Comparative Study Of Efficacy Of Two Kinds Of Microscopic Varicocelectomy And Its Effects On Sperm Quality And Sex Hormone Levels

Background:Varicocele (VC) is a different degrees of dilation and tortuosity of the veins of the pampiniform plexus draining the testicle. VC is a common male reproductive system disease which can be found in any age of men, and the incidence of VC is 10% to 15% in normal male population. But the more common in young adults, the incidence rate of 17 to 19 years old in the late adolescence was as high as 26%. VC is divided into primary varicocele and secondary varicocele according to the etiology. It is usually located on the left side of the testis, and also can be on both sides or on the right side. There is no obvious clinical symptom usually, but somebody may appear the clinical symptoms like scrotal swelling, local bulge pain, dull pain and tired with a standing posture, or it is worsen after long standing which is relieved or disappeared after supine rest. Spermatic vein and plexiform venous plexus expansion would damage the testis. With the development of disease, spermatogenic cells and sertoli cells of testis are pathological changes, and it leads to a decrease in the number and quality of sperm in VC patients, even without sperm. In addition, venous blood reflux causes a large amount of material as steroids, prostaglandin,5-serotonin and so on in the testis in VC patients, and such substances can affect the production of testosterone, progesterone, follicle stimulating hormone and other sex hormones to change the level of sex hormones in VC patients. Therefore, the varicocele can be said to be one of the main reasons affecting male fertility. Due to the lack of conscious symptoms, patients with VC often cannot be timely diagnosis and treatment, even early diagnosis and prompt treatment can reverse and cure it. Surgical treatment is the main treatment, and part of the surgical treatment combined with drug treatment can obtain the ideal effect. The traditional surgical treatment is the open surgery, it is generally take the position of groin and posterior peritoneum as incision for high ligation of the internal cord vein, and resection of the scrotum part of the dilated veins. With the wide application of laparoscopy in the urinary tract, surgical treatment of VC is mainly inguinal laparoscopic varicocectomy or retroperitoneal laparoscopic varicocectomy in domestic and international clinical at present. In recent years, with the aid of microscope, clinicians may be more aware of the location of arteries, veins and lymphatic vessels. Because of the advantages such as fewer traumas, less complications and obvious curative effect, the low microsurgical varicocectomy is considered as the gold standard for the operation of VC. The inguinal microsurgical varicocectomy or retroperitoneal microsurgical varicocectomy are recommended for the treatment of VC. Especially retroperitoneal microsurgical varicocectomy, it can not only reduce the possibility of damage to the inferior epigastric artery and vein as well as the testicular atrophy caused by puncturing, but also has many advantages such as simple operation, surgical trauma, fewer complications, recurrence rate and improve the quality of semen, and so on.Objective To treat the VC patients using inguinal microsurgical varicocectomy or retroperitoneal microsurgical varicocectomy respectively. To compare the clinical efficacy, the sperm quality before and after surgery, the improve of sex hormone level and complications after surgery, and to investigate the better method of operation incision in the ligation of the cord vein under the microscope.Methods(1) Object of studyIn December 2015 to March 2014,98 cases of hospitalized patients with primary VC in the Department of Urology of Dongguan Donghua Hospital were selected as study subjects whose clinical symptoms were scrotal pain, infertility and sterile after married.Inclusion criteria:9) Age≥ 18 years and≤80 years;10) The symptom of patients was no significant improvement after conservative treatment such as physical or drug. The patients who had the related symptoms of pain, falling inflation and dull pain of testicular or perineal region and waist radiating pain which affecting the quality of daily life.11) Patients have a normal sex life more than 1 year but not sterile.12) Patients determined13) Patients identified as primary VC after physical examination and color Doppler sonography.14) The degree of VC was identified above Ⅱ degree after by color Doppler ultrasound indexing standards.15) Patients with abnormal semen quality.16) Patients agreed and signed the informed consent of patients.17) Patients would to complete the six-month follow-up.Exclusion criteria:14) Patients with secondary VC.15) Patients with open surgical procedures.16) Patients with other diseases such as urinary system, reproductive system inflammation caused by the scrotum, testicles ache.17) Patients with pain caused of abdominal, pelvic and retroperitoneal tumor compression.18) Patients with secondary obstructive disease of iliac vein and inferior vena cava.19) Patients with history of retroperitoneal and pelvic surgery.20) Patients with severe liver and kidney dysfunction, severe hypertension, active peptic ulcer, hyperthyroidism, severe infection, cancer, blood diseases and autoimmune rheumatic diseases21) Patients with coagulation disorders or bleeding tendency.22) Patients could not tolerate the narcotic drugs.23) Patients could not tolerate the surgery.24) Patients with mental abnormality and could not complete this study.25) Patients could not contact or follow-up timely in the follow-up period.26) The other conditions were not suitable for inclusion.(2) Grouping and surgical methods98 patients with primary VC were randomly divided into observation group and control group by the prospective randomized controlled study methods. The observation group of 50 cases was treated with retroperitoneal microsurgical varicocectomy, and the control group of 48 cases was treated with inguinal microsurgical varicocectomy.(3) Observed indicatorThe observed indicators including the number of blood vessels, operation time, volume of loss bleeding, hospitalization time, pain degree and the recovery time of gastrointestinal function after operation in two groups were observed, recorded and comparatively analyzed.The testicular volume, semen parameters (appearance, semen volume, pH, sperm density, sperm count, the rate of sperm survival, sperm motility of grade A and grade A+B and the rate of normal morphology sperm) and sex hormone level in peripheral blood (total testosterone, progesterone, follicle stimulating hormone, prolactin and estrogen) in two groups were observed, recorded and comparatively analyzed.The complications (such as scrotum pain, testis atrophy and hydrocele of tunica caginalis) in two groups were observed, and the recurrence rate after operation was compared between the two groups.