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Techniques of Varicocelectomy

Treatment of varicoceles is an appropriate consideration in some patients with infertility, pain or testicular atrophy. No medical therapies are available for either treatment or prevention; however analgesic agents may alleviate associated pain when present.

Palpable varicoceles should be corrected in adolescent boys when accompanied by ipsilateral testicular atrophy or if the varicocele is very large. It has been suggested that adolescents with varicocele and an abnormal gonadotropin response to LHRH may also benefit from repair.

A variety of surgical approaches have been advocated for varicocele repair (varicocelectomy), including open surgical, laparoscopic, and percutaneous techniques. Ideally, the perfect procedure would be one that ligates both the veins contributing to the varix at the time of repair and those that could cause a recurrence in the future. However, some veins clearly must be preserved so as to allow drainage of blood from the testis and prevent vascular engorgement. Therefore, the ideal procedure should be one that leaves the testicular arteries, lymphatics, and vas deferens intact. A minimally invasive procedure which reduces morbidity, pain and recovery time is also desirable.

TechniqueArtery preservedHydroceleFailurePotential for serious morbidity
Radiographic embolizationYes0%5-11%Yes
Microscopic subinguinalYes0%1%Yes 

Retroperitoneal Technique: The retroperitoneal method that may be used involves an even higher incision on the abdomen to sever the veins further up (the retroperitoneal 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%.

Inguinal Technique:
Another method of varicoceles surgery is called an inguinal varicocelectomy. Although most infertility specialists use the microscopic subinguinal 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 subinguinal 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%).

Laparoscopic Technique:
The third technique used to repair a varicocele is 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.

Radiographic Embolization:
The fourth option is a catheter directed embolization, and is a non-surgical, outpatient treatment performed by an interventional radiologist using imaging to guide catheters or other instruments inside the body. Mild IV sedation and local anesthesia are used during the approximately one hour procedure to ensure that patients are relaxed. During the procedure, an interventional radiologist makes a tiny nick in the skin at the groin using local anesthesia, through which a thin catheter (much like a piece of spaghetti) is passed into the femoral vein, directly to the testicular vein. The physician then injects contrast dye to provide direct visualization of the veins so s/he can map out exactly where the problem is and where to embolize, or block, the vein. By placing embolization coils, the interventional radiologist blocks the blood flow in the vein which reduces pressure on the varicocele. By embolizing the vein, blood flow is redirected to other healthy pathways.

Technique: The technique most closely approaching this "ideal" is the mini-incision, inguinal, or subinguinal microsurgical varicocelectomy with delivery of the testicle. Although it is a technically demanding approach, the real advantages of the microsurgical approach to varicocele repairs are reliable identification and preservation of the testicular artery or arteries, cremasteric artery or arteries, and lymphatic channels and reliable identification of all internal spermatic veins and gubernacular veins. Delivery of the testis assures direct visual access to all possible routes of venous return, including external spermatic, cremasteric, and gubernacular veins.
Postoperatively, venous return is via the vasal veins, which drain into the internal pudental system and usually have competent valves.

NOTICE: Please use this information carefully. This information should not be used in place of the advice given to you by your doctor. This information may contain errors.

-- Edited by beckerj at 18:41, 2007-12-26

-- Edited by beckerj at 16:31, 2007-12-26

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