Varicocelectomy: A Complete Article

4/5/2017

The enlarged and inflamed veins in your scrotum, especially those in the spermatic cord, that are producing your varicocele need to be removed so your testicles can receive the proper nutrients and oxygen they need. If not treated, your testicles will begin to suffer from the blood stasis, affecting your fertility in the long run and producing testicular and inguinal pain.

A varicocelectomy is a surgical procedure that could provide some benefits to varicocele patients. It is usually recommended to (Woo Suk et al, 2013):

Patients that have palpable varicocele (with or without Valsalva maneuvers).
Couples with known infertility, especially if the woman is fertile or has a treatable cause of infertility.
Males with abnormal sperm quality or low count.
Varicocele associated with testicular pain, which did not improve after taking pain and anti-inflammatory medication.

What To Do Before Surgery

After your doctor explained to you how the procedure is done, what is the best thing for your case, its benefits, risks, and possible complications, you will have to follow certain guidelines and know some things before going into surgery.

Prepare all your health insurance documentation days before surgery.
You will have to do a series of pre-surgery exams and consultations besides the one with your urologist. These consist in Internal Medicine and Anesthesia examinations, a chest X-ray, an EKG, a series of blood laboratories, plus other tests like a spermiogram.
Schedule your agenda knowing that the surgical procedure only lasts about 45 minutes to 1 hour, and you will be able to return home the very same day. Depending on each case, the doctor could keep you in observation after the procedure, taking more hours of your agenda. Of course, you will need some assistance after the surgery, so tell a family member or friend to help you with that.
If you take any medications or supplements, is very important to tell this to your doctor. You will need to stop taking blood thinners like aspirin or warfarin to reduce the risk of bleeding during and after the surgery. You will also have to tell if you suffer from any allergy, especially to medications.
Some doctors recommend shaving the genital area before surgery. In other cases, the healthcare personnel will take care of that. Either way is up to you and your comfort.
Follow your doctor´s instructions on fasting. Approximately 8 to 12 hours before surgery you will not be able to eat or drink.

What Happens Moments Prior to Surgery?

When you arrive for surgery, you will usually be attended by the nurses who will ask you to change your clothes for a hospital gown. The anesthesia personnel will lie you down on the surgical table and will usually administer a sedative to calm you down and the anesthesia medication, either a local or a general one, depending on what you and your doctor decided when talking about the procedure.

Is a norm to use a bladder catheter to remove the urine during the procedure, but do not worry, it will be introduced after the anesthesia. If you decide to go with the general anesthesia, the doctor will intubate you. From this moment on, your vital signs will be checked by the responsible team, who will check them before, during, and after the surgery.

During the Procedure

The most popular method is the microsurgical varicocelectomy, either with the inguinal or sub-inguinal technique, as several studies show (Binsaleh et al, 2007; Zini, 2007; Woo Suk et al, 2013; Mehta et al, 2013; Gde, 2013). Other options include the laparoscopic method, the open surgery technique, and the embolization option, which is likely to be the least beneficial one of all.

The main focus of the surgeon is getting inside the pelvic region and cut the enlarged veins found in the spermatic cord, which are compromising the blood flow, for then clamping, tying or cauterizing them.

After the Surgery Recommendations

You will wake up in the recovery room, where the nurses and doctors will assist you. You will spend some time recovering, while you receive painkillers and maybe some sedative, if you want them. At this moment you can be accompanied by a companion, either family or friend.

The doctor will give you prescriptions for medications you need to take, such as antibiotics, painkillers, anti-inflammatory, etc. You will receive guidelines to clean your incisions, as well as recommendations like putting ice on your scrotum several times a day, avoiding sexual activity for up to 2 weeks to 1 month, avoiding exercising and taking home rest for work for a few weeks, etc.

After surgery consultations with the doctor will be scheduled to observe your progression as well as a new spermiogram to analyze sperm quality and count.

So, What Could Go Wrong?