(4) Follow-upThe follow-up time was 6 months. The testicular volume, semen parameters and sex hormone level in peripheral blood were detected in two groups in 1,3 and 6 months after operation.(5) Statistical methodAll of the experimental data was entered by Excel and collected statistics by SPSS 19.0. The counting data was compared with chi square test, and the results were expressed as percentage (%). Measurement data was compared with t test of independent sample, the results were expressed as mean±SD (x±s). If.P<0.05, the difference was considered statistically significant.Results(1) Comparison results of two groups on general informationThe difference between the two groups in general data of marital status, average age, body mass index, the average duration of illness, diseased parts, clinical classification of spermatic vessels and scrotal pain were no statistical significance (P>0.05).(2) Comparison results of two groups on clinical efficacy① The number of the blood vessels in the observation group was significantly less than that in the control group (.P=0.000).②The operation time of the control group was significantly less than that of the observation group (P=0.000).③ The hospitalization time and recovery time of gastrointestinal function of the observation group was significantly shorter than that in the control group (P<0.05).(3) Comparison results of testicular volume and semen quality before and after operation④ The testicular volume, sperm density, sperm count of two groups in 1,3 and 6 months after operation were significantly increased which compared with the preoperative (P<0.05), respectively. And the survival rate of two groups in 1,3 and 6 months after operation was significantly higher than that in the preoperative (P<0.05). The sperm motility of level A and A+B of two groups in 3 and 6 months after operation were significantly increased which compared with the preoperative (P<0.05). The rate of normal sperm morphology of two groups in 3 and 6 months after operation were significantly increased which compared with the preoperative (P<0.05).② 6 months after operation, the sperm count in the observation group were significantly higher than that in control group, the difference was statistically significant (P<0.05), and the rate of normal morphology sperm of observation group was significantly higher than that of control group (P<0.05).③ The sperm count and sperm motility of level A+B of two groups in 3 months after operation were significantly increased which compared with 1 months after operation (P<0.05). And the rate of normal morphology sperm of two groups in 3 months after operation were significantly increased which compared with 1 months after operation (P<0.05). The differences were statistically significant (P<0.05)④ The sperm density, sperm count, sperm motility of level A and A+B of two groups in 6 months after operation were significantly increased which compared with 1 months after operation (P<0.05). And the rate of normal morphology sperm of two groups in 6 months after operation were significantly higher than that in 1 months after operation (P<0.05).(4) Comparison of sex hormone levels before and after operation① There was no significant difference in serum estrogen level of two groups in 1,3 and 6 months after operation compared with the preoperative (P>0.05);② In the two groups, the serum level of total testosterone was significantly increased and the serum levels of progesterone and follicle stimulating hormone were significantly decreased in 3 and 6 months after operation which compared with preperative (P<0.05).③ In the two groups, the serum level of total testosterone was significantly increased and the serum levels of follicle stimulating hormone was significantly decreased in 3 and 6 months after operation which compared with 1 months after operation (P<0.05).④ The serum levels of progesterone in the two groups were significantly decreased in the two groups in 6 months after operation which compared with 1 months after operation, and the difference was statistically significant (P<0.05).(5) Comparison results of postoperative complicationObservation group and control group were 14.00% and 27.08% of patients had postoperative complications, respectively. And the difference between the two groups was no statistically significant (P=0.175). Complications occurred in the two groups such as scrotal edema, wound infection, scrotal pain, testicular epididymitis, etc. But the differences between the two groups were no statistically significant (P>0.05). There were 3 cases with testicular hydrocele in control group. There were no postoperative hemorrhage and testicular atrophy in the two groups.(6) Comparison results of recurrence rate after operationAt 6 months follow-up, the recurrence rates of the observation group and the control group were 2% and 4.17% respectively, and the difference between the two groups was no statistically significant (P=0.971).ConclusionThe retroperitoneal microsurgical varicocectomy and inguinal microsurgical varicocectomy were recommended for VC treatment. Both retroperitoneal microsurgical varicocectomy and inguinal microsurgical varicocectomy were minimally invasive surgery for the treatment of the common use of the micro surgery. Because of the different ways of incision, the exposure of arteries, veins and lymphatic vessels were different in the two kinds of operation. And the visual field of operation had great significance in many aspects, such as the effect of operation, intraoperative injury, postoperative complications and recurrence. In the results of this study, the retroperitoneal microsurgical varicocectomy had the advantages of simple operation, less surgical trauma, shorter recovery time, less complications and low recurrence rate compared with inguinal microsurgical varicocectomy. And it could obviously improve the clinical symptoms and the quality of sperm. Because of fewer samples included in this study, the high inclusion and exclusion criteria and short duration of follow-up, there would be some deviations in the results of the study. Therefore, validation of large sample size and longer follow-up studies should be performed.