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  • Varicolelectomy (Microsurgical)

    About the Authors

    Raymond Costabile, MD COL U.S.A (ret) assumed the position as the Jay Y. Gillenwater Professor of Urology and Vice Chairman at the University of Virginia in July 2004 following his retirement from the U.S. Army after 28 years of service. His principle clinical and research interests are in the areas of male infertility, male and female sexual health and urologic oncology. He also serves as Senior Associate Dean for Clinical Strategy in the School of Medicine.

    Dr. Costabile was previously assigned as Chief of the Urology Service and Urology Residency Program Director at Madigan Army Medical Center in Tacoma Washington.  He assumed the position in May 1999 after 10 years at Walter Reed Army Medical Center. During his tenure he was also an Associate Professor of Surgery at the Uniformed Services University in Bethesda, MD. From December 2001 until September 2003, Dr. Costabile commanded the 47th Combat Support Hospital to include its deployment to Iraq/Kuwait where it was the largest coalition military hospital deployed during OPERATION IRAQI FREEDOM. Under Dr. Costabile’s command, the 47th CSH was the principle combat hospital, responsible for caring for over 92% of all battle casualties during the initial nine months of the conflict.

    Dr. Costabile attended Georgetown University, Washington, DC, where he received a Bachelor of Science degree in Biology/Theology.  After receiving his medical degree from Georgetown University School of Medicine, Dr. Costabile completed his surgical internship and urology residency at Walter Reed Army Medical center, Washington, DC.  He was then afforded a fellowship in impotence and infertility from 1991-1993 at the University of Virginia Health Sciences Center, Charlottesville, Virginia.

    Dr. Cara Cimmino on Urologybook.com

    Dr. Cara Cimmino

    Cara B. Cimmino MD is currently practicing in the Urology Department at Piedmont Hospital in Atlanta, Georgia.  She attended the University of Michigan, Ann Arbor, where she received her Bachelor of Arts degree in Psychology in 2001.  She remained in Ann Arbor to attend the University of Michigan Medical School from 2002-2006.  After medical school, Dr. Cimmino completed a six year urology residency at Lahey Clinic Medical Center, Burlington, MA in 2012.  She then spent one year at the University of Virginia in Charlottesville completing an additional fellowship in Male Infertility and Andrology.  Special interests include: male infertility, vasectomy, vasectomy reversal, male and female sexual medicine, and andrology.

    Introduction

    A varicocele is an abnormal dilation of veins in the pampiniform plexus of the spermatic cord.  Approximately 15% of men in the general population have varicoceles, but this number increases to 40% in subfertile men (1).  Diagnosis is made on physical exam in the supine and standing position, and severity graded on a scale of I-III.  Grade I varicoceles are those that are not seen on visual inspection, and are palpated only during Valsalva maneuver.  Grade II varicoceles are also not seen grossly, but are palpated both at rest, and with Valsalva.  Finally Grade III varicoceles are those dilated veins that can be observed upon visual inspection of the scrotum.  Though ultrasound can be helpful in confirming the presence of varicoceles in those patients who are difficult to examine secondary to body habitus or prior surgery, varicoceles diagnosed on ultrasound alone, but not clinically are termed “subclinical,” and do not require intervention.  Varicoceles can be asymptomatic, or can lead to testicular pain, testicular atrophy, and infertility as demonstrated by an abnormal semen analysis.

    Indications for varicocelectomy:

    1. Symptomatic, large varicocele causing testicular pain.
    2. Palpable or visible varicocele with abnormal semen analysis in man desiring fertility.
    3. Palpable varicocele with ipsilateral testicular atrophy defined as size less than 20% of the contralateral testicle.
    4. Bilateral varicoceles with testicular atrophy.

     

    Relative indications include psychological concern regarding future fertility or cosmetic displeasure with varicoceles.  This procedure is not indicated in asymptomatic men with normal semen analyses or a subclinical (nonpalpable) varicocele.

    Surgical Technique

    Special equipment and Instruments:

    Operating microscope with variable magnification from 6-32 power (diploscope allowing identical optical field for surgeon and assistant preferred), toothed and smooth tissue microforceps, Jake clamp, needletip bovie electrocautery, 5-0 silk ties, microirrigator made from a 10-mL syringe and 24-gauge angiocatheter with papaverine irrigation available, and 1 inch penrose drain.  Some surgeons utilize micro Doppler probe for identification of the testicular artery.

    Patient Positioning and Preparation:

    Microsurgical varicocelectomy can be performed under local, regional, or general anesthesia.  These authors prefer general anesthesia in order to limit patient movement under the operating microscope.  Patient is positioned in supine.  Correct patient positioning is essential to allow the surgeon to sit or stand comfortably while supporting the ulnar portion of hands, wrists, and forearms to minimize tremor.  The operating microscope should be positioned at the head or foot of the operating table with an overhanging suspensory bar.  Microscope foot pedals and bipolar pedal for operative cautery should be placed in a comfortably accessible position for the surgeon.

    The inguinal region is clipped free of hair.  Standard alcohol-based or povidone-iodine solutions should be utilized to sterilize the scrotum and inguinal region.

