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   DIVISION OF MALE REPRODUCTIVE MEDICINE AND SURGERY                   
  Microsurgical Varicocelectomy
Cord Exposed
Large / dominant vein within the cord.
Large vein divided between silk ties.
Multiple large veins contributing to a varicocele.
Clear lymphatic vessels preserved to prevent hydrocele formation.
Labelled structures preserved during varicocele ligation.

What is a Varicocele?
Varicocele is a term used to describe abnormally dilated veins (called the “pampiniform plexus” of veins) in the scrotum.

How does a varicocele form?
Veins throughout the body carry blood from various organs back to the heart. Normally, they have valves that ensure the blood moves in the proper direction. However, when valves in the testicular vein don’t work properly, gravity can make blood collect in the scrotum, causing a varicocele. They usually occur on the left side, likely related to the course of the testicular vein in the abdomen.

How common are varicoceles?
Varicocele’s are very common, and they are not dangerous. In fact, 15% of all adult men have a varicocele. For many men, their varicocele will go unnoticed throughout their life, or it will not cause any problems at all. About 20% of adolescents have varicoceles, so a fraction of them likely resolve spontaneously.

What problems are associated with varicoceles?
Varicoceles can cause three main problems: Impaired fertility, decreased testosterone production by the testis, or scrotal discomfort. For this reason, they are not usually treated unless there is reason for concern about one of these problems. In some cases, varicocele can cause azoospermia, or the complete lack of sperm in the ejaculate (see HERE for more information about azoospermia).

Since varicoceles are so common and since they usually go undetected throughout life, likely around 80% of men with varicoceles are able to conceive with their partners without any medical intervention. Also, as mentioned above, most men with varicoceles do not experience hormonal issues or discomfort.

One important consideration is that larger varicoceles seem to have greater adverse effects. See below for the size classification of varicoceles.

How does a varicocele affect the testis?
There are numerous theories, but most agree that one way is by carrying warm blood from the abdomen down towards the testis in the scrotum. The testis functions optimally at around 3 degrees below body temperature, thus this warmer blood can affect its ability to make sperm and testosterone. Other theories include mass effect on the testis as well as exposing the testis to various chemicals from the adrenal gland, which sits near the top of the testicular vein.

Are varicoceles dangerous?
Varicoceles are not life threatening, but rarely then can be associated with dangerous conditions. For example if a varicocele forms on the right side and not the left, it is important to make sure there is no mass or other abnormality in the abdomen that might be causing it.

Also, varicoceles should “reduce” or decrease in fullness when a patient is lying down since the gravity no longer fills the pampiniform plexus of veins. When a varicocele doesn’t reduce, it also raises concern that there is an abdominal blockage such as a mass or tumor that could be causing the mass.

Finally, it seems varicoceles almost always have effects on testosterone production. However, many men with varicoceles will maintain satisfactory levels of testosterone throughout their lives without treatment. In rare cases, however, varicocele could lead to severely low testosterone, with its associated complications including metabolic syndrome, diabetes, and osteoporosis.

What is the “Grading” system for varicocele size?
Varicocele grading systems help characterize the size of varicocele, which then helps to guide treatment. Various systems have been created, but below is the most commonly used scale today:

Grade 0

 Seen on ultrasound, but not physically detectable (also called “subclinical varicocele”)

Grade I

 Palpable (felt on exam) when the patient is performing the valsalva maneuver (“bearing down”)

Grade II

 Palpable even without valsalva

Grade III

 Varicocele causing visible deformity of the scrotum.

Even within Grades II and III, there can be varying sizes appreciated by experienced physicians, and the findings can help decide whether or not to treat the varicocele.

Can varicoceles cause problems later in life?
Data from Johns Hopkins and other institutions suggests that both fertility parameters and testosterone levels can both be progressively affected over time. For example, varicoceles are more common in men who have previously fathered children, but are currently having difficulty conceiving. Also, almost all men who undergo varicocele repair see increased testosterone levels after repair. (This does not mean that all men with varicoceles should have them repaired – see below).

