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How is a varicocele fixed?

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The microscopic sub-inguinal approach

The gold standard for fixing a varicocele (varicocelectomy) is the microscopic sub-inguinal approach. 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 delicate part of the operation is performed 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 about 1 - 1 " is made in the numb 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 sleeps through the procedure completely. The anesthesiologist can administer as much sedatives and an appropriate dosage of pain medication. There may be some discomfort, swelling and bruises for several days afterwards. Almost all men go back to work after 2-3 days. Studies have shown that after this type of varicocelectomy men use less pain medication than most people use after a typical dental procedure.

The inguinal varicocelectomy

An alternate method of fixing a varicocele is called an Inguinal Varicocelectomy. Although most infertility specialists use the microscopic sub-inguinal approach, this is the operation, which is performed in most cases by general urologist. In this case the incision is made just like a hernia incision. The abdominal muscles that cover the varicocele are cut at the point where they leave the abdomen. The cord is exposed. Then using the naked eye or magnifying lenses worn as glasses, the veins are cut.

The incision is longer than a sub-inguinal incision. It also is higher making the scar visible above the pubic hair. Because the abdominal muscles are cut, the postoperative pain is significantly increased and the healing process takes longer. Also, if the microscope is not used, it is harder to see and spare the arteries and lymphatics or to see and sever all of the necessary veins. Thus, the arteries bringing blood to the testicle are also usually not spared and there is a higher incidence of failure (5-15%) and hydrocele formation (3-30%).

The retro-peritoneal approach

The third method that may be used involves an even higher incision to sever the veins further up (the retro-peritoneal approach). This leaves a more obvious and unusual scar. It also involves cutting abdominal muscles, which increases postoperative pain and recovery. The artery is not preserved. It has a failure rate of 15-25% and a risk of hydrocele formation of approximately 7%.

Repaired laparoscopically

Finally a varicocele may be repaired laparoscopically, but the patient must be placed under a general anesthetic. A catheter (tube) is placed into the bladder in order to allow the urine to drain out so that the bladder does not get in the way of the procedure. A small incision is made under the umbilicus (bellybutton) and the abdomen is filled with air. After this is done, the needle is then replaced with a larger bored trocar (sharp tool) and a sheath to be placed so that the camera can be placed in the abdomen. Under vision, an additional two incisions are made in the abdominal wall and two working instruments placed into the abdomen. The bundle carrying the vein and arteries are identified. At this point, this bundle is transected. Care is taken not to transect the vas accidentally.

This procedure is not generally recommended because it requires that the patient be under a general anesthesia, that a Foley catheter be inserted and that, instead of an incision outside the abdominal wall, three incisions in the abdominal wall must be made. There are also inherent risks with laparoscopy which are greater than that of the small open procedure done with microscopic varicocelectomy.


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