Varicocele, a common cause of male infertility, is characterized by dilated veins within the pampiniform plexus of the scrotum. Among the various treatment options, microscopic varicocelectomy and percutaneous embolisation are two widely used approaches aimed at relieving symptoms and improving fertility outcomes. Each method offers distinct advantages and limitations in terms of efficacy, complication rates, recovery time, and cost.

This comparison aims to evaluate the clinical outcomes of microscopic varicocelectomy versus embolisation to determine which treatment provides the most effective and patient-friendly solution.

Microscopic varicocelectomy

Microscopic varicocelectomy is a surgical procedure used to treat varicocele by tying off the enlarged veins in the scrotum using a high-powered operating microscope. This technique allows for precise identification and preservation of important structures, reducing the risk of complications and improving success rates.

Varicocele embolisation

Varicocele embolisation is a minimally invasive, image-guided procedure in which a radiologist inserts a catheter into a vein and blocks the abnormal veins causing varicocele using coils or a sclerosing agent. This stops blood flow to the varicocele, relieving symptoms without the need for surgery.

Advantages and disadvantages of microscopic varicocelectomy

Here’s a concise overview of the advantages and disadvantages of microscopic varicocelectomy:

Advantages:

• High success rate: Effective in improving fertility and reducing varicocele recurrence.
• Low recurrence rate: Microscope allows precise identification and ligation of veins.
• Minimal complications: Preserves arteries and lymphatic vessels, reducing risks such as hydrocele formation.
• Outpatient procedure: Usually done under local or general anesthesia with same-day discharge.

Disadvantages:

• Invasive: Requires a small surgical incision.
• Longer recovery time compared to non-surgical options like embolisation.
• Requires general or regional anesthesia.
• Technically demanding: Needs specialized training and equipment.

Advantages and disadvantages of varicocele embolisation

Here are the advantages and disadvantages of varicocele embolisation in a clear and concise format:

Advantages:

• Minimally invasive: No surgical incision; performed through a small catheter.
• Quick recovery time: Most patients resume normal activities within a day or two.
• Local anesthesia only: Reduces anesthesia-related risks.
• Useful for recurrent varicocele: Effective in patients who had previous surgery.
• Outpatient procedure: Typically completed in under an hour with same-day discharge.

Disadvantages:

• Radiation exposure: Involves fluoroscopy (X-ray imaging).
• Technical failure risk: In some cases, the veins may not be accessible via catheter.
• Higher recurrence rate compared to microscopic varicocelectomy.
• Limited availability: Requires skilled interventional radiologists and specific facilities.

Comparison of microscopic varicocelectomy and Embolisation

Here is a side-by-side comparison of Microscopic Varicocelectomy and Varicocele Embolisation, focusing on key clinical and practical aspects:

Comparison: Microscopic Varicocelectomy vs. Varicocele Embolisation

Summary:

• Microscopic varicocelectomy is often considered the gold standard for long-term outcomes and low recurrence, especially in infertility cases.
• Embolisation is a good alternative for those seeking a non-surgical approach with quicker recovery, or when surgery is not an option.

Microscopic varicocelectomy and embolisation: Which is the best?

Here’s what current medical literature indicates regarding the question: “Microscopic varicocelectomy vs. Embolisation: Which is best?”

Evidence-Based Insights

1. Microscopic Varicocelectomy: Established Gold Standard

• A multiple-treatment meta-analysis of 35 trials found that subinguinal and inguinal microsurgical varicocelectomy offered the highest pregnancy rates, significant improvements in sperm density and motility, and the lowest odds of complications and recurrence compared with other treatments—including embolization/sclerotherapy.
• Another meta-analysis confirmed that compared with open and laparoscopic varicocelectomies, the microsurgical approach resulted in higher pregnancy rates, better sperm parameters, fewer complications and recurrences, albeit with longer operative time.
• A randomized clinical trial also highlighted microsurgery’s superiority over open and laparoscopic methods, with zero hydrocele formation, a significantly lower recurrence rate, and somewhat higher pregnancy rate (40%) over 18 months.

2. Embolisation: A Viable Minimally Invasive Alternative

• In a head-to-head prospective study (Toulouse, France), embolisation matched microsurgical ligation in sperm improvement, spontaneous pregnancy (35.5%), and overall satisfaction—but patients undergoing embolisation had faster recovery and less postoperative pain.
• A 16-study meta-analysis showed that endovascular treatments (like embolization) had fewer adverse events compared to surgery, and demonstrated similar recurrence and pregnancy rates.
• Other reports note that embolisation yields a high technical success rate and leads to significant relief of pain, improvements in ultrasound grading, and sperm parameters—with low adverse events.

3. Technical Success vs. Failure Rates

• One study with 158 patients reported a 19.3% technical failure rate for bilateral embolisation—considerably higher than the expected <5% failure rate with microsurgery—suggesting that bilateral varicoceles are better served by microsurgical approach, while unilateral left-sided varicoceles could be addressed by either method.

Summary Table

3. Takeaway

• Microscopic varicocelectomy remains the gold standard, especially valued for fertility outcomes, sperm improvement, and long-term durability.
• Embolisation stands out as a safe, less invasive, and quick-recovery alternative, with comparable outcomes in many cases—ideal for unilateral varicoceles or patients who prefer minimal downtime.
• For bilateral varicoceles, microsurgery may be the safer and more reliable option due to lower technical failure rates.

Summary

Microscopic varicocelectomy and embolisation are two leading treatments for varicocele, a condition often linked to male infertility. Microsurgical varicocelectomy is widely considered the gold standard due to its high success rates, significant improvements in sperm quality, and low recurrence and complication rates. In microsurgical varicocelectomy, recurrence rate is generally under 5%, and in the hands of a skilled surgeon, can be as low as 0.8%. Microscopic surgery is currently considered the gold standard for varicocele repair.

Medical studies consistently favor microsurgical varicocelectomy for long-term success, particularly in restoring fertility. Embolisation, a minimally invasive radiological procedure, with the added benefits of quicker recovery and less postoperative pain.

Prof. Dr. Emin ÖZBEK

Urologist

Istanbul – TURKIYE