Varicocele is the enlargement of the veins of the test, that is, varicose veins. It is mostly seen on the left side. The disease can sometimes be seen in both testicles. This is called bilaeral (double-sided) varicocele. If this disease is not treated, it will lead to serious problems such as infertility and erection problems in the future. The most effective method of treatment is surgery. Microsurgery is the most effective surgery method today. The success rate after surgery is quite high. In this article, I will give up-to-date information about bilateral varicocele and its treatment, using my own experience.

Evaluation of patients with varicocele

Patients are evaluated in detail before surgery. Especially if patients have infertility problems, evaluations should be made regarding this. If the patients are children, there is no need for a spermiogram. Ultrasonography also provides information about the internal structure of the testicle and neighboring structures. Methods to be followed in the evaluation of varicocele patients:

• Detailed medical inquiry
• Urological examination
• Scrotal ultrasonography (scrotal USG).
• Spermiogram
• Hormonal tests (Testosterone, FSH, LH, prolactin)

Varicocele examination and grade

Varicocele examination is performed while standing and with the patient straining. On outpatient examination, varicocele is divided into 3 degrees:

• Grade 1: Varicocele is present on palpation when the patient is standing and straining.
• Grade 2: There is a varicocele when the patient is examined while standing without straining.
• Grade 3: There is a visible varicocele when the patient is evaluated while standing. Enlarged veins (varicose veins, varicocele) are visible to the normal eye.

Varicoceles that are not palpable on examination but detected on scrotal ultrasonography (USG) are called subclinical varicoceles. If the patient does not have an infertility problem or has no pain, these cases do not need to be treated.

Is bilateral varicocele seen?

Varicocele is seen in 15-20% of adult men. It is mostly seen in the left testicle. There are also studies showing that varicocele is usually seen bilaterally, unlike the classical information that it is seen unilaterally and on the left. In a study of 255 patients, venography reported that 17.6% of the patients had a varicocele in the left testicle, 1.5% in the right testicle, and 80.8% in both testicles.

When is bilateral varicocele surgery performed?

Not every varicocele patient needs to be treated or undergo surgery. Especially in patients who are not palpable during examination and are detected only by scrotal USG, there is no need for surgery if there are no conditions such as pain, infertility, low testosterone, testicular atrophy. Varicocele surgery should be performed in the following cases:

• If there is pain
• If there is testicular atrophy (shrinkage)
• If there is hormonal insufficiency (low testosterone, hypogonadism)
• If there is infertility
• If you have erectile dysfunction (ED, erectile dysfunction, erectile dysfunction, impotence)
• If assisted reproductive methods will be used (to have children)
• If there is a significant (Grade 2.3) varicocele on examination
• Adolescent patients (adolescent age, childhood varicocele)

Does bilateral varicocele cause pain, can the pain be relieved by surgery?

There is no severe pain due to varicocele disease. Mild, dull pains in the groin are usually observed, especially in those who stand for long periods of time. Groin pain is not only caused by varicocele, there are other causes of pain as well. If groin pain is due to varicocele, it will be resolved with surgery; groin pain due to reasons other than varicocele will not disappear with surgery. This situation must be told to patients before surgery.

How to prepare before surgery?

Since these patients are young, they generally do not have any serious health problems and the postoperative period is uneventful.

• Routine surgical tests are taken from patients
• No drinks or food should be taken orally 5-6 hours before the surgery.
• Hospitalization is done on the day of surgery
• After the consent forms for surgery are approved, the patient is taken into surgery

What is the surgery duration, anesthesia type and hospital stay?

Bilateral microscopic varicocele surgery takes approximately 1-1.5 hours. The surgery is performed with general anesthesia or spinal anesthesia (anesthesia from the waist down). We usually discharge our patients on the same day. They are discharged 5-6 hours after the surgery.

What should be taken into consideration after surgery?

The post-operative period is quite comfortable. Patients are evaluated 5-6 hours after surgery on the same day and discharged if there is no problem. If general anesthesia is given within 5-6 hours after the surgery, no oral eating or drinking is allowed. In patients who underwent spinal anesthesia, patients continue to eat and drink normally after surgery. Patients given spinal anesthesia should not stand up for 6-7 hours after surgery. After the surgery, patients’ pain is relieved by giving painkillers. Patients are discharged by giving antibiotics and painkillers orally. If the doctor deems it appropriate, supportive treatments that regulate sperm production are started after the surgery.

