How does varicocele surgery work? How is the operation to remove varicocele performed and contraindications for it. Possible complications after surgery

Are you here: Nervous

The male body is susceptible to many diseases, including varicocele. Otherwise, this is called varicose veins (dilation of the veins) of the testicles and is formed when there is insufficient or complete absence of blood flow in the scrotum due to enlarged veins in the pampiniform plexus of the spermatic cord.

The disease was first described by Celsius in Art. BC. But the connection between testicular varicose veins and their dysfunction was proven only in the 19th century. The danger of the disease lies in the development of infertility.

When is surgery necessary?

Surgery for varicocele is prescribed for a man at any age in order to preserve the ability to fertilize. It is performed in the following cases:

bad spermogram;
testicular atrophy;
changes in testicle size;
pain in the groin.

With such symptoms, there is only one way out - surgical intervention, during which the patient ligates the veins passing near the spermatic cord and forces the blood to flow in a different direction. There are many types of operations for the treatment of varicocele and each of them has its own characteristics. The patient is pre-injected with anesthesia. The operation lasts about an hour.

Organizational aspects

10 days before surgery, the following studies are expected to begin:

general urine examination;
if necessary, it is recommended to do an ultrasound of the scrotum or a contrast Doppler ultrasound, during which a complete picture of the situation is obtained;
blood tests, in particular for the Rh factor, sugar content, coagulability, and general indicators;
X-rays of light;
testing for AIDS, hepatitis C and B

On the day of the operation, you need to completely stop drinking and eating, take a shower and carefully shave the groin area. If you are taking medications for chronic diseases (diabetes, hypertension, bronchitis, etc.), drug therapy is agreed with your doctor.

How is varicocele surgery performed?

There are many types of operations for treatment: laparoscopy, traditional surgery, according to Ivanissevich, carried out directly with direct contact, microsurgical methods and innovative developments.

Operation Palomo

performed by the Palomo method, involves incision of the testicular vein affected by varicose veins. It is performed above the inguinal canal. The surgeon immediately gains access to the testicular vein, ligates it and removes it. This approach will reduce the risk of injury to the neurovascular bundle. The operation can be performed under either local or general anesthesia. After the operation and suturing, a sterile bandage is fixed on the wound. The man can go home the very next day, and the stitches are removed within 8-9 days.

Varicocele: Ivanissevich operation

The most common method of treating varicocele in men is the Ivanissevich operation.

It consists of ligating the mouth of the testicular vein.
In this case, it is reached directly through the groin area, making a longitudinal oblique incision, behind which the venous inguinal plexus is located.
The mouth of the testicular vein is first ligated and then cut.
After the operation, the wound is sutured, connecting each layer, and then skin sutures are applied.

Before surgery, local anesthesia is administered. In some cases, general anesthesia is acceptable. However, it is worth remembering that Ivanissevich’s operation for varicocele can lead to consequences: damage to the femoral artery and other formations located in the neurovascular bundle of the inguinal canal.

Varicocele: endoscopic surgery

This method of getting rid of the problem is better than the previous one, since it is gentle (no incisions are made in the groin). In this case, all the principles of laparoscopy are used.

For varicocele, laparoscopic surgery involves making 3 small incisions (1 cm) in the abdominal cavity, through which an endoscope or laparoscope with a camera and miniature instruments is inserted. By moving the instrument during the operation, they enter the mouth of the testicular vein, where, using a titanium clip, clipping and subsequent cutting of the vein are performed.

According to reviews from doctors, this technology is good for its minimal tissue damage, rapid healing of scars and restoration of the body.

The disadvantage of laparoscopy is the inability to use local anesthesia, since the abdominal cavity is involved. In case of damage to both testicular veins (varicocele on the left and right), laparoscopic surgery for varicocele is the best option.

How does endovascular embolization surgery work?

This operation is performed under visual control.

To do this, an intravascular endoscope 2 mm thick is inserted through the femoral vein and advanced to the testicular vein.
Next, the course of the varicocele operation is as follows: the vein is examined using a radiopaque substance.
Then, a sclerosant is injected into its expanded part - a substance through which “gluing” (embolization) of the lumens of blood vessels occurs.
This method of treating the disease is carried out without anesthesia, is minimally invasive, takes less time, has virtually no consequences or relapses, and is well tolerated by the patient.

Operation Marmara

Microsurgical operation of varicocele using the Marmara method is also based on ligation of the testicular vein. The incision is made along the outer edge of the inguinal canal in the area located below the level of wearing underwear. It is there that the testicular vein is located under the skin. The length of the incision is maximum 2 cm. The advantage of the method is the almost complete absence of relapses and complications in the postoperative period.

Treatment with laser

Laser surgery for varicocele is a modern, less complicated technique that is performed without incisions in the groin.

The operation is performed using an intravascular endoscope.
The presence of a miniature camera allows you to quickly find the location of the affected vessel, which is then coagulated under the influence of a laser beam and is no longer involved in the general blood flow.
When treating varicocele, surgery using this method can be performed without anesthesia.

When surgery is not possible

Despite the good tolerance of the operation, there are also contraindications that do not allow surgical treatment. Thus, sclerotization is not carried out when:

Increased pressure in the veins located near the disease area.
The anastomases are large, which can result in sclerosant getting into healthy arteries and veins.
Situations when it is impossible to insert a probe into the veins due to their structure

You cannot perform an open operation in the following cases:

Active inflammatory processes.
Diseases in the stage of decompensation, when elimination of organ dysfunction is impossible without treatment (for example, with cirrhosis of the liver, diabetes).

Endoscopic surgery for varicocele is not prescribed for the above reasons, or if the client has undergone abdominal surgery in the past. In this case, the clinic is disrupted and the risk of doctor errors increases.

Recovery

Many men are interested in how long the recovery period lasts. It all depends on the characteristics of the body. It may take 2 weeks for complete recovery. To restore spermatogenesis, a man after surgery may be prescribed:

Dietary supplements based on zinc and selenium;
ointments containing antibiotics;
vitamin preparations;
hormonal medications;
Painkillers may also be needed.

After surgery, during the first two days you must follow the following recommendations:

move as little as possible and rest as much as possible;
do not wet the wound (if pain occurs, you can apply ice);
Be sure to wear a bandage (it helps hold the testicles in place).

In the first two weeks the following are strictly prohibited:

bath;
physical activity;
sex.

Complications

Surgery for varicocele may be accompanied by the following complications:

Neuralgic pain that occurs due to injury to nerve endings.
Relapse (reoccurring disease).
Hydrocele of the testicle as a result of injury to the lymphatic vessels.
Deep vein thrombosis due to hematoma in the puncture area or contrast injection.
Inflammatory processes.
Lymphatic edema is another consequence of surgery due to injury to the lymphatic vessels.
Reduction in testicular size. Caused by affecting the spermatic artery.
Damage to the ureter or intestines due to the inexperience of the doctor.

Varicocele is a dangerous disease that leads to serious consequences such as cancer. Self-medication will only make the situation worse. Therefore, at the first symptoms of heaviness or pain in the testicles, sexual dysfunction, swollen veins, you should immediately consult a doctor for advice.

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Diagnosis of varicocele

Feeling the scrotum
A mandatory procedure that allows you to determine the severity of varicocele. Ultrasound(ultrasonography). Ultrasound is always combined with Dopplerography (a technique that determines the quality of blood supply) of the renal vessels (arteries and veins) and the testicular vein.
The study is carried out with the patient standing (orthostasis) and lying down (clinostasis) with the measurement of the blood flow gradient in these positions.
During an ultrasound, it is necessary to perform Valsalva maneuver:

Enlargement (varicose veins) of the testicular vein in size when the body is in an upright position.
When the body is lying down, the vein collapses (reduces in size).

The testicular vein should not exceed 2 millimeters in diameter (normal). The speed of venous blood flow in the vein should not exceed 10 centimeters per second (normal). Absence of venous reflux (normal).

Ultrasound also allows you to determine the hemodynamic variant of varicocele, as well as identify renal venous hypertension (if any).

General urine analysis before and after physical activity (march test). A positive march test - the appearance of a small amount of red blood cells in the urine (microhematuria) and the presence of protein in the urine (proteinuria) indicates renal venous hypertension.
X-ray methods. X-ray methods include:
Antegrade phlebotesticulography or retrograde renal phlebography - these research methods are performed after preliminary injection of a contrast agent into the veins of the scrotum.
Hormonal profile study – includes the concentration of testosterone, estradiol, prolactin, FSH (follicle-stimulating hormone), LH (luteinizing hormone).
Semiological research(semen examination) - in most patients pathospermia is detected (a decrease in the number of motile forms of sperm and an increase in the number of pathological forms) of varying degrees.

Treatment of varicocele

Non-drug treatment: Conservative treatment of varicocele is not effective.

Drug treatment: Drug treatment is prescribed only after surgery to stimulate spermatogenesis. Most often, a complex of vitamins and biologically active food supplements (containing selenium and zinc) are prescribed. Sometimes hormonal drugs are prescribed (androgens, human chorionic gonadotropin), they are used under strict laboratory control.

Preparation for surgical treatment: involves taking tests before surgery (to exclude decompensation of any organ or organ system). The following tests are required:

General blood test (to determine the state of hematopoiesis)
Blood type and Rh factor (for blood transfusion if necessary)
Urinalysis (to check kidney function)
Biochemical blood test (glucose, creatinine, urea)
ECG (electrocardiogram) – to determine the work of the heart
Chest X-ray (to exclude lung pathology)

Surgical treatment
Currently, there are more than 120 types of surgical treatment for varicocele.
All operations can be divided into two groups:

Group I – operations in which the connection with the renal artery is preserved.
Group II – operations in which the communication with the renal artery is interrupted

Currently, microsurgical techniques are successfully and widely used in the treatment of varicocele. This made it possible to reduce the number of relapses (repeats) of the disease, as well as significantly reduce the risk of complications after surgery.

Microsurgical methods for treating varicocele
Laparoscopic clipping of the testicular vein
Laparoscopic varicoetomy is an endoscopic and minimally invasive method for the treatment of varicocele.


Indications for laparoscopic testicular vein clipping surgery	Advantages of the laparoscopic method over classical operations	Contraindications for laparoscopic testicular vein clipping
Varicocele 1, 2, 3 degrees	Possibility of vein clipping for bilateral lesions	Abdominal surgeries in the past.
Reno-testicular type of varicocele	Reduced risk of postoperative complications
Ileo-testicular type of varicocele	The length of hospital stay is reduced to 2-3 days
Mixed type varicocele	Almost complete absence of pain in the wound
	No pain when walking on the first day
	Good cosmetic effect
	Good sperm count after surgery

The operation is performed under general anesthesia (the patient is put under anesthesia). A trocar is inserted near the navel and the abdominal cavity is examined. Then the veins of the testicle are found, and the artery and lymphatic vessels are carefully separated from the veins. Then the veins are clipped (applying special clips) and the operation is completed.

Endovascular phlebosclerosis
The method consists of blocking the testicular vein with various substances or special devices.

Indications for the use of endovascular phlebosclerosis	Advantages of endovascular phleboskerosis	Contraindications for endovascular phlebosclerosis
Reno-testicular type varicocele	The operation is performed under local anesthesia (the patient is conscious)	Large reno-testicular collaterals, which can lead to drug entry into the systemic circulation
No renal vein stenosis	Hospital stay is reduced to 2 days	Renal venous hypertension
Absence of venous hypertension	Absence of surgical intervention as such (with this method there are no incisions)	Loose vein type
	This method allows you to avoid complications such as hydrocele.
	Possibility of re-occlusion of the vein in case of relapse of the disease

Endovascular obliteration (occlusion) of the testicular vein is performed in both adults and children. Various substances are used for occlusion:

Spiral emboli
Fabric glue
Wire umbrella devices
Various cylinders
Drugs that cause vein sclerosis

This method consists of catheterizing the femoral vein, then the probe is passed to the testicular vein and a thrombotic drug is injected, the blockage of the vein is checked and the operation ends.

Possible complications after surgery

Complications developing after classical operations.

Hydrocele (hydroxycele) – a complication in which fluid accumulates in the lining of the scrotum. In this case, hydrocele appears due to a violation of the outflow of lymphatic fluid. Disruption of lymph outflow occurs due to ligation of the lymphatic vessels along with the testicular vein during surgery.

This complication is treated, as a rule, either by puncture of the affected part with pumping out fluid or by surgery to restore lymph outflow.

Testicular atrophy. A very rare but serious complication is testicular atrophy. Testicular atrophy is characterized by a decrease in testicular size and a significant decrease in its function. According to statistics, this complication develops in 1:1000 patients operated on for varicocele.

Postoperative pain occurs due to blood overflow of the epididymis and, as a result, stretching of its capsule. But most often, patients after surgery experience a decrease in pain sensitivity.
Complications developing after laparoscopic clipping of the testicular vein.

Complications develop extremely rarely. The most common complication is mild abdominal discomfort after surgery, which is due to pneumoperitoneum (abdominal cavity filling with air). Performed during endoscopic surgery for better visualization of organs. Over time, the air is absorbed and the discomfort goes away.
Complications that develop during testicular vein embolization:

Allergic reactions to contrast agent. Can be avoided by administering desensitizing drugs before surgery
Thrombophlebitis of the veins of the pampiniform plexus. Can be avoided by preventing thrombosis.
Perforation of vessel walls.

Surgery to remove varicocele is indicated for varicose veins of the spermatic cord, as this is the main cause of infertility in men. Therefore, surgical treatment must be carried out at the very beginning of the formation of a testicular tumor.

Indications for surgical treatment

Due to the expansion of the veins, the normal blood supply to the testicular tissues and the process of thermoregulation are disrupted. The number of sperm decreases and they become less mobile. In most cases, the left side is affected, although bilateral pathology sometimes occurs.

Varicocele can be congenital and usually begins very early, but does not manifest itself in childhood. The first clinical signs begin to appear as the child grows older (in adolescence).

Surgery to remove varicocele is needed if the following symptoms are present in a teenager or an adult man: The course of the disease in a teenager may be asymptomatic, so the indication for surgical removal of varicocele may be data obtained as a result of the Valsalva maneuver, ultrasound examination or palpation of the pampiniform plexus. The effectiveness of treatment depends entirely on the degree of the disease and the chosen technique. If necessary, the patient is prescribed a testicular biopsy.

pain in the groin;
feeling of discomfort;
swelling;
testicular swelling.

The technique of surgical manipulation depends on the size of the testicle and the age of the patient. Before starting treatment, it is necessary to prepare for testicular surgery for varicocele in order to avoid serious complications and consequences.

Advice: The earlier the disease is detected, the sooner treatment will begin and the risk of developing serious complications will decrease. Therefore, if you have the slightest sign or concern, you should consult a doctor.

Preparing for surgery

Preparation for surgery begins with a laboratory examination of the patient. It is needed to exclude certain diseases: chronic diseases, lung pathologies, problems with the gastrointestinal tract. All this can affect the course of the operation and the patient’s condition.

Before performing surgery to remove varicocele, it is necessary to establish the main cause that causes blood stagnation in the testicle.
Also, depending on this, the type of operation is selected that will help preserve the man’s ability to fertilize.
Immediately before surgery, the hair growing in the area of the surgical field is shaved.
First of all, you need to take a general urine and blood test, blood test for creatinine, Rh factor and group.
An analysis for the prothrombin index and an electrocardiogram is also prescribed.
The doctor is obliged to familiarize the patient with information about how long the operation will take and the methodology for carrying it out.

