The gold standard for fixing a varicocele is the microscopic sub-inguinal varicocelectomy. Sub-inguinal refers to the location of the incision. This single incision is about one inch above the top of the penis and one inch to either side. If both sides are being operated on, two incisions are made. The scars will later be covered by pubic hair. This is where the spermatic cord (the bundle carrying the vas deferens, the testicular arteries, the veins, the lymphatics, and the muscles) leaves the abdominal wall. By making the incision here, the abdominal muscle can be avoided, which results in significantly less postoperative discomfort and significantly reduced healing time.
Microscopic means that an operating microscope is used. This large microscope stands above the patient, and the doctor performs the delicate part of the operation while looking through it. This allows the surgeon to clearly see all the veins that need to be severed, as well as the arteries and the lymphatics, which drain fluid from the space between the testes and the surrounding sac, to be avoided and not severed.
In this approach, a patient is usually sedated (asleep, but not intubated - this is safer for the patient). While sleeping, a local anesthetic is injected into the area. An incision of about one to one and a half inches is made in the numbed area. The spermatic bundle (cord) is located, grasped, and brought out of the patient's body. Using the microscope, the layers of muscle surrounding it are stripped away. The artery is identified and a tie loosely placed around it for identification. The veins are then sequentially located and severed. The cord is then placed back into the patient's body and the tissues are closed, layer by layer. The skin is generally closed with a plastic surgery stitch; the stitches are placed under the skin so that they need not be removed later.
There is little discomfort associated with this method and the recovery time is fairly quick. During the procedure, the patient feels almost nothing; in many cases, the patient completely sleeps through the procedure. The anesthesiologist can administer sedatives and an appropriate dosage of pain medication. There may be some discomfort, swelling, and bruises for several days afterward. Almost all men go back to work after 2 to 3 days. Studies have shown that after this type of varicocelectomy, men use less pain medication than most people use after a typical dental procedure.
An alternate method of varicocele surgery is called an inguinal varicocelectomy. Although most infertility specialists use the microscopic sub-inguinal approach, a varicocelectomy is sometimes performed by a general urologist. In this case, the incision is made just like a hernia incision. The abdominal muscles that cover the varicocele are cut at the point where they leave the abdomen. The cord is exposed. Then, using the naked eye or magnifying lenses worn as glasses, the veins are cut. The incision is longer than a sub-inguinal incision. It also is higher, making the scar visible above the pubic hair. Because the abdominal muscles are cut, the postoperative pain is significantly increased and the healing process takes longer. Also, if the microscope is not used, it is harder to see and spare the arteries and lymphatics or to see and sever all of the necessary veins. Thus, the arteries bringing blood to the testicle are also usually not spared and there is a higher incidence of failure (5% to 15%) and the formation of hydrocele, a collection of fluid around the testicle (3% to 30%).
The third method that may be used involves an even higher incision to sever the veins further up (the retro-peritoneal approach). This leaves a more obvious and unusual scar. It also involves cutting abdominal muscles, which increases postoperative pain and recovery. The artery is not preserved. It has a failure rate of 15% to 25% and a risk of hydrocele formation of approximately 7%.
Finally, a varicocele may be repaired laparoscopically, but the patient must be placed under a general anesthetic. A catheter (tube) is placed into the bladder in order to allow the urine to drain out so that the bladder does not get in the way of the procedure. A small incision is made under the umbilicus (bellybutton) and the abdomen is filled with air. The needle is replaced with a larger, bored trocar (sharp tool) and a sheath so that the camera can be placed in the abdomen. Under vision, an additional two incisions are made in the abdominal wall and two working instruments are placed into the abdomen. The bundle carrying the vein and arteries is identified. At this point, this bundle is transected. Care is taken not to transect the vas accidentally.
This procedure is not generally recommended because it requires that the patient be under a general anesthesia, that a Foley catheter be inserted, and that instead of an incision outside the abdominal wall three incisions in the abdominal wall must be made. There are also inherent risks with laparoscopy that are greater than those with the small open procedure done with microscopic varicocelectomy.
Success rates of varicocele treatments can be measured in terms of resulting pregnancy rates: 60% of men will establish a pregnancy within one year of varicocelectomy. Seventy-two percent of men will do so after two years. This compares to 16% of men whose partners will conceive without undergoing a varicocelectomy during the same period.
Success rates can also be measured by change in semen analysis results. Sixty-five percent of men will show a significant improvement in the semen analysis within 12 months. A significant change is defined as a doubling of the total motile count. The total motile count is the calculated number of sperm that the man actually ejaculates.
Men with larger varicoceles will show more significant improvement. In these men, 69% will have a three-fold improvement in the total motile count in the ejaculate. Many men have a large varicocele on one side and a small varicocele on the other side. A recent study addressed whether, in these cases, both varicoceles should be repaired or if just the larger one should. Sixty-five percent of men with bilateral (two sided) varicoceles with a small varicocele on one side and a large varicocele on the other chose to have both varicoceles repaired. This group showed a 104% increase in the total motile count. Twenty-six percent of the men decided to have surgery only on the left side and they showed an average improvement of 45% in the total motile count. In general, even if only a small varicocele is found on the opposite side of a large varicocele, it is recommended that they both be repaired.
Another study of 25 men older than 45 years of age showed an average preoperative concentration of 12.7 million/cc, a motility of 29.6%, and a normal morphology (shape of 24.4%). Postoperatively, the average concentration was 20.3 million/cc. The average motility was 44.7% and the average morphology was 30.7% normal morphology. It would appear that even older men with long standing varicoceles will show significant improvement from a varicocelectomy.
It takes 78 days from the beginning of the sperms' development until they are ready to be ejaculated. This is a continuous process very much like an assembly line. At any given time, there should be millions of sperm at all stages of development.
It therefore takes a minimum of 4 months to see any significant improvement in the semen analysis after a varicocelectomy. Increased improvements can often be seen for up to two years. If, however, there has been no improvement within 6 months, other options should be simultaneously considered.
A varicocelectomy does not in any way negatively affect the sperm, and, while waiting for improvement, additional and alternative steps can be taken by the couple.
Finding a Doctor
Some urologists have completed specialized training in male infertility (fellowships), and it is recommended that you locate one of these physicians to perform your surgery.
After their general urological training, (5 to 6 years post medical school) some physicians choose to complete additional training in infertility (a fellowship). During their fellowship, they are exposed to large numbers of men with infertility problems and focus on the diagnosis and treatment of these men.
A significant part of the advanced training is spent mastering microsurgery, surgery that is performed under an operating microscope. Facility with this technique enables them to perform the most sophisticated and least invasive surgeries appropriate to varicoceles as well as other male infertility surgeries (e.g., vas reconstruction).
Additionally, as part of their fellowship, these urologists are also trained to understand female infertility and the interface between the two disciplines. Infertility is a couple's issue; physicians treating the couple should understand the medical issues of both parties and work comfortably with the couple and other involved physicians, using a team approach.
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