The history of varicocele: from antiquity to the modern ERA

Abstract

Men have most likely been affected by varicocele since the assumption of the upright position. In De Medicina, written during the first century AD, Celsus credits the Greeks with the first description of a varicocele, and he recorded his own acute observation: "The veins are swollen and twisted over the testicle, which becomes smaller". Celsus himself is credited with the distinction between varicocele (dilation of surface veins) and "cirsocele" (dilation of deep veins). There has been a long history of treatment attempts and failures, some of which are remarkably strange, that have sometimes culminated in tragedy, as in the case of French professor Jacques-Mathieu Delpech (1772- 1832). Although some questions regarding the etiopathology and treatment of varicocele remain unanswered, a succession of more or less conservative attempts involving all medical cultures has been performed throughout history. The report by W.S. Tulloch in 1952 brought varicocele into the era of modern evidence-based medicine, and varicocele surgery finally progressed beyond the aim of merely relieving scrotal pain and swelling. From 1970 to 2000, varicocelectomies gained worldwide attention for the treatment of male infertility. Several innovative procedures to correct varicoceles began to appear in the world's literature as interventional radiology, microsurgery, laparoscopy, and robotics, while comprehensive review articles were also published on the subject of varicocelectomies. Microsurgery is nowadays used worldwide and it can be considered to be the gold standard for correcting infertility linked to varicocele.

Keywords: Varicocele; history of medicine.

Figure 1. Riace Bronzes: Statue A, the Younger, and detail of the scrotum.

Figure 2. Two cauteries from the 1st century AD. A cautery is a short square-shaped handle with a long, thin or round pointed rod. Roman doctors used cauteries as a counter-irritant, haemostatic, bloodless knife, or as a tool to destroy tumors.

Figure 3. An advertisement in the Chicago Tribune in 1899 heralding the virtues of a varicocele cure in five days. The advertisement states “Do not wear a suspensory. Throw it away”.

Figure 4. Cooper's reduction scrotoplasty: partial excision of the scrotum, leading to an upward adjustment of the affected testicle (“inner support”).

Figure 5. King's (upper) and Andrew's (lower) scrotal clamp. Reduction scrotoplasty, unlike that of cooper, involved the application of the clamps longitudinally following the median raphe. Andrew's clamp was specifically designed to obviate injurious pressure on the tissue during the operation.

Figure 6. Heurteloup's scrotal clamp. It was an effective cutting device to isolate and cut the redundant scrotum. After having detached the removable blades, transfixed wires blocked with lead beads were applied.

Figure 7. Vidal's technique: with the patient standing upright, the vas deferens were isolated and two silver wires, one large and the other one small (i.e. one thicker, the other one thinner), were passed behind and in front of varicose veins. The two wires were then progressively rolled until the veins ulcerated.

Figure 8. One of the most popular techniques for varicocele ligation in the 19th century (scrotal window) involved ligature of the varicose packet with two loops, anterior and posterior, passed with a transfixed needle, thereby saving the vas deferens.

Figure 9. Microsurgical anastomoses. (Left) Ishigami's technique: testicular-saphenous anastomosis. (Right) The FOX technique: direct anastomosis of two or three dilated veins of the pampiniform plexus with the great saphenous vein.

Figure 10. Marmar's subinguinal microsurgical technique. Delivery of the testis is not performed; the varicose veins are clipped with hemoclips and transected, with controlled sclerosis of small cross-collateral veins. Proximal and distal control of the spermatic cord is obtained by cinching the Penrose drains.

Figure 11. Goldstein's subinguinal microsurgical technique. This technique involves a more aggressive approach with arterial dissection and venous ligation, and delivery of the testis as part of the procedure to ligate gubernacular veins.