Varicocele Surgery: Everything You Need to Know

A varicocelectomy is a surgery done to treat a varicocele, a condition in which veins inside the scrotum (called the pampiniform plexus) become abnormally enlarged. Surgery is generally performed when the swelling of the veins causes chronic pain or male infertility. Although effective in relieving testicular pain, there remains considerable debate as to how effective varicocele surgery is in restoring male fertility.

What Is Varicocele Surgery?

Varicocele surgery, also known as varicocelectomy, describes three different surgical techniques that are typically performed on an outpatient basis. Both men and boys may be candidates for treatment.

Each type of surgery aims to restore normal blood flow to the testicle by blocking or cutting off these enlarged veins.  By restoring normal blood flow the environment around the testicle also becomes more conducive to testosterone and hormone production. The surgical options include:

• Microsurgical varicocelectomy: An open surgery that approaches the obstruction through an incision in the groin. The blood flow is redirected when the abnormal veins are clamped or tied off.
• Laparoscopic varicocelectomy: A laparoscopic procedure similar to microsurgical varicocelectomy that accesses the obstruction through one or several tiny incisions in the abdomen.

Percutaneous embolization: A minimally invasive procedure in which a narrow tube is fed through a vein in the neck or groin to the location of the testicular veins inside the abdomen. Using either chemicals or tiny metal coils, the veins are blocked off so that blood flow can be diverted to normal veins.

Microsurgical varicocelectomy through a subinguinal incision (lower portion of the groin) is known to have the best outcomes and is therefore the procedure of choice in treating symptomatic varicoceles. The surgeries are done by urologists and the percutaneous embolization is done by interventional radiologists.

Contraindications

There are few absolute contraindications to varicocele surgery other than those associated with surgery in general (such as a current infection, adverse anesthesia reactions, or severe malnutrition).

Not every varicocele requires surgery. Most low grade varicoceles will have no symptoms or cause issues with fertility or hormones levels.  Research shows that repairing higher grade varicoceles has more benefits for the patient. 

A 2014 committee opinion issued by the American Society for Reproductive Medicine advises against surgery in men with subclinical low grade varicocele (meaning varicocele seen on ultrasound but without overt symptoms) or those with symptoms but normal sperm counts. In cases like these, there is no clear evidence that surgery can improve sperm quality or quantity.

Similarly, men with severe bilateral varicocele (meaning varicocele in both testicles) are advised against embolization due to significantly higher failure rates.

Potential Risks

As with all surgeries, varicocele surgery carries a risk of injury and complications. The most common include:

• Hydroceles (the build-up of fluid around the testicles)
• Post-operative infection
• Vascular perforation
• Intestinal injury (mainly with laparoscopic varicocelectomy)
• Scrotal numbness (caused by nerve injury)
• Thrombophlebitis (the formation of a blood clot in a vein, if in a surface vein it is superficial thrombophlebitis)
• Varicocele recurrence

Purpose

Varicocele is a common condition affecting 15% to 20% of all males and 40% of men with infertility. It can cause pain and lead to azoospermia (the absence of motile sperm) and testicular atrophy (shrinkage).

Although the cause of varicocele is not entirely clear, it is believed that the size or geometry of the veins servicing the testicles are simply inadequate in some men, likely from birth. It may also be due to the failure of the within the pampiniform plexus that are meant to prevent the backflow of blood.

The problem with varicocele is that the pampiniform plexus function as the temperature regulator of the testicles, keeping them 5 degrees lower than the rest of the body. When the veins become blocked or obstructed, the backflow of blood causes the temperature to rise, lowering sperm production and sperm count.

Varicocele tends to affect the left testicle more than the right due to the direction of blood flow through the scrotum. Bilateral varicocele is extremely rare but can occur.

Chronic Pain

Not all varicoceles require treatment. Surgery may be considered if a varicocele is causing chronic pain and conservative measures (such as anti-inflammatory drugs, scrotal support, and the limitations of activity) fail to provide relief.

If surgery is indicated, the healthcare provider will perform tests to rule out other possible causes and characterize the nature of the pain. The investigation may involve:

• Physical examination
• Urinalysis
• Urine culture
• Scrotal ultrasound
• Abdominal ultrasound or CT scan

If varicocele compounded with testicular pain occurs in men who have undergone a vasectomy or have been treated for inguinal hernia, or undergone other procedures in the groin or testicle, the healthcare provider may opt to perform a spermatic cord block (involving the injection of anesthesia into the cord that houses the pampiniform plexus). If there is improvement in pain then microsurgical cord denervation and varicocelectomy may be pursued instead of varicocele surgery alone to permanently block pain signals.

Male Infertility

The treatment of male infertility with varicocele surgery remains controversial. Depending on the surgical approach, the benefits of treatment don't always correspond with improvements in pregnancy rates.

Due to these limitations, the ASRM endorses the use of varicocele surgery when most or all of the following conditions are met:

• A couple has tried and failed to get pregnant.
• Varicocele is detected on physical examination.
• The female partner has normal fertility or potentially treatable infertility.
• The male partner has abnormal semen parameters.
• The time to conception is not a concern (such as with younger couples who may have more time to conceive than older couples).