Types of operations

Today, there are different types of testicular surgery to remove varicocele. Among them are the most important:

Marmara operation for varicocele;
laparoscopic varicocelectomy;
laser surgery;
Ivanissevich operation.

The Marmara microsurgical operation is the best method for replacing a diseased testicular vein with a healthy vein. To do this, doctors provide themselves with mini-access to the required area of the body, without penetrating the abdominal cavity. The microsurgical technique is considered the least traumatic among all other techniques, since it almost never causes the appearance of cosmetic skin defects.

Also, microsurgery has the lowest risk of relapse and serious complications. Its advantages include a quick recovery period and low invasiveness.

Microsurgical manipulation does not require mandatory hospitalization of the patient in a hospital and can even be performed on an outpatient basis. The preparatory period is standard, as for all other surgical interventions.

Progress of Operation Marmara

The patient is given an anesthetic injection, which has an anesthetic effect. The anesthesiologist decides how much anesthetic to administer based on the patient’s total weight and age. Next, the surgeon makes a small incision in the groin area no more than 2-3 cm. After the swollen vein is found, it is bandaged, stitched and crossed. This helps normalize blood flow and relieve the negative symptoms of varicocele.

During Marmara microsurgery, in rare cases, accidental nerve damage in the groin or bleeding may occur.
The recovery period is only 3 days, and the stitches are removed already 8-10 days after they are applied.
The only disadvantages of this technique include the high cost, because special tools and expensive optics are used.

During the postoperative period, it is recommended to avoid severe physical activity and sudden movements. You cannot have sex for one month and you must protect the incision area from friction. Underwear should be natural and not tight.

After three months, you should take a spermogram in order to assess the ability of sperm to fertilize. Six months after treatment, you can return to your normal lifestyle.

Advice: The doctor must decide which types of surgical interventions to prefer from all available ones, taking into account the patient’s age and individual problem.

Progress of Ivanissevich's operation

During the Ivanissevich operation, complete closure of the lumen of a varicose vein is performed under local anesthesia for adults. For children, surgery is usually performed under general anesthesia. It takes about 30 minutes. This type of treatment for testicular varicocele is considered cheaper. The essence of the method is to cut and ligate the left vein in the testicle. This helps eliminate the main negative factor that causes backflow of blood into the plexus of the testes.

The postoperative period in this case is longer, and the risk of complications is quite high.
During all manipulations, the femoral artery and other anatomical formations in the inguinal canal may be damaged.
In addition, the disadvantages include complete dissection of the abdominal wall and penetration into the abdominal cavity.
The patient will be unable to work for several months.
There remains a chance of relapse, which is about 40%.
The advantages of Ivanissevich’s operation include the absence of the need to use special equipment and the ability to perform it for everyone.

Laparoscopic surgery

Endoscopic varicocelectomy is performed in cases where the patient has bilateral dilatation of the veins of the spermatic cord. Incisions are made in the navel, left and right iliac region. Their size very often does not exceed 1 cm. Endoscopic devices, instruments and an endoscopic television camera pass through them. Therefore, the doctor can monitor the progress of the operation and, if necessary, adjust his actions.

The most non-invasive operation is considered to be laparoscopic, which occurs with minimal trauma to the patient.
In this regard, it carries a lower risk of complications than other types of surgical interventions, which often cause bleeding or the formation of infiltrates.
After using the laparoscopic technique, the patient does not receive a cosmetic defect, since the seam remains almost invisible.

Disadvantages include the high cost of the operation and the need for general anesthesia. The postoperative period usually takes about 3 days, after which the patient is discharged. The doctor tells him when he needs to come to have the stitches removed, how many days it will take to fully recover after varicocele surgery, etc.

Laser surgery for varicocele

The advantages of this type of intervention include the absence of the need for anesthesia and a quick rehabilitation period.

You can also highlight the minimal risk of complications or serious consequences.
Surgeries for varicocele have significant differences from circumcision of the foreskin, surgery to remove a testicle in men, or amputation of the penis.
Only a doctor can answer the question of how long the rehabilitation period will take and what the cost of surgery to restore the testicle will be.
Laser treatment of varicocele is one of the most modern methods of solving this problem.
To do this, there is no need to make an incision in the groin area, and all manipulations are performed using an intravascular endoscope.
Fiber optics helps to find the exact area of vessel dilation and coagulate it under the action of a laser beam.
After this, it is switched off from the general bloodstream.

Contraindications

Not all patients can undergo surgical treatment of the testicle, as there are certain contraindications. Laparoscopic surgery cannot be performed if the patient has already undergone such an intervention earlier or if he has a malignant tumor. Microsurgical operation is prohibited if the patient has diabetes mellitus or severe cardiovascular pathologies.

Before undergoing surgery to remove testicular varicocele, the patient must undergo a thorough examination so that the doctor identifies the exact cause of the disease.
After this, it will be possible to select the optimal type of surgical intervention, taking into account the individual pathology, the patient’s age and his financial capabilities.

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Varicocele - general information

Varicocele is a very common disease that develops from insufficient functioning of the valves of the internal testicular vein or their complete absence, and is characterized by dilation of the veins of the spermatic cord of the testicle.

According to its anatomical structure, the sexual organ consists of a tubular muscular wall, with a passing testicular artery, which supplies blood to this organ, and venous vessels through which the outflow of blood occurs in the opposite direction.
The spermatic cord contains the vas deferens, which exists to transport sperm to the urethra and lymphatic vascular collectors.

This disease affects up to 20 percent of the male population. The anatomical features of the structure of this organ provoke the occurrence of this disease on the left side. Right-sided varicose veins may indicate a tumor in the right kidney. The internal testicular vein drains blood from the testicle.

On the right side, the outflow of blood is directed to the inferior vena cava, while on the left side all the blood is directed to the left renal vein.
The testicular vein has a much lower hydrostatic pressure than the renal vein into which it flows.
During normal activity of the testicular vein valves, blood from the renal vein does not enter the testicular vein.
If these valves do not exist or their operation is ineffective, blood from the system, where the pressure is much higher, will be thrown to where the pressure is lower.

In this case, blood from the left renal vein will flow into the left testicular vein. As a result, blood circulation in the testicle is disrupted - blood stagnates in the veins of the spermatic cord. From the accumulation of a large amount of blood, its temperature rises, which has an extremely negative effect on its function, and subsequently will lead to its complete loss. Normal spermatogenesis is possible under the condition of a stable temperature, which is also lower than body temperature.

Elevated temperature negatively affects the process of formation and maturation of sperm.

Manifestations of the disease

Clinically, the manifestation of varicose veins of the spermatic cord is manifested by pain in the scrotum and its significant enlargement. Sometimes the clinical picture is completely absent.

Most often, varicocele is discovered in adolescence.
Having reached a certain stage, it has no tendency to develop further.
Often they learn about the existing diagnosis during the next medical examination.

Patients rarely complain about this disease. This is due to the fact that the symptoms of such a disease are more likely to be visual than to cause any concern. There may be slight, nagging pain on the affected side, which tends to intensify with walking, physical activity and sexual arousal. Often, an enlarged left side of the scrotum can be detected when a man is standing. In a supine position, it is not possible to see any sign of the disease due to its absence.

When the disease is in an advanced state, then the feeling of pain is constant. This disease is characterized by a significant enlargement of the scrotum, a decrease in the left testicle, and varicose veins of the scrotum.

Is surgery necessary?

If a varicocele is diagnosed, men are interested in: is surgery necessary in this case?
When treating varicose veins, there is no other method than surgery.
However, not all cases of varicocele are an indication for surgery.

The operation should be performed for male infertility, when, due to existing disorders, the quality, motility and quantity of sperm deteriorate, with constant pain in the testicular area, for an aesthetic effect and for the reason that the affected testicle stops growing at puberty.

What types of varicocele removal operations are there?

To have an idea of how surgery is performed for varicocele, it is necessary to consider all the main surgical techniques used today.

Laparoscopic intervention technique– is characterized by high efficiency and is low-traumatic. During the intervention, it is possible to intraoperatively determine the number of branches of the internal testicular vein, perform their resection, without touching the artery, which makes relapse impossible. During the operation, the patient is under general anesthesia. Patients are discharged after surgery the very next day.
Microsurgery– this technique is carried out using local anesthesia, takes several hours, is highly effective, but some complications and relapses are possible. For such an intervention, a specialized microscope is required.
X-ray endovascular surgery– to perform it, X-ray control is used, under which the testicular veins are blocked. Being minimally invasive, the operation is not highly effective.
Open surgeries that are traditional– such methods include Ivanisevich and Palomo operations. A somewhat outdated version of surgical intervention. It is traumatic and has a high rate of complications and relapses. The recovery process is long. It is performed under local anesthesia.

The main reason for treating varicocele is the prevention and treatment of male infertility.

Postoperative period

After surgery for varicocele, sex is possible after the rehabilitation period, taking into account the characteristics of each organism and the type of operation, this is approximately three weeks. After surgery, sex usually remains at the same level.

The most unpleasant complication after surgery may be damage to the nerve located in the inguinal canal.

In addition, there may be cases when, after varicocele surgery, bleeding occurs, the postoperative wound becomes infected, and testicular hydrocele occurs. In almost all cases, patients recover quickly and the pain goes away. If pain still occurs, you should consult your doctor.

Varicocele is a disease that is common in young people.
It is necessary to follow the rules of prevention so that, if necessary, you do not miss the early diagnosis of varicocele.
This includes proper distribution of physical activity, avoiding constipation, and periodic visits to a urologist.

Stages of the disease and indications for surgery

There are 4 degrees of development of varicocele:

Varicose veins are determined only by ultrasound.
The veins of the pampiniform plexus are palpated in a standing position.
By palpation in any position, the doctor can diagnose the disease.
Veins are visible to the naked eye.

A decrease in spermatogenic function, which can eventually lead to infertility, usually begins only in the last stages of the disease.

The operation can be performed in the following cases:

Disturbances in sperm formation were revealed. During the study, it was found that the number of spermatozoa in the seminal fluid is reduced, their motility is reduced, and blood or pus is present.
The patient is experiencing pain. They begin to appear at stages 2-3 of the disease, at first they are minor. Unpleasant sensations intensify when walking, after physical activity. Note. In the vast majority of cases, varicocele of the left testicle develops, so the pain most often has the same localization.
The patient is not satisfied with the appearance of the scrotum.
The testicle begins to decrease in size.

In the absence of symptoms, surgery may also be recommended. Some doctors believe that surgery, done in a timely manner, can prevent infertility. Others believe that this is an unjustified risk and advise limiting monitoring through periodic examinations and ultrasound.

Important! The operation is usually not performed before the age of 18. According to statistics, in adulthood, after surgical intervention, relapses occur much less often - re-development of varicocele. Therefore, it is better to carry it out after puberty.

Compression of the veins can lead to the development of so-called “secondary varicocele”. It occurs as a result of a tumor, cyst or other formation. In this case, the patient is worried about fever, blood in the urine, dull or stabbing pain in the lumbar region. With secondary varicocele, it is necessary to eliminate the cause of the disease, vein truncation surgery is not required until the results of therapy for the underlying pathology appear.

Contraindications

Different surgical techniques may have different contraindications. Open surgical interventions are not performed for:

The presence of diseases in the stage of decompensation (impaired organ functions that cannot be restored without treatment) - diabetes mellitus, cirrhosis of the liver, etc.

Inflammation in the active stage.

In addition to the described contraindications, endoscopic operations are not performed in cases of previous surgical interventions in the abdominal cavity. This is due to a violation of the clinical picture and an increased likelihood of physician errors.

Sclerosis is not carried out with the following contraindications:

Large anastomoses (bridges) between vessels, which can lead to the entry of the drug used for gluing into healthy veins or arteries;
Increased pressure in nearby veins (eg, renal veins);
The structure of the vessels does not allow the insertion of a probe (the crumbly nature of the veins).

Preparing for surgery

10 days before the proposed procedure, patients need to undergo some tests:

Blood test (general, group and Rh factor, coagulability, sugar content).
General urine analysis.
X-rays of light.
Electrocardiogram (can be prescribed to all patients or only to men over 30 years of age).
Analysis for hepatitis B and C viruses, HIV.

In addition, the doctor usually prescribes an ultrasound of the scrotum or an ultrasound using the Doppler method (using a contrast agent) to obtain a more complete clinical picture. Additional studies are possible depending on the patient's condition.

In the morning before surgery you need refuse food and water, take a hygienic shower. The pubis and abdomen must be clean shaved. Taking medications for chronic diseases (diabetes, hypertension, bronchitis, etc.) must be agreed with your doctor.

Methods of performing the operation

The classification of surgical treatment methods can be based on the method of access and technology. Based on the second characteristic, two large groups of operations are distinguished:

With preservation of the recocaval anastomosis;
With its excision.

Note. A renocaval shunt (anastamosis) is a communication bridge between two testicular veins. It occurs as a pathology due to varicocele and contributes to blood stagnation.

The second method is currently recognized as the most effective and is used most often.

According to technology, it is customary to distinguish three main types of operations:

Laparoscopy (minimally invasive method);
Endovascular sclerotherapy;
Open surgery (can be performed in various modifications - according to Marmar, Ivanissevich, Palomo).

Important! Removal operations for varicocele are not performed. All vessels remain inside the body; they are either glued together (sclerotic) or ligated.

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Stages of the disease (varicocele)

at the first stage there are no external manifestations of varicocele, except on palpation;
at the second stage of the disease, dilated veins on the testicle (usually the left one, due to anatomical features) are clearly visible, but its size is not changed;
at the third stage, with pronounced varicose veins, a change in the size of the testicle is visible.

Symptoms of varicocele

In the initial stages, a varicocele may not bother a man with pain symptoms. However, this disease can progress into chronic disease and lead not only to discomfort in sexual life, but also to infertility.
The occurrence of pain caused by varicocele can be observed in the groin, scrotum, and both testicles. Characteristic is a sharp increase in pain when walking, running, physical activity, or during sexual intercourse.

Diagnosis of varicocele

Primary diagnosis of the disease is carried out using an external examination of the patient, palpation, and ultrasound. The doctor may also prescribe tests to study sex hormones in the blood and a spermogram to determine the degree of impaired fertility.

Treatment of varicocele and effect on male infertility

Treatment of varicocele is carried out exclusively by surgery, since only surgery can give the best effect. There are different types of operations. It is believed that at present the microsurgical method of surgical treatment is the most effective: it allows surgical intervention to be performed with the least tissue damage as a result, rehabilitation time takes less time. The operation helps restore blood flow in the testicles and restore normal spermatogenesis (production of a sufficient number of living and anatomically correct sperm). Improving the quality of sperm and eliminating pain will allow you to have a full sex life, without the threat of infertility.

From childhood, varicocele prevention should be done, since hereditary acquisition of the disease is possible. It is important to see a urologist regularly.

https://euromed.ru/patients/simptomy/male-infertility/varicocele/

Causes of varicocele

Varicocele is not an independent urological disease. Doctors view it as a symptom of pathology of the renal veins or inferior vena cava, a genetic developmental abnormality.

