Definition and Overview
Varicocelectomy is the surgical repair of varicoceles or abnormally dilated testicular veins in the scrotum. The enlarged veins, which are also referred to as pampiniform plexus, are very similar to varicose veins that develop in the legs. The exact causes of the condition remain unknown, but one of the theories suggests a malfunctioning valve prevents the proper flow of blood within the vein, causing it to bulge.
In many cases, varicoceles lead to pain and the appearance of a swollen scrotum but its biggest complication is the likelihood of infertility due to poor-quality sperm and decreased function of cells responsible for producing testosterone, the male hormone.
Who Should Undergo and Expected Results
Based on official figures, varicoceles affect up to 15 percent of the whole male population. It is diagnosed in 35 percent of men with primary infertility (inability to conceive within a year of sexual intercourse without birth control) and 75 percent with secondary fertility (infertility after a successful birth of one or more children). The condition also affects 15 percent of teens.
The condition is usually detected during a routine physical exam, in which patients are made to stand and hold their breath while the doctor checks on the size of the scrotal sacs. One of the primary indications of varicoceles is that one of the sides, which is often the left, appears bigger than the other.
Further tests including scrotal ultrasonography with Doppler imaging may be performed to have a more accurate diagnosis as well as determine the actual diameter of the affected vein and the retrograde blood flow.
Since varicoceles do not resolve on their own, patients, particularly those who are unable to conceive, resort to varicocelectomy. So far, the procedure has provided excellent outlook especially in addressing infertility problems. As varicocelectomy has the ability to stop and reverse the damage caused by varicoceles, as well as improve testicular function, up to 70 percent of patients who undergo the treatment are expected to conceive following the procedure.
How Does the Procedure Work?
Varicocelectomy is often recommended if the size of the affected testicle is at least 20 percent bigger compared to the unaffected testicle, if semen analysis shows abnormal results, or if the condition causes the patient consistent pain and affects his daily activities.
Two of the most common techniques for varicocele repair are radiographic embolization and microsurgical varicocelectomy, which is considered the gold standard because of its high success rates and low risk of complications.
During a radiographic embolization, the patient is administered with either local or general anesthesia and an antiseptic is applied to the site where the catheter is inserted, which can be the groin or neck. Using image guidance, the catheter is inserted through the skin and into the femoral vein then led towards the varicoceles using guide wires. A small amount of dye contrast is then injected to make the affected vein visible on the X-ray. Once the catheter is in position, tetradecyl sulfate, which works like glue, or a metal coil is used to divert blood flow away from varicocele, reducing pressure and swelling in the affected testicle in the process. Radiographic embolization is less invasive than conventional surgery and can relieve pain and swelling as well as improve sperm quality.
In microsurgical varicocelectomy, the patient is administered with anesthesia, which can be regional, local, or general. The surgical site is exposed while the surrounding skin is draped. A 2-3 centimeter incision is then made in the external inguinal ring or the groin.
The index finger is then inserted into the incision toward the scrotum and on the side of the spermatic cord. Using a Richardson retractor, the spermatic cord is isolated and grasped with a Babcock clamp. All the veins that feed the varicocele are then identified and divided while ensuring that structures that play an important role in preserving testicular function are protected. The surgeon then proceeds by ligating blood vessels that could cause the potential recurrence of the condition. At the end of the surgery, the cord should contain only the cremasteric muscle with ligated veins, vas deferens, and testicular arteries. The testicle is then returned into the scrotum and the incision is closed.
Possible Risks and Complications
Pain is a common complication of the procedure, which can be controlled or minimized with medications. The doctor may also advise the patient to avoid any strenuous physical activity for a month.
Other possible complications include the formation of blood clots, injury to the nearby tissues and organs, as well as hydrocele formation or the buildup of fluid-filled sacs around the testicles that can cause the scrotum to swell. These have the tendency to grow and become uncomfortable and painful. In such cases, the condition warrants another surgery.
There is also the risk of recurrence of varicoceles.
Gontero P, Pretti G, Fontana F, et al. Inguinal versus subinguinal varicocele vein ligation using magnifying loupe under local anesthesia which technique is preferable in clinical practice? Urology 2005;66:1075-9
Goldstein M. Surgical management of male infertility and other scrotal disorders. In Campbell's Urology, 8th edition. Walsh PC, Retik AB, Vaughan ED, Wein AJ, eds. Philadelphia W.B. Saunders; 2002. p 1573-4.