Varikotsele

Description:

The Varikotsele-varicosity of a seed cord, belongs to widespread diseases of children's reproductive system. At children and teenagers to a varikotsela it is shown in 12.4%-25.8% (Isakov Yu. F., 1969; Yerokhin A. P., 1979). Serious violations of a spermatogenesis are noted approximately at 30% of the patients operated at children's age (Kondakov V. T., Pykov M. I., 2000). In total connect more than 40% of childless marriages with varicosity of yaichkovy veins (Tiktinsky O. L., 1983; Godlevsky D. N.) that negatively affects a modern demographic situation and is the obvious testimony of trouble in treatment.

Varikotsele's symptoms:

There are several classifications to a varikotsela.
1.    on the party of defeat:
a.) left-side;
b.) right-hand;
c.)  bilateral;
2.    on an etiology:
a.)  primary;
b.)  symptomatic;
c.)  functional (a number of authors carry it to secondary);
3.    on character of a venous reflux:
a.)    with a renotestikulyarny reflux;
b.)  with an ileotestikulyarny reflux;
c.)  with the mixed reflux option;
4.    on degree:
a.)  the first;
b.)  the second;
c.)  the third;
5.    on a combination to hypertensia in a renal vein:
a.)  to a varikotsela with a gipertenzionny syndrome in a renal vein;
b.)  to a varikotsela without gipertenzionny syndrome in a renal vein;
6.    on an opredelyaemost by physical methods:
a.)  clinical;
b.)  subclinical.
Primary to a varikotsela (in domestic literature "idiopathic") – it is caused by insolvency or pathology of valves of a yaichkovy vein, developing against the background of its inborn changes (absence in a wall of veins of collagen of the 4th type and lack of collagen of the 3rd type).
Secondary to a varikotsela – it is caused by venous hypertensia in a renal vein and the return blood flow from a renal vein on yaichkovy in a grozdyevidny texture and then on system of an outside seed vein in the general ileal with formation of a compensatory renokavalny anastomosis. Venous hypertensia in a kidney can be caused by an organic stricture of a renal vein owing to cicatricial process in the cellulose surrounding a vein, kidney tumors, a ring-shaped renal vein, damages of kidneys like "arteriovenous fistulas" of posttraumatic or tumoral character, a nephroptosis, thrombosis of a renal vein that in children's surgical practice meets extremely seldom.
The functional stenozirovaniye of a renal vein (functional to a varikotsela), i.e. a prelum in an ortostaza of the left renal vein between an upper mesenteric artery and an aorta is intermediate at excessively acute angle of its otkhozhdeniye. Corner size between an aorta and an upper mesenteric artery changes depending on position of a body. In a klinostaza the corner is more and outflow on a renal vein is not broken. In an ortostaza venous current is perverted and sent from a renal vein down a yaichkovy vein to a grozdyevidny texture, in a klinostaza its direction usual – from a yaichkovy vein in renal. Sharp overflow of a grozdyevidny texture in a standing position disappears upon transition of the patient to a prone position. In domestic literature this state is known as "aortomezenterialny tweezers" and meets frequency about 18% among all children with the varikotsel. In our observation among 120 children with the varikotsel at one child this state was not confirmed neither by means of doppler sonography, nor by means of an angiographic research.
It is necessary to tell that the classification used earlier to a varikotsela on stages lost a little now the clinical value as numerous researches did not reveal correlation between a stage to a varikotsela and extent of disturbance of a spematogenez.
Allocation of clinical and subclinical forms to a varikotsela is of great importance. Symptoms to a varikotsela at subclinical  forms do not come to light at physical and the researches revealed at ultrasonic methods. As a rule, patients with subclinical forms come to light at inspection concerning infertility already at adult age. For this reason it is so important to reveal early it a disease and at an opportunity to begin the conservative therapy directed to improvement of an intraorganic blood-groove in a small egg.  
Varikotsele develops preferential on the left side (70-90% of cases). Its localization on both sides decides by various authors on frequency of 14-23%, on the right side – to 10.6% that, as a rule, demonstrates existence at the patient of vascular anomalies, or volume formations of retroperitoneal space.