Water should not be allowed to touch the wound area for a week after the surgery. Heavy physical activities and weight lifting should be avoided for 4-6 weeks. Control spermiogram is performed at the earliest in the 3rd month after surgery.

Bilateral microscopic varicocele surgery

The surgery is performed under general or spinal anesthesia. By entering through a 2-3 cm incision in the groin, the spermatic cord (the structure containing the testicular artery, vein, lymph vessels and seminal duct) is located. Under the microscope, the artery, lymphatics and seminal duct of the testicle are preserved and the enlarged veins (veins, varicose veins) are ligated and cut. The surgery takes approximately 1-1.5 hours. Since the surgical incision is closed aesthetically, there is no scar left at the surgery site afterwards. To prevent recurrences during surgery, veins other than the spermatic cord, if any, must be located and tied. Since very small veins are found and tied with microsurgery, the recurrence rate is extremely low and the success rate is high.

What is testicular damage like in unilateral and bilateral varicocele patients?

There are various causes of testicular damage and infertility due to varicocele. These are: increased temperature in the testicles, hormonal deficiency, increase in free radicals (increased oxidative stress), sperm DNA damage. Studies have shown that oxidative stress and inflammatory markers in the seminal fluid increase more in patients with bilateral varicocele than in unilateral patients. This shows that deterioration in sperm quality and infertility will be a more serious problem in patients with bilateral varicocele. Therefore, in patients with bilateral varicocele, surgery is required on both sides.

Do patients who are single or have children need varicocele surgery?

Varicocele disease is one of the important causes of infertility in men. If there is an infertility problem, these patients must undergo surgery. However, varicocele has serious complications other than infertility. These are mainly problems such as pain, testicular atrophy, hormonal insufficiency (testosterone deficiency, hypogonadism), decrease in sexual desire (decreased libido, loss of libido), premature ejaculation and erection problems (erectile dysfunction, ED). In this regard, surgery is required even if a person with varicocele has children or does not want children. If the disease is bilateral, bilateral surgery should be performed.

Should bilateral varicocele always require surgery?

If the patient has varicocele in both testicles, the patient should be evaluated in detail and appropriate treatment should be given accordingly. If the patient has varicocele and infertility evident on physical examination in both testicles (G-2,3), these cases require surgery. If there is a significant varicocele on one side and a subclinical varicocele on the other testicle, that is, a varicocele that can only be detected by scrotal USG, surgery should be performed on the prominent side. It is not wrong to operate the other side in the same session, but the decision can be made based on the spermiogram result. If there is no improvement, surgery should be recommended. If there is a subclinical varicocele in both testicles, if the spermogram and hormones are not normal, and if there is an infertility problem, surgery is also required in these cases.

What is the success rate of bilateral varicocele surgery?

The success rate of varicocele surgery using the microsurgical method is high, complications are few and the recurrence rate is low. Recovery of sperm parameters after surgery depends on the patient’s condition. If testicular atrophy has developed, there is a hormonal disorder, spermiogram values ​​are very low, and the patient is older, the recovery rate is lower. In addition, if patients consume alcohol, smoke, or are overweight, these also negatively affect the results. We give patients additional treatments to achieve more effective results after surgery. If patients use excessive alcohol and cigarettes, they should definitely quit, and overweight patients should definitely reach their ideal weight.

As a result of the evaluation of 1743 patients who underwent varicocele surgery, the group with significant varicocele in both testicles was compared with the patients with significant varicocele on the left and subclinical varicocele on the right. As a result, it has been reported that the rate of having children is higher in patients who underwent bilateral varicocele surgery. Likewise, it has been reported that there is a greater improvement in sperm count, movement and shape in patients who have bilateral surgery (Andrologia. 2019 Dec;51(11). In this regard, bilateral varicocele surgery is a procedure that gives the best results in suitable patients.

What are the complications of bilateral varicocele surgery?

If varicocele surgery is performed in careful and experienced hands, it is generally a procedure with little or no side effects. Negativities (complications) that may be seen in surgeries performed with microsurgery are extremely few. Complications that may occur in bilateral surgery are the same as in single-sided varicocelectomy surgery. We can summarize these as follows

• Wound infection
• Pain
• Hydrocele
• Testicular atrophy

In summary: Although varicocele is most often seen on the left side, it can be seen on both sides. If left untreated, it will cause serious problems in the future. If there is a Grade 2/3 varicocele and it is bilateral, testicular damage and spermiogram test distortion are at a higher rate than in unilateral cases. The most effective treatment method is surgery performed with the microsurgical method (microsurgical varicocelectomy), which we also do.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY