What is Varicocele?
It is an abnormal enlargement of the group of veins located in the scrotum. This plexus of veins drains the testicles. The testicular blood vessels originate in the abdomen and travel down through the inguinal canal within the spermatic cord on their way to the testis. Upward flow of blood in the veins is ensured by small one-way valves that prevent backflow. Defective valves, or compression of the vein by a nearby structure, can cause dilatation of the testicular veins near the testis, leading to the formation of a varicocele. Collection of blood within the veins results in increased temperature within the testes causing decrease in efficiency of the sperms produced. This results in infertility or subfertility in males. The sperm count and motility is reduced and their shape is also altered. It usually occurs in the left testes, but may be present on both sides.
Varicocelectomy is by far the most commonly performed operation for the treatment of male infertility. Varicocele occurs when the network of veins that leave the testis (pampiniform plexus) become elongated and enlarged. The valves within the pampiniform plexus when they work properly only allow the blood to flow away from the testicle - if there is something wrong with them, blood builds up. Approximately 15% of men have a varicocele. A varicocele develops over time. The network of veins often appear visibly blue through the scrotum and feel like "a bag of worms". When the patient lies down symptoms are less evident. When both the testicles are affected it is called bilateral varicocele else unilateral vericocele if only the left or right one is affected. Varicose veins people get in their legs are similar to a varicocele.
It is one of the most common causes of male infertility. Varicoceles can lower a man's sperm count and undermine the quality of his sperm. In some cases, the testicles may shrink. The incidence of varicocele, investigated for infertility is approximately 40%. In the last few years, with the introduction of minimal invasive techniques, varicocelectomy has been performed successfully.
Laparoscopic varicocelectomy is a safe, effective and minimally invasive technique. In addition to its better cosmetic results and its advantage in case of bilateral disease, it allows an excellent exposure and control of the affected vessel.
Cause of Varicocele
The idiopathic varicocele occurs when the valves within the veins along the spermatic cord do not work properly. This process is also known as varicose veins, which are common in the legs. This results in backflow of blood into the pampiniform plexus and causes increased pressures, which on rare occasion can lead to permanent damage to the testicular tissue due to disruption of normal supply of oxygenated blood via the testicular artery.
A majority of idiopathic varicoceles occur on the left side, apparently because the left testicular vein connects to the renal vein (and does so at a 90-degree angle), while the right testicular vein drains at less than 90-degrees directly into the significantly larger inferior vena cava. Isolated right sided varicoceles are rare.
A secondary varicocele is due to compression of the venous drainage of the testicle. A pelvic or abdominal malignancy is a definite concern when a right-sided varicocele is newly diagnosed in a patient older than 40 years of age.
Signs and symptoms of Varicoceles
- Reduced testicular function leading to Infertility.
- Reduced testosterone levels in body causing hypogonadism.
- Testicular discomfort .
- Testicular atrophy.
Laparoscopic Treatment for Varicocele
There are several treatment options for varicocele, depending on symptoms and seriousness of the condition. If the varicocele is not causing any symptoms of pain and infertility is not an issue, no treatment is warranted. In cases of mild discomfort, the condition usually can be managed by wearing an athletic supporter or snug-fitting underwear during strenuous activity or exercise.
Treatment for varicocele is indicated in the following conditions:
A) Adolescent (age 12-18 years) with large varicocele and evidence of decreased testicular size. The size of testes on the side where varicocele is present is smaller than the opposite side. Treatment is advised although the varicocele is not causing pain or other symptoms as it would improve function of the affected testes.
B) Any person with varicocele induced testicular pain. Pain is usually described as 'dragging' and worse with prolonged exercise or standing.
C) Varicocele that is men who are subfertile or infertile. Correction of varicocele would result in 50%-70% improvement in men with low or poor sperm count.
The goal of treatment of the varicocele is to obstruct the refluxing venous drainage to the testis while maintainingarterial inflow and lymphatic drainage. Varicocelectomy is the most common surgical procedure for infertility in males.
There are several treatment options for varicocele, depending on symptoms and seriousness of the condition. If the varicocele is not causing any symptoms of pain and infertility is not an issue, no treatment is warranted. In cases of mild discomfort, the condition usually can be managed by wearing an athletic supporter or snug-fitting underwear during strenuous activity or exercise.
Laparoscopic Varicocelectomy : Under general anesthesia, three small incisions (5mm each) are made in the abdomen. Varicoceles on the right or left or both can be approached. A thin tube with a camera at one end is inserted through one of the incisions. This is called as the laparoscope. The abnormal veins are identified. Small instruments are inserted through the other incisions and the abnormal veins are clipped and divided. The arterial and lymphatic supply is untouched, only the venous flow to the scrotum and testes is rerouted to normal veins.
Microsurgical or Open technique Varicocelectomy : This is the trans-inguinal approach where a small incision is made over the groin. The distended varicocele veins are identified with the aid of an operative microscope and surgically ligated and divided. The use of an operative microscope, which offers up to 6 X magnification, is necessary to identify clearly the dilated veins and avoiding injury to artery and lymphatics. Blood flow is re-routed to normal veins.
Embolization of Varicocele : Under mild sedation and local anesthesia, a small puncture is made at the groin skin. A fine catheter is passed into the underlying vein and followed into the testicular vein
An x-ray dye is injected to map out where the problem is and where to embolize or block. By using coils or balloons, blood flow to the varicosed veins is blocked and is re-directed to other healthy pathways. The entire procedure can be completed within 2 hours and requires the expertise of interventional vascular surgeons.
Advantages of Laparoscopic Varicocele Surgery over other techniques
Advantages of Laparoscopic Varicocele Surgery over other techniques include:
1.Accurate identification of all the veins and avoiding injury to the artery and lymphatic vessels as the surgery is done under magnification during laparoscopy.
2. Varicoceles from both sides of the body can be corrected at the same time without needs for further surgical incisions.
3. Rapid recovery from surgery with minimal pain as the small 5mm wounds causes minimal trauma to tissue. Surgery is completed within 45 minutes, even in the case of varicoceles occurring on both sides ie with bilateral varicoceles. Patient can be discharged a few hours after surgery and return to work is within 48 to 72 hours.
4. Accurate identification of all the veins and avoiding injury to the artery and lymphatic vessels as the surgery is done under magnification during laparoscopy
5. Varicoceles from both sides of the body can be corrected at the same time without needs for further surgical incisions
6. Rapid recovery from surgery with minimal pain as the small 5mm wounds causes minimal trauma to tissue
7. Surgery is completed within 45 minutes, even in the case of varicoceles occurring on both sides. Patient can be discharged a few hours after surgery and return to work is within 48 to 72 hours.
8. Complications are rare. Injury to abdominal organs can occur in less than 1% of cases. Testicular artery injury (1%) and hydrocele formation (1-5%) is not common. Improvement in sperm counts can be expected in 50%-70% of patients within 3 months. Overall pregnancy rates are between 10-20%.
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