Dr. med. Dirk Manski

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Varicocele Treatment: Surgery (Varicocele Ablation) (2/2)

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:

No Indications for Surgical Treatment

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 a 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:
Testicular atrophy:

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



References

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, 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


  Deutsche Version: Therapie der Varikozele: Einfluss auf die Infertilität?