Varicocele Treatment: Surgery (Varicocele Ablation) (2/2)
Review literature: (Bong and Koo, 2004) (Miller et al, 2002) (Rubenstein et al, 2004).
Indications for Varicocele Treatment
Indications for Surgical Treatment
- Large varicoceles in adolescents
- Childhood varicocele with testicular atrophy
- Varicoceles with elevated FSH concentrations, or low testosterone concentration
- Varicoceles with scrotal pain
- Cosmetic indication
- Male infertility with pathological semen analysis and varicocele: varicocele ablation is worth a trial. In randomized studies there were conflicting results, e.g. causes by different inclusion criterias (Evers and Collins, 2004). In the meta-analysis of Marmar (2007), the varicocele ablation could increase the pregnancy rate 2.7 fold in patients with infertility and abnormal semen analysis.
No Indications for Surgical Treatment
- Asymptomatic varicocele with normal sperm count or azoospermia.
- Childhood varicocele with normal testicular volume: a spontaneous regression of the varicocele can be expected in up to 70%. Regular control of the testicular volume in 6 months intervals until the first semen analysis is possible is good alternative to surgical treatment. Controlled trials are missing.
Suprainguinal Surgical Procedures for Varicocele Treatment
A common procedure is the retroperitoneal ligation of the internal spermatic vein (vena testicularis) between anterior superior iliac spine and renal vein (Palomo oder Bernardi procedure). Surgical approach with a Gibson incision. The ligation can be carried out as a mass ligation (dissection of artery, vein and lymphatic vessels) or as an artery sparing ligation. The artery sparing ligation preserves lymph vessesl and reduces the incidence of hydrocele formation, the recurrence rate is increased.
The retroperitoneal ligation is also feasible using the laparoscopic or retroperitoneoscopic approach. Compared to the open surgical technique, no dramatic clinical benefits exist for the laparoscopic technique.
Inguinal Surgical Procedures for Varicocele Treatment
after the inguinal spermatic cord exposure, all veins are ligated at the level of the internal inguinal ring, except those associated with the vas. The testicular artery and lymph vessel should be preserved; the operation should be carried out using optical magnification.
Surgical Procedures for Varicocele Treatment using Embolization
Retrograde Varicocele Sclerotherapy:
Retrograde varicocele sclerotherapy is an angiographic embolization/sclerotherapy of the internal spermatic vein via a transfemoral access. Disadvantages are the possibility of vascular complications, exposure to radiation and the procedure time.
Antegrade Varicocele Sclerotherapy:
For antegrade varicocele sclerotherapy, scrotal exposure of the spermatic cord in local anesthesia is necessary. After exposure of a varicocele vein (with radiographic diagnosis) a sclerosing agent is injected. Disadvantages are the possibility of testicular atrophy due to extravasation of sclerosing agent.
Complications of Surgery in Varicocele Treatment
Up to 7% of hydrocele formation is possible after retroperitoneal mass ligation. In sclerotherapy or artery sparing ligation, there is only a 1% risk of hydrocele formation.
Recurrence of a varicocele:
- 1–2% varicocele recurrence after retroperitoneal mass ligation.
- 7–11% varicocele recurrence after selective embolization or artery sparing retroperitoneal ligation.
Testicular atrophy is possibility after antegrade sclerotherapy due to extravasation of sclerosing agent.
Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
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Bong und Koo 2004 BONG, G. W. ; KOO, H. P.:
- The adolescent varicocele: to treat or not to treat.
In: Urol Clin North Am
31 (2004), Nr. 3, S. 509–15, ix
Evers und Collins 2004 EVERS, J. L. ; COLLINS,
- Surgery or embolisation for varicocele in subfertile men.
In: Cochrane Database Syst Rev
(2004), Nr. 3, S. CD000479
Dubin, L. und R. D. Amelar (1970). Varicocele size and results of varicocelectomy in selected subfertile men with varicocele. In:
Fertil Steril 21, S. 606–609.
Miller u.a. 2002 MILLER, J ; PFEIFFER, D ;
SCHUMACHER, S ; TAUBER, R ; MüLLER, S. C. ;
- Die Varicocele testis im Kindes- und Jugendalter.
41 (2002), S. 68–77
Rubenstein u.a. 2004 RUBENSTEIN, R. A. ;
DOGRA, V. S. ; SEFTEL, A. D. ; RESNICK, M. I.:
- Benign intrascrotal lesions.
In: J Urol
171 (2004), Nr. 5, S. 1765–72