It was more than 40 years ago, as a
first‑year Urology resident, that I
performed my first varicocele ligation
(a Palomo procedure1) under the watchful
eye and able hands of my staff physician.
I dutifully read all I could the night before
the procedure and became familiar with
the names of Barfield, Macomber and
Sanders, Tulloch, MacLeod, Ivanissevich,
Palomo, Amelar and Dubin and others
who had written about varicoceles being
associated with abnormal semen parameters
and a potentially surgically correctable
cause of male infertility. During and after
our uneventful surgical procedure, I was
grilled as to the anatomy and known
pathophysiology of a varicocele. I felt
well‑versed from my reading and proudly
regurgitated all I had learned about the
anatomy of the left testicular vein and
pampiniform plexus, incompetent or absent
valves in the vein, increased testicular
temperature, sluggish flow of blood from
the left testis and possible toxins from the
opposing left adrenal gland vein entering the
dilated, incompetent testicular vein – any
or all of which could contribute to disturb
spermatogenesis and cause infertility. It
all seemed simple enough! I pretty much
thought we knew all we needed to know
about this so‑called “bag of worms.”

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