The use of varicocele surgery in men with non-obstructive or subclinical varicocele is the subject of rampant debate. Although studies have yet to offer consistent findings, a 2016 review in Fertility and Sterility suggests that it may be beneficial in men who decide to pursue in vitro fertilization (IVF) after surgery.

Pediatrics

The benefits of varicocele surgery in boys is not as clear as they are in men. Though the onset of symptoms is often be detected in early adolescence, there is no guarantee that preemptive treatment can sidestep future infertility.

Varicocele surgery may be pursued in boys with the following triad of conditions:

• Chronic testicle pain
• Abnormal semen parameters
• Progressive growth in testicle size (with a greater than 20% difference between testicles)

While some surgeons will treat very large varicoceles in boys despite an absence of pain or sperm abnormalities, the practice is generally discouraged.

How to Prepare

If varicocele surgery is recommended, you will meet with either a urologist qualified to perform a varicocelectomy or an interventional radiologist trained to perform percutaneous embolization. The specialist will walk you through the procedure and tell you what you need to do before and after surgery.

Location

Varicocele surgery is performed in the operating room of a hospital or in a specialized surgical center. The surgical tools vary by the procedure and by surgeon preference and experience. Among them:

• Microsurgical varicocelectomy is performed with traditional surgical tools and specialized microsurgical equipment, including a stereoscopic microscope (20X resolution) or Da-Vinci robotic platform and microvascular instruments.
• Laparoscopic surgery is performed with narrow surgical equipment and a fiberoptic scope called a laparoscope.
• Percutaneous embolization is a guided procedure involving an endovenous catheter and live X-ray images viewed on a video monitor.

What to Wear

You will need to change into a hospital gown for varicocele surgery, so wear something comfortable that you can easily get out of and back into. Leave jewelry and other valuables at home.

You should also be prepared to remove eyeglasses, dentures, hearing aids, hairpieces, and lip or tongue piercings before surgery, particularly when undergoing general anesthesia.

Food and Drink

If undergoing general anesthesia, regional anesthesia, or a form of intravenous sedation known as monitored anesthesia care (MAC), you will need a period of fasting to avoid pulmonary aspiration and choking.

Healthcare providers will usually advise you to stop eating at midnight the night before the procedure. In the morning, you can take any medications your practitioner approves of with a sip of water. Within four hours of the surgery, nothing should be taken by mouth, including gum or ice chips.

Fasting may not be required if only local anesthesia is used. Even so, double-check with the surgeon as MAC is often used with local anesthesia to induce "twilight sleep." In such cases, fasting is needed.

Medications

Certain medications are commonly stopped prior to any surgical procedure. These include medications that promote bleeding, impair blood clotting, or impede healing. The most common of these include:

• Anticoagulants: Blood thinners like Coumadin (warfarin) and anti-platelet drugs like Plavix (clopidogrel) are typically stopped 48 hours before surgery.
• Nonsteroidal anti-inflammatory drugs (NSAIDs): Over-the-counter and prescription painkillers like Advil (ibuprofen), Aleve (naproxen), aspirin, and Celebrex (celecoxib) are typically stopped four days before surgery.
• Diabetes medications: Certain anti-diabetes drugs like Glucophage (metformin) and insulin may also need to be stopped on the day of surgery.

What to Bring

On the day of surgery, you will need to bring your driver's license, identity card, or other forms of government photo ID. Also, bring your insurance card and an approved form of payment if coinsurance or copay costs are required upfront.

You will also need a friend or family member to drive you home. Even if the procedure is performed under local anesthesia, you need to avoid any unnecessary movements for the first one or two days.

Most surgeons will advise against driving or operating heavy machinery for the first 24 hours. This is doubly true if you have undergone intravenous sedation or general anesthesia.

What to Expect on the Day of Surgery

Try to arrive at least 30 minutes before your appointment so that you have plenty of time to check-in, fill out the necessary forms, and sort out any insurance issues.

Before Surgery

Once you have signed in, you are led by a member of the surgical team to a pre-operative room and provided a hospital gown to change into. The pre-operative preparations can vary but typically involve:

• Vital signs: Including blood pressure, temperature, and heart rate
• Blood tests: Including a comprehensive metabolic panel (CMP) and arterial blood gasses (ABG)
• Electrocardiogram (ECG): Involving the placement of probes on your chest to monitor heart rate and electrical activity during surgery
• Pulse oximetry: Involving the placement of a probe on your finger to monitor blood oxygen levels
• Intravenous (IV) line: Involving the insertion of a tube into a vein in your arm to deliver anesthesia, sedation, medications, and fluids

The treatment area will also be shaved and washed with an antimicrobial cleanser prior to surgery.

If general anesthesia, regional anesthesia, or MAC is to be used, you will meet with an anesthesiologist beforehand to review your medical information, including any drug allergies or adverse reactions to anesthesia you may have had in the past.

