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Varicocele is a problem characterized by the deformation and malfunction of the venous valves and the subsequent backflow of the blood which result in the dilation of the veins around the testicle. As one can expect, it is not possible to treat such a mechanical problem with some medications and herbal drugs.

In varicocele, the aim of the treatment is to cut off the connection between the varicocele (result) and the refluxing vein(s) (cause). In this way, there will be no more reflux into the varicocele and it will disappear by time. The venous blood of the testicle will continue to flow normally through other veins of the testicle which have normal valves. After successful treatment, the pain goes away because the blood pressure in the veins return to normal. Sperm parameters may get better since the temperature of the testicle become normal and the small testicle may reach its normal size by time since the impaired blood circulation returns to normal.

 

There are two kinds of treatment that can cut off the connection between the varicocele and the refluxing veins:

• Surgical operation

• Embolization

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Surgical operation

Surgery has been the classic treatment of varicocele for decades. Its goal is to tie up the refluxing vessel and disconnect it from the varicocele. For this, the skin is cut above, at or below the groin, the incompetent veins are tried to identify based on their appearance and all the veins that seem abnormal are tied up. Lymphatic channels and testicular artery branches are tried to avoid but it may sometimes be impossible differentiate these vessels from the veins. Thus, they may also be tied up unintentionally. Sometimes it may be extremely difficult to isolate the testicular artery from the surrounding veins. In this case, the testicular artery also has to be tied up with these veins to prevent recurrence of varicocele through these veins. The ligation (tie-up) of the testicular artery rarely cause symptoms although loss of testicle has been reported in some cases. But it has been shown in some studies that ligation of the testicular artery during varicocele surgery may compromise sperm parameters in the future. Unintentional ligation of the lymphatic channels during varicocele surgery is quite common and may cause accumulation of fluid around the testicle, which is called “hydrocele”. Hydrocele may occur in up to 30% of the patients and is one of the most bothering complications of varicocele surgery.

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The surgical techniques in varicocele may differ according to three parameters:

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The incision site:

• Over the groin

• At the groin

• Below the groin

The operation type:

• Open surgery

• Laparascopy

Use of microscope

• Macroscopic (with the naked eye)

• Microscopic (with microscope)

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There are currently four surgical techniques that are commonly used in varicocele:

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1. Retroperitoneal high ligation (Palamo technique): This is one of the most common surgical operations for varicocele. An incision is made to the skin over the groin and the main testicular vein is found and tied up easily. In this operation, the risk of recurrence is relatively high, the testicular artery may have to be ligated and hydrocele is relatively common due to unintentional ligation of lymphatic canals.

2. Laparoscopic ligation: The same operation is performed through smaller incisions. This operation is technically more challenging than the Palamo technique. After the operation, the patient returns the normal life in a shorter time but the complication rate is not very different from the open surgery.

3. Macroscopic inguinal ligation (Ivanissewich technique): This operation is performed through a relatively large incision made at the groin without using a microscope. The refluxing veins are more easily seen and tied up easily. Therefore, the recurrence rate is relatively low. But the risk of accidental ligation of the testicular artery and lymphatic channelss are practically the same.

4. Microscopic inguinal or subinguinal ligation (Microsurgical operation): Microscopic inguinal or subinguinal ligation (MicrosurgicaIn this operation, an incision is made at or below the groin and the testicle is taken out of the scrotum. Then, using a microscope, almost all the veins around the testicle are tied up. The arteries and lymphatic channels are tried to be spared. This operation, when performed in the best centers, may have quite a low rate of recurrence and complications such as hydrocele and testicular loss. But in centers with a low referral rate, these rates may become higher. Besides, this operation is technically more challenging, time consuming and invasive than the other techniques.l operation):

 

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Advantages and disadvantages of the varicocele surgery:

Surgical operations of varicocele can be performed anywhere in the world and does not require any special equipment or material. The potential benefits and risks of surgery are well-known owing to the large experience worldwide. In general, varicocele can be permanently cured with surgery in 70-95% of the patients.

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However, varicocele surgery may have some important disadvantages:

• During surgery, it is not possible to know exactly which vein is refluxing and which vein has a normal function. Thus, the refluxing veins are tried to identify based on their appearance; it is assumed that the larger and more tortuous veins are the refluxing veins and they are tied up. However, this assumption is not always true and as a result, normal veins are also ligated besides the abnormal ones. Sometimes a large vein that has a normal function may be ligated instead of a small but refluxing vein and this is the most important cause of early recurrence after varicocele surgery.

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• During surgery, it is also quite difficult to differentiate the testicular arteries from the veins. To facilitate this, the arteries may be made larger using some drugs and a microscope may be used. Despite these measures, the testicular arteries may be unintentionally ligated. This generally creates no symptoms to the patient. But in some, the testicle may be lost and in others, sperm parameters may worsen in older ages. 

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• One of the most important disadvantages of varicocele surgery is the unintentional ligation of the lymphatic channels that result in accumulation of fluid around the testicle, which is known as hydrocele. Hydrocele is rather a disturbing condition for the patient causing testicular pain and swelling. It generally occurs several months after the operation but sometimes it may be seen later. Most hydroceles will regress spontaneously in months or years but in some patients, repeated percutaneous drainage or surgery may be necessary. Even after surgery however, hydroceles may recur in about 1/3 of the cases.