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Varicocele Treatment: Surgery (Varicocele Ablation)

• Varicocele: Classification, pathophysiology, signs and symptoms
• Varicocele: Treatment (Surgery)

Asymptomatic varicoceles in adolescents need regular observation, disease progression may necessitate surgery. Varicoceles in adults are treated if symptoms are present (pain or subfertility).

Indications for Varicocele Treatment

Indications for Varicocelectomy:

• Large varicoceles in adolescents, especially with testicular atrophy, elevated FSH or low testosterone, pathological semen analysis or bilateral manifestation.
• Varicoceles with scrotal pain
• Men with varicocele and subfertility: varicocele surgery improves results of semen analysis. The meta-analysis of Marmar (2007) found an 2.7fold increase of the pregnancy rate. Varicocelectomy reduces DNA fragmentation of spermatozoa and improves results of assisted fertilization (Machen et al., 2019).
• Men with varicocele and non-obstructive azoospermia: individual studies have demonstrated an improvement in sperm extraction rate after varicocelectomy, with 14% sperm detection in the postoperative semen analysis (Sajadi et al., 2019). Further studies are needed.

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 six months intervals until the first semen analysis is possible.

Surgical Therapy of Varicocele

Different techniques have been published, which are presented with conflicting eponymy in the secondary literature. In principle, therapy can be performed suprainguinally, inguinally, scrotal, transvenous (retrograde or antegrade), laparoscopically or retroperitoneoscopically (Gonzalez, 2014).

Suprainguinal Surgical Procedures

Retroperitoneal ligation of the vena testicularis between anterior superior iliac spine and renal vein. Surgical approach with a musclesplitting Gibson incision. The ligation can be limited to the vein (first description by Ivanissevich 1918) or a mass ligation of artery, vein and lymphatic vessels is done (first description by Palomo 1949). The vein selective ligation preserves lymph vessesl and reduces the incidence of hydrocele formation. The retroperitoneal ligation is also feasible using the laparoscopic or retroperitoneoscopic approach. The excellent view and magnification allows reliable protection of lymphatic vessels and artery [details see section varicocelectomy].

Inguinal Surgical Procedures for Varicocele Treatment

Inguinal approach to the spermatic cord, all veins are ligated at the level of the internal inguinal ring, except those associated with the vas (first description by Bernadi 1941). The testicular artery and lymph vessel are preserved; the operation should be carried out using an operating microscope.

Sclerotherapy of Varicoceles

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. First description by Formanek 1981.

Antegrade Varicocele Sclerotherapy:

Scrotal exposure of the spermatic cord in local anesthesia. Cannulation of a small varicocele vein (with radiographic diagnosis) and injection of a sclerosing agent. Disadvantages are the possibility of testicular atrophy due to extravasation of sclerosing agent. First description by Tauber 1993.

Complications of Surgery in Varicocele Treatment

Hydrocele:

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:

Testicular atrophy caused by injury of the testicular artery (<1%) in inguinal varicocelectomy or antegrade sclerotherapy (extravasation of sclerosing agent).

References

Evers und Collins 2004 EVERS, J. L. ; COLLINS, J. A.: 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. ; WEIDNER, W.: Die Varicocele testis im Kindes- und Jugendalter.
In: Urologe
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

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