Surgical anatomy of the spermatic cord
Running inside the inguinal canal towards the testicle, the spermatic cord contains the following structures: vas deferens, testicular artery, testicular veins, cremasteric artery, deferential artery, lymphatics, genital branch of the genitofemoral nerve, and small nervous plexuses.
The testis blood supply derives mainly from the testicular (or internal spermatic) artery that arises directly from the aorta, bilaterally. The second arterial blood supply is the deferential artery, which derives directly from the hypogastric (internal iliac) artery or from the superior vesical artery (branch of the anterior division of the hypogastric artery). The third blood supply of the testis consists of branches of the cremasteric (or external spermatic) artery deriving from the inferior epigastric artery ( Fig. 41.1 ).
As the main artery supplying blood to the testis is the testicular artery, this information has to be taken into account while performing surgery of spermatic cord. It has been demonstrated that if the testicular artery has to be divided, testicular atrophy is avoided by the presence of the deferential and cremasteric arteries, but in cases in which a patient underwent previous vasectomy or other surgeries compromising the deferential artery, the testicular artery needs to be preserved during operations including varicocelectomy.
The testicular artery divides distally branching into the superior and medial epididymal arteries that supply blood to the superior pole and intermediate portion of the epididymis. On the other side, the inferior pole of the epididymis is vascularized by the deferential artery. These two arterial systems are strictly interconnected, so that if either the testicular artery or the deferential artery are to be dissected, the residual epididymal vascularization is more than adequate.
It is also surgically relevant to know that a single testicular artery is observed in 50% of spermatic cords, with two arteries in 30% and three arteries in 20% of cases.
The testicular venous drainage has a different distribution than the arterial system. Small parenchymal branches that arise from the testicle drain into either a group of veins near the mediastinum testis or on the surface of the testis. These two groups of veins, together with the deferential veins, anastomose with each other around the testicular artery forming the pampiniform plexus. After ascending along the testicular artery, the anastomosed veins of the pampiniform plexus join to form two or three veins at the level of the inguinal canal. These become one single vein (testicular or internal spermatic vein) that drains into the inferior vena cava on the right and into the renal vein on the left side.
It is important to note that anatomical variations where the testicular veins anastomose with the external pudendal, cremasteric, and vasal veins can occur. In these cases, the chance of varicocele recurrence after varicocelectomy is increased.
The pampiniform plexus facilitates the exchange of heat between veins and the testicular artery, permitting a decrease in temperature of 2°C to 4°C of the arterial blood arriving to the testis. For this reason, in patients with varicocele this temperature differential is decreased, resulting in a higher probability of testicular dysfunction due to higher testicular temperature.
Innervation to the testis and epididymis, which is solely an autonomic innervation, runs alongside the gonadal vessels. The nerves directed to the testis originate from the renal and aortic plexuses, deriving from T10–T11. The genital branch of the genitofemoral nerve supplies sensation to the parietal and visceral tunica vaginalis and the overlying scrotum.
Varicocele is a genital condition resulting in an abnormal dilation and tortuosity of the internal spermatic veins within the pampiniform plexus. It is found in 15% of male population and can be related to infertility, testicular pain, hypogonadism, and failure of ipsilateral testicular growth and development. Twenty-five percent of cases of abnormal semen analysis are associated with varicocele, since it has been demonstrated that this condition is linked to progressive decrease in testicular function.
Surgical varicocelectomy significantly improves semen parameters such as sperm count and motility, increasing live birth rates. Different surgical and radiological techniques of varicocele correction have been described. The surgical approaches can be retroperitoneal (Palomo technique) with an incision at the level of the internal inguinal ring, inguinal (Ivanissevich technique), microsurgical inguinal and subinguinal (with the use of a microscope or loupe), and laparoscopic. The radiologic/interventional approach consists of an antegrade embolization or a retrograde sclerotherapy, with the endovascular occlusion of the refluxing internal spermatic veins.
Three-port laparoscopic varicocelectomy
Indications and contraindications
The indication for the treatment of varicocele is still a matter of debate. The American Urological Association and the American Society for Reproductive Medicine recommend varicocele repair for infertile men with a clinically palpable varicocele and at least one or more abnormal semen parameters with the female partner having either normal or potentially treatable fertility. In case of a reduction in ipsilateral testicular size, varicocele treatment is also advised.
The laparoscopic approach carries an increased number of potential complications compared to the microsurgical one. For this reason, it is a valid technique in patients with previous groin surgery (e.g., hernia repair) in which an inguinal approach can be challenging, or in the case of a bilateral varicocele.
Contraindications include previous major abdominal or retroperitoneal surgery, large abdominal wall hernias, and conditions impeding sufficient pneumoperitoneum (cardiac or respiratory comorbidities). A technique that permits the sparing of the spermatic artery is preferred; if the artery has to be divided, prior testicular surgery that compromises collateral blood supply becomes a contraindication.
Different laparoscopic varicocelectomy techniques can be performed. In this chapter, we describe artery- and lymphatic-sparing procedures. The sparing of the lymphatics leads to a lower postoperative hydrocele rate.
Patient preoperative evaluation and preparation
The preoperative evaluation for laparoscopic varicocelectomy, as for the open and microscopic technique, includes physical examination, laboratory studies, and imaging.
Physical examination consists of a complete genital examination, including the Valsalva maneuver in standing position. Particular attention must also be paid to size discrepancy between the testes.
Standard preoperative laboratory studies, including urine culture, are recommended. In adult patients, semen analysis (performed on at least two separate occasions) is also encouraged.
In addition, an abdominal ultrasound aids in the detection of major abdominal masses or aortic aneurism.
An informed consent form including the possibility of conversion to open surgery should be given to the patient. No bowel preparation is needed, and a single dose of broad-spectrum antibiotic such as cefazoline should be administrated.
Operating room configuration and patient positioning
The operating room configuration is shown in Fig. 41.2 . A single monitor is positioned at the foot of the bed, the surgeon and the assistant are in front of each other, with the surgeon standing on the side of the table opposite to the varicocele to be ligated. The scrub nurse is positioned behind the surgeon.
The patient has to be placed in a supine position with arms adducted or abducted on arm boards according to the surgeon’s preference. A slight Trendelenburg position facilitates the procedure avoiding the intestines’ presence while reaching the spermatic cord. The surgical field is prepared from the xiphoid process to the upper thighs, including the penis and scrotum.
We describe a three-port technique, with the first trocar positioned at the umbilicus ( Fig. 41.3 ). Placement of the first trocar can be achieved both using a Verres needle or with an open laparoscopic approach. Pneumoperitoneum is subsequently set at a pressure ranging from 10 to 15 mm Hg. The second trocar is placed, under direct vision and after inspection of the abdomen, on the midline, halfway between the pubis and the umbilicus. The third trocar is positioned laterally to the rectus muscle on a line between the umbilicus and the anterosuperior iliac spine ipsilateral to the varicocele. The 5-mm umbilical trocar is used for camera and insufflation, whereas the two remaining 5-mm trocars provide access to laparoscopic instruments. For bilateral varicocele ligation the three-port configuration remains unchanged, moving the camera in the pararectal trocar contralaterally to the last side to be treated and using the umbilical and inferior midline trocars as operative ones.