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Varicocele Treatment: Indications for Surgery

• 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 the results of semen analysis. The meta-analysis of Marmar (2007) found a 2.7fold increase in the pregnancy rate. Varicocelectomy reduces the DNA fragmentation of spermatozoa and improves results of assisted fertilization (Machen et al., 2019).
• Men with varicocele and non-obstructive azoospermia: individual studies demonstrated successful sperm extraction after varicocelectomy, with 14% sperm detection in the postoperative semen analysis (Sajadi et al., 2019). Further trials are needed.

No Indications for Surgical Treatment

• Asymptomatic varicoceles with a normal sperm analysis.
• Childhood varicocele with regular testicular volume: a spontaneous regression of the varicocele occurs in up to 70%. The control of the testicular volume in six-month intervals until the first semen analysis is recommended.

Surgical Procedures for the Treatment of Varicoceles

Different techniques have been published, with conflicting eponymy in the secondary literature. In principle, surgical treatment of varicoceles is performed with a suprainguinal, inguinal, scrotal, transvenous (retrograde or antegrade), In principle, surgical treatment of varicoceles is performed with a suprainguinal, inguinal, scrotal, transvenous (retrograde or antegrade), laparoscopic, or retroperitoneoscopic technique (Gonzalez, 2014).

Suprainguinal Surgical Procedures

Suprainguinal surgical techniques aim at the retroperitoneal ligation of the vena testicularis between anterior superior iliac spine and renal vein. The surgical approach is a muscle-splitting 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 vessels 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 Technique for Varicocele Treatment

The inguinal surgical technique uses an 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 procedure is best done using a operating microscope.

Sclerotherapy of Varicoceles

Retrograde Varicocele Sclerotherapy:

Retrograde varicocele sclerotherapy is the angiographic embolization/sclerotherapy of the internal spermatic vein via transfemoral or transjugular access. Disadvantages are the possibility of vascular complications, exposure to radiation, costs, and the procedure time. First description by Formanek 1981.

Antegrade Varicocele Sclerotherapy:

Antegrade varicocele sclerotherapy is the angiographic embolization/sclerotherapy of the internal spermatic vein via a scrotal approach of the spermatic cord in local anesthesia. It includes cannulating a small varicocele vein (with radiographic diagnosis) and injecting 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 vein-selective 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 vein-selective retroperitoneal ligation.

Testicular atrophy:

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

References

Baazeem, A.; Belzile, E.; Ciampi, A.; Dohle, G.; Jarvi, K.; Salonia, A.; Weidner, W. & Zini, A. Varicocele and male factor infertility treatment: a new meta-analysis and review of the role of varicocele repair.
Eur Urol, 2011, 60, 796-808.

Bong und Koo 2004 BONG, G. W. ; KOO, H. P.: The adolescent varicocele: to treat or not to treat.
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Chanc Walters, R.; Marguet, C. G. & Crain, D. S. Lower prevalence of varicoceles in obese patients found on routine scrotal ultrasound.
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Evers und Collins 2004 EVERS, J. L. ; COLLINS, J. A.: Surgery or embolisation for varicocele in subfertile men.
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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.

Marmar, J. L.; Agarwal, A.; Prabakaran, S.; Agarwal, R.; Short, R. A.; Benoff, S. & Thomas, A. J. Reassessing the value of varicocelectomy as a treatment for male subfertility with a new meta-analysis.
Fertil Steril 2007, 88, 639-648

Miller u.a. 2002 MILLER, J ; PFEIFFER, D ; SCHUMACHER, S ; TAUBER, R ; MüLLER, S. C. ; WEIDNER, W.: Die Varicocele testis im Kindes- und Jugendalter.
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  Deutsche Version: Therapie der Varikozele: Operative Techniken