Importantly, this does not mean that all men with varicoceles should be treated. As mentioned above, many men do just fine throughout their lives without ever knowing they had a varicocele.

How is a varicocele detected?
“Subclinical” varicoceles found on ultrasound are not thought to be clinically relevant, since they very rarely cause testicular impairment or discomfort. In few cases, ultrasound may detect varicoceles when physical exam is difficult due to the patient’s anatomy, or when other findings lead a physician to order a scrotal ultrasound.

Large varicoceles can often be seen with the naked eye, or a patient can feel something resembling a “bag of worms” in their scrotum. More commonly, however, a varicocele is only detected upon examination by a physician. 

Thus, the best way to detect a varicocele is by careful physical examination by a urologist. Even seasoned general urologists often are not confident about the diagnosis, so if there is any doubt, one should obtain an ultrasound and/or see a physician specializing in varicoceles and other scrotal pathology.

When are varicoceles usually found?

Varicoceles are usually found due to one of the following scenarios:
•  Most commonly, its found in a completely asymptomatic man being evaluated for infertility.
•  A mass in the scrotum may be detected by the patient or by a physician during routine exam.
•  A man may present to a physician with pain in the scrotum.

What kind of pain does a varicocele can a varicocele cause?
For most patients, varicocele does not cause any noticeable discomfort. However, mild or severe scrotal pain can result from varicocele. Patients typically report an “aching” sensation in the scrotum, usually associated with prolonged standing or activity. The discomfort is commonly relieved by lying supine (on one’s back) and raising one’s feet.

Varicoceles may cause more severe pain if the veins develop thrombophlebitis (blood clotting and inflammation). The evaluation of patients with scrotal pain should include scrotal ultrasonography to rule out other pathology and urine tests to rule out infection.

Repair of a varicocele may be considered when there is no other identifiable cause of the pain and the pain qualities are consistent with a varicocele, however there can be no guarantee that varicocele repair will eradicate the pain.

In the modern era, microsurgical denervation of the spermatic cord should also be considered at the time of varicocele ligation in patients with scrotal pain.

Varicocele and Fertility
Varicoceles are found on physical examination of roughly one third of men being evaluated for failure to conceive. They are categorized by size (see the grading system, above) and by their presence on one or both sides of the scrotum. It is important to know that varicoceles of all sizes may affect fertility. In addition, new evidence shows that sperm function may be affected by varicoceles in ways that are not detected by semen analysis.

A varicocele on one side of the scrotum has an effect on both testes in regards to function and temperature. As mentioned before, varicoceles that cannot be felt by the physician but are diagnosed by ultrasound or other imaging studies are not considered clinically significant.

When Should a Varicocele Be Repaired?
It’s important to have an individualized approach to varicocele management. The decision to treat a varicocele is made based on the size of the varicocele, the patient’s fertility goals, symptoms of low testosterone levels or scrotal discomfort, blood tests such as testosterone levels, and/or semen analysis findings.

Also, the age and fertility of the patient’s female partner are very important factors to consider when deciding whether or not to treat a varicocele. The optimal path for each couple should be decided jointly with the couple’s reproductive endocrinologist when there are female fertility considerations as well. If the female partner has not yet been evaluated, she should undergo basic testing to ensure there are no findings that would change the management of a varicocele.

There is strong evidence to suggest that repairing a varicocele improves testicular function and may prevent any further testicular damage over time, but this correlates closely with the size of the varicocele. Thus, testicular function should be assessed directly by semen analysis, measurement of testis volume, and/or blood tests. If there is evidence of damage to the testicle, varicocele repair might be important to improve testicular function and/or prevent further decline.

When the testis appears to be unaffected by the varicocele, there are varying opinions on whether to treat a varicocele. If you desire varicocele ligation to protect future testicular function, it is important to have a thorough discussion with your surgeon, and to have realistic expectations about the chances of any measurable benefit, and the risks of side effects from the procedure. We only favor treating a patient for any condition when this “risk to benefit ratio” is favorable.

An alternative to treatment is to observe patients with varicoceles over time by checking serial semen analyses and / or blood tests, and only treating if there is evidence that the varicocele is impairing testicular function.

