Laparoscopic Varicocelectomy

A varicocele is an enlarged or dilated group of veins in the scrotum (the sac that holds the testicles). Varicoceles are located along the vas deferens, a blood vessel-rich cord that connects the epididymis, which is the area where sperm are stored, to the prostate gland, a walnut-shaped gland below the bladder that supplies part of a man's seminal fluid. Varicoceles occur when scrotal vein valves malfunction and blood pools, causing the veins to become varicose (swollen). In most men the resulting varicocele is on the left side of the scrotum.

Varicoceles are serious because they can cause infertility. Approximately 40 percent of all men evaluated for primary infertility (meaning they are unable to father a child) have a varicocele; 80 percent of all men with secondary infertility (meaning they have fathered at least one child, but are not currently able to do so) have a varicocele. Despite this fact, physicians aren't entirely certain why varicoceles cause infertility. One theory is that increased blood in the veins because of varicoceles increases the temperature of the scrotal environment, which in turn raises the temperature of the testicles so that sperm production decreases. This sperm damage can occur in both testicles even if a varicocele is on one side of the scrotum because the varicocele transfers blood to the whole scrotum and both testicles.

Varicoceles usually develop slowly during adolescence when the testes grow dramatically and more blood flows to them, which may pool on return to the heart if a vein valve malfunctions. Approximately 16 percent of adolescent boys have a varicocele, a percentage that is repeated among adult men.

In some men, varicocele does not cause any symptoms. If the sperm number and quality are normal treatment may not be required in such cases. In some however, varicocele may cause important problems including infertility. The most common symptoms of varicocele are as follows:

1. Pain: In patients with varicocele, pain may occur because of the increased blood pressure in the veins around the testicle.

2. Infertility: The blood accumulated in the testicular veins may increase the temperature in the testicle. This may decrease the sperm count and mobility and cause sperm deformation by time. In one study, about 40% of the infertile men were found to have varicocele. In 50-70% of such cases, correction of the varicocele with embolization or surgery may result in improvement of sperm parameters.

3. Atrophy: In varicocele, retention of the deoxygenated venous blood in the testicular veins may impair the blood circulation and cause testicular atrophy (shrinkage). If the patient is diagnosed at an early stage and treated properly, the testicle may regrow and reach its normal size.

4. Bad appearance: Some varicoceles may be large enough to be readily seen when the patient is standing. This may disturb some patients and cause psycological problems.

5. Leg varicosities: In some patients, varicocele may be accompanied by leg varicosities. Likewise, in patients with leg varicosities a varicocele may be detected just by coincidence. In such patients, both the varicocele and leg varicosities may be caused by the insufficiency of the main testicular vein, and the occlusion of this vein may not only treat the varicocele but also be beneficial for the leg varicosities.

What are the causes of veicoceles?

The valves in the veins that go along the spermatic cord do not work properly, a similar process as varicose veins in the legs. A defect in the valves leads to a backflow of blood into the pampiniform plexus, raising pressure there and causing the veins to dilate, and eventually damaging testicular tissue. Most varicoceles occur on the left side, where the left-testicular vein is.

How is a varicocele diagnosed?

It is best to catch a varicocele before it can cause major problems, such as infertility. Self-exam of the scrotum is the best way to diagnose a varicocele early. A varicocele can feel like a "bag of worms", and is usually found in the left testicle. The majority of varicoceles are detected by a doctor during a health checkup.

Laparoscopic varicocelectomy

Laparoscopic varicocelectomy is one of three main treatment options for varicoceles. The other two options are varicocele embolization (non-invasive) and traditional varicocelectomy (open surgery). Laparoscopic varicocele surgery is very similar to open surgery but is less invasive. It is a relatively new procedure often used as an alternative to testicular varicocele surgery with varicolectomy. Men with varicoceles associated with significant pain or those who have fertility problems often seek treatment.

Laparoscopic varicocelectomy is performed by surgeons who specialize in urologic surgery. The patient is put under general anesthesia while three surgical cuts, each approximately 5 millimeters in length, are made in the patient’s abdomen. Using tools inserted though these small incisions, including a tool to magnify the area, the surgeon can sever the enlarged veins from the healthy ones. Then veins that direct blood into an already enlarged varicocele can be tied off so that the varicocele will eventually disappear. During a traditional varicocelectomy, one long incision is made near the top of the penis. Advantages of laparoscopy over this type of open surgery include a lower risk of damage to vital testicular arteries and reduced post-operative pain. Patients typically need to stay home for up to three days after the procedure in order to recover. They may experience bruising and pain where incisions were made.

Open surgery to find and preserve the tiny artery that brings blood to the testes. Magnification allows identification and preservation of the testicular arteries and lymphatics, reducing the risk of complications after surgery. Microsurgery contributes to higher success rates and fewer complications.

Varicocele Embolization

Varicocele embolization is an outpatient, image-guided procedure that uses a catheter to place a tiny coil and/or drugs into the problem blood vessel to divert blood flow away from the varicocele. Unlike varicocele surgery, embolization requires no incision, stitches, or general anesthesia. Several studies have shown that embolization is just as effective as surgery and recovery is significantly less. Embolization patients can return to full activities in a day or two, but varicocele surgery patients may need to avoid strenuous activity for several days or even weeks

1. Accurate identification of all the veins and avoiding injury to the artery and lymphatic vessels as the surgery is done under magnification during laparoscopy

2. Varicoceles from both sides of the body can be corrected at the same time without needs for further surgical incisions

3. Rapid recovery from surgery with minimal pain as the small 5mm wounds causes minimal trauma to tissue

Surgery is completed within 45 minutes, even in the case of varicoceles occurring on both sides. Patient can be discharged a few hours after surgery and return to work is within 48 to 72 hours.

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