The term “reflux” is used to describe the process of blood moving through the veins of the spermatic cord in the opposite direction. Reflux happens:

Primary. It is a consequence of: - lack of valves in the testicular vein (congenital anomaly); - weak venous wall.
Secondary. It occurs due to valvular insufficiency, which develops due to high pressure in the renal veins and the inferior vena cava. Due to venous hypertension, blood seeks additional pathways for outflow. A large area is formed that connects the vena cava and the renal vein. Since the dilated communication occurs between the external and internal spermatic veins and the common iliac vein, it compensates for the high pressure in the renal vein. Among the causes of high pressure in the renal veins: - Localization of the left renal vein behind the aorta. - Spasm of the lumen of the renal vein. - Annular shape of the renal vein. .- Presence of arteriovenous fistula.

Possible causes of venous reflux (and, as a consequence, varicocele) include conditions that compress the spermatic cord:

diseases of the scrotum;
pathologies of the inguinal canal;
abdominal hernia.

Symptoms of varicocele

Signs of varicocele depend on how dilated the veins of the spermatic cord are. In the first and second stages, the disease does not manifest itself in any way. It can only be detected during a medical examination using ultrasound.

At the third stage, men complain of:

Discomfort, pain in the scrotum area (can be aching or sharp, severe).
Inconvenience while running, walking (pain that occurs in the groin when moving often resembles neuralgia).
Increased sweating.
Burning sensation in the scrotum.
Deterioration of sensitivity during sexual intercourse, decreased libido.

During a physical examination at the third stage of varicocele, the urologist records dilated veins reaching the lower pole of the testicles and descending below it. The affected testicle is located lower than the healthy one, causing the scrotum to appear asymmetrical.

At the fourth stage of varicocele, pain becomes unrelated to movements and physical work. It never goes away and gets stronger at night. The scrotum increases significantly in size. Testicular asymmetry is clearly visible.

If you notice similar symptoms, consult a doctor immediately. It is easier to prevent a disease than to deal with the consequences.

Diagnosis of varicocele in men

If a varicocele is suspected, the doctor first feels the scrotum to understand how much the veins of the spermatic cord have dilated. The patient is prescribed:

Get an ultrasound and Doppler ultrasound.
Take a urine test using the March test (before physical activity and immediately after it). If red blood cells and protein are detected (positive result), we can talk about venous hypertension.
Undergo x-ray methods.

Ultrasound as a way to detect varicocele

During the examination, the man first lies down, then stands. Changing posture is necessary in order to determine the speed of blood flow in different positions. During the procedure, the ultrasound diagnostic doctor must perform the Valsava maneuver. Its essence is as follows: the testicular vein increases and expands when the patient stands, and decreases if he lies down.

Normally, ultrasound shows that:

the diameter of the testicular vein is not more than 2 mm;
the speed of venous blood flowing through the testicular vein is no more than 10 cm/s;
There is no venous reflux.

With a large diameter of the testicular vein and reflux, a diagnosis of “varicocele” is made.

Also, using ultrasound diagnostics, the doctor can determine the development of renal venous hypertension, if any.

X-ray methods for varicocele

Of the radiological methods used to diagnose varicocele, the following can be used:

retrograde renal venography;
antegrade phlebotesticulography.

They involve injecting a contrast agent into the scrotum before taking pictures.

Additional methods for diagnosing varicocele

Men who are at high risk of developing varicoceles should undergo two additional tests:

Semiological. Aimed at studying sperm quality. Most people with varicocele have pathospermia (a small number of motile sperm).
Hormonal profile assessment. The levels of estradiol, testosterone, luteinizing and follicle-stimulating hormones, and prolactin are determined.

A full diagnosis can be performed at any modern urological medical center.

Treatment of varicocele in men

Treatment of varicocele in men without surgery is not effective. Doctors resort to drug therapy only after surgery to stimulate spermatogenesis.

Typically, operated patients are prescribed vitamin-mineral complexes and nutritional supplements containing selenium and zinc. Hormones may be used if necessary.

Operations for varicocele in men

The cost of surgery for varicocele depends on the chosen surgical method. Today there are more than a hundred ways to combat this disease. All of them can be divided into two large groups:

Provide for maintaining communication with the renal artery.
Interrupting communication with the renal artery.

Now doctors give preference to microsurgical techniques, which reduce the duration of the rehabilitation period, minimize the risk of developing postoperative complications and reduce the likelihood of disease recurrence.

Preparing for surgery

Before the operation, the man must undergo the following tests:

CBC (to determine clotting);
blood type and Rh factor (any surgical intervention is associated with the risk of bleeding, so doctors need to know what blood type the patient has);
OAM (to check kidney function);
electrocardiogram (to study the functioning of the heart);
blood biochemistry for urea, glucose and creatine;
chest x-ray.

Types of operations performed to remove varicocele

A man will find out how much an operation to remove varicocele costs at a preliminary consultation. The price is determined by the complexity of the planned intervention and the type of equipment used.

Operation according to Ivanissevich

The Ivanissevich operation is most often used by surgeons to remove varicoceles in men. Its essence is ligation and resection of the left testicular vein. As a result, reflux is eliminated.

The indication for this type of treatment is grade 3 and 4 varicocele. Contraindications include: hemophilia, diabetes mellitus. It should be noted that this is one of the oldest ways to solve the problem.

Marmara operation for varicocele

The Marmara operation is the safest way to remove varicocele. It is passed through the outer ring of the inguinal canal. This is the main advantage of this type of treatment - it is much easier to find an enlarged vein through the groin than through the abdominal cavity.

The incision made does not exceed 2-3 cm. Having gained access to the canal of the groin area, in which the testicular vein is located, the doctor ties it, stitches it and crosses it. The surgical incision is then sutured.

Sperm quality improves significantly after Marmara surgery.

Laparoscopic surgery for varicocele

Laparoscopic testicular vein clipping is a minimally invasive and endoscopic method for removing varicoceles. They resort to it when:

any degree of illness;
mixed type varicocele.

The price of varicocele laparoscopy is quite high, but it is justified, since the operation is characterized by a large number of advantages:

Allows clipping of veins if they are affected on both sides.
Almost completely eliminates the risk of complications.
Reduces hospital stay to 3 days.
Provides excellent cosmetic effect (the seam is almost invisible).
After treatment there is almost always a good spermogram.
Even in the first days while walking, the patient does not feel pain.

Laparoscopy of varicocele is performed under general anesthesia.

Endovascular phlebosclerosis for varicocele

Endovascular phlebosclerosis is the closure of the lumen of the testicular vein using a special device or composition. The operation is performed for the renotesticular type of pathology, if there is no venous hypertension and stenosis of the renal artery. It does not require general anesthesia and does not involve any incisions. Within 2 days after treatment, the man can return home.

Endovascular obliteration of the testicular vein can be performed not only in adults, but also in children. To close the vein, use:

cylinders;
fabric glue;
spiral emboli;
wire devices shaped like umbrellas;
preparations for vein sclerosis.

Complications arising after surgical treatment of varicocele

After treatment of varicocele (especially if an Ivanissevich operation was performed), complications may arise:

Hydrocele of the testicle (fluid collects in the lining of the scrotum).
Testicular atrophy (the testicle significantly decreases in size and its functions deteriorate).
Pain in the groin area (the blood-filled epididymis stretches its capsule).
Perforation of vascular walls.

Why is varicocele dangerous?

Varicocele leads to male infertility. The disease is also accompanied by:

pain in the scrotum;
production of antisperm antibodies (due to disruption of the barrier between testicular tissue and blood);
high testicular temperature;
excessive production of hydrocortisone;
disruption of the production of pituitary hormones.

Prevention of varicocele

If a man is predisposed to developing varicocele, prevention measures are usually ineffective.

To minimize the likelihood of dilatation of the veins of the spermatic cord, you need to:

wear comfortable underwear that provides good support but does not pinch the scrotum;
do not lift heavy objects;
treat constipation in a timely manner;
have regular sex life;
exercise;
take walks.

https://illness.docdoc.ru/varikotsele

Testicular varicocele in men: what does the diagnosis mean?

If a man is diagnosed with varicocele, then initially one might think that the disease is somehow related to varicose veins, since both names have the same root. Indeed, the names are similar, as are the mechanisms of pathology development.

Testicular varicocele is a varicose vein in the spermatic cord. This disease is observed mainly in adolescents aged 14–15 years and in young men of reproductive age. Statistics show that in general the pathology occurs in 15% of men.

Symptoms of testicular pathology in men

Varicocele disease in men belongs to the category of pathologies that occur without significant symptoms. Most often, originating during puberty of a young person, it quickly develops to some extent and then stops. There are also cases when the disease regresses on its own and then disappears altogether.

However, the following alarming signs of this disease may indicate a developing varicocele:

Increase in size and descent of the left testicle (if the pathology is localized on the left).
Mild “pulling” pain in the scrotum and groin. While walking or during heavy physical activity, these sensations may become more pronounced and cause discomfort.
If the scrotum is severely drooping on one side, this may interfere with normal walking.
Pain in the scrotum, bulging of its veins, shrinkage of the left testicle (with severe varicose veins of the testicle).

If signs of varicocele are detected, it is better to immediately go to a specialist rather than wait for the pathology to regress.

Causes of varicocele in men

The reason why varicocele appears is the occurrence of a malfunction of the valves in the veins of the testicles. These valves should normally prevent blood from flowing back at any level of pressure in the veins. In cases where, when the pressure increases (for example, during physical exertion), the valve does not cope with its job, the blood flows in the opposite direction, expanding the vein near the spermatic cord.

The cause of varicocele may also be associated with a kidney tumor. If a tumor is localized in the kidney, it compresses the renal vein and disrupts blood flow in the ovarian vein, which just branches off from the renal vein. As a result of blood stagnation, varicose veins develop.

Degrees (stages) of development and types of disease

The more dilated the testicular veins are, the deeper the degree (stage) of varicocele development:

Zero degree. As a rule, a disease to this extent is discovered by chance if the patient is prescribed a Doppler ultrasound of the scrotum to examine signs of other male pathologies (for example, hernia, tumor, etc.). During palpation, dilation of the testicular veins cannot be felt.
First degree. An enlarged testicular vein can be detected by palpation only with the patient standing.
Second degree. Testicular veins affected by varicose veins can be easily palpated in any position.
Third degree - dilation of the veins is noticeable upon visual examination of the scrotum.

Left-sided varicocele is the most common variant of the pathology. The cause of varicocele is the special location of the vein surrounding the left testicle. It is connected to the renal vein, which, in turn, due to its plethora, often suffers from the influence of various internal and external factors. In 98% of cases of the total number of identified pathologies, it is varicocele of the left testicle (varicocele on the left) that is diagnosed.

Bilateral varicocele or varicocele of the testicle on the right can develop due to vascular abnormalities, which, in turn, can be congenital or a consequence of vascular diseases.

Is varicocele dangerous and why: what complications and consequences of the disease may arise in men?

Despite the fact that varicocele often has mild symptoms and may not affect a man’s normal life, this disease has complications. The first and most important threat from varicocele is infertility in men.

The chain of formation of an unpleasant complication is as follows: blood flow in the scrotum is disrupted, the testicles do not receive proper blood supply, and harmful compounds and free radicals begin to accumulate in them. The consequence of these factors is impaired spermatogenesis. There are fewer sperm in a man’s semen or their morphological qualities sharply decrease. In other words, the sperm of a man with varicocele cannot fully participate in the fertilization process. However, you should not literally think that varicocele always leads to infertility. We are talking only about individual observed cases.

Another consequence that the presence of varicocele leads to is phimosis. The problem is more common in boys and is expressed in the lack of opening of the penis due to a narrowed foreskin.

The doctor will be able to explain to the man how dangerous varicocele is in each specific case after diagnosis.

Ultrasound diagnostics for the diagnosis of varicocele

When, visually or by palpation, the doctor (and maybe the patient himself) detects the presence of enlarged, thickened veins, a decrease in the size of the testicle on the affected side, an ultrasound with Doppler is prescribed to clarify the diagnosis.

An ultrasound probe is applied to the scrotum, and the doctor begins to study certain parameters. Ultrasound technology allows you to compare the size of the testicles, determine their consistency, and also estimate the size of the vein surrounding the testicle. You also need to evaluate the speed of blood flow in this vein, which determines how correctly and fully the testicle will function.

If the ultrasound monitor visualizes veins with noticeable thickenings (there may be several of them, they look like dark circles), a varicocele is confirmed.

What treatment is prescribed for men when they are diagnosed with testicular varicocele?

Before talking about treatment, you need to decide which doctor to go to if you suspect a varicocele. Urologists deal with this problem. Very often, the first meeting with a urologist for young men occurs at school, when various medical examinations at the military registration and enlistment office begin in high school. After such checks, young people learn about their problem for the first time, after which they only have to make an appointment with a urologist for a more detailed diagnosis.

Treatment of varicose veins of the spermatic cord of the testicle involves surgery. But it is important to know for sure whether surgery for varicocele is necessary or is it not indicated for everyone?

If a boy has pain, there is a decrease in the testicle on the affected side, and there are signs of underdevelopment of this testicle, surgery is needed. It is also prescribed to men with varicocele who cannot have children. A preliminary examination of sperm (spermogram) is carried out, which shows the presence or absence of spermatogenesis disorders. However, the doctor does not give a 100% guarantee that after eliminating the varicocele, the patient will have the opportunity to have children.

If there are no special indications for surgery, the varicocele is simply observed over time.

Types of operations

Today, doctors use several methods and types of surgical operations to treat varicocele:

Laparoscopy for varicocele involves punctures of the skin in several places to provide access to the veins of the instrument (laparoscope). If dilated veins are detected, they are ligated.
Endovascular sclerotherapy involves gluing together pathological vessels by introducing a special therapeutic substance into them.
Open surgery for varicocele involves an incision in the pubic part with further ligation of the vein.

From the last group of operations, it is worth considering the Marmara operation technique for varicocele. The doctor makes an incision in the pubic region close to the ilium, then excises the integument and subcutaneous tissue, isolates the spermatic canal and ligates the vein.

To determine the patient’s health status before surgery for varicocele (laparoscopy, Marmar, or others), tests are prescribed: blood sugar, coagulability, Rh factor, HIV, hepatitis, urinalysis, fluorography, ECG.

Is it possible to treat varicocele without surgery? Non-surgical conservative treatment for varicocele is usually unsuccessful and only makes sense as a preparation for surgery.

Rehabilitation and recovery after surgery for varicocele

The postoperative recovery period in the case of surgery to eliminate varicocele may have different periods:

1 month for microsurgery or laparoscopy;
2 months for open operations.

For normal recovery after surgery to remove varicocele, a man/boy needs:

exclude physical activity;
maintain sexual rest;
exclude visiting saunas, swimming pools, baths;
Avoid drinking alcohol.

What can be the consequences and complications after surgery to eliminate varicocele in men?

Any operation is always associated with risk, so in case of varicocele it is necessary to clearly determine whether it is indicated or not. The main complications after varicocele surgery include:

the appearance of swelling, hematoma in the scrotum area;
pain in the testicles;
purulent and serous discharge from the area of the puncture or incision;
redness of the skin;
increased temperature of the penis;
disturbance of spermatogenesis;
infectious contamination as a result of the use of non-sterile surgical instruments.

