Varicocele = enlarged vein (veins are blood vessels that carry blood toward the heart)
Ectomy = removal of
Varicocelectomy refers to surgical removal or ligation (dividing and securing or sealing the ends) of veins in the spermatic cord. The spermatic cord is the name for the combination of structures that travel from the testicle, up the groin region, and into other areas of theabdomen or pelvis. The cord is wrapped in layers of tissue called fascia. Within the cord on each side are the:
- Vas deferens: This is the spaghetti-like tube that transports sperm from the testicle to the urethra (tube through which you urinate and ejaculate semen).
- Arteries: These are the blood vessels that transport blood to the testicle and surrounding structures. The main artery is the testicular (gonadal) artery.
- Veins: These are blood vessels that transport used blood back in the direction of the heart.
- Nerves: There are small nerve fibers that supply sensation or reflex action to this area.
- Lymphatics: These are small vessels that drain tissue (lymph) fluid that surrounds the testicle.
For unknown reasons, the veins may become dilated (too large), and this is termed avaricocele. A varicocele may interfere with normal sperm production and consequently fertility(ability to produce normal sperm). Much like varicose veins in the legs, these veins can be visible to the naked eye. There is a grading system that we as urologists use to classify these veins, although size does not necessarily correlate with how problematic their presence may be. In other words, a larger varicocele does not necessarily indicate worse infertility.
While there are different theories as to why varicoceles may be associated with infertility, the "increased temperature" theory is most widely accepted. Your body temperature is 98.6degrees. The testicles hang low in the scrotal sac so that they can exist at just over 96 degrees(2 degrees lower); the temperature at which normal spermatogenesis (the production of sperm)can successfully occur. When a varicocele is present, there is more blood (traveling in the dilated veins) pooled around the testicles at any given time. The result is that the testicles are warmer than they should be to function properly. Consequently, spermatogenesis may be impaired.
Varicoceles are sometimes discovered by the patient,
by the physician, or accidentally because you have a
scrotal or testicular ultrasound (sonogram) test done
for another reason. In the younger patient, these are
In married men, the most common reason to evaluate for a varicocele is infertility. In other words, a couple has long been unsuccessful at achieving pregnancy.
Any one, but more often a combination of physical examination, semen analysis, and ultrasound of the testicles will confirm the diagnosis. Because of your anatomy (the drainage patterns of the veins) the vast majority of varicoceles are on the left side. A few are on both sides, and rarely do we see a right side only presentation. Sometimes we can diagnose avaricocele just by looking. Other times we can only feel it. In some situations, it is only apparent on ultrasound examination. Sometimes, the testicle on that side may have been affected over time and is atrophied (shrunken) as a result. This finding may indicate a worse result for return to normal fertility following repair.
With varicoceles, any presentation is possible:
- There may be a normal semen analysis and a normal size testicle with a large or small varicocele.
- There may be an abnormal semen analysis and a small testicle with a small or large varicocele.
"In whom do we recommend that a varicocelectomy be performed?"
Not all varicoceles cause subfertility (diminished ability to impregnate) or infertility (complete inability to impregnate). In patients that do not want to have children or are finished having children, there is no need to have the procedure. In unusual instances, a large varicocele may cause discomfort, and we may suggest a repair in select patients. This would not be for fertility purposes. For the patients that present with a history of inability to impregnate that are then found to have a varicocele (with abnormal semen analysis), the answer is usually straightforward. In most of these patients, we would recommend a varicocelectomy. The first dilemma is in younger boys or adolescents. These patient are not yet attempting to have children, and so it is not yet known whether they have problems with fertility because of their varicocele. The second dilemma is in males old enough to father children (but who have not yet had any children) who currently have a normal semen analysis despite their varicocele. In either of these patients we cannot predict whose varicocele will eventually cause a problem. For that reason, we may suggest that the varicocele be repaired. The reason is twofold. Many physicians believe that permanent damage is occurring to the sperm-producing cells of the testicle even before the semen analysis is abnormal. The second reason is because your best chances to achieve normal fertility after the procedure is when it is performed before these men analysis is abnormal or the testicle has shrunken. Once you have any subfertility, your results are less likely to be as good after the procedure.
If after your consultation and this written explanation, you still have questions please let us know.
As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you.
The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood ("blood thinners, aspirin, anti-inflammatory medicines, etc...") The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds ) whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past 10 days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.