As is well known, a surgical procedure can have its complications, some minor, some more serious. As stated above, the preferred surgical method is the microsurgical varicocelectomy, which provides the least number of complications (Carbone et al, 2003; Baazeem et al, 2011; Woo Suk et al, 2013; Mehta et al, 2013). Either way, here is a list of some of the complications that could happen, taking into consideration that the experience of the surgeon, as in others procedures, can sometimes make the difference.

During and after surgery, bleeding can be present due to blood thinners medications, wrong suture methods, defective sutures, etc.
Acute incapacity to pee or fully emptying the bladder.
Inflammation, redness, pain, and drainage from the incisions, which up to some level is normal and could last weeks to return to the normality.
Infections accompanied by high fever, nausea, vomiting, and other general symptoms.
Days or weeks after surgery, fluid can concentrate around the affected testicle, producing a hydrocele.
Chronic testicular pain due to some nerve damage.
Infertility due to damage produced to the spermatic cord.
Testicular loss due to arterial damage.
Reappearance of varicocele in the surgically intervened testicle.
Other complications can also occur.

In the End, is it Worth It?

As several studies mentioned above show, microsurgical varicocelectomy is the best option among the surgical procedures, dealing with minor complications rates and better outcomes. However, the same and other studies (Kantartzi et al, 2007; Shamsa et al, 2010; Baazeem et al, 2011; Kroese et al, 2012; Woo Suk et al, 2013; Gde, 2013) conclude that more investigation is needed to make microsurgical varicocelectomy the best option to treat varicocele.

In the major part of these studies, varicocelectomy did not improve sperm quality or count in a significant way compared to the control group (in the studies that provided a control group), while in others it did improve the sperm parameters, but the studies were not well-designed.

As per the pregnancy outcome, most of the conclusions were suggesting but not conclusive, giving low pregnancy rates after varicocelectomy. More studies should be done based on pregnancy rates after varicocelectomy as the primary outcome to have a definitive information.

Other than that, these studies showed that the microsurgical varicocelectomy NNT (number needed to treat) is 7, meaning that for every 7 patients who receive surgery, 1 gets the benefits. When compared with the embolization option, which has an NNT of 17, the previous method received more recommendations. However, an NNT of 7 is not that good, considering that the patients are going into surgery taking many risks when they could consider alternative treatment methods instead.

Either way, having all the information, is up to every patient to decide what he thinks is best for him.

Dealing with Informed Consent.

Before the surgery, you will be asked to read and sign an informed consent in which the whole process with its benefits, risks, complications, anesthesia, and different phases are explained in total details. This informed consent is a way of mixing health with laws and bioethics.

Is basically a legal document where you declare you know everything there is to know about the procedure and let the doctors do their jobs, accepting their terms and conditions. For this reason is very important for you to discuss every single detail with your health care team before signing any paper and going into surgery.

These are some questions you could ask your doctors before deciding for surgery:

What is your personal success rate for this procedure? And what is your failure rate?
What are the risks and complications that I should be concerned with?
Can you provide alternative and less invasive options that could be beneficial for me, instead of surgery?
Why do I need this surgery?
This surgery will solve my varicocele once and for all?
Can you explain the whole surgical procedure to me?
If I decide to not do the surgery, what will happen to me?

References:

Author: Dr. Stefano Pizzo

Dr. Stefano Pizzo is a general practitioner. He graduated from Universidad de Oriente (UDO), Barcelona, Venezuela. In his last year as a Medical student, he lent his services in the Departments of Gynecology and Obstetrics, General Surgery, Traumatology, Internal Medicine, and Pediatrics at the "Luis Ortega" Central Hospital in Nueva Esparta State, doing assistance work in its Emergency and Hospitalization areas. Since then, he became a trained expert in Neural Therapy and he occupies the majority of his time writing valid and certified medical and scientific articles, especially in the Anti-Aging and Alternative Medicine fields.

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