Varikokel nakal
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Transcript of Varikokel nakal
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Varikokel
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Varicocele
• Definition
• Etiology
• Pathophysiology of testicular changes
• Clinical features
• Investigations
• Treatment –
- Expectant treatment
- Indication of intervention
- Treatment options
- Complication of surgery
• Complication of untreated varicocele
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Definisi
Varikokel adalah dilatasi abnormal dari vena pada pleksus pampiniformis akibat gangguan
aliran darah balik vena spermatikainterna.
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Etiologi
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Etiologi
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Etiologi
Peningkatan Tekanan Vena
Perbedaan letak vena spermatika
interna kanan dan kiri menyebabkan
terpelintirnya vena spermatika
interna kiri, dilatasi dan terjadi
aliran darah retrogard.
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Patogenesis
Disfungsi Bilateral•Aliran darah retrograd sisi kanan didapatkan pada pria dengan varikokel sisi kiri .
•peningkatan aliran darah testikular bilateral dan peningkatan temperatur
Gonadotoksin•Nikotin memiliki implikasi sebagai kofaktor pada patogenesis varikokel.
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Histo-pathological changes
Both testes affected evenly by unilateral varicocele
• Tubular thickening
• Interstitial fibrosis
• Hypo-spermatogensis
• Maturation arrest
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Grade of Varicocele
• varikokel teraba saat pasien berdiri dan manuver valsava berulangkaliDerajat 1
• varikokel terlihat saat pasien berdiri dan manuver valsava sekali saat berbaring varikokel tidak tampak.Derajat 2
• variokel teraba dan terlihat jelas saat pasien berdiri tanpa manuver valsava. Saat berbaring varikokel tidak terlihat jelas.Derajat 3
• varikokel terlihat jelas baik pasien berdiri maupun duduk seringkali disertai nyeri.Derajat 4
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Manifestasi Klinis
• Kebanyakan laki-laki yang didiagnosa sebagai varikokel tidak mempunyai
gejala.
• Pasien datang ke dokter biasanya mengeluh belum mempunyai anak setelah
beberapa tahun menikah.
• keluhan testis terasa berat,di dalam pleksus pampiniformis dapat diraba
sebagai struktur yang terdiri atas varises pleksus pampiniformis yang
memberikan kesan raba seperti kumpulan cacing.
• Varikokel jarang menyebabkan nyeri.
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Diagnosis
Anamnesis
Pasien datang ke dokter biasanya mengeluh belum mempunyai anak setelah beberapa tahun menikah, atau kadang-kadang mengeluh adanya benjolan di atas testis yang terasa nyeri.
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Pemeriksaan Fisik
• adanya distensi kebiruan dari dilatasi
vena.Inspeksi
• dengan valsava manuever ataupun tanpa
valsava.
• Varikokel yang dapat diraba dideskripsikan
“bag of worms”
Palpasi
• stetoskop Doppler mendeteksi adanya
peningkatan aliran darah pada pleksus
pampiniformisAuskultasi
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Pemeriksaan Penunjang
• Angiografi/venografi
sering digunakan untuk mendeteksi
varikokel yang kecil atau subklinis, karena dari penemuannya
mendemonstrasikan refluks darah vena abnormal di daerah retrograd menuju ke ISV dan pleksus pampiniformis.
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USG & Colour Doppler
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Ultrasonografi
• terplintirnya tubular yang digambarkan yang letaknya berdekatan dengan testis.
• Varikokel bisa berukuran kecil hingga sangatbesar, dengan beberapa pembesaran pembuluhdarah dengan diameter ± 8 mm.
• Varikokel dapat ditemukan dimana saja diskrotum (medial, lateral, anterior, posterior, atau inferior dari testis)
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PENATALAKSANAAN VARIKOKEL
Indikasi operasi
• Asymptomatic varicocele with >20% volume loss of Testis (>2ml)
• Pada pasien dengan parameter semen yang abnormal harus dioperasi dengan tujuan membalikkan proses yang progresif dan penurunan durasi-dependenfungsi testis.
• atrofi testikular ipsilateral atau dengan nyeriipsilateral testis yang makin memburuk
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Treatment alteratives
(Obliteration of internal spermatic veins)
• Scrotal approach
• Inguinal approach (modified Ivanissevich)
• Retroperitoneal approach (Palomo’s)
• Sub inguinal approach
• Laparoscopic approach
• Per-cutaneous embolization – through trans
femoral/ trans jugular access (Detachable
balloons or steel coils are used)
• Micro Surgery
• Antigrade scrotal sclerotherapy (ASS)
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Insisi
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Teknik Retroperitoneal (Palomo)
Teknik retroperitoneal (Palomo) memiliki
keuntunganmengisolasi vena
spermatika interna kearah proksimal,
dekat dengan lokasidrainase menuju vena
renalis kiri.
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Teknik Inguinal (Ivanissevich)
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Laparoscopic
approach
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Percutaneous embolization
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Percutaneous embolization
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Microsurgery
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Antegrade Sclerotherapy
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Complications of treatment
• Hydrocele formation – due to ligation of lymphatics
• Recurrence
• Testicular infarction
• Migration of coil to pulmonary artery – usually not
fatal
• Infection & haemorrhage
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Complication of untreated varicocele
• Male infertility
• Testicular atrophy