Varicocele microsurgery

What a varicocele is

A varicocele is an enlargement of the network of veins that drain the testicle, caused by valves within those veins failing so that blood pools rather than draining efficiently. It is essentially a varicose vein of the scrotum. Around 15% of all men have one, and it is far more common — roughly 40% — among men presenting with fertility problems.

Varicoceles occur on the left side in the great majority of cases, because of the way the left testicular vein drains. They are graded from subclinical, visible only on ultrasound, through to large and easily visible on examination.

Why it affects fertility

The pooled blood raises the temperature around the testicle, and sperm production is temperature-sensitive. It also exposes the testis to a build-up of metabolic waste products and increases oxidative stress. The result can be reduced sperm count, poorer movement, abnormal shape, and increased sperm DNA fragmentation. In some men it also progressively reduces testicular size and testosterone production.

Importantly, most men with a varicocele are fertile. Having one is not in itself a reason for surgery.

Who should have it repaired

Repair is generally recommended where all of the following apply:

• The varicocele is palpable on examination, not merely visible on a scan
• There is a documented abnormality of the semen, or raised sperm DNA fragmentation
• The couple has documented infertility
• The female partner has normal fertility, or a treatable and identified cause

Other accepted indications include pain that has not responded to conservative measures, a varicocele causing reduced testicular growth in adolescents, and in selected men, low testosterone associated with a large varicocele.

Why microsurgical repair

There are several ways to treat a varicocele — open non-microsurgical ligation, laparoscopic surgery, and radiological embolisation. Microsurgical subinguinal ligation is widely regarded as the reference standard because the operating microscope allows the surgeon to see and preserve the structures that matter:

• The testicular artery is identified and protected. Injuring it risks testicular atrophy.
• The lymphatic vessels are preserved, which is what prevents the hydrocele (fluid collection) that is a common complication of non-microsurgical techniques.
• Every draining vein is identified and tied, including the small ones that are invisible to the naked eye, which is why recurrence rates are lowest with this approach.

The operation and recovery

The procedure is performed under general or regional anaesthetic as a day case. A small incision, around 2 to 3cm, is made low in the groin at the level of the external ring. Under the microscope, the spermatic cord is examined and each vein is divided while the artery, the vas deferens and the lymphatics are preserved. The incision is closed with dissolving sutures.

Discomfort and bruising last around one to two weeks. Most men return to desk work within a few days, and to sport, cycling and heavy lifting at three to four weeks. Supportive underwear helps in the first fortnight.

Semen analysis is repeated at three months and again at six, because sperm production runs on an approximately three-month cycle and improvement is not immediate. Where improvement occurs, it typically continues over the first six to nine months.

Risks

Risks include bruising and wound infection, hydrocele formation, recurrence or persistence of the varicocele, testicular artery injury with atrophy, and chronic pain. These are uncommon with microsurgical technique but are discussed fully before surgery. There is also the possibility that semen parameters do not improve.

My experience

Microsurgery for varicocele is part of the core male infertility practice I established at Guy's Hospital in 2012, and I run a national training fellowship in male infertility surgery. I teach these techniques on the BAUS FRCS(Urol) course, for the British Fertility Society and the RCOG, and internationally through the AGOUR course.