Clinical Conditions

Varicocelectomy is the most common operation performed for male infertility.

Varicocele is found in approximately 10-15% of unmarried military recruits, 35 % of infertile men who have never fathered a child and 81 % of men who were once fertile but are now infertile (secondary infertility).

Figure 1. A: The large varicocele can be seen through the scrotal skin. B: Illustration of a patient with a large left-side varicocele

Repair of varicocele will halt any further damage to testicular hormone function and in a large percentage of men, result in improved spermatogenesis, as well as enhanced Leydig cell function. The potentially important role of urologists in preventing future infertility underscores the importance of utilizing a varicocelectomy technique that minimizes the risk of complications and recurrence.

Today the many techniques for varicocelectomy include retroperitoneal, inguinal, and subinguinal varicocele repairs with and without magnification, laparoscopic repair, and percutaneous varicocelectomy with radiographic embolization of the internal spermatic veins.

Figure 2. Retroperitoneal, inguinal, and subinguinal incisions for varicocele repairs. A dot is made to mark the external inguinal ring (X).

The open surgical procedures can be performed with loupe or microscope magnification. The advantages of the microsurgical approach to varicocele repairs are reliable identification and preservation of the testicular artery or arteries, cremasteric artery or arteries, and lymphatic channels and reliable identification of all internal spermatic veins and gubernacular veins. Delivery of the testis assures direct visual access to all possible routes of venous return, including external spermatic, cremasteric, and gubernacular veins. Postoperatively, venous return is via the vasal veins, which drain into the internal pudental system and usually have competent valves.

Figure 3. Skin incision of varicocelectomy. The size of the testis governs the size of the skin incision. A small testicle can be delivered comfortably through a 2.0 to 2.5 cm incision, while large testicle can comfortably delivered through a 3.0 to 3.5 cm incisions.

Figure 4. Maneuver used to expose the spermatic cord in a subinguinal varicocelectomy. An ݩndex finger is hooked under the external inguinal ring while a small Richardon retractor is slid along the dorsum of the index finger and pulled in the opposite direction. With gentle traction the cord is exposed and encircled with a Babcock clamp.

The goals of varicocele repair are to relieve pain in symptomatic cases and to improve semen parameters, testicular function, and pregnancy rates in couples with male factor infertility associated with varicocele. Studies have shown that varicocele repair can improve all three of these parameters. Varicocele repair results in a significant improvement in semen analysis in 60 to 80 percent of men. Men with large varicoceles have poorer preoperative semen quality than men with small varicoceles, but repair of large varicocele results in greater improvement than repair of small or moderate sized varicoceles. In infertile men with low serum testosterone levels, microsurgical varicocelectomy has been shown to improve serum testosterone levels. In a controlled trial of varicocele repair in infertile men that compared surgery versus no surgery, the surgery group revealed a pregnancy rate of 44 percent at one year compared to 10 percent in the no surgery group.

Marc Goldstein, M.D. with his operating microscope at the New York Hospital-Cornell Medical Center

Using the microsurgical technique (Goldstein, et al. J. Urol 148:1808-1811, 1992) at New York Hospital-Cornell Medical Center, in 1,500 men who underwent microsurgical varicocelectomy, the couples' pregnancy rate was 43 % after one year and 69% after 2 years compared to 16% in couples with men who declined surgery and had hormone treatment or used insemination.

There have been only 14 recurrences (1%), no hydrocele, no testicular atrophy, and a 1% incidence of inadvertent unilateral (one side only) testicular artery ligation.

Figure 5. The gubernacular vein and external spermatic perforators. Delivery of the testicle enables the surgeon to identify and ligate these vessels, which are responsible for some varicocele recurrences. Once all external spermatic perforators and gubernacular veins have been divided, the testicle is retruned to the scrotum and the spermatic cord remains elevated over a large Penrose drain for stabilzation in preparation for microscopic examination.

Figure 6. Under the operating microscope, the spermatic cord is examined. The internal and external spermatic fasciae are incised longitudinally and retracted with the straight clamps.