Recurrence of varicocele: is it possible for the disease to return after surgery?

Before surgery, many patients are interested in whether varicocele can recur after surgery? It must be said that the likelihood of varicocele recurrence is small, but it exists.

The reasons for the return of the disease may be poorly performed manipulations by the doctor, the patient’s failure to comply with the rules of conduct in the postoperative period, a genetic predisposition to the disease, or abnormal vascular structure. Also, the cause of relapse of varicocele can be a pathology of the cardiovascular system, against the background of which varicose veins of the lower extremities develop.

Prevention of testicular varicocele in men

To prevent varicocele disease and prevent it from progressing to a deeper degree, you should:

avoid stress;
lead an active lifestyle, avoid prolonged sitting;
Healthy food;
take vitamins containing zinc, selenium;
have regular sex life.

How can varicocele affect conception and is pregnancy possible after surgery to eliminate male pathology?

Urologists often hear the question: can a woman become pregnant from a man with varicocele or is it possible for him to conceive and have children after surgery?

The diagnoses of varicocele and infertility can overlap - that is, the first causes the second. But this is not always the case. It is difficult to give an unambiguous answer as to when you can get pregnant after removal of a varicocele. Definitely not earlier than 1–2 months after the operation, since a man needs sexual rest during this period.

Studies do not provide specific figures about the statistics of infertility with varicocele or what the proportion of successful pregnancies is after eliminating the pathology. It is only worth saying that if varicocele is the only pathology in the male body and it is this disease that affects the quality of sperm and the lack of conception, then after the operation is performed, the probability of becoming pregnant will be high.

In principle, you can have children with varicocele, if this pathology does not cause underdevelopment of the testicle and impaired spermatogenesis.

https://mcgenesis.ru/services/urologia/varikocele-u-muzhchin

Varicose veins of the spermatic cord and epididymis are a fairly common disease, which affects 17% of men, mainly at a young age. Treatment depends on the stage of the disease and its extent. If there are obvious clinical signs, when the veins are observed visually, there is pain, surgical intervention is indicated to ligate the inflamed veins, since a serious threat is created for the development of male infertility.

Removal of testicular varicocele is performed under anesthesia (usually local) and in several cases general anesthesia is required. What methods of surgical therapy are used in modern medicine to treat varicose veins of the pampiniform plexus, what their features, advantages and disadvantages will be discussed in this article.

Causes of formation of varicose veins of the testicular veins

The causes of varicocele development are divided into two types: primary and secondary. Primary include venous insufficiency, manifested in the weakness of the venous walls and valves, secondary are all other factors, the action of which causes an increase in blood pressure in the testicular veins, which leads to the development of venous insufficiency. The result of these reasons is the development of varicose veins and deformation of the scrotal veins. Let's take a closer look at how this happens.

Varicoceles have several stages, ranked depending on the degree of deformation of the varicose veins. The earliest is called subclinical or preclinical because the disease is at the stage of formation, is latent, has no signs and can only be detected using ultrasound diagnostics, which is quite difficult in the absence of symptoms.

At this time, the venous valves cease to close completely, and blood reversal occurs. This phenomenon is called reflux. It leads to increased intravascular pressure and negatively affects the functional activity of the testes since steroid hormones produced by the adrenal glands are delivered to the testicles with reverse blood flow.

Need to know. In childhood and adolescence, the development of varicocele does not require the presence of factors that cause an increase in venous pressure, since venous insufficiency has a genetic predisposition and is inherited. Therefore, if there have been cases of varicocele in the family, it is important for young men to undergo regular medical examinations before the end of puberty.

The appearance of the first signs indicates the progression of the disease and its transition to a clinical form. At the beginning, a man feels mild periodic pain of a dull or nagging nature, which at first occurs rarely and usually after significant physical exertion, heavy lifting or sexual contact.

These are symptoms of the first stage of varicocele, in which the inflammation of the veins is still minor and they are not only not visible visually, but simply palpating the scrotum is not enough to determine them. It is possible to establish the presence of the disease during physical diagnosis only by performing the Valsalva maneuver.

Its essence is that during palpation the patient strains his abdominal muscles or deliberately coughs; the doctor can detect tension in the veins. For a more accurate diagnosis, the patient is always sent for ultrasound diagnostics using Doppler, which will measure the diameter of the vessels in the areas of varicose veins and determine the intensity of reflux.

The data obtained are important not only for clarifying all aspects of the disease, but their value lies in the fact that, based on the primary data obtained, it is possible to track the course of the disease and monitor the situation in the recovery period after surgical treatment.

Subclinical and first-degree varicoceles are the least dangerous for men’s health; therefore, at this period of disease development, it is possible to use medications and traditional medicine to stabilize varicose veins and maintain spermatogenesis at the proper level.

But in subsequent stages, extremely unfavorable conditions are created for the functioning of the testes and even for their anatomical integrity, therefore diagnosing the second and especially the third stage of varicocele is a direct indication for immediate surgical intervention.

It is characterized by persistent pain in the scrotum, which can be either periodic or long-lasting. They occur not only after physical activity, but also at the end of the day. At this stage, upon palpation, the inflamed veins are already clearly identified, but only in an upright position, lying down they subside.

The Valsalva maneuver is not required. Visually, veins can appear in the scrotum, which indicates the progression of the disease and its possible transition to the third degree. Semen analysis shows a significant deterioration in the process of gamete formation.

The most dangerous and easily diagnosed third stage. An abundant plexus of inflamed veins develops in the scrotum, clearly visible visually, which is why the scrotum acquires a bluish tint. Due to insufficient blood circulation, its tissues, as well as the histological structures of the testicles, experience problems with trophism and gas exchange, so the skin of the scrotum changes, the diseased testicle becomes smaller and sags.

The pain is constant and quite severe. Laboratory tests show a strong decrease in the synthesis of steroid sex hormones and a deterioration in sperm count, which requires urgent surgery to eliminate varicocele. To fully understand what the negative impact on a man’s body is, in the next section we will briefly discuss this issue.

Damage to men's health caused by varicocele

It does not pose a significant danger to the patient’s life and poses a major threat primarily to the reproductive system, and also has a negative effect on endocrine processes, which in turn changes the overall hormonal background, decreased sexual desire and potency. Table 1 shows the negative consequences that develop due to varicose veins of the spermatic cord and epididymis.

Table 1. Diseases associated with the development of varicocele:

Pathology	What caused her appearance
Complete or partial loss of fertility	An increase in the total area of veins in the scrotum due to varicose veins leads to hyperthermia. Violation of histological structures provokes autoimmune reactions and death of sperm.
Degradation of testicular tissue structure	Slowing blood circulation, impaired nutritional and respiratory function, stagnant processes, accumulation of active chemicals negatively affect the cellular structures of the testis
Testicular atrophy	Hypoxia in the third degree of varicocele can lead to severe degradation of the histological structures of the testis
Decreased testosterone levels in the blood	In Leydig cells, synthetic activity decreases due to hypoxia, testicular atrophy, as well as during the reflux of steroid hormones with reverse venous blood during reflux
Decreased potency and libido	With reduced synthesis of male sex hormones, 90% of which are produced in the testes, not only the intensity of spermatogenesis decreases, but also “male strength”.

The most noticeable effect on the course of spermatogenesis is an upward change in the temperature regime in the scrotum. The testicles are specially placed outside the peritoneum in order to provide the optimal temperature at which full-fledged reproductive gametes can be formed, as a rule, this is 34.5 degrees with minor fluctuations allowed.

The scrotum has a special muscle, the cremaster, which is responsible for raising or lowering the testicles, as well as several other muscles responsible for tightening or relaxing the skin layers. This ensures proper thermoregulation. With the development of varicose veins, a significant network of inflamed veins develops around the testicle, so the temperature invariably increases with the development of varicocele.

At the terminal stage, it can reach 37 degrees, with a negative effect on a healthy testicle and if a doctor does not intervene during the course of the disease, then the development of infertility occurs in the vast majority of cases. Therefore, the answer to the question of whether surgery is needed for varicocele or not should be obvious to the reader.

In addition to an increase in temperature, the development of germ cells is negatively affected by a slowdown in blood circulation, which worsens metabolic processes in cells and slows down their metabolism. At the same time, they experience oxygen starvation.

In areas of deformed veins, stagnant processes form, due to which there is an increased concentration of active chemicals (for example, free radicals, nitrogen oxides, etc.) that cause undesirable chemical processes. All this leads not only to a decrease in the functioning of cells, but also to their lysis, so histological structures degrade.

The blood-testicular barrier in the testicles separates the site of gamete synthesis from aggressive cells of the immune system, which, when thinned, begin to pass through it and destroy sperm, mistaking them for foreign agents. This is how an autoimmune reaction develops, which is responsible for the formation of a persistent immune response.

The nutritional function of the hemotesticular barrier is associated with the localization in it of the so-called nurse cells or Sertoli cells, which ensure proper trophism of developing and newly formed sperm.

Germ cells, due to their specification, have lost some of their organelles; therefore, with the help of cytoplasmic bridges, they connect with nurse cells, which are responsible for the metabolic processes of sperm. Accordingly, a decrease in the number of Sertoli cells will negatively affect the quality of male germ cells.

The same processes inhibit the activity of Leydig cells responsible for the synthesis of steroid male sex hormones, the main of which is testosterone, which is responsible for the manifestation of sexual characteristics, muscle growth, potency and libido.

Since many people will wonder if everything is so scary, is surgery necessary for varicocele or are there cases in which conservative treatment is possible? Let's consider this issue in more detail.

When can varicocele surgery be delayed?

The mere presence of a confirmed diagnosis of varicocele is an indication for surgery, but it is not always performed.

The reason for postponing surgery to a later date may be:

if the disease is in the early stages and in a reliably stable state;
short period of illness;
age of the patient (children and elderly people);
the presence of other pathologies that do not allow surgical intervention;
if the onset of infertility is not scary for a man, for example, he already has a sufficient number of children;
the patient’s categorical refusal to undergo surgery or lack of financial opportunity.

In the early stages of the disease (subclinical and first degree), the negative processes occurring in the testes are small, therefore, as a rule, the spermogram does not show deviations from the norm, and the histological structures remain unchanged.

Therefore, if the doctor is confident that the patient’s condition is stable, a delay may be possible until the disease begins to progress. Treatment is determined for the patient and detailed instructions are given regarding preventive measures. Typically, venotonics, antioxidants and drugs to stimulate meiosis (the process of formation of germ cells) are prescribed.

The patient must adhere to certain restrictions related to preventing an increase in pressure in the scrotum, move more and adhere to a number of other tips, which are detailed in the section on prevention after varicocele surgery below in the text, as well as in the video in this article.

Surgical treatment may not be carried out at all in cases where the preservation of reproductive function is not important for a man, for example, due to his advanced age or he has a sufficient number of children and is no longer planned. This option is possible if the varicocele is stable, there is no threat of destruction of the histological structure, and the disease itself does not cause severe discomfort.

Important. If delaying surgery to remove varicose veins of the scrotum concerns men of childbearing age, then constant monitoring by a urologist is required and the patient must be registered at a dispensary.

A high percentage of postponing surgery is typical for young patients. As a rule, in children and adolescents, varicocele is detected at the first stage between the ages of 13 and 16 years. The delay is due to several reasons.

Firstly, the initial stages of the disease do not have a significant negative impact, and secondly, children have a high probability of developing a postoperative relapse since the venous system does not have time to quickly adapt to the rapidly growing youthful body.

The child is constantly monitored and is prescribed supportive drug therapy aimed at maintaining the disease. The operation is performed at the end of puberty or if a deterioration in the patient’s condition is noticed.

But this approach to treating children is somewhat outdated. Previously, for surgical intervention they used mainly the technique developed by Ivanissevich, which is simple, but has a high probability of developing postoperative complications.

At the moment, medicine has made several progressive steps and today, in all regions of our country, various operations for varicocele are available, characterized by low trauma, high efficiency, while the risks of relapse are minimal.

Therefore, many doctors are inclined to believe that it is reasonable to surgically remove diseased veins of the spermatic cord in the early stages of the disease, which will guarantee the integrity of all histological structures and minimize the risk of infertility in the boy in the future, when he grows up.

When is surgery necessary?

The most guaranteed way to avoid loss of reproductive function is early diagnosis and prompt elimination of the detected problem.

There are cases when surgical intervention is required immediately:

varicose veins of the scrotum 2 or 3 degrees;
testicle affected by varicose veins;
pathological changes in sperm or their quantity in the spermogram;
a biochemical blood test reveals a strong decrease in testosterone levels;
reduction of the testicle due to degradation of the tissue structure of the testicles.

It must be emphasized once again that there is no alternative to surgical treatment. All other treatment methods prescribed by a doctor are aimed at maintaining and stabilizing the disease.

It should be understood that at the moment modern medicine does not have and in the foreseeable future will not have conservative methods to restore deformed veins and correct malfunctioning valves.

Important! Varicocele can be completely cured, but only after surgery to remove the inflamed veins.

Surgical treatment of varicocele

At the moment, it is possible to remove inflamed testicular veins in more than a hundred ways, but in real practice no more than ten methods and their varieties are used. This section will compare operations for varicocele, taking into account their positive and negative characteristics.

Regardless of the chosen technique, the essence of treatment is to eliminate blood circulation through deformed veins; nutrition of the testicle will be carried out through the remaining healthy vessels, which is quite enough to ensure all physiological processes occurring in the testes.

Operations Ivanissevich and Palomo

In 1924, the Argentine surgeon Ivanissevich proposed a technique for the surgical elimination of varicose veins through retroperitoneal access. From then until today, this type of operation has been dominant since the positive aspects are the lowest price and simple technique, and the operation does not require any special conditions in the operating room or the presence of special instruments.

The note. Classical has long been practically the main method of surgical treatment of varicocele, but recently preference has been given to more modern methods carried out mainly through micro-access or using special probes.

Despite the fact that today there are already quite a few new minimally invasive methods of treatment, classical operations still remain in first place, mainly due to the lack of special surgical equipment in most clinics in our country that allows modern operations to be carried out with high precision during operation. with vessels.

The principle of varicocele surgery according to Ivanissevich is as follows. On the body in the area of the peritoneum in the left iliac region at the level of the anterior superior iliac spine parallel to the course of the inguinal canal, skin, subcutaneous tissue and muscle tissue are excised.

Through an incision up to 6 centimeters in size, the surgeon reaches the veins of the spermatic cord and removes them. Afterwards, the diseased veins are clamped using Kocher clamps, ligated, suppressed, and the veins are returned to their original place. Layer-by-layer sutures are placed on the incision. The duration of the entire operation, as a rule, is within 30-40 minutes.

The negative aspects of the methodology dominate over the positive ones in the overall assessment. This consists, firstly, in the significant likelihood of relapses and complications, since some of the testicular vein anastomoses often go unnoticed and become inflamed again, and secondly, tissue damage, especially muscle damage, takes a long time to heal, so the period of complete recovery lasts at least six months.

The types of operations for varicocele of Ivanissevich and Palomo are quite similar due to the fact that the second was a student of the first. The difference lies in Palomo’s proposal to simultaneously cut off the testicular vein and the artery of the same name.

