The Evolution and Refinement of Varicocele Treatment: A Historical Perspective

Abstract

Varicoceles were identified in men since antiquity because these lesions were visible, palpable and painful. The earliest surgical repairs were reported in the first century AD because of pain, and the first to nineteenth centuries were referred to as the ``Pain Era.'' The initial surgeries were limited to the scrotum, and they included ligation of the enlarged veins within the scrotum plus cautery of the veins on the outer wall of the scrotum. In 1677, the microscope was invented, and one of the earliest discoveries with this instrument was the finding of sperm in the semen. However, it was not until the nineteenth century before investigators began to study the semen of infertile men with varicoceles. It became apparent that men with varicoceles often had lower sperm counts, but the cause of the decrease was unclear. Some early investigators suggested excess testicular heat, and new surgical procedures were introduced to reduce the length of the scrotum to aid testicular support and scrotal cooling. In the late nineteenth century, several surgeons introduced inguinal approaches for hernia repairs, and soon these approaches were adopted for the treatment of varicoceles. With these types of exposures, surgeons were able to study the spermatic cords and the distribution of the spermatic arteries and veins. Soon, inguinal/supra inguinal approaches were used for varicocele surgery, but there were still reports of post varicocelectomy failures, post-op hydroceles and cases of testicular atrophy. In 1957, a dramatic event occurred. The ``Fertility Era'' began when a patient with azoospermia and a varicocele had a varicocelectomy. Soon thereafter, he produced sperm and had a child. Subsequently, other studies revealed that many men with varicoceles had low sperm densities and more of these men began to have varicocele surgery for infertility. Venography became available, and it documented retrograde blood flow into the internal spermatic veins of men with varicoceles. In addition, the pathophysiology of varicoceles was studied in humans and animal models. Some important semen findings revealed sperm DNA damage, reactive oxygen species (ROS) in the semen of infertile men with varicoceles, and changes in semen proteomics, etc. In addition, a variety of new procedures were developed to treat these lesions. They included venography and embolization of internal spermatic veins, microsurgical repairs, laparoscopy, robotic surgery, etc. The history of these advancements will be reported in Chap. 1, and more extensive scientific details will be covered in the other chapters of this book.