Repair of a varicocele in the male partner of an infertile couple is indicated when:

•  There is objective evidence of a male factor (e.g. abnormal semen analysis),
•  The wife’s fertility status is intact or treatable, AND
•  There are no other obvious causes for male infertility (i.e. obstruction, malignancy, or genetic abnormality).
         
How is a Varicocele Repaired?
There are three categories of approaches:

With varicocele embolization, small coils are introduced through a vein in the groin area and are used to block the veins in the abdomen feeding the varicocele. The long-term success rates seem to be slightly lower compared to an open surgical approach, and treatment can take more than one procedure. However, there is no incision, so we often strongly consider this approach for children. In addition, it is sometimes used in patients with a previously failed surgical repair, pain as the main indication for surgery, and body features that increase the risk of surgery such as morbid obesity.

In laparoscopic varicocele ligation, a camera and small instruments are introduced to the abdomen, where the veins feeding the varicocele are clipped. This procedure also has lower long-term success rates. In addition, although complications are rare, when they do occur they can be far more serious than other approaches. Finally, the rate of hydrocele (collection of fluid around the testis) after surgery is higher with this approach.

Finally, there are multiple open surgical approaches. For most patients, we perform a microsurgical subinguinal varicocele ligation. This approach yields the highest success rates and lowest complication rates, has the lowest cost, and essentially eliminates the risk of dangerous intra-abdominal injuries.

How is microsurgical subinguinal varicocele ligation performed?
For this procedure, the patient is asleep under general anesthesia. An incision is made in the lower groin area, and the spermatic cord is isolated. All of the veins feeding the varicocele are identified and divided, while important structures for testicular function are preserved. The image below shows the key structures at >20X magnification. Veins have been divided between black silk suture, while all important structures have been protected.

Why perform a subinguinal microsurgical operation?
The subinguinal approach allows us to avoid cutting muscle fibers, leading to less pain and decreased risk of hernia after surgery.

Why perform a subinguinal microsurgical operation?
The use of our state-of-the-art surgical microscope to carefully preserve important structures helps prevent complications (such as hydrocele) while dividing the veins contributing to the varicocele.

How many days are spent in the hospital?
Microsurgical varicocelectomy is an outpatient procedure, so patients typically go home the same day.

What are the complications of varicocele repaired?
Potential complications from varicocele repair include persistent/recurrent varicocele, bruising, infection and testicular tenderness. A hydrocele, collection of water around the testis, occurs in an extremely small number of men. For those patients undergoing the non-surgical repair, there is the added risk of reaction to the contrast agent used in the procedure. Finally, there is an extremely low risk of loss of the testicle.  Insurance typically covers microsurgical varicocelectomy.

How Does Repairing a Varicocele Positively Affect Fertility?
         
In 540 infertile men with a clinical palpable varicocele who underwent microsurgical varicocelectomy and were followed more than 1 and 2 years postoperatively for alterations in semen quality and conception, respectively:

  •  A greater than 50% increase in total motile sperm count, was observed in 271 patients (50%).
  • An overall spontaneous pregnancy rate of 36.6% was achieved after varicocelectomy with a mean time to conception of 7 months (range 1 to 19).
  •  Of preoperative In-Vitro Fertilization/Intra Cytoplasmic Sperm Injection (IVF and ICSI) candidates, 31% became Intrauterine Insemination (IUI) candidates
  • Of all IUI candidates 42% gained the potential for spontaneous pregnancy.
  • Microsurgical Varicocelectomy has significant potential not only to obviate the need for assisted reproductive technology, but also to down stage or shift the level of assisted reproductive technology needed to bypass male factor infertility.
Cayan S, Turek PJ.  J Urol. 2002 Apr;167(4):1749-52

This means that repairing a clinically significant varicocele can significantly improve semen parameters and allow for natural conception or lessen the need of reproductive assistance. 

Does varicocele ligation affect testosterone production?
For most patients, testosterone levels do rise after repair. However, it is important for each patient to discuss the pros and cons of surgery for their particular situation.