Varicoceles are abnormally dilated spermatic cord veins that allow retrograde blood flow to the testes. Patients should consider treatment of varicocele if they are experiencing infertility, pain or testicular atrophy. Surgical varicocelectomy is a minimally invasive and highly effect approach to the treatment of varicocele. Studies have shown that a subinquinal, microsurgical approach with intraoperative Doppler ultrasound may have the most effective outcome with the lowest risk of recurrence or other complication. The operation can typically be performed in under one hour and recovery is brisk with most men returning to work within one to two days.
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.
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.
Dr. DUC's nurse will provide you with specific instructions on how to prepare for surgery. In general, very little preparation is required.
Eat normally the night before surgery, but follow the directions that anesthesia recommends for the morning of surgery. If no specific directions have been given, withhold all food and drink the morning of surgery.
Do not take any aspirin at least 10 days prior to the procedure, as it have a side effect that can reduce platelet function and lower blood clotting ability.
- Start with clear liquids or something light and then progress to your normal diet.
- You should rest for the first 24 hours following the procedure to lessen the chance of swelling. Avoid strenuous exercise (including sex) or heavy lifting for 5-7 days. After that, you can do all of your normal activities, but at the start, let discomfort be your guide: if it feels uncomfortable, slow down.
- Apply ice packs (frozen peas or mixed vegetables work well) to the groin area over the covered area for 24 hours to help with swelling.
- Shower daily. In 48 hours, remove the outer, clear dressing and gauze just prior to showering. Steri-strips will remain and will curl up and fall off in 7-10 days.
- Take your prescribed pain medicine, usually Vicodin, for moderate discomfort. Always take the Vicodin with food in your stomach, so that you do not get nauseated. You can take Tylenol or Ibuprofen for mild discomfort.
After a General Anesthetic:
- Do not make important decisions until the next day as some anesthetics have a delayed metabolism and can interfere with the ability to perform these tasks.
- Avoid alcoholic beverages for 24 hours.
- Do not drive or operate heavy machinery for 24 hours.
- Do not eat any heavy or large meals until the next day as a heavy meal may be difficult to digest. Spicy and greasy foods should be avoided.