For a long time this caused controversy between supporters and opponents of this method of removing varicocele, since some believed that the testicle would not receive enough blood circulation, others showed the absurdity of the former’s judgment since there are many anastomoses between the vessels and in practice doctors often ligated both the artery and the vein, which is not caused negative consequences.

Nevertheless, the technique proposed by Polomo did not gain wide recognition over time, and the Ivanissevich operation became the main operation for removing varicocele until the 90s of the last century.

The note. The high level of complications after surgery using these techniques forced doctors to modify classical operations and exclude lymphatic vessels during ligation, which reduced the likelihood of postoperative development of hydrocele and testicular edema.

Pay attention to Table 2, which briefly provides a comparative description of classical abdominal operations using the methods of Ivanissevich and Palomo.

Table 2. Positive and negative aspects of the Ivanissevich and Palomo operations.

Strengths

Weak sides

the operation does not require special surgical equipment;

low cost of treatment;
spinal anesthesia for varicocele surgery;
The duration does not exceed an hour, usually 30-40 minutes.

relapses and complications occur in 30-40% of cases;
hospitalization 7-14 days;
removal of sutures 7–8 days;
a noticeable postoperative scar remains;
long recovery period - at least 6 months;
The pain after the anesthesia wears off persists for several days.

Varicocelecomy from subinguinal microaccess using the Marmara technique

The technique is essentially similar to the abdominal surgeries mentioned above, but a different technique is used. The entire operating process takes place under optical magnification, so a special microscope must be installed in the operating room; as an alternative, surgeons use special magnifying glasses.

This allows the doctor to perform manipulations much more correctly when ligating the veins, while with a high probability the nerve and lymphatic fibers, as well as the testicular artery, remain intact. In this case, not only the spermatic vein is suppressed, but also its collectors, which significantly reduces the risk of relapses.

Subinguinal access involves an incision in the area of the external inguinal ring at a distance of about one centimeter from the base of the penis, so in order to reach the veins of the spermatic cord, the muscle tissue of the peritoneum is not damaged, and this shortens the rehabilitation period.

After dissection, a small surgical opening of no more than 4 centimeters is formed, through which veins are extracted, which can be examined in length better than with classical techniques. Before ligation, all other vessels and tissues must be isolated and set aside, which prevents their injury.

After bandaging and cutting off all found inflamed veins, the wound is sutured. Stitches are usually removed after a week, and if the stitch is cosmetic, it will resolve on its own.

Thus, the surgical technique for varicocele allows not only to effectively treat varicose veins of the pampiniform plexus, but also to significantly reduce recovery time. The treatment does not require hospitalization, and the patient ends up at home on the evening of the operation. Pay attention to Table 3, which shows the distinctive features of this technique.

Table 3. Positive and negative aspects of varicocelecomy using the Marmara method:

Characteristics of the operating technique

Strengths

Weak sides

duration – 30-40;
local anesthesia;
one day hospital stay;
incision 3-4 cm;
the postoperative scar is barely noticeable, hidden under panties;
probability of complications – 5%, relapses up to 7%;
the testicular vein is cut off along with its collectors;
more opportunities to examine the vessels of the pampiniform plexus;
short recovery periods, up to a month maximum.

high cost;
presence of an operating microscope.

Important. When operating using the Marmara technique, hospitalization is not required!

Laparoscopic or endoscopic surgery

They began to use it in surgical practice only recently, about 30 years ago. Its appearance made a truly significant breakthrough in medicine, since it became possible to operate without dissecting the tissues of the abdominal cavity, and the accuracy of the manipulations performed increased significantly.

A laparoscope is a tube with a micro-camera and a cold light source at the end, which allows you to display an image on a monitor screen, so the doctor can not only monitor all the work in real time, but also enlarge the resulting image, take screenshots, etc.

With this method, general anesthesia is performed, so the patient will have to go to the hospital for several days. In order to facilitate manipulation and expand the surgeon’s area of action, carbon dioxide is pumped into the peritoneum, and micro-instruments and a laparoscope are inserted through three small holes (the largest hole in the navel area is 10 mm, and the other two are 5 mm each on the left and right in the iliac region)

This type of operation has many advantages, which is explained by more detailed visualization and the ability to examine vessels from both sides along their entire length.

Note. Laparoscopic surgery is the only way to simultaneously eliminate bilateral varicocele and the best way to treat relapses.

Diseased veins are found and ligated using microinstruments. The whole process lasts on average about an hour and a half, after which the patient is taken to the ward. As a rule, no problems arise after the anesthesia wears off since postoperative complications are unlikely and the man leaves the clinic on the second or third day. More details about all the nuances are indicated in Table 4.

Table 4. Positive and negative aspects of laparoscopic surgery:

Characteristics of the operating technique

Strengths

Weak sides

there are no incisions, microtools are inserted through small holes;
visualization of the operation on the monitor;
relapse rate is no more than 2%, complications are extremely rare;
the ability to examine veins along their entire length;
hospital stay is two days on average;
short rehabilitation periods;
after anesthesia, the pain is mild and does not last long;
the possibility of treating varicose veins on the left and right simultaneously, the best way to eliminate relapses.

general anesthesia;
duration 1.5–2 hours;
high cost;
specially equipped operating room;
the presence of certain experience and skills of the surgeon.

Embolization and sclerotization of the testicular vein

The benefit of varicocele surgery using this method lies in its fundamental difference from all other methods of surgical removal of varicose veins. In this case, the veins are not ligated or cut off, but are clogged with the help of special substances or devices (vein gluing agents, titanium staples, spirals, etc.), so the blood circulation in them stops, and the diseased veins resolve over time.

Blood flow is gradually restored through the collaterals in full, sufficient to satisfy the physiological needs of the testis.

The occluding agent is delivered to the desired vein using a special catheter, first inserted into a larger vessel, and all manipulations are monitored by X-ray equipment, so postoperative complications are completely excluded.

The proportion of relapses during sclerotization is up to 7%, which can occur for the following reasons:

insufficient fixation of the closure agent in the vessel;
persistence of reflux due to incomplete closure of the venous lumen;
incorrectly selected blockage site.

Surgery for varicocele in adults using this method lasts about 1–1.5 hours without hospitalization and has the shortest recovery time. In Table 5 you can find a comparative description of the described technique.

Table 5. Positive and negative aspects of testicular vein embolization for varicocele:

Characteristics of the operating technique

Strengths

Weak sides

mandatory autoradiographic preliminary diagnosis;
since the diameter of the surgical opening is several millimeters, no traces are left on the body;
local anesthesia;
the treatment is almost painless;
no postoperative complications;
the risk of relapse is no more than 7%;
treatment is carried out on an outpatient basis;
the shortest rehabilitation period.

high price;
the operating room must be equipped accordingly;
Carrying out such operations with blood vessels requires the experience and skills of medical personnel;
the patient receives a dose of x-ray radiation.

Important. This method of treating varicocele is of great importance for those men who are contraindicated for surgical intervention.

Testicular vein revascularization

The essence of this microsurgical operation is to remove the inflamed vessel and suturing a healthy vein in its place in the immediate vicinity. The epigastric vein is usually used for bypass surgery. The operation is quite technically complex and is performed under general anesthesia, since even minimal movement significantly complicates its implementation.

An incision of no more than 6 centimeters is made in the area of the inguinal canal parallel to the running spermatic vessels. After completion, sutures are placed on the wound, which are removed after a week. The rehabilitation period is quite long, and full recovery requires at least three months.

The clear advantage of this technique is the rapid restoration of blood flow to the testicle in full, which has a positive effect on the physiological side. But due to the high complexity of its implementation, this technique is now rarely used, since there are simpler and highly effective methods for treating varicocele.

In addition, at the bypass site there is a possibility of blood clots forming, breaking off and migrating through the bloodstream. Table 6 shows the main advantages and disadvantages of this surgical technique.

Table 6. Positive and negative aspects of testicular vein revascularization in the treatment of varicocele:

Characteristics of the operating technique

Strengths

Weak sides

circulation is restored immediately and in full;
the likelihood of complications and relapses is not high.

high complexity of execution;
risks of blood clots;
after treatment, stitches are applied and a scar remains;
general anesthesia;
hospitalization;
time for complete recovery of at least three months;
high cost.

Testicular vein bypass or revascularization

Without going into the specifics of medical terminology, the essence of the operation is that a shunt is created from a circumcised testicular vein, which is sutured to a nearby vein. In this case, the blood immediately begins to circulate, the blood flow is completely restored, which is good from a physiological point of view.

Microequipment is used to manipulate the veins, and all actions are monitored using a camera to ensure high precision.

We will briefly describe how surgical correction takes place. To access the veins, an incision of about 5-6 cm is made in the peritoneum, through which the testicular and epigastric veins are removed along their entire length in order to completely excise the varicose vessel, in its place the epigastric vein is sutured. Once revascularization is complete, the veins are placed in place and the incision is sutured layer by layer.

Note. The main advantage of the operation is the rapid restoration of blood flow to the testicle, which creates good conditions for normalizing its functioning. Among the negative aspects, the risks of blood clots forming at the shunt site should be noted.

Features of bypass surgery

Like all other techniques, testicular revascularization has its own distinctive features:

To perform the operation, the patient needs general anesthesia;
The varicose vein is removed immediately, rather than dissolving for some time, so the blood flow quickly normalizes, which is beneficial for the physiology of the testis;
The technique is classified as microsurgical; it requires microinstruments and a microscope;
Prescribing medications in the first few days has general principles, as with other methods: painkillers, antibiotics, anti-inflammatory drugs, immunomodulators and vitamins;
I put stitches on the incision. In the first days, a sterile bandage is used, which is replaced after two days and so on until healing;
Usually the sutures are removed on the seventh or eighth day; after the operation, a scar will remain on the body.

Complications may be similar to those during surgery using the Ivanissevich method, with the difference that the likelihood of their occurrence is significantly lower. There are also prerequisites for the formation of thrombosis.

Due to the complexity of the procedure and the risk of side effects, shunting in the treatment of varicocele is used less and less. The advent of more advanced techniques has further reduced the use of revascularization for the treatment of testicular varicose veins.

The table briefly summarizes the main characteristics of the described surgical techniques that are most often of interest to patients.

Comparative table of operations to eliminate varicocele

View	Hospitalization (days)	Rehabilitation period (weeks)	Probability of relapse	Photo
Ivanissevich or Palomo	From 8 to 14	2-4	30%
Marmara	1-2, or without hospitalization	2	5-7%
	2	2	1-2%
Bypass surgery	3	2	5%

Other methods of surgical treatment of varicocele

The above operations are the most popular and most often used in modern medicine, but there are several more methods for surgical removal of varicocele that should be mentioned. Previously, they were more widespread, but today they have been successfully replaced by modern and less traumatic methods.

Such operations include:

Ligation operation for varicocele. This method is also known as the Goldstein operation for varicocele. Treatment in this case involves ligation of not only the testicular vein, but also the cremasteric vein. The essence is to evacuate the testicle through a surgical wound, the size of which will depend on the size of the testis, after which the spermatic duct and its artery are isolated, and all the veins and their inflamed collectors are lysed. In this case, special attention is paid to the isolation of nerves and lymphatic ducts in order to prevent their injury. The operation requires magnifying equipment (an operating microscope or special glasses). After the operation is completed, the wound is sutured layer by layer and an antiseptic bandage is applied to it. The risks of relapses or complications are approximately the same as with varicocelecomy from a subinguinal microaccess.
Yakovenko's operation for varicocele. Her technique was proposed in 1955. The idea is to ligate the cremasteric vein. The technique of the operation is not complicated, it does not last long under local anesthesia, but there is a high probability of developing a postoperative relapse or complication. An incision is made directly on the scrotum from the side of the diseased testicle, after which the spermatic cord is removed into the surgical wound, and the inflamed cremasteric vein is identified. Bandaging is performed at the beginning and end of the deformed area, then the varicose veins are excised. In this case, it is important to isolate all the inflamed branches and do the same manipulations with them. Once completed, the wound is sutured tightly.
Kocher operation for varicocele. In essence, it resembles the operation of varicocele using the Yakovenko method, but with the difference that all inflamed veins are ligated, and the scrotal incision is made not from the side, but along the central commissure of the scrotum, which is covered by the penis, which is more aesthetically advantageous. The operation is performed under local anesthesia and, as a rule, is performed in cases in which there is no other way to get to the inflamed veins, although with the advent of modern techniques this is no longer relevant.

Possible complications

No surgical technique provides an absolute guarantee of protection against the development of postoperative complications. This applies to a greater extent to open-cavitary classical operations and less to endoscopic methods of treating varicocele.

It is based on various reasons, both due to the fault of the doctor, for example, ligation of not all collectors, weak ligation of veins, passion for the cosmetic side, etc., and due to the fault of the patient who does not comply with the rules of postoperative recovery.

The most likely negative consequences may include:

Relapse occurs when the veins are not properly ligated or when the branches of the testicular vein remain unnoticed. Sometimes a doctor may confuse and mistakenly ligate completely the wrong vessels;
Hydrocele of the testicle (hydrocele) forms when the lymphatic vessels are damaged due to impaired lymph circulation;
Testicular atrophy is possible when the testicular artery is damaged;
Numbness of an area of skin, usually on the inner thigh. This happens when the innervating nerve is cut.

Complications appear within a short period of time after completion of treatment, and relapses can occur both immediately and over a longer period. Both are treated surgically; with hydrocele, it is possible to eliminate the pathology with the help of a puncture.

An immediate reason to contact a doctor for help would be the manifestation of the following signs:

the appearance of temperature;
the appearance of edema, redness, swelling or liquid discharge of a cloudy nature with an unpleasant odor at the incision site;
the appearance of blood stains or continuous enlargement of the hematoma;
signs of inflammation of the scrotum, its increase in size;
increased pain or other discomfort that causes concern.

Features of rehabilitation

The timing of the rehabilitation period and complete recovery depend primarily on the surgical technique and less on the patient’s compliance with the prescribed instructions. The most time for rehabilitation will be spent after classical open cavity treatment methods using the methods of Ivanissevich and Palomo.

Patients feel most comfortable after endoscopic and microsurgical interventions. Everything depends not so much on the establishment of constant blood flow and healing of the veins, but on the restoration of other tissues, the dissection of which was necessary to gain access to the diseased veins.

The operated patient must strictly follow the rules of rehabilitation. In order to avoid a relapse or damage to the integrity of the sutures, the main thing is to avoid stress and increase intra-abdominal pressure.

To do this you should refuse:

any heavy physical activity;
until the doctor allows you to lift heavy objects more than 10 kg;
Light sports are allowed, but you should refrain from long or intense running, as well as from riding a bicycle or horse;
avoid constipation or diarrhea as this puts strain on the veins;
avoid colds and prevent respiratory diseases with a prolonged cough.

For the first few days, the patient must remain in bed. After a short time, you can and should move more, walk or do athletics, which will increase blood circulation in the pelvic organs. It is mandatory to give up bad habits.

There are no special requirements for dieting, but it is advisable to exclude fatty cholesterol-containing foods for the period until complete recovery, and give preference to seafood, chicken, and plant foods rich in vitamins and fiber. And the most important thing is not to forget to visit a doctor in a timely manner to monitor the recovery process.

Conclusion

Thus, when comparing surgical techniques for removing varicocele, the most optimal are varicocelectomy from a mini-access using the Marmara technique and laparoscopic surgery.

