Varicocele Surgery With Microsurgery Method

Varicocele is one of the important diseases that cause infertility in men. The most important feature of this disease is that it can be corrected with surgery. If the problem is on the male side and due to varicocele, the rate of having children is high with an appropriate surgery.

Today, the most frequently performed surgery method, which is accepted as the “gold standard” treatment in the treatment of varicocele, is the operation performed with the “microsurgery” method. In this article, I will talk about varicocele surgery in line with my 25 years of experience.

What is varicocele?

Varicocele is the enlargement of the veins of the testicles (testicular veins, pampiniform plexus), that is, its varicose veins. Just like in the legs, varicose veins form in the veins of the testicles. It is mostly seen on the left side, sometimes it can be seen in both testicles. The cause of the disease is not fully known. Reasons such as insufficiency of the valves in the left testicular veins, opening of the left testicular veins at a right angle to the renal vein and following a long path are accepted as the causes of the disease.

As a result of the expansion of the veins due to varicocele, the accumulation of dirty blood in the testicles for a long time causes damage to the testis. Over time, the testicle shrinks, sperm production is adversely affected, and the male hormone (testosterone) decreases. As a result, male infertility occurs. Sexual problems occur when testosterone levels drop.

How is varicocele diagnosed?

It is very easy to diagnose varicocele. The diagnosis of varicocele can be made only by examination. Varicocele examination is done while the patient is standing. There is no need for a very advanced radiological examination. Sometimes, scrotal ultrasonography is required for low-grade varicocele that cannot be detected on examination. In addition, the dimensions of the testicles are evaluated exactly by ultrasonography.

What are the varicocele stages (grade)?

On examination, varicocele disease is divided into 3 grades (stage, grade):

• Grade 1: Enlarged veins can be palpated as a result of the patient’s mouth and nose and straining during outpatient examination.
• Grade 2: Varicose veins are mildly visible on standing examination, and become more evident with straining.
• Grade 3: Varicose veins are visible without increasing intra-abdominal pressure while the patient is being examined outpatient, and become more evident with straining.

Ultrasonically, varicocele is classified in 2 ways:

• Stop type varicocele: When the patient breathes deeply and inflates his abdomen, if there is no back leakage (reflux) in the testicular veins on ultrasound, it is called a stop type varicocele. This type of varicocele is also called subclinical varicocele.
• Shunt type varicocele: When the patient increases intra-abdominal pressure, there is a backward flow (reflux) in the testicular veins.

What are the varicocele surgery methods?

The most effective treatment of the disease is surgery (surgical treatment). Varicocele surgery is performed by opening a 2-3 cm incision from the groin. Varicocele surgery methods:

• Open varicocele surgery: It is the classical varicocele surgery. Enlarged testicular veins are found and ligated by entering through a 2-3 cm incision in the groin. It is the most common surgical method.
• Varicocele surgery performed by microsurgical method: It is the operation of ligating the enlarged testicular veins by opening a 2-3 cm incision from the groin. In this method, there is no recurrence or extremely low (1-3%) since very small veins can be seen and ligated with a microscope. The testicular artery and lymphatic vessels are seen with a microscope and are not ligated. Therefore, testicular damage and hydrocele development are almost nonexistent in this surgery. It is the most preferred surgery today. We have been operating our patients with this method for 20 years and our results are extremely successful.
• Laparoscopic/robotic varicocele surgery: It is a tried and tested method of surgery. Not much is done anymore. The recurrence rate is high. The success rate is less than the microsurgery method. Varicocele surgery is not performed with robotic method.
• Embolization (radiological method): It is a very old method. It is done by embolization of varicose testicular veins with special substances. Since the recurrence rate is very high in this method, it is not done much anymore. We also do not recommend the embolization method to our patients.

What are the complications of varicocele surgery?

Complications related to varicocele surgery are extremely rare in experienced hands. Complications that may occur after varicocele surgery:

• Wound infection: Wound infections due to varicocele surgery are extremely rare if attention is paid to sterility and prophylactic antibiotics are given. The surgery is done with a very small incision, there is no need for daily dressing since aesthetic sutures are placed.
• Hydrocele development: The lymphatics of the testis must be protected very well during the operation. In the surgery, only the veins (vein) of the testis are ligated. If the lymphatics are connected, a condition called hydrocele develops. Hydrocele is the accumulation of the lining between the layers called tunica vaginalis surrounding the testis. The treatment is surgery.
• Development of testicular atrophy: As a result of damage to the arteries of the testis during surgery, reduction in testicular size (testicular atrophy) develops. Since very small arteries can be seen in the operation performed with microsurgical method, arterial damage is extremely low.
• Bleeding: Bleeding after varicocele surgery, subcutaneous hematoma is extremely rare when good bleeding control is performed.

What kind of anesthesia is given for the surgery, how many days do patients stay in the hospital?

General anesthesia or spinal anesthesia is used for varicocele surgery. The surgery takes about 45 minutes. Patients are discharged 5-6 hours after surgery or stay in the hospital overnight.

Pre-operative preparation

Since varicocele is seen in young men, the surgery is usually uneventful.

• Before the operation, routine blood tests are taken from the patients and chest X-rays are taken. If there is no problem in the examinations, there is usually no need for further tests.
• The drugs used by the patients are questioned,
• If blood thinners are used, it is discontinued one week in advance.
• Oral eating and drinking is stopped for 4-5 hours before the operation.

What should be considered after the operation?