  Manifestation symptoms to a varikotsela are usually poor. The following options meet:
1. patients do not show essential complaints and the diagnosis is made at screening surveys, and at adult age – at inspection concerning sterile marriage;
2. patients show complaints to periodic nagging pains in the corresponding half of a scrotum. Pains can amplify at an exercise stress, sexual excitement and in vertical position of a body (because of increase in venous pressure);
3. patients show complaints to existence of expanded veins in a scrotum ("a bunch of the worms" revealed at self-inspection and focusing attention of the patient, especially during puberty.
Pains in lumbar area of the stupid or pricking character can be clinical manifestation secondary to a varikotsela, connected with venous hypertensia (the expressed pain syndrome, fever, an oliguria) and blood impurity in urine (recurrent macro - and a microhematuria, a proteinuria is sometimes observed).

Varikotsele's reasons:

By the conducted histologic and immunohistochemical researches it is proved that development to a varikotsela is the cornerstone the disturbances of an embryogenesis of venous network of a small egg and a seed cord which are expressed in loose type of a structure of veins when instead of one vessel the network of veins of muscular type of various morphological characteristic is found; disturbances of formation of collagen in walls of vessels (absence in walls of venous vessels of collagen of the 4th type, considerable disturbances in formation of collagen of the 3rd type). All these changes lead to discomfort in system of outflow of blood, to development of compensatory processes, their destabilization and formation to a varikotsela. Changes in a wall of veins (expansion, a sclerosis, destruction of valves) revealed in bioptata, accumulating on inborn pathology of formation of vessels, have secondary character. They can be a consequence of lack of the valve in the mouth of a testicular vein, rise in pressure in the left renal vein, a venous reflux, a retrograde current of blood due to the smaller number of valves in the left yaichkovy vein, in comparison with right, and damages of valves.
In prepubertatny and the beginning of the pubertal period boys intensively grow that affects additional increase in pressure in a grozdyevidny texture at the expense of a gain of orthostatic pressure. During the same period the strengthened inflow of an arterial blood to a small egg is observed. The blood outflow increasing in this regard evenly stretches a yaichkovy vein, moving apart valves and, opening, thus, a way to retrograde intake of blood from the crowded renal vein in yaichkovy. Under the influence of much the increased pressure varicose deformation of walls of the changed network of yaichkovy veins and a grozdyevidny texture develops.
Long stagnation of a venous blood leads to temperature increase, development of sclerous changes in a small egg and disturbance of a differentiation of a spermatogenic epithelium. These disturbances can be also caused by blood shunting when the arterial blood, passing a microcirculator bed of a parenchyma of a small egg, comes to venules at once, at the same time the circulator hypoxia of tstikulyarny fabric which is one of major factors of formation of a patospermiya and infertility develops. At the same time the gematotestikulyarny barrier which function is performed by a basal membrane and Sertoli's cells is damaged. Autoimmune process develops. The blood which appeared in the general bed the circulating antibodies owing to the different reasons can break a gematotestikulyarny barrier of the right small egg and cause disturbance of its morphology and functions. Further it can be shown by decrease in the general spermatogenesis, emergence of pathological forms of spermatozoa and development of infertility.

Varikotsele's treatment:

Now treatment to a varikotsela is performed according to option of disturbance of the intraorganic blood circulation revealed by means of doppler sonography. The purpose of treatment is elimination of a venous reflux by surgical intervention. Treatment to a varikotsela - operation.
There are several options of operative measures:
1.okklyuziruyushchiye operations at various levels of a yaichkovy vein;
2.mikrokhirurgicheskiye operations - imposings of different types of a veno-venous anastomosis.
There are following types of quick accesses:
· retroperitoneal (Palomo, Ivanissevich, Bernardi's operations);
· pakhovy and podpakhovy (Marmar's operations, Yakovenko);
· laparoscopic;
· interventsionalny vascular (the selection transvenous embolization).
For today for treatment of a varikotsela Palomo and Ivanissevich's operations which are carried out as with use to a laparoscopic technique, and open retroperitoneal access, and also transvenous embolization are used. The combination of both methods is possible.