All open abdominal surgeries performed in the classical way have the greatest likelihood of developing postoperative complications and relapses. The effectiveness of treatment depends not only on the chosen method of varicocele removal, but to a greater extent on the characteristics of the diagnosis, stage and duration of the disease.

Varicocele – a disease in which, due to impaired blood flow in the vessels of the scrotum, dilation of the veins of the pampiniform plexus of the spermatic cord occurs.

Varicocele was described by Celsius in the 1st century AD, and only in the 19th century was the connection between varicocele and functional testicular failure proven. A serious complication of varicocele is infertility.

The problem of infertile marriages has recently become very relevant. 40% of infertile marriages are caused by male infertility. According to studies, almost 30% of men suffer from varicocele. It has also been proven that 40-80% of patients with varicocele had a decrease in fertility.

The incidence is not uniform across age groups: for example, in preschool age the incidence does not exceed 0.12%, and between the ages of 15 and 30 it becomes 3-30%. This disease develops especially often among athletes and manual workers.

Anatomy and physiology of the testicles

The testicles are a paired oval-shaped glandular organ. The testicles are located in the scrotum. The testicle is approximately 4 centimeters in length and 3 centimeters in diameter. The weight of the testicle is approximately 20 grams. The testicle consists of lobules (250-300). Each lobule consists of 2-3 seminiferous tubules (straight and convoluted tubules).

The testicle, like a gland, performs:

Exocrine function (production of sperm in convoluted tubules)
Intrasecretory function (production of male sex hormones - androgens)

Oxygenated blood enters the testicle from the testicular artery, which originates from the abdominal aorta. The outflow of blood from the testicle is carried out into the testicular vein. Venous blood enters the vein through the pampiniform plexus, which is part of the spermatic cord. Venous blood from the left testicular vein enters the renal vein. Blood from the right testicular vein flows into the inferior vena cava.

Causes of varicocele

Today, varicocele is considered not as an independent pathology, but as one of the manifestations of a genetic developmental anomaly or a disease of the inferior vena cava and renal veins acquired during life.
Blood flow in the opposite direction (retrograde) is called reflux. It can be primary and secondary.

Primary reflux develops when:

Congenital anomaly in the testicular vein (lack of valves in the vein)
Genetic predisposition to weakness of the venous wall.

Secondary reflux appears due to secondary (acquired during life) valvular insufficiency. Secondary valvular insufficiency occurs due to hypertension (high pressure) in the venous system of the inferior vena cava and renal veins. Venous hypertension leads to the need for additional pathways for the outflow of venous blood. This leads to the formation of a wide communication between the renal and cava veins. The communication is formed between the internal and external spermatic veins and the common iliac vein. Thus, this message compensates for the increased venous pressure in the renal vein.

The main causes leading to renal venous hypertension are:

Narrowing of the lumen of the renal vein
Location of the left renal vein behind the aorta
Annular renal vein
Arteriovenous fistula

Considering the anatomical feature (the left testicular vein flows into the renal vein, and the right ovarian vein into the inferior vena cava), varicocele develops on the left in 80-86% of cases, on the right in 7-15%, bilaterally in 1-6% of cases.

Any pathological conditions of the scrotum, inguinal canal, abdominal cavity (hernia), which lead to compression of the spermatic cord, can cause venous reflux (backflow of blood) and, as a result, lead to varicocele.

Factors leading to disturbances in spermatogenesis (the process of sperm formation):

Increased testicular temperature
Disruption of the barrier between blood and testicular tissue (which can lead to the production of antisperm antibodies)
Excess production of the hormone hydrocortisone
Disturbances in the production of various pituitary hormones

Recently, a genetic risk factor for the development of varicocele has been identified.

Symptoms of varicocele

In the early stages, varicocele is very often asymptomatic (patients do not complain about anything). A number of patients note heaviness and pain in the scrotum area on the affected side. The pain is of moderate intensity and nagging in nature. The pain may radiate to the groin area. As a rule, the pain intensifies with walking and physical activity.

While taking a hot bath, patients may notice enlarged veins on the affected part of the scrotum.
But the most important complaint that forces patients to consult a doctor is infertility (the inability to conceive a child).
According to the WHO (World Health Organization) classification, there are 3 degrees of severity of varicocele.

1st degree - dilated veins of the scrotum are not visible and cannot be palpated; they can only be determined by the Valsalva maneuver
2nd degree - the veins are not visible, but are well palpated (palpable)
3rd degree - dilated veins are visible, as they protrude through the skin, very well palpated

Varicoceles are also classified according to the hemodynamic type of reflux:

Reno-testicular (reflux from the renal veins into the testicular veins)
Ileo-testicular (reflux from the iliac veins into the testicular veins)
Mixed type (combination between the two types described above)

Diagnosis of varicocele

Feeling the scrotum
A mandatory procedure that allows you to determine the severity of varicocele.

Ultrasound(ultrasonography). Ultrasound is always combined with Dopplerography (a technique that determines the quality of blood supply) of the renal vessels (arteries and veins) and the testicular vein.

The study is carried out with the patient standing (orthostasis) and lying down (clinostasis) with the measurement of the blood flow gradient in these positions.
During an ultrasound, it is necessary to perform Valsalva maneuver:

Enlargement (varicose veins) of the testicular vein in size when the body is in an upright position.
When the body is lying down, the vein collapses (reduces in size).

The testicular vein should not exceed 2 millimeters in diameter (normal). The speed of venous blood flow in the vein should not exceed 10 centimeters per second (normal). Absence of venous reflux (normal).

With varicocele of the first degree, the diameter of the testicular vein becomes 2 millimeters larger than normal and positive (up to 3 seconds) reflux is determined. Severe reflux indicates a more severe stage of the disease.
Ultrasound also allows you to determine the hemodynamic variant of varicocele, as well as identify renal venous hypertension (if any).

General urine analysis before and after physical activity (march test). A positive march test - the appearance of a small amount of red blood cells in the urine (microhematuria) and the presence of protein in the urine (proteinuria) indicates renal venous hypertension.

X-ray methods.
X-ray methods include:

Antegrade phlebotesticulography or retrograde renal phlebography - these research methods are performed after preliminary injection of a contrast agent into the veins of the scrotum.

Hormonal profile study – includes the concentration of testosterone, estradiol, prolactin, FSH (follicle-stimulating hormone), LH (luteinizing hormone).

Semiological research(semen examination) - in most patients pathospermia is detected (a decrease in the number of motile forms of sperm and an increase in the number of pathological forms) of varying degrees.

Treatment of varicocele

Non-drug treatment
Conservative treatment of varicocele is not effective.

Drug treatment
Drug treatment is prescribed only after surgery to stimulate spermatogenesis. Most often, a complex of vitamins and biologically active food supplements (containing selenium and zinc) are prescribed. Sometimes hormonal drugs are prescribed (androgens, human chorionic gonadotropin), they are used under strict laboratory control.

Preparation for surgical treatment involves taking tests before surgery (to exclude decompensation of any organ or organ system). The following tests are required:

General blood test (to determine the state of hematopoiesis)
Blood type and Rh factor (for blood transfusion if necessary)
Urinalysis (to check kidney function)
Biochemical blood test (glucose, creatinine, urea)
ECG (electrocardiogram) – to determine the work of the heart
Chest X-ray (to exclude lung pathology)

Surgical treatment
Currently, there are more than 120 types of surgical treatment for varicocele.
All operations can be divided into two groups:

Group I – operations in which the connection with the renal artery is preserved.
Group II – operations in which the communication with the renal artery is interrupted

Classical operations on varicocele

One of the most common operations is according to Ivanissevich. It consists of ligation and further resection of the left testicular vein. This leads to the elimination of reflux from the renal vein into the pampiniform plexus. But with this operation there is a possible risk of developing renocaval anastomosis due to difficulty in the outflow of venous blood from the kidney.

Microsurgical methods for treating varicocele
Laparoscopic clipping of the testicular vein
Laparoscopic varicoetomy is an endoscopic and minimally invasive method for the treatment of varicocele.


Indications for laparoscopic testicular vein clipping surgery	Advantages of the laparoscopic method over classical operations	Contraindications for laparoscopic testicular vein clipping
Varicocele 1, 2, 3 degrees	Possibility of vein clipping for bilateral lesions	Abdominal surgeries in the past.
Reno-testicular type of varicocele	Reduced risk of postoperative complications
Ileo-testicular type of varicocele	The length of hospital stay is reduced to 2-3 days
Mixed type varicocele	Almost complete absence of pain in the wound
	No pain when walking on the first day
	Good cosmetic effect
	Good sperm count after surgery

Endovascular phlebosclerosis
The method consists of blocking the testicular vein with various substances or special devices.

Indications for the use of endovascular phlebosclerosis	Advantages of endovascular phleboskerosis	Contraindications for endovascular phlebosclerosis
Reno-testicular type varicocele	The operation is performed under local anesthesia (the patient is conscious)	Large reno-testicular collaterals, which can lead to drug entry into the systemic circulation
No renal vein stenosis	Hospital stay is reduced to 2 days	Renal venous hypertension
Absence of venous hypertension	Absence of surgical intervention as such (with this method there are no incisions)	Loose vein type
	This method allows you to avoid complications such as hydrocele.
	Possibility of re-occlusion of the vein in case of relapse of the disease

Endovascular obliteration (occlusion) of the testicular vein is performed in both adults and children. Various substances are used for occlusion:

Spiral emboli
Fabric glue
Wire umbrella devices
Various cylinders
Drugs that cause vein sclerosis

This method consists of catheterizing the femoral vein, then the probe is passed to the testicular vein and a thrombotic drug is injected, the blockage of the vein is checked and the operation ends.

Possible complications after surgery

Complications developing after classical operations.

This complication is treated, as a rule, either by puncture of the affected part with pumping out fluid or by surgery to restore lymph outflow.

Allergic reactions to contrast agent. Can be avoided by administering desensitizing drugs before surgery
Thrombophlebitis of the veins of the pampiniform plexus. Can be avoided by preventing thrombosis.
Perforation of vessel walls.

Prognosis for varicocele

According to studies, relapse of the disease is detected in 2 - 30% of cases.
In 90% of patients after surgery, an increase in the number of actively motile forms of sperm is observed. But only in 45% of cases do spermatogenesis indicators approach normal levels. The longer the disease and the older the patient’s age, the less often the spermatogenesis indicators approach normal.

Prevention of varicocele

Prevention consists of eliminating congestion in the pelvis. To do this you need:

Correction of constipation (constipation)
Elimination of prolonged physical stress
Regular sex life (involves regular sex)
Playing sports (athletics and swimming are best)
Adequate rest (includes adequate sleep and walks)

FAQ

When can you have sex after surgery?

After surgical treatment of varicocele, it is recommended to abstain from sex for three weeks. This time is just enough for the body to recover after surgery. Failure to comply with the period of abstinence leads to the appearance of pain on the side where the operation was performed.

Patients' fears and fears that erectile function decreases after surgery to eliminate varicocele are not justified. Studies have shown that the operation does not affect the quality of sex.

How much does surgery to remove varicocele cost?

On average, an operation to eliminate varicocele, together with the cost of a bed, costs from 20,000 to 90,000 rubles. The cost of the operation depends on the clinic and the method used to solve the problem of varicocele. For example, in Moscow, surgical treatment using the Ivanissevich method costs 32,000 rubles, and endoscopic treatment of varicocele costs 50,000 rubles.

Surgery to remove varicocele – reviews

Alexander 30 years old
I felt heaviness in the left side of my scrotum. I consulted a urologist. He prescribed an ultrasound of the prostate and other organs, then passed a couple more tests. The doctor diagnosed grade 2 varicocele and prescribed surgery. He said that I could choose the method myself and told me what it cost and how much. I chose the Ivanissevich operation, it cost 27,000 rubles. Endoscopic surgery costs almost 50,000 rubles. I had the operation done by professionals, according to my doctor. I felt pretty good after the operation. After 5 days I was discharged. Almost a month has passed and I feel great, no problems.

Vladimir 23 years old
I visited the urologist with a friend. The urologist said that I have grade 2 varicocele. I didn't believe it at first. But then he explained what was happening and said that this could lead to infertility. I was a little puzzled. The doctor reassured me and suggested endoscopic surgery. He explained that the seam would be almost invisible and that I would recover quickly. I agreed and went in for surgery. They took all the necessary tests from me and did an ultrasound. Then there was an operation under general anesthesia. Discharged on the 2nd day. I felt pretty good. And I only had one cosmetic stitch, which I tell you, healed very quickly and was almost invisible. I was very pleased with both the doctors and the operation itself.

Marmara operation for varicocele, what is the effectiveness of such a microsurgical operation?

Medicine is increasingly striving for low-traumatic surgical operations for various diseases. Surgeons can develop in this direction thanks to the improvement of high-precision medical equipment, namely endoscopic and computer technologies. Likewise, in the treatment of varicocele in countries with developed medicine, classical operations are performed quite rarely. For several years now, preference has been given in the treatment of varicocele all over the world. microsurgical varicocelectomy or surgery using the Marmara method, this operation is considered the standard in the treatment of varicocele .

Indications for microsurgical varicocelectomy surgery:

varicocele grade 1-3 , both one-way and two-way process;
soreness in the testicular area , feeling of heaviness in the scrotum, decrease in testicular volume;
bad spermogram – impaired sperm formation, infertility.

Contraindications to Marmara surgery:

1. Temporary contraindications:

blood clotting disorder;
exacerbation of chronic diseases;
acute infectious diseases (ARVI, tonsillitis, sinusitis and others);
infections of the genitourinary system (cystitis, urethritis, pyelonephritis), including sexually transmitted diseases;
severe concomitant diseases that are in the stage of decompensation (for example, diabetes mellitus with complications and uncontrolled glucose levels).

2. Absolute contraindications: allergy to local anesthetics (anesthesia intolerance).

Technique for microsurgical varicocelectomy:

1. The operation is performed under local anesthesia.
2. The incision is made in the area of the outer ring of the inguinal canal; its dimensions are very small, only about 20 - 30 mm in diameter.
3. They reach the inguinal canal, where the varicose vein is located.
4. This vein is ligated in two places, in the area of transition into a healthy vessel, then stitched; all this happens under the control of a microscope, the image is displayed on a computer screen.
5. The affected vein is excised using special instruments.
6. The postoperative wound is sutured.
7. The average time for the operation including preparation is half an hour.

Recovery after surgery using the Marmara method:

After a few hours, the patient can be discharged home;
complete restoration of normal general health and cessation of pain in the postoperative wound occurs within 2 days;
sutures are removed on the 7-8th day;
having sex and resuming physical activity are possible immediately after the stitches are removed, that is, after a week.

Advantages of the Marmara operation:

1. Low-traumatic surgery: there is no need to enter the abdominal cavity, cut muscles and fascia, there is no risk of injury to other blood and lymphatic vessels, nerves.
2. Fast and painless surgical procedure.
3. General anesthesia – there is no risk of complications associated with general anesthesia and tracheal intubation.
4. Low risk of complications during surgery.
5. Fast recovery period, there is no need for a long stay in the hospital, and you can return to your usual rhythm of life within a week.
6. Small postoperative scar , which is located in the pubic hair, hidden under underwear. Almost all men are embarrassed to talk about their gentlemanly health problems, and a large scar always gives rise to unnecessary questions.
7. There are virtually no postoperative complications in the form of hydrocele, relapses occur extremely rarely, 5-25 times less than with other methods. And more serious complications do not occur at all.
8. Greater percentage of restoration of the reproductive system (fertility), normalization of spermatogenesis and the ability to conceive a child.