Patients usually have an uneventful post-operative period. We discharge our patients on the same day. Matters to be considered after the procedure:

• Pain reliever and antibiotic prophylactic treatment against infection is started for post-operative pain.
• Patients do not eat or drink for 4-5 hours after the operation, they are fed intravenously.
• After 4-5 hours, water and watery foods are taken by mouth, after a day, normal eating and drinking is started.
• Since we usually cover the surgical site aesthetically, there is no need for dressing every day.
• Patients start their normal lives at home the next day,
• After 1 week, they can continue their normal daily work and life, take a shower and have sexual intercourse.
• It is recommended to do heavy sports and not to lift heavy for 1 month.
• Spermogram analysis is requested 3 months after the operation. According to the degree of damage to the testicles before the operation, improvement occurs in the sperm analysis. In the later periods, if necessary, spermogram is performed again in the 6th month. In the controls, the doctor may recommend additional drug therapy depending on the situation. Children under the age of 18 do not need a spermogram.

Does SSI cover the varicocele surgery, what is the price?

The amount paid by SSI for varicocele surgery is the same for all contracted hospitals. SGK pays a very small amount, contracted hospitals charge additional fees. The cost of the surgery varies from hospital to hospital. We offer our patients options and perform their surgeries at the place that suits them.

Are herbal or drug treatments effective in treatment?

Medication or herbal treatments have no place in the treatment of varicocele. Varicose veins are removed by surgery, and in some patients, according to the doctor’s evaluation, adjunctive drug treatments may be recommended.

In which cases should surgery be performed?

The definitive treatment of the disease is only possible with surgery. In varicocele patients, absolute surgery is required in the following cases:

• If the patient has pain: Pain due to varicocele is usually a blunt pain that hits the groin. It is especially common in those who stand for long periods of time. It improves after surgery due to varicocele.
• If the patient cannot have children, that is, if there is infertility: The most important complaint in varicocele disease is infertility. If married couples cannot have children despite having regular and unprotected intercourse, it should be investigated. If a varicocele is detected in a man, it must be operated on.
• If there is shrinkage in testicles in children: Testicular shrinkage (atrophy) develops over time due to varicocele. Varicocele must be treated surgically in patients with shrinkage in the testicles. If testicular atrophy has developed due to varicocele in children, this situation is corrected with microsurgical varicocele surgery. If testicular atrophy has developed due to varicocele in adults, the testicle will not return to normal size with surgery, but there may be improvement in the spermogram. In pediatric varicocele cases, there is no need to have a spermogram before and after surgery, because sperm production in children is not fully mature.

What happens if varicocele is not operated?

Varicocele is an important disease. Especially grade 3 varicocele cases cause serious problems and surgery must be performed. We can list the common problems in patients with long-term disease who do not undergo surgery as follows:

• Infertility: Varicocele is one of the important causes of male infertility. It is possible to treat with surgery. With surgery, 50-80% improvement is achieved in the spermogram. The pregnancy rate is around 20-70%.
• Shrinkage of testicles: Testicular shrinkage (atrophy) develops in varicocele patients who do not undergo long-term surgery. In this regard, even if the patients have children, if there is varicocele, surgery should be performed. Testicular atrophy is higher in those with G-2 and G-3 varicoceles. In adults, testicular atrophy due to varicocele does not improve with surgery, but surgery is beneficial so that more testicles are not adversely affected.
• Loss of sexual function (erection failure, erection problem): If testicular atrophy due to varicocele has developed, testosterone hormone production is negatively affected and erection problems occur as a result. In this regard, if there is a varicocele, surgery is required to prevent erection problems in the future.
• Premature ejaculation: Studies have reported premature ejaculation (premature ejaculation) due to varicocele. Since varicocele surgery can prevent the occurrence of this condition, surgery is recommended for these patients.

Is it right to have IVF without varicocele surgery?

If the patient has a varicocele, if in vitro fertilization is performed without varicocele surgery, these patients have a lower chance of having children. Studies have shown that the fertility rate of these couples is higher if the in vitro fertilization method is applied after varicocele surgery.

For this reason, we recommend our patients to undergo surgery if they have varicocele, especially G-2 and G3 varicocele. Otherwise, if in vitro fertilization is performed in a patient with varicocele without surgery, the rate of having a child is low.

Is varicocele surgery performed in azoospermic patients?

There are various causes of azoospermia. One of them is varicocele disease. If the patient has varicocele and it is thought that this situation causes azoospermia, varicocele surgery should be performed. After the surgery, the same rate of improvement may not be seen in every patient. If azoospermia has developed due to varicocele and the testicles are not severely atrophic, recovery can be achieved with surgery.

What is the best surgical method in the treatment of varicocele?

Varicocele surgery with Microsurgery method is accepted as the “gold standard” treatment method in the treatment of the disease today. With this method, an incision of 2-3 cm is made from the groin, and the enlarged veins are found and ligated. With Microsurgery, testicular artery and lymphatic vessels are seen under the microscope and only the veins are ligated by preserving them.

Since the testicular artery (arterial vein) is not connected, the testis is not damaged, and since the lymphatics are protected, complications such as hydrocele (water collection) in the testicles do not occur. In addition, the recurrence rate is very, very low, the improvement in sperm results and the rate of having children are higher with this surgery.

The advantages of varicocele microsurgery are as follows:

• The recurrence rate is negligible
• Hydrocele and testicular atrophy (shrinkage) are not seen
• Better improvement in sperm results
• The rate of having children is higher

In summary; Varicocele is one of the important causes of infertility in men. It is mostly seen on the left side. It is possible to treat it with surgery, the most effective surgical method for the treatment of varicocele is surgery performed by microsurgical method (microsurgical varicocelectomy). With this method, the rate of having children is high.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY

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