To review the basics of what we discussed in the office: The procedure can take anywhere from 1-3 hours depending on an individual's anatomy and whether one or two sides must be repaired. There are different types of incisions or approaches that can be used depending upon your anatomy and your surgeon's preference. Regardless, they each involve a small incision near the groin area. The position of the incision may vary a bit depending on the type of procedure being done. The spermatic cord is identified and its contents examined. All of the veins in the actual cord or around the outside of the cord will be divided and the ends secured. In certain instances, it may be necessary to extend the procedure underneath the testicle to get to veins that are there. Once satisfied that all veins have been divided, inspection of other spermatic cord structures (the arteries, vas deferens, nerves, and lymphatic vessels) is again performed to ensure that they are normal and intact. The incision is then closed and your procedure is completed. Some surgeons may even tie off one of the arteries. Because there is more than one artery supplying the testicle, removal of one is unlikely to damage the testicle.
Some surgeons perform varicocelectomy laparoscopically. Laparoscopic surgery is performed by placing surgical instruments and a camera through small holes in the abdominal wall. The camera projects the surgery onto a television monitor. *If your child's case is to be done in this fashion, you may also receive a written educational pamphlet on laparoscopic surgery so that you understand it better.
You or your child will be in the recovery room for a short time before being sent home. You or your child may have discomfort over the incision site and adjacent areas. There will be a small bandage over the surgical area which is to remain until your follow up with us unless otherwise directed. Occasionally, there may be small blood staining on the bandage. If the dressing becomes soaked, or you see active blood oozing, please contact us immediately. You or your child may shower the day after surgery, but no bathing or swimming for 7-10 days(unless otherwise instructed). We ask that you or our child refrain from any strenuous activity until your follow up office visit. Every patient has some degree of swelling and bruising, and it is not possible to predict in whom this might be minimal or significant. It is very important to apply ice compresses to the area as instructed. We strongly encourage you to take the following day off of work or school and perhaps more if going there requires strenuous activity or heavy lifting. In the first 24 hours it is to your advantage to minimize activity and rest in a lying down position. Some patients have almost no discomfort while others are somewhat uncomfortable for a few days to weeks. Severe pain is unlikely but possible. We may provide a prescription for pain medication to alleviate most of the discomfort. Take this medication as prescribed and as needed. If any side effects occur, contact our office immediately.
Expectations of Outcome
In those patients that had abnormal semen parameters prior to surgery, there will be improvement in 60-80% following varicocelectomy. *It should be noted, however, that return to normal parameters does not guarantee normal fertility (an ability to successfully impregnate).It is estimated that about half of patients with improved parameters will be able to achieve pregnancy without assisted reproductive technology. Again, the initial size of the varicocele does not correlate with future fertility rates. In general, younger patients and those without testicular atrophy have a better prognosis for future fertility: basic principle "the longer the history of the varicocele before surgery, the worse the future fertility after surgery".
Possible Complications of the Procedure
ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to:
Failure: As mentioned, a varicocelectomy may fail to improve semen parameters or improve future fertility.
- Recurrence or Persistence: Rarely, a varicocele can return due to engorgement of tiny veins that could not be seen during the operation. A patient may notice this soon after surgery or months later.
- Hydrocele: This is perhaps the most commonly seen complication, occurring in10-15% of patients. This is a collection of fluid around the testicle. While some resolve without intervention, occasionally hydrocelectomy (surgical drainage of this fluid) maybe required.
- Vas Ligation: This is very rare. If the vas deferens (tube that transports the sperm) is inadvertently divided, microscopic surgical repair would be performed. However the function of the vas deferens may be permanently damaged. the vas deferens may also become occluded (blocked) due to scarring or inflammation over time.
- Hematoma: When a small blood vessel continues to ooze or bleed after the procedure is over, the area of collected blood is referred to as a hematoma. The human body normally re-absorbs this collection over a short period of time. A drainage procedure is rarely necessary.
- Infection: Infection is possible following any surgical procedure. Usually, local wound care and antibiotics are sufficient. Occasionally, an infection may require drainage.
- Chronic Pain: As with any procedure, a patient can develop chronic pain in an area that has undergone surgery. Although this is very rare, it is perhaps a bit more common with any procedure that involves the groin area (such as an inguinal hernia repair).Typically, the pain disappears over time, although some feeling of numbness may persist. If persistent, further evaluation may be necessary.
- Paresthesia(s): As mentioned earlier, there are small nerves that run inside or directly alongside the spermatic cord. After varicocelectomy, it is possible to have areas of numbness on the scrotal sac or inner thigh area. Over time, the sensation usually returns. Less commonly, the area may stay numb forever.
- Testicular Ischemia/Loss: Each testicle is supplied by blood vessels. If all vessels were unable to deliver blood to the testicle, the testicle on that side would decrease in size and lose function. This is quite rare.
We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).
The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While Delta Medix endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. Delta Medix cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.
Delta Medix, P.C.