Left varicocele

　　Regarding the causes of varicocele:

　　One: Anatomical factors

　　1. The internal spermatic vein is long and enters the renal vein at a right angle, so the blood flow encounters certain resistance. The left internal spermatic vein near the left renal vein has no valves, so blood is prone to backflow.

　　2. Normally, the muscle fiber tissue in the tunica albuginea of the spermatic cord can produce a pump effect to promote venous return. When the above muscle fiber tissue atrophies or relaxes, it is not conducive to venous return, causing varicocele of the spermatic cord.

　　Two: Physiological factors

      Young and middle-aged men have strong sexual function, and the blood supply to the contents of the scrotum is abundant. Therefore, some varicoceles may gradually disappear with age. In addition, long-term standing and increased abdominal pressure are also risk factors for the disease.

　　Three: Other factors

      Posterior peritoneal lesions, hydronephrosis, and other compressions of the internal spermatic vein can cause symptomatic or secondary varicocele. Primary varicocele disappears quickly when lying flat, while secondary varicocele often does not disappear or disappears slowly. You can also communicate with experts at Beijing Jianguo Hospital privately through online consultation to obtain correct guidance.

　　Whether it is open surgery or laparoscopic surgery for varicocele, complications may occur, the most common of which are:

　　1.Hydrocele of the tunica vaginalis or scrotal effusionThe scrotal edema and hydrocele of the tunica vaginalis are the most common complications after surgery, with an incidence between 3% and 40%. It is widely believed that the mechanism of scrotal edema is related to lymphatic vessel injury. The lymphatic vessels accompanying the spermatic arteries and veins are damaged during the operation, leading to extravasation of lymph fluid and significant local edema. The veins have been ligated, resulting in obstruction of blood return. In severe cases, hydrocele of the tunica vaginalis may occur.

　　2.Testicular atrophyThe incidence of testicular atrophy is about 0.2%. Testicular artery injury is one aspect that is difficult to avoid in the Palomo procedure, mainly due to the ligation of the testicular artery, which leads to a sharp decrease in blood supply to the testicles, resulting in ischemic atrophy. However, most scholars believe that there are abundant anastomoses between the internal artery of the spermatic cord, the vas deferens artery, and the cremaster muscle artery. Even if the testicular artery is ligated by mistake, the latter two branches are sufficient to provide enough blood supply to the testicles, and there will not be serious consequences. From the current literature, only occasional reports of complications such as testicular atrophy have been found.

　　3.Nerve injury: During high ligation of the spermatic venous plexus via the inguinal approach, the nerves that may be damaged include the ilioinguinal nerve, the genitofemoral nerve, and almost never mentioned, the spermatic superior and inferior nerves. During varicocele surgery, the incidence of genitofemoral nerve injury during laparoscopic surgery is between 2% and 9%, with symptoms such as temporary numbness in the anterior and medial aspect of the thigh and the lateral aspect of the surgical incision, generally appearing between 0 to 10 days postoperatively (on average, 3 days), and symptoms lasting an average of about 8 months. There are no definitive literature reports on the spermatic superior and inferior nerves being mentioned, and some studies suggest that the injury to these nerves may lead to apoptosis of spermatogenic cells.

　　4.Vas deferens injury: Damage to the vas deferens is a theoretical complication of varicocele surgery, as during surgery, the vas deferens appears white, has a firm texture, and is tubular in structure, clearly distinguishing it from the color and structure of surrounding tissues such as blood vessels. Any urologist or andrologist can correctly identify and separate it to avoid accidental clamping.

　　5.Acute epididymitis: Acute epididymitis may occur postoperatively and is related to ligation or injury of the testicular artery during surgery. Since the testicular artery runs along with the spermatic vein, it is easy to be damaged during surgery. After the injury, the epididymis and testicle, which are already in a state of hypoxia and metabolic disorders, become further hypoxic and their resistance further reduced before the compensatory blood vessels are established, making them more susceptible to infection. The main symptoms of this disease are swelling, tenderness, and enlargement of the affected scrotum, unclear boundaries, and fever occurring between 5 to 10 days postoperatively.

　　6.Scrotal emphysema and omental emphysema: Scrotal emphysema and omental emphysema are unique complications of laparoscopic surgery related to the establishment of pneumoperitoneum and are unrelated to the ligation of the varicocele itself.

　　In addition, there are other rare complications, such as postoperative pain in the lumbar and sacral region, and testicular pain, which may be related to the anatomical structure of the spermatic cord itself. Overstretching the spermatic cord during surgery can cause discomfort in the renal area; damage to abdominal and pelvic organs during surgery, such as intestines and bladder, is often caused by rough surgical techniques or lack of familiarity with the anatomy; occasionally, there may be injuries to the femoral vessels such as the femoral artery and femoral vein, which are often due to the surgeon's unfamiliarity with the inguinal anatomical layers or excessive lateral traction by the assistant, leading to deviation from the aponeurosis of the external oblique muscle into the femoral ring during surgery; or combined with inguinal hernia; incision infection (including umbilical incision) is related to poor aseptic operation. Therefore, clinical physicians should pay attention to prevention and appropriate treatment, and inform patients and their families of the risks and possible complications before surgery.

