Varicocele Surgery

A varicocele is an abnormal dilatation and tortuosity of the pampiniform plexus of veins within the spermatic cord, caused by venous reflux due to incompetent or absent valves in the testicular vein.

Epidemiology:

Common (≈15% of men, up to 40% in infertile men).

Usually left-sided (due to perpendicular drainage of left testicular vein into left renal vein).

Right-sided or sudden-onset varicocele → suspect retroperitoneal mass/renal tumor compressing IVC or renal vein.

Pathophysiology

Venous reflux → increased scrotal temperature, hypoxia, and toxin accumulation → impaired spermatogenesis → infertility.

Clinical Features

• Often asymptomatic.
• Dull aching scrotal pain, heaviness (worse on standing, relieved by lying down).
• Infertility.

Signs:

• “Bag of worms” feel above testis, more prominent on standing and with Valsalva maneuver.
• Grading:  Grade I: Palpable only on Valsalva.
•  Grade II: Palpable without Valsalva, not visible.
• Grade III: Visible through scrotal skin.
• Testicular atrophy in long-standing cases.

Diagnosis

Clinical examination (standing, supine, Valsalva).

Scrotal Doppler ultrasound: gold standard for confirmation (reflux, vein >3 mm).

Semen analysis: to assess infertility.

Renal ultrasound/CT: in isolated right-sided varicocele or sudden-onset in older patient (to rule out secondary cause).

Management

1. Conservative

Asymptomatic, normal semen analysis → observation.

2. Indications for treatment

• Infertility with abnormal semen parameters.
• Symptomatic (pain, heaviness).
• Testicular atrophy (especially in adolescents).

3. Definitive treatment options

• Microsurgical subinguinal varicocelectomy (gold standard; least recurrence, best fertility outcomes).
• Inguinal or retroperitoneal (Palomo technique).
• Laparoscopic varicocelectomy.
• Percutaneous embolization/sclerotherapy (radiological).

Complications

• Infertility.
• Testicular atrophy.
• Recurrence after surgery.
• Hydrocele (common complication of surgery if lymphatics are damaged).