During Surgery

Once you prepped for surgery, you are wheeled into the operating room and placed in a supine (upward-facing) position on the operating table.

The choice of anesthesia can vary by procedure. Microscopic or laparoscopic surgery may involve general anesthesia or a regional block (such as spinal anesthesia). Percutaneous embolization is usually performed under local anesthesia with or without MAC.

The choice of surgery also varies by the goals of treatment. Among them:

• Microscopic varicocelectomy is considered the treatment of choice for male infertility.
• Laparoscopic varicocelectomy is better suited for adolescents but can also be used to treat varicocele pain or infertility in men.
• Percutaneous embolization is less commonly used to treat infertility but may be ideal for men with varicocele pain who either cannot tolerate anesthesia or want to avoid more invasive procedures.

While the aims of the various procedures are similar—to redirect blood flow to reduce venous swelling—the means are very different.

Microscopic Varicocelectomy

With microscopic varicocelectomy, the urologist will access the pampiniform plexus via a 3- to 5-centimeter incision over the inguinal canal which houses the spermatic cord. The cord is elevated and opened to expose the spermatic veins.

Using a microscope and specialized surgical tools, the urologist will apply tiny clamps or sutures to ligate (close off) the vessel. Once the blood flow has been amply diverted, the surgeon will close and suture the wound.

Laparoscopic Varicocelectomy

For laparoscopic varicocelectomy, three "keyhole" incisions of between 1 and 1.5 centimeters are made in the lower abdomen—one to accommodate the laparoscope and the others to accommodate forceps, retractors, and other surgical equipment.

Prior to ligation, the abdomen is slightly inflated with carbon dioxide to provide better access to the inguinal canal. Once the abnormal veins are exposed and ligated (again with clamps or sutures), the wound is stitched and reinforced with tissue glue or small adhesive strips.

Percutaneous Embolization

Prior to the insertion of the catheter (either through the jugular vein of the neck or femoral vein of the leg), a contrast dye is injected into the bloodstream to help visualize the procedure via a real-time X-ray technique known as fluoroscopy.

Using video guidance, the catheter is fed to the treatment site. But, rather than ligating the vessels, the veins are either sclerosed (scarred) with a chemical agent or occluded (blocked) with minute metal coils. Once the blood flow has been diverted, the catheter is removed and the tiny incision is sealed with adhesive strips.

After the Surgery

After surgery, you are wheeled to a recovery room until you are fully awake and your vital signs have returned to normal. Grogginess, fatigue, and nausea are not uncommon There may also be pain in and around the incision site.

Let the attending nurse know if any of these symptoms are severe. A non-NSAID pain reliever like Tylenol (acetaminophen) or anti-nausea drugs like Zofran (ondansetron) can be prescribed if needed.

Once you are steady enough to walk, you can change back into your clothes and leave. Wound care instructions will be provided.

Recovery

Recovery from varicocele surgery can take anywhere from one to two days for percutaneous embolization, two to four weeks for laparoscopic surgery, and three to six weeks for open surgery.

Even so, most people be able to return to work within a few days. If your job involves heavy lifting, your healthcare provider may advise that you wait longer.

Healing

When returning home from surgery, lie down as much as you can for the first 24 hours. In addition to Tylenol, you can treat local pain and swelling with a cold compress. Bruising is also common.

Avoid getting the wound wet, and change the dressing regularly as per your healthcare provider's instructions. When showering, try not to soak the wound and pat (rather than rub) the skin with a soft towel. When changing the dressing, check for any signs of infection and call your practitioner immediately if symptoms develop.

Coping With Recovery

It is important to avoid lifting anything heavier than 10 pounds for the first week. Strenuous physical activity (including cycling or jogging) should also be avoided for around three weeks or until your healthcare providers give you the OK. Overexerting yourself can dislodge coils or clamps and promote the formation of clots and thrombophlebitis.

With that said, regular walking is advised to improve blood circulation and avoid constipation. Start slowly, increasing the speed and duration gradually as you begin to heal.

Most men can return to normal sexual activity one to two weeks after percutaneous embolization and between four and six weeks after varicocelectomy. Be sure to get your healthcare provider's OK before engaging in sexual activity. Premature intercourse can lead to the rupture of vessels, the recurrence of varicocele, and other complications.

Follow-Up Care

Your healthcare provider will schedule one or more follow-ups to see how well you are healing and check for any post-operative problems. Additional ultrasounds and physical exams may be involved.

If the aim of surgery was to restore fertility, your practitioner will wait three to six months before performing a sperm analysis. This is because spermatogenesis (the development of new sperm cells) takes roughly 72 days, and testing any earlier may lead to false results.

Outlook

Varicocele surgery is generally considered safe in men and boys, offering high levels of pain relief with relatively few side effects.

When used appropriately in men with infertility, varicocele surgery can triple the likelihood of conception from 13.9% to 32.9%. Even if the sperm count is not fully restored, varicocelectomy can greatly improve the efficacy of IVF and other forms of assisted fertility.