Figure 7. The artery is microscopically dissected free of all surrounding tissue, tiny veins and lymphatics, using a fine-tipped, microsurgical needle holder and forceps. The pulsation of suspected artery is evaluated by seeing a pulsating column of blood appears just over the needle holder. Then, a 0-silk ligature is encircled for identification and preservation of artery.

The method of varicocele repair influences the chances of a poor outcome or complications. Use of a microscope enables a surgeon to find and preserve the tiny artery that brings blood to the testes. Magnification also allows identification and preservation of the lymphatics, eliminating the risk of hydrocele (bag of water forming around the testis) after surgery.

Figure 8. Periarterial veins are lighted with 4-0 silk ligature. Hemoclips placed on the internal spermatic veins.

Figure 9. Lymphatic are clearly identified and preserved, under the operating microscope ( magnification 15x)

Figure 10. Skin incision at the termination of the procedure. After the incision has been infiltrated with Marcaine solution with epinephrine, it is closed with a 5-0 Monocryl subcuticular closure with reinforced with Steri-strips. 

Finally, the newer methods can be done less invasively through tiny cuts (one inch or less) and almost always as an outpatient procedure. Expert radiologists can also fix varicoceles by putting balloons in the abnormal veins, through small cuts in the upper thigh, although this method takes longer and has a significant higher failure rate. Laparoscopy, so commonly used in female infertility, can also be used in men to repair varicoceles successfully. At Cornell, we have stopped using laparoscopy to fix varicoceles because it is more invasive than our microsurgical method and risks injuring organs inside the abdomen.

In summary, varicoceles are identified in 35% of men with primary infertility and 81% of men with secondary infertility. Studies have shown that varicocele causes progressive duration-dependent injury to the seminiferous epithelium. Varicocele repair is thought to halt this duration-dependent process.

Table. Techniques of Varicocelectomy

Technique Artery Preserved Hydrocele
(%)
Failure
(%)
Potential for Serious Morbidity
Retroperitoneal NO 7 15–25 NO
Conventional Inguinal NO 3–30 5–15 NO
Laparoscopic YES 12 5–15 YES
Microscopic Inguinal YES 0 1 NO

The most common complications from varicocelectomy are hydrocele, varicocele recurrence, and testicular artery injury. Use of the operating microscope allows for reliable identification of spermatic cord lymphatics, internal spermatic veins and venous collaterals, and the testicular artery or arteries so that the incidence of these complications can be reduced significantly. Delivery of the testis through a small subinguinal incision provides direct visual access to all possible avenues of testicular drainage. In addition, men with larger varicoceles have poorer preoperative semen quality, but repair of large varicoceles results in greater improvement (128% increase in motile sperm) than repair of small varicoceles (27% increase.) Microsurgical varicocelectomy provides a safe and effective approach to varicocele repair with preservation of testicular function, improvements in semen quality, and improvements in pregnancy rates in a significant number of men.

Suggested References

1. Goldstein M., Gilbert BR, Dicker AP, Dwosh J, Gnecco C: Microsurgical inguinal varicocelectomy with delivery of the testis: An artery and lymphatic sparing technique. J. Urol 148:1808-1811, 1992

2. Mattews, GJ., Matthews, ED., Goldstein, M: Induction of spermatogenesis and achievement of pregnancy after microsurgical varicocelectomy in men with azoospermia and severe oligoasthenospermia. Fertil Steril, 70 (1):71-75, 1998.

3. Marmar Jl, Kim Y: Subinguinal microsurgical varicocelectomy: A technical critique and satistical analysis of semen and pregnacy data. J. Urol 152:1127-1132, 1994

4. Goldstein M: Surgery of Male Infertility. W. B. Sauders Company, Philadephia, 1995

5. Su LM, Goldstein M, Schlegel PN: The effect of varicocelectomy on serum testosterone levels in infertile men with varicoceles. J. Urol 154:1752-1755, 1995

6. Gorelick JI, Goldstein M: Loss of fertility in men with varicocele. Fertil Steril 59: 613-616, 1993

7. McClure RD, Hricak H. Scrotal ultrasound in the infertile man: detection of subclinical unilateral and bilateral varicoceles. J. Urol 135:711-715, 1986

8. Eskew LA, Watson NE, Wolfman N, et al: Ultrasoundgraphic diagnosis of varicoceles. Fertