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Summary

Varicoceles (swollen veins in scrotum) are the main cause of impaired sperm generation and infertility in men. The condition affects about 15% of the male population in the world. Varicocelectomy is the most commonly used surgical treatment for varicoceles. The standard care is to do an open surgical varicocele repair with microscopic assistance to lessen the possible complications. The goal of the treatment is to remove the affected veins while retaining the arterial flow and drainage of the lymphatic system.

  1. What is varicocelectomy?
  2. Why is varicocelectomy recommended?
  3. Who can and cannot get varicocelectomy?
  4. What preparations are needed before varicocelectomy?
  5. How is varicocelectomy done?
  6. How to care for yourself after varicocelectomy?
  7. What are the possible complications/risks of varicocelectomy?
  8. When to follow up with your doctor?

Varicoceles are abnormally enlarged veins in the scrotum (the sac that holds the testes and that produces sperm and testosterone). Varicocelectomy is the removal of these swollen veins in the scrotum for the repair of varicoceles.

Varicoceles are similar to varicose veins (twisted and swollen) found in the legs. These veins in the scrotum are a part of the pampiniform plexus (a network of veins) that helps in keeping the temperature of the scrotum 5 degrees lower than the belly or pelvis. A low scrotal temperature is required to make good quality sperms. However, when these veins become enlarged, it results in overheating of testes, leading to decreased sperm production and reduced sperm function. This, in turn, results in low fertility.

Varicoceles are quite common on the left side and are found in about 15% of the general male population, in 35% of the men with primary infertility and in 75-80% of the men with secondary infertility. They are graded as 0, I, II and III depending on their size. The grading assists in deciding the treatment for varicoceles.

Varicocelectomy can be done as laparoscopic varicocelectomy or by the traditional open surgical approach. Microscopic varicocelectomy and laparoscopic varicocelectomy are the most commonly used approaches for a varicocelectomy.

However, open surgical varicocele repair with microscopic assistance is considered the standard surgery to lessen possible complications.

Generally, varicoceles show no symptoms. However, some men may experience a dull discomfort in the affected testicle, especially after physical activities, such as exercise or standing for a long time. The symptoms improve when the individual lies down. The testicle on the side that has varicocele may be smaller than expected.

The condition may cause infertility. It may also lead to slow growth of the left testicle during puberty.

A varicocele might require surgery if you have any of the following conditions:

  • Small size of the gonads or slow testicular growth in teens
  • Pain in the scrotum
  • Aesthetic issues

Surgery for varicoceles is recommended if you experience the following:

  • Abnormalities on semen analysis
  • A higher follicle-stimulating hormone, which shows that the varicocele is causing stress on the process of sperm production
  • If a varicocelectomy might increase your chances of having a baby
  • Grade III varicoceles and asymmetrical testicular growth

Mild grade I varicoceles with no testicular asymmetry and that show no symptoms may not require an operation.

Those who do not show any symptoms need not be treated.

A varicocele is generally described as a ‘bag of worms’ due to its look and feel. So, your doctor will perform a thorough physical examination of the spermatic cord or might suggest an ultrasound to confirm the diagnosis. He/she may check for a varicocele while you are standing.

Below are the tests that your doctor may suggest for a proper diagnosis:

Other routine tests that you will be asked to get done before the surgery are:

You may be asked to follow the below-mentioned steps before the surgery:

  • You can eat normally the evening before the surgery.
  • Do not eat or drink anything after midnight the previous day and the morning of the surgery.
  • If you need to take any medicines, swallow them with a small sip of water.
  • Inform your doctor about all the medicines that you take, including prescription and over-the-counter medicines, vitamins, herbs and other supplements. In case you are taking any blood thinners such as warfarin, clopidogrel or aspirin, your doctor may ask you to stop them before the surgery

The duration of varicocelectomy is about two to three hours. The following steps are carried out during the surgery:

  • You will be given general anaesthesia that will make you sleep during the procedure. 
  • However, if spinal anaesthesia is considered, you will receive an injection in your lower back that will make your lower body feel numb. If local anaesthesia is considered, you will receive an injection in the specific area that will be operated.
  • An intravenous line, which will supply fluids and medicines, will be put into a vein in your arm.
  • You might be given a medicine to prevent blood clots. 
  • A tube will be inserted into your throat to assist in breathing.
  • A catheter (thin tube) will be put in your bladder to drain urine.

Laparoscopic varicocelectomy

During a laparoscopic varicocelectomy, the surgeon will make a few small cuts on your abdomen. A laparoscope (a thin, lighted tube) will be placed through one of the incisions, and the abdomen will be filled with gas to allow the doctor to see clearly the inside of your body. With the help of the other tools inserted through the other openings, the doctor will cut the swollen veins and seal their ends with tiny clips. All the tools will be removed once the operation is complete, and the incision will be closed with stitches.

Open surgery

If you undergo an open surgery technique is used, the doctor will make an incision will be made on your abdomen or the groin and he/she will cut and seal the swollen veins through this incision. A microscope is sometimes used during an open varicocelectomy. The magnification due to the microscope helps the surgeon identify and work on the tiny veins and preserve the small arteries and vessels carrying fluid around the testicles. 

After the surgery, you will be taken to a recovery room to monitor your vitals for one or two hours before shifting you to a normal ward. 

When you wake up, you will feel drowsy for a while due to the anaesthesia, and your throat might be sore if a breathing tube has been used. When you can get up on your own, the catheter from your bladder will be removed. Your doctor will give you some medicines to manage the pain.

Your doctor may give you the following instructions while leaving the hospital. Make sure to follow them properly at home:

  • Do not swim or take a bath or do anything that may make your incision wet until your doctor tells you to.
  • Do not have sex for one to two weeks after the surgery.
  • Do not drive for the first 24 hours after the surgery.
  • Do not strain when passing stools.
  • To help reduce swelling, apply a cold compress (or ice) to your scrotum for the first 2 days after you reach home. Do not apply the compress for more than 10 minutes at a time.
  • Do not skip any dose of medicine. 
  • You should not do any strenuous activity for at least three weeks.
  • Do not lift anything heavy either until your doctor allows you to.
  • You can wear scrotal support (jockstrap) to help minimise discomfort while you stand, walk or exercise in the first few weeks after the operation.
  • You will be able to resume work in five to seven days. Avoid exercising for 10-14 days.

When to See the Doctor?

Call your healthcare provider immediately if you have any of the following symptoms:

  • Fever of 100oF or above
  • Signs of infection, such as swelling, warmth, increased redness, worsening pain or foul-smelling drainage, at the incision site
  • Pain that does not improve even with medicines
  • Swelling in the scrotum that does not go away
  • Trouble while passing urine
  • Persistent nausea

The following risks are associated with a varicocelectomy:

  • Wound infection
  • Bleeding or haematoma (formation of a blood clot)
  • Varicocele recurrence
  • Fertility not restored
  • Hydrocele (fluid around a testicle)
  • Shrinking of a testicle
  • Temporary decrease in sperm count
  • Chronic pain
  • Injury to the vas deferens or genitofemoral nerve or testicular artery

Your doctor will schedule your follow-up visit in seven days to check the incisions and remove the stitches or staples. A sample of your semen may be checked in three to four months to see if the number and quality of sperm have improved. You may need a semen analysis every two months after this procedure to ensure whether the quality of your sperm has improved.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.

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References

  1. Weill Cornell Medicine: Center for Male Reproductive Medicine and Microsurgery [Internet]. New York, US; Microsurgical Varicocelectomy
  2. Binsaleh Saleh, Lo Kirk C. Varicocelectomy: microsurgical inguinal varicocelectomy is the treatment of choice. Can Urol Assoc J. 2007 Sep; 1(3): 277–278. PMID: 18542804.
  3. Urology Care Foundation. American Urological Association [internet]. Maryland. U.S.; What are Varicoceles?
  4. John Hopkins All Children's Hospital [Internet]. Johns Hopkins Medicine. The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System; Varicocele
  5. Cleveland Clinic. [Internet]. Cleveland. Ohio. US; Varicocele
  6. U Health [Internet]. University of Utah. Utah. US; VARICOCELE
  7. Kimber C.P. (2007) Varicocelectomy (II). In: Godbole P.P. (eds) Pediatric Endourology Techniques. Springer, London
  8. Saint Luke's Health System [Internet]. Kansas city. US; Laparoscopic Varicocelectomy
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