Disadvantages of microsurgical varicocelectomy:

The main disadvantage of the Marmara operation is its price. – cost of the operation averages from 300 to 1300 USD e.

When can a family plan a pregnancy after surgery for varicocele?

Varicocele This is one of the common causes of male infertility. A third of all cases of primary and four out of five cases of secondary infertility are associated in one way or another with varicocele.

Causes of infertility with varicocele:

1. Poor blood supply to the testicle – with varicose veins, both the flow of blood and its outflow worsen. The result is a lack of nutrients and oxygen for sperm formation and an accumulation of harmful substances.
2. Testicular atrophy can develop with a long course of varicocele, while the testicle significantly decreases in size and partially loses its functions.
3. Immune process – there is always an inflammatory process in the wall of varicose veins, as a result – the immune system sends a large number of cells to the site of inflammation. These immune cells interfere with sperm production and an autoimmune reaction may develop.
4. Venous stagnation in the testicle leads to disruption of thermoregulation, and sperm quality and potency directly depend on temperature. Everyone knows that with hypothermia, as well as with overheating, a man can have “gentlemanly punctures.”
5. With significant dilated veins can compress the seminiferous tubules and interfere with normal ejaculation.

But besides varicocele, other factors not related to varicose veins (sexually transmitted diseases, hormonal disorders, prostatitis and prostate adenoma, unhealthy lifestyle and many others) can lead to male infertility. And in up to half of cases, infertility is caused by a whole complex of reasons and factors.

With varicocele, fertility disturbances in men may not occur. And infertility associated with varicocele is not a death sentence, and after surgical treatment, many men manage to restore fertility and give their significant other a long-awaited pregnancy.

The most important thing is not to start the varicocele process and at any stage not to refuse treatment, both surgical and conservative. You can't give up!

It should be noted that Success in treating infertility with varicocele depends on the treatment method. Thus, conservative treatment makes it possible to conceive a child only in 10-15% of cases. While surgical treatment makes it possible to become pregnant in half of the cases in the first year after surgery, and up to 70% in the second year. And in another 20% of cases, there is an improvement in sperm quality, but this is not enough to conceive a child.

But many operations in every tenth case, on the contrary, worsen the spermogram, which is most likely due to postoperative complications or the development of adhesions in the area of the testicles and seminiferous tubules.

Also, the restoration of fertility after surgery is affected by:

age of the man;
duration and stage of varicocele;
spermogram results before varicocele treatment;
the presence of concomitant pathologies of the male reproductive system.

When restoring the reproductive system, it is very important, if possible, to treat and eliminate other factors affecting reproductive function. It is important to lead an active, normal, healthy lifestyle, including sexual life, this increases the chances of pregnancy in the family by 50%.

Planning pregnancy after surgery for varicocele:

In 6 months after surgical treatment, and after the Marmara operation after 3 months perform a spermogram . If the sperm is of high quality and sperm activity is good, then you can get down to business.
If after 6 months the spermogram indicators have not recovered to normal, then the analysis is repeated 8 and 12 months after surgical treatment. And during this time, additional methods of examination of the male reproductive system are carried out, and, if necessary, concomitant conditions are treated.
Pregnancy is possible with normal sperm count. Poor-quality sperm can fertilize an egg, but this poses a risk of genetic disorders in the child.

Usually pregnancy is possible after 6-12 months.

As you can see, patients with varicocele not only have a chance of becoming a father, they are quite high.

Is it possible to play sports and is it possible to join the army after surgery for varicocele?

You can return to sports on average after 1 month, after the Marmara operation - immediately after the stitches are removed, and after the Ivanissevich operation - after 3 months. Before the permitted period, it is better to minimize physical activity; you should not lift weights of more than 4-5 kg.

After the recovery period, physical activity should begin with small ones, gradually increasing to the usual or desired level.

Do not forget that excessive physical activity and lifting heavy weights in themselves can cause varicose veins in the scrotum before surgery, and after surgery this can lead to the development of recurrent varicocele. So you have to be careful with weights.

Important! If, while playing sports, a man feels discomfort in the scrotum area, then physical activity should be avoided for a while, and it is also better to consult your urologist about this issue.

Do they take you into the army with varicocele?

Varicocele often affects teenagers and young people of military age. Therefore, the question of military service is very important. I would like to remind you that the decision on the suitability of a young man is made only by the doctor of the medical unit at the military commissariats.

Absolute contraindication to military service:

varicocele of the 3rd degree;
two relapses in the form of 2nd degree varicocele after surgery.

Temporary deferment to military service:

An operation for the 1st-2nd degree, a deferment is given for 6 - 12 months, then they are sent to serve.
2nd degree varicocele - surgical treatment is recommended, but the conscript may refuse surgery, then the final word goes to the urologist or andrologist. Usually such young people are not called up for military service, but in the event of martial law, mobilization cannot be avoided.

The following is not a contraindication to military service:

varicocele 1st degree;
varicocele of the 2nd degree 6-12 months after effective surgical treatment (including after treatment of the first relapse).

Some guys, not wanting to serve in the army, try to increase the degree of varicocele through heavy physical activity, chronic overheating and other methods, or refuse surgery to cure varicocele. In this case, it is important to decide what is more important - to avoid the army or to be a full-fledged man, in the future the father of a family. Everyone has their own choice!

What to do if a varicocele remains after surgery (a relapse has developed) or pain in the testicle persists?

Pain in the testicle after surgery for varicocele can normally persist for a week. After this period, discomfort is possible for 3 weeks after physical activity, sexual intercourse or masturbation. If after removal of the sutures, that is, after 7-8 days, pain in the scrotum persists, you should urgently consult a doctor, because this may be the result of surgical errors or complications of the operation.

Causes of pain after surgery for varicocele:

Causes of postoperative testicular pain	Why do they arise?	What to do, how to treat?
Stretching of the epididymis with varicose veins	This is the most common cause of postoperative pain that persists for a long time. This condition occurs due to late treatment for varicocele, at stages 3-4.	Gradually, pain and discomfort completely disappear on their own.
Damage to the ovarian artery	Sometimes, due to his inexperience or carelessness (or due to the use of imperfect equipment), a surgeon may confuse a vein and an artery, and during the operation, instead of varicose veins, he may ligate the artery. In this case, the patient is concerned about pain, discomfort and a gradual decrease in the size of the testicle. This happens extremely rarely, but it can cost the patient serious consequences. Damage to the ovarian artery is at risk testicular atrophy. In this case, the testicle is partially destroyed and ceases to fully perform its functions, disrupting hormonal levels (decreased testosterone levels) and the formation of active sperm.	Usually, blood flow to the testicle is restored over time due to bypass vessels (collaterals). If testicular atrophy has developed, hormonal therapy is necessary to stop the atrophy process. In severe cases, they resort to removing the destroyed gonad.
Lymphatic vessel damage	It is the cause of testicular hydrocele (hydrocele), which manifests itself in addition to pain by enlargement of the scrotum, usually on one side.	Treatment of hydrocele of the testicle is only possible through surgery.
Damage to the spermatic cord	Rarely during classical operations, but it can happen. This complication is associated with the anatomical proximity of the blood vessels and the spermatic cord.	In this case, the surgeon usually immediately sees his errors and can restore the integrity of the seminiferous tubule by stitching. But if the damage was not immediately noticed, then sometimes it is necessary to form a stump and remove the testicle from the damaged side over time.

After any operation you may also experience relapses of the disease. During microsurgical and laparoscopic operations, the risk of developing varicocele recurrences is much lower, while during classical abdominal operations, relapses occur quite often, up to 40% of all surgical interventions.

Recurrence of varicocele– the appearance of all symptoms of varicocele some time after surgery (from 1 week to several months and even years), while varicocele is confirmed by various instrumental diagnostic methods (ultrasound, angiography).

9 out of 10 relapses are the result of surgeon errors during surgery.

Causes of recurrence of varicocele associated with errors during surgery:

1. Error in diagnosing vascular anastomoses(formation of additional thin vessels that bypass varicose veins), if these vessels are not removed during surgery or only partially removed, they can cause re-formation of varicoceles.
2. Carrying out surgical treatment in childhood and adolescence(that is, the operation was performed too early), which is due to the anatomical characteristics of the testicular vessels and the peculiarities of the course of the disease itself. To treat varicocele in children and adolescents, it is necessary to find the optimal time for surgery, because with late treatment various complications and relapses can also occur.
3. During the operation the wrong vessel was ligated or all necessary varicose vessels were not blocked .
4. Failure of clips, sutures and other methods of closing varicose veins.
5. Outflow disturbance(extremely rarely) through the veins of the pelvis or external spermatic vein.
6. With embolization of the ovarian vein, it is possible migration of emboli(an embolus is a substance (air, fat, specially created chemical compounds) that blocks the lumen of blood vessels, like a cork in a bottle).

Risk of complications can be reduced by choosing the correct and effective method of operation and a detailed examination of the testicular vessels using various instrumental methods (angiography, CT, ultrasound with Doppler and others).

Treatment of recurrent varicoceles can only be done surgically. Reoperating on varicocele is much more difficult. To treat relapses, the same surgical operations are used as in the primary treatment of varicocele, with preference given to microsurgical and laparoscopic operations.

If a relapse develops after repeated surgery , then the risk of developing testicular atrophy, infertility and testicular hydrocele in such a patient increases significantly. Treatment of repeated relapse is also carried out surgically. And, probably, it makes sense to choose another doctor or clinic, because such relapses are a mistake of the surgeon.

Varicocele in children and adolescents, what are the causes, features and what to do?

In childhood, varicocele is a fairly common phenomenon; 10-15% of boys aged 11 to 17 years have this vascular pathology. Basically, the first manifestations of the pathology appear from the age of 11, and by adolescence, by the age of 14-15, obvious symptoms appear; in very rare cases, varicocele is detected in preschool children.

Causes of varicocele in childhood:

the most common cause of testicular varicose veins in children and adolescents is a congenital cause or anatomical features, that is, the child is born with it, but does not acquire it;
lifting weights – feeling their strength and trying to quickly become men, boys without special training begin to lift weights, which contributes to an increase in intra-abdominal pressure and the development of varicocele;
heavy physical activity ;
frequent or chronic respiratory diseases accompanied by a strong cough;
lack of sexual intercourse during sexual arousal (quite a common occurrence for teenagers) it increases pressure on varicose veins;
constipation and other factors.

If the cause of varicocele in a teenager is anatomical features, then the logical question becomes why varicocele does not occur in children under 10-11 years of age, because the anatomical features of the testicular vessels are also present in infancy. The whole point is that problems begin with puberty and an increase in the size of the testicles . Enlarged gonads put pressure on the testicular veins, contributing to the development of varicose veins.

Typically, in boys, varicocele is detected during an annual preventive medical examination, especially when examined upon referral from military registration and enlistment offices.

Manifestations of varicocele in adolescence similar to those in adults. Young men may also experience changes in sperm count and decreased sperm activity.

In boys, the gonads are just going through a stage of development and maturation, during which the supply of sufficient oxygen and nutrients is very important. When the venous outflow is disrupted, the gonads suffer from their deficiency, which is why increased risk of complications such as testicular atrophy and/or seminal canal, and as a result – male infertility in the future. For the purpose of prevention and timely detection of possible pathology, boys should be taught to visit a urologist, just as girls should be observed by gynecologists.

In addition to varicose veins, many children with congenital pathology experience impaired blood flow in other vessels (renal vein, mesenteric vessels, and others). Therefore, children and adolescents with signs of varicocele must undergo angiography and ultrasound with Dopplerography to determine blood flow in the pelvic vessels.

Interesting! In children, congenital varicocele is often accompanied by connective tissue abnormalities, for example, flat feet or club feet, scoliosis, physiological phimosis and other diseases.

Treatment of varicocele in adolescents, as in adults, only involves surgical removal of testicular varicose veins or blocking blood flow through them. In pediatric practice, the same surgical techniques are used, but microsurgical and laparoscopic operations are preferable, which are less traumatic and have a low risk of complications and relapses.

It is important to schedule surgery at the appropriate time, when the testicles are fully formed, but grade 3 varicocele has not yet developed. This task is difficult for the surgeon; in some cases it is difficult to find a middle ground. Surgical treatment for growing gonads very often results in relapses of varicocele, as well as with delayed treatment of the disease.

Varicocele in children and restoration of fertility(ability to reproduce).

Due to impaired maturation of the gonads in childhood, restoration of spermatogenesis is important, because even surgery performed in young men does not always provide complete recovery. The potential before surgery is very important in this; a bad spermogram before treatment significantly increases the risk of remaining infertile (50%). Also, to increase the effectiveness of the operation, conservative therapy is recommended immediately before surgery and in the postoperative period for 3 months, which increases the chance of restoring fertility by more than 20%.

Drug treatment of varicocele in adolescents aimed at restoring fertility:

antispasmodics (No-shpa, papaverine);
angioprotectors (Detralex, Pentoxifylline, Etamzilat and others);
membrane stabilizers (Phenytoin, Quinine);
antioxidants (vitamins, ozone therapy);
prostaglandin inhibitors - anti-inflammatory drugs (Prednisolone, Nimesulide, Indomethacin and others).

Is it possible to cure varicocele without surgery? Are there any means of conservative and traditional medicine? Can varicocele go away on its own, without treatment at all?

Varicocele is a problem not only for men, but also for women, because because of this male pathology they are often deprived of the joy of motherhood. And in many ways, men’s fertility depends on themselves. Only with careful attention to their men's health can men overcome infertility associated with varicocele. Therefore, it is very important for him to follow all the treatment methods recommended by doctors. And official medicine claims that the only effective treatment for varicocele is various surgical operations, which provide a great chance of restoring the ability to conceive a child.

If a gentleman refuses surgical treatment because of fear of the operation itself, possible complications, or even refuses to go to a male doctor, then he should understand that conservative treatment of varicocele is ineffective. It may make sense to resort to drug therapy if varicocele is just beginning, that is, in the first stage of the disease. This therapy can stop the process, but it cannot cure a man of varicocele. And if there are negative changes in the spermogram, then taking pills and herbs is generally pointless, they will not restore masculine qualities in any way.

It also makes sense to resort to conservative therapy in preparation for surgery and in the postoperative period.

venotonics: Detralex, Ginkgo Biloba, Aescusan, Venolek, Vasoket;
vitamins: ascorbic acid (C), retinol (A), tocopherol (E);
drugs that improve blood circulation : Trental, Nicotinic acid, Pentoxifylline and others;
anticoagulants: Heparin, Aspirin, Troxevasin, Ibustrin, Hepatrombin and others.

It is also very important to adhere to proper nutrition and lifestyle to achieve better results.