    Procedure

    Utilizing an index finger tracking up from the scrotum to the level of the external inguinal ring is an excellent tool to assist with marking appropriate location for incision.  Once marked, a 2 cm incision is made sharply in the skin.  The incision is then carried down through the subcutaneous tissue and Camper’s fascia with needletip electrocautery.  Army navy retractors are introduced into the incision utilized to assist in identification of Scarpa’s fascia, which is then sharply entered with metzenbaum scissors and gently spread to reveal the spermatic cord.

    Gentle traction on the ipsilateral testicle can assist with identification of the spermatic cord.  Once identified, the cord is grasped through the incision with an Allis clamp.  A Jake clamp is carefully manipulated underneath the cord, and subsequently a one inch penrose drain is grasped and passed underneath these structures, effectively delivering the spermatic cord into the operative field.  Careful inspection is carried out to ensure all cord structures have been captured above the penrose drain.  The Jake clamp can is then passed underneath the penrose drain for added stability of the surgical field.

    At this point the operating microscope is brought into the field.  The external and internal spermatic fascia are then dissected carefully with microforceps and incised with needletip electrocautery to expose the cord structures lying within.  Care is taken to identify the vas deferens, and preserve this structure.  The large dilated veins are identified visually with gentle dissection, and microforceps carefully passed underneath once isolated.  5-0 silk ties are then passed underneath the varicosities, and   veins are then suture ligated and divided.  Alternatively surgical clips can be applied to the vein, rather than silk ties prior to division.

    The spermatic cord is inspected prior to suture ligating each vein to identify the spermatic artery pulsation.  Papaverine irrigation through an angiocath tipped syringe can be utilized as needed to identify the pulsation of the artery if visualization is difficult.  Alternatively, some surgeons choose to aid visual pulsatile inspection with a micro Doppler probe to audibly identify arterial flow through the spermatic artery, and confirm its protection.

    Dilated veins are continually identified, suture ligated, and divided with care to preserve the testicular artery.  An effort is made to identify and preserve large lymphatics, as well as the vas deferens, and cremasteric arteries.  Once all large vessels have been divided, the cord is inspected again to identify the intact spermatic artery.  Gentle pressure on the testicle can identify any residual dilated veins.

    Once the procedure is complete and hemostasis is achieved, the operating microscope can be removed from the field.  The penrose drain and Kelly clamp are removed and the cord is returned to the incision.  Gentle traction on the testicle is applied to return the testicle to the dependent portion of the scrotum.

    Scarpa’s fascia is closed with 3-0 absorbable suture.  Skin is closed with 4-0 monocryl subcuticular suture.  Local anesthetic is injected into the wound prior to completion of closure, and steri-strips and dry sterile dressing are applied to the wound.

    Of note, some surgeons choose to deliver the testicle into the field prior to introducing the operating microscope in order to identify and additionally ligate the gubernacular veins.  This is not the practice of these authors.

    Postoperative Care

    Microsurgical varicocelectomy is an outpatient procedure, and patients are discharged after recovery from anesthesia.  Narcotic pain medication is prescribed for the immediate postoperative period.  Patients are advised to decrease physical activity and heavy lifting for 1-2 weeks.  Showering may occur on postoperative day one, and bathing should be avoided for 1 weeks time.

    Potential Complications

    • Postoperative recurrence:  This complication typically results from incomplete ligation of collateral venous channels. The recurrence rate associated with microsurgery is less than 2%, and can be corrected by a repeat surgical procedure or by radiographic embolization.
    • Hydrocele:  Incidence off this complication is reportedly 0%-0.69% with microscopic subinguinal varicocelectomy as described here.  It is believed to be caused by ligation of lymphatic channels, thus the importance of identifying and sparing such structures during dissection.
    • Testicular atrophy:  This is the rare result of injury to the testicular artery during dissection. The incidence is very low owing to the collateral arterial supply provided by the vasal and external spermatic arteries.  The incidence is slightly higher in repeat varicocelectomies due to the previously compromised arterial supply.
    • Bleeding and infection:  Rarely reported, <1%. (2, 3)

    Outcomes

    Overall, varicocelectomy is associated with an improvement in sperm parameters and with pregnancy rates ranging from 40% to 60% depending on maternal factors (4). In a meta-analysis that included only randomized studies of clinical varicoceles with abnormal semen parameters, the data support the practice of varicocelectomy for male infertility (5).

    References

    1. Fretz PC, Sandlow JI. Varicocele: current concepts in pathophysiology, diagnosis, and treatment. Urol Clin North Am 2002;29:921-937.
    2. Goldstein M, Gilbert BR, Dicker AP. Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique. J Urol 1992;148:1808-1811.
    3. Cayan S, Kadioglu TC, Tefekli A, et al. Comparison of results and complications of high ligation surgery and microsurgical high inguinal varicocelectomy in the treatment of varicocele. Urology 2000;55(5):750-754.
    4. Schlesinger MH, Wilets IF, Nagler HM. Treatment outcome after varicocelectomy: a critical analysis. Urol Clin North Am 1994;21:517-529.
    5. Evers JL, Collins JA. Assessment of efficacy of varicocele repair for male subfertility: a systematic review. Lancet 2003;361:1849-1852.

     

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