Prof Saim Yılmaz, MD
"Most varicoceles can be nonsurgically
treated with embolization"
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. Our body tries to deliver this blood via alternate channels (collaterals) into the venous circulation. Despite this compensation, some deoxigenated blood always retains in the veins around the testicle and cause them to enlarge by time (varicosele). As one can expect, it is not possible to treat such a mechanical problem with some medications and herbal drugs.
In varicocele disease, there are two components: 1. The cause (the incompetent vein with absent or broken valves that leaks the venous blood back into the veins around the testicle). 2. The result (enlarged veins around the testicle called varicocele which is formed by the increased pressure of the accumulated venous blood). For an ideal varicocele treatment, both the cause and the result should be treated. In surgery however, either the cause or the result of the disease can be addressed. In conventional surgery, the refluxing vein, which is the cause of varicocele, is ligated via a small incision at the groin and varicocele itself is left untreated. In microsurgery, the enlarged veins around the testicle (varicocele itself) are ligated one by one via an open surgery but the cause (refluxing vein) is left untreated.
Surgery has been the classic treatment of varicocele for decades. There are two types of surgeries. Conventional surgery and microsurgery.
In conventional surgery, the 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 to preserve these structures. 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.
Microsurgery: (microscopic inguinal or subinguinal ligation):
In this operation, an incision is made at or below the groin and the testicle is taken out of the scrotum. Then, using a microscope, the enlarged 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 a lower rate of recurrence (2-10%) and complications such as hydrocele and testicular loss. But in centers with a low referral rate, these rates may become much higher. Besides, this operation is technically more challenging, time consuming and invasive than the conventional surgeries.
The complications of microsurgery are similar to conventional surgery and include hydrocele and injury to the testicular arteries and veins. Although the recurrence rates of microsurgery is reported to be lower than conventional surgery, we have to say that in our routine practice, we had to do embolizations in many patients who previously underwent microsurgery for varicocele.
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.
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.
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.
Another disadvantage 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.
Perhaps the most important weakness of surgery is the inability to treat both the cause and the result in varicocele patients. In conventional surgery, only the refluxing vein is ligated whereas nothing is done to the pampiniform plexus (the varicocele). In microsurgery, the varicocele itself is treated by ligating the enlarged veins around the testicle (pampiniform plexus) whereas nothing is done to the refluxing vein that cause varicocele.
In contrast, embolization has the potential to treat both the refluxing vein (the cause) and the varicocele (the result) in a single session and this may produce a better outcome. We must say that in varicocele patients that we treated in this fashion, we have never seen any recurrence on color Doppler ultrasound.
The surgical techniques that are commonly used for varicocele.
Hydrocele is one of the most common complications of varicocele surgery.