　　1. Patients may exhibit symptoms such as headache, fatigue, and over-sensitivity of the nervous system.

　　2. The main manifestations of primary varicocele are that the patient's scrotum swells when standing, feels heavy and坠胀, the lower abdomen, inguinal canal, or waist is involved, and the symptoms are aggravated during walking and labor, and alleviated when lying flat.

　　3. Sexual dysfunction.

　　4. The patient's history of primary diseases such as renal tumor and hydronephrosis is also one of the manifestations of varicocele.

  These are the most common clinical symptoms of left varicocele.

　　1. To prevent left varicocele, smoking and alcohol should be avoided, and spicy foods should be avoided. Drink more water and eat more fresh vegetables and fruits.

　　2. To prevent left varicocele, rest, live a regular life, keep a pleasant mood, and avoid fatigue.

　　3. Timely treatment of urinary and reproductive system infections such as prostatitis, urethritis, etc., to reduce the chance of inflammation, is an important means to prevent left varicocele.

　　4. Since the occurrence of varicocele is related to intense sexual desire and excessive congestion of the sexual organs, controlling excessive sexual desire is an important link in preventing left varicocele.

　　5. Pay attention to the cleanliness and hygiene of the perineum to prevent retrograde infection to prevent left varicocele.

　The clinical examinations are as follows:

　　1. Imaging examination

　　⑴ Ultrasound and color Doppler ultrasound examination (recommended): Especially using color Doppler ultrasound examination, it can judge the blood reflux phenomenon in the internal scrotal veins. This non-invasive examination has the characteristics of convenience, good reproducibility, high resolution, and accurate diagnosis, and can be used as the first choice for detection methods.

　　⑵ Infrared scrotal temperature measurement method (optional): A non-invasive examination. Studies have shown that the temperature of the scrotum is positively correlated with the degree of varicocele, but it is greatly affected by the surrounding tissues and environmental temperature, with a high rate of false positives.

　　⑶ Scrotal varicocele angiography (optional): Scrotal varicocele angiography is a reliable diagnostic method. The results of the angiography can be divided into three levels: mild: the length of the contrast agent reflux in the internal scrotal veins reaches 5cm; moderate: the contrast agent refluxes to the level of the fourth and fifth lumbar vertebrae; severe: the contrast agent refluxes to the scrotum. Since this examination is an invasive examination with high technical requirements, it has limited its clinical application. Scrotal varicocele angiography can help reduce the failure rate of high ligation surgery and analyze the reasons for the failure of surgery.

　　2. Laboratory examination

　　⑴ Semen analysis (recommended): If immature sperm is detected in the semen, it can be determined that there is an abnormality in testicular function. At least two semen analyses are required for patients with varicocele.

　　⑵ Sperm antibody test (optional): Patients with infertility should be examined for serum or seminal fluid sperm antibodies.

　　3. Measurement of testicular volume (recommended)

　　In the examination of varicocele, it is necessary to determine whether the testicles are damaged and whether they have surgical indications. The size of the testicles must be measured. There are many methods to measure the size of the testicles, including visual comparison, ruler measurement, Prader mold, Takihara mold, and ultrasound, etc. Most scholars believe that B-ultrasound is the most accurate method for measuring the size of the testicles.

　　Vitamin E has a certain function in the recovery of blood vessels, so eating foods rich in vitamin E regularly can definitely have a certain effect on the prevention and recovery of varicocele. Common foods rich in vitamin E include: sesame oil, lettuce leaves, corn oil, peanut oil, and the peel of citrus fruits, which also contain a lot of vitamin E; milk, eggs, and fish liver oil also contain a certain amount of vitamin E; animal foods such as meat and fish have very little vitamin E; fruits and other non-green leafy vegetables also have very little vitamin E. Vegetables such as cauliflower, lettuce, and cabbage are rich in vitamin E, as well as tomatoes, celery, and chili.

　　Vegetable oils are the best food source of vitamin E, and foods rich in vitamin E include sesame, milk, eggs, peanuts, walnuts, lean meat, lettuce, etc. In addition, soybeans, peanuts, walnuts, seeds, animal liver, egg yolks, butter, and corn, as well as yellow and green vegetables, are all rich in vitamin E. Therefore, patients with varicocele should take more of these foods.

　　Treatment Methods for Left Varicocele:

　　Mild varicocele without symptoms does not require treatment.

　　Non-surgical treatment: for mild varicocele or those with neurasthenia, the scrotum can be supported and cold compresses can be applied.

　　Surgical treatment: severe varicocele, sperm count continuously below 20 million for three consecutive times, or atrophy of the testicle; when lying flat, the varicose veins can disappear, and the high ligation of the internal spermatic vein can be performed.

　　Surgical approaches include: mainly retroperitoneal through the iliac fossa and through the inguinal canal, and it is not necessary to add a shunt operation. The main reasons for surgical failure are the leakage of venous branches and the injury of the internal artery of the spermatic cord.

　　This is how the expert introduces the treatment of varicocele on the left side, and patients can receive treatment under the direction of the doctor according to their actual situation.