal veins, but also the periarterial trunk.
References:
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