Daily and nutritional regimen for varicocele:

1. avoid lifting heavy objects and heavy physical activity,
2. walking and swimming tones blood vessels well,
3. daily exercise , calf raises are especially effective,
4. hardening also have a positive effect on vascular tone, water procedures at low temperatures should be started gradually, increasing the area of influence and lowering the water temperature,
5. refrain from going to the bathhouse or sauna,
6. to give up smoking , alcohol or drug abuse,
7. diet: the diet should contain a large number of different fruits and vegetables, seafood, cereals, dried fruits, bee products,
8. drinking plenty of fluids: at least 2 liters of clean water, drinking green tea, juices, fruit drinks is encouraged,
9. food restrictions: meals should be frequent and small, exclude fatty, fried, smoked, spicy and salty foods,
10. regular sex life (not often, but by no means rare).

Also there are traditional methods varicocele treatment, which can have a positive effect in the first degree of the disease, as well as in support of surgical treatment:

All these folk remedies improve vascular tone and have an analgesic effect.

Varicocele - photo, what does varicocele look like before and after surgery?

Photo: angiography of testicular varicose veins with varicocele on the left.

Varicocele 3rd degree : varicose veins of the testicle on the left are visible to the naked eye.

And this is what it looks like postoperative suture after Marmara operation .

Varicocele complicated by lymphostasis , which led to swelling of the scrotum, dilated veins are clearly visualized.

Photo of the genital organs of a man with varicocele complicated by testicular hydrocele (hydrocele). Dilated veins are visualized on the scrotum.

And this is what they look like varicose veins during classical abdominal surgery (according to Ivanissevich).

Photo varicose veins of the testicles during laparoscopic surgery, recurrence of varicocele. Dilated veins are visible against the background of postoperative sutures. Relapse occurs due to errors during surgery.

Varicocele is a male disease caused by varicose veins of the pampiniform plexus of the spermatic cord. The disease occurs as a result of poor functioning of the venous valves, which should prevent the reverse flow of blood. The pressure in the veins increases, causing the vessels to dilate.

Surgery for varicocele is the best way to treat a fairly common disease.

Surgery for varicocele is the best treatment. Conservative therapy, according to scientific data, is considered ineffective.

Indications

Varicocele of 1st degree, as well as dilatation of the scrotal vein of 2nd degree, do not require surgical intervention. Only observation by a surgeon and urologist for 6 months is enough, especially for boys 12-14 years old.

Removal of grade 3 varicocele is considered necessary if there are indications such as:

palpation of dilated veins;
constant pain of varying intensity;
decreased spermatogenesis;
enlargement, swelling, sagging of the scrotum.

Long-term stagnation of venous blood leads to complications: testicular atrophy, sclerotic changes, ischemia, and subsequently to a decrease in sperm production and the development of infertility.

Types of operations for varicocele

Traditional surgical treatment for varicocele consists of cutting and ligating the dilated spermatic vessel.

There are several methods and modifications of treatment:

Ivanissevich method;
Marmar operation;
Yakovenko operation;
Bernardi operation;
endovascular occlusion of the testicular vessel with varicocele;
laparoscopic varicocelectomy.

Let's look at the most common methods in more detail.

Operation Marmara

The second name of the operation is microsurgical varicocelectomy. The essence of the operation is the excision and ligation of the affected veins. An andrologist makes an incision in the groin area, its length is no more than 2 cm. The spermatic cord is removed and the veins are ligated. The operation in men is performed under a special microscope using microsurgical instruments, then the wounds are sutured layer by layer with a cosmetic suture.

Operation Ivanissevich

This surgical treatment is the most traumatic and ineffective as a result of the frequent occurrence of postoperative relapses and complications.

Ligation of the vessel to eliminate reverse blood flow is done under general anesthesia by cutting a 5 cm long layer of skin in the iliac region, cutting the fascia and the walls of the canal in the groin. The patient is hospitalized in the hospital for a period of 2 weeks.

Operation Palomo

Removal of varicocele using the Palomo method is a modification of the Ivanissevich operation. The incision is made slightly higher. In this case, the skin, skin tissue, fascia, and abdominal cavity are dissected layer by layer, the seminal vessels are found, the vessels and arteries are crossed and ligated. The wound is stitched up.

Laparoscopy

Laparoscopic surgery refers to progressive methods of treating testicular varicocele using a special thin laparoscope tube, including a lens, eyepiece or manipulator for examining internal organs. The duration of the procedure depends on the degree of the disease and takes 30-60 minutes. The method is often used for the immediate elimination of 2-sided varicocele.

Endoscopy

Endoscopy of varicocele is a method of diagnostic examination of testicular veins using an endoscope and endosurgical instruments.

An endoscope is a special optical lighting device consisting of a tube, a light source, a mini-camera, and attachments for taking samples if necessary.

This method of getting rid of varicocele allows minimal tissue trauma and reduces pain after surgery.

Sclerotherapy

Sclerotherapy for varicocele is the introduction of a sclerosant into the spermatic vein, causing the lumen of the vein to close due to the proliferation of connective tissue.

The procedure involves inserting a needle or plastic catheter. First, a radiopaque substance is injected, a picture is taken, then a sclerosant is used, which destroys the inner wall of the spermatic vein. The catheterized vein is ligated and divided.

Embolization

Endovascular surgery involves installing a catheter through the right femoral vein, then through the renal vein into the seminal vessel, followed by the introduction of a contrast agent and the examination. During this procedure, it is necessary to exclude narrowing of the renal vein. An embolization coil is inserted through the catheter to block blood flow.

Preparing for surgery

Before the operation, the following tests and examinations are prescribed:

tests for AIDS, syphilis, hepatitis B and C;
coagulogram;
blood type and Rh factor;
blood biochemistry;
general blood analysis;
general urine analysis;
cardiogram;
spermogram (ejaculate analysis);
Ultrasound and Doppler ultrasound of the scrotal organs.

Some tests before surgery have a shelf life of only 15 days, tests for RW, HIV - up to 3 months.

To determine treatment tactics, studies such as:

renal-testicular venography;
transscrotal testicular phlebography.

In severe cases, antegrade venography is prescribed.

It is mandatory to undergo an examination by a therapist and undergo fluorography.

Immediately before removing the varicocele, you need to take a shower and shave your genitals. Experts recommend not taking food or water for 12 hours to avoid a number of complications after general anesthesia.

How the operation is performed

The course of the operation directly depends on the method of treating varicocele.

The most effective, safe and affordable way is to eliminate venous dilatation according to Marmar. This method is characterized by minimal tissue trauma compared to other approaches, low invasiveness, and the smallest number of relapses and complications.

At the first stage, pain relief is performed in the form of local anesthesia. To reduce the patient's anxiety, mild premedication is used.

The treatment technique for varicocele is as follows:

The surgeon dissects the skin layer, tissue, and fascia with a scalpel, separates the tissue with mini-retractors, presses small vessels and drains the wound.
Anesthesia is injected under the levator testis muscle.
The doctor finds the spermatic cord and secures it with 2 clips. At this stage, specialists use a special optical system for improved visualization of the wound and precision of manipulation.
Dilated veins are tied with silk threads and dissected.
To reduce vasospasms and prevent intraoperative testicular ischemia, a solution of papaverine hydrochloride is used. The surgical field is irrigated with this product and the condition of the applied ligatures is checked.
The patient should close his mouth, pinch his nose, strain and exhale. This action is necessary to increase intra-abdominal pressure and enhance the filling of blood vessels. Then the Valsalva maneuver is administered and the wound is carefully inspected to identify undetected vessels.

The patient should be under medical supervision for several days.

How long does it last

Depending on the method and method of treating varicocele, the operation time can vary from 30 minutes to 1-2 hours.

Features of the operation in children

Surgical intervention for varicocele in children is undesirable for a number of reasons:

the frequency of varicocele recurrences is higher than in adulthood;
dysfunction of the right or left testicle;
possible irreversible complications and consequences.

Adolescents with varicocele are prescribed maintenance drug therapy. The doctor himself calculates the frequency, time of administration and dosage of drugs.

Surgical procedures can only be performed after puberty.

What not to do after surgery

The postoperative period is the recovery of the body and rehabilitation after surgery. The duration and characteristics of the period depend on the method of treatment for varicocele.

you cannot engage in physical exercises, sports, or lift weights;
Cycling is contraindicated for 1 month;
Do not remove the bandages or get them wet for 48 hours after treatment of varicocele;
do not use antibiotic ointment without your doctor’s permission;
Sexual activity is prohibited for the first 14 days;
Bathing procedures are contraindicated for 5 days;
You cannot visit saunas or baths.

The patient should lie down as much as possible for 24 hours. Only after the first day can he move and take walks for better blood flow.

How much does surgery for varicocele cost?

The cost of the procedure for removing varicocele depends on the region, city, level of the clinic, and methodology.

Cost of surgery according to Ivanissevich:

in Moscow - 18 thousand rubles;
in St. Petersburg - 9-20 thousand rubles;
in Novosibirsk - 10 thousand rubles;
in the regions of Russia - 5-7 thousand rubles.

Prices for treatment of varicocele using the Marmara method:

in Moscow, St. Petersburg - 28-48 thousand rubles;
in the regions of Russia - 18 thousand rubles.

Endoscopic treatment in Moscow costs 44 thousand rubles, in St. Petersburg - 25 thousand rubles.

Varicocele. Male disease

Technique for performing Marmara surgery for varicocele

Operation Ivanissevich

In the final stages of varicocele, surgery is the only effective treatment method. But surgery for varicocele is tolerated quite easily, without causing complications in most clinical cases.

Indications

Surgery is indicated in a number of cases:

Decreased spermatogenic function, which was revealed during a laboratory examination.
The occurrence of pain, which becomes more intense after physical activity. Similar symptoms are typical for patients with grade 3 varicocele.
There is a decrease in testicle size.
If the patient is not satisfied with the aesthetic appearance of the scrotum.
With bilateral varicocele in children.

Most often occurs when the left testicle is affected.

In the absence of symptomatic signs of the disease, doctors do not recommend removal, because they consider this radical method of treatment unjustified. But some of them believe that in order to avoid progression of the pathological process, surgical intervention is already necessary for grade 1 varicocele.

Kinds

Methods of surgical intervention are classified according to technology:

With preservation of the communication bridge (reno-caval shunt) between the veins of the testicles.
With its removal. Recognized as more effective.

There is also a classification based on the method of access to the affected area.

Operation Marmara

This method has a low degree of invasiveness. Microsurgical subinguinal varicocelectomy () can be performed under local anesthesia, during which men experience minor pain.

After surgery, the risk of developing testicular hydrocele is reduced. But the disadvantages are the long duration and high cost of the procedure, and the risk of injury to the testicular artery.

Operation Ivanissevich

During surgery for varicocele, the dilated veins of the scrotum are ligated while preserving the lymphatic vessels in the inguinal groin.

Local anesthesia is allowed. Surgical treatment using this method is effective in 90% of cases.

Operation Palomo

The essence of the operation is similar to the elimination method described above. To avoid repeated exacerbations, the internal spermatic artery is ligated, which can cause disruption of blood flow in the testicular parenchyma.

To reduce the risk of damage to the lymphatic vessels supplying blood to the seminal canal, they are stained: a special substance is injected with a needle into the testicular tissue.

Microsurgical operation for varicocele. Dr. Seymur Mehdiyev (2016)

Varicocele: Surgery

Varicocele. Operation Marmara

Laparoscopy

The name comes from the Greek words laparos - belly and scopo - looking at.

To eliminate testicular varicocele, local anesthesia or epidural anesthesia is used (anesthetic is injected into the spinal area).

Clips are applied to the internal spermatic vein.

During surgery, the pelvic organs may be damaged.

Endoscopy

The procedure technique does not involve an incision in the groin area. The method is effective for bilateral varicocele.

A puncture is made in the peritoneum, through which an endoscope is inserted (thanks to it, the doctor receives an image on the monitor) and the necessary instruments. The veins are tightened with titanium staples followed by cutting off.

Rehabilitation lasts several weeks.

Sclerotherapy

No hospitalization required. On the day of surgery, the patient can go home.

Embolization

Endovascular surgery consists of making a puncture in the thigh, where a catheter is inserted through the renal vein into the spermatic vein. Then a substance is injected that promotes the formation of a blood clot in the dilated vein. At this stage, the patient may experience pain.

The main advantage of the method is to reduce the number of relapses after surgery due to preliminary examination of the veins and thrombosis of additional branches.

Preparing for surgery

The urologist may prescribe a laboratory examination, which includes a number of procedures:

Blood chemistry. The surgeon is interested in the group and Rh factor, an indicator of sugar and clotting.
Analysis of urine.
Electrocardiogram (at 30 years and older).
Detection of hepatitis B and C viruses.
Ultrasound of the scrotum.

Before starting surgical treatment, it is prohibited to consume water and food. Water treatments are mandatory. The intimate area and belly must be shaved.

How the operation is performed

The technique depends on the type of surgical intervention for varicocele:

- Surgical intervention according to Marmar consists of making an incision in the pubic area. The surgeon then ties the vein and stitches it. The procedure is carried out using magnifying magnifying lenses placed in front of the doctor. This reduces (but does not completely eliminate) the risk of accidental damage to nerves or arteries. Additionally, a Doppler sensor is used, which allows you to accurately determine the type of vessels and perform ligation of only the veins.
- The Ivanissevich operation includes the following manipulations: an incision about 5 cm long is made, and then, using blunt curved scissors, the doctor grabs the choroid plexuses and ties them. The wound is sutured in layers. The recovery period is long.
- Yakovenko's operation is carried out similarly to the Ivanissevich method, but ligation of the veins is carried out according to the projection at the level of the scrotum.
- Bernardi's operation involves ligating the dilated veins at the level of the internal ring of the inguinal canal. The artery is not damaged.
- Bypass surgery (creating an additional path for blood outflow from the testicle, bypassing the renal vein) involves sewing the spermatic vein into the femoral vein. But in most clinical cases, shunt thrombosis is observed.

How long does it last

1. For open surgical procedures - about an hour.
2. For laparoscopy or endoscopy - about half an hour.

But it is important to consider the severity of the disease.

Features of the operation in children

Surgery for varicocele in boys is undesirable for a number of reasons:

The frequency of repeated exacerbations is greater than in adulthood.
The functioning of the testicles is impaired.
The consequences may be irreversible.

The patient is prescribed maintenance drug therapy. The frequency, time interval and dosage of drugs is prescribed by the doctor.

Surgery for varicocele is recommended after puberty.

Only with bilateral varicocele can the surgeon recommend not waiting for the start of sperm formation. In this case, the doctor resorts to an endoscopic technique to eliminate the defect.

What not to do after surgery

Within 14 days it is prohibited:

Engage in sports that require excessive physical exertion.
To take a bath.
Be sexually active.

Radical methods of treatment for varicocele do not have a negative effect on erectile function, therefore it is not contraindicated after the indicated, if the patient does not feel discomfort: nagging pain, stinging, tingling. But in the first month it is necessary to limit the number of sexual acts to 1 time per week. It is worth waiting for the wound to heal completely.

If difficulties arise in the sexual sphere 3 months after the removal of varicocele, then you should consult a doctor.

How much does the operation cost?

The facts show the following:

Varicocele is not treated under compulsory medical insurance. This is just a discount.
Sclerotherapy for varicocele will cost 20-30 thousand rubles.
Laparoscopy is estimated at 15-25 thousand rubles.
You will have to pay additionally for anesthesia.

In provincial cities of Russia, you need to pay about 6 thousand rubles for open surgical intervention, and in Moscow - 8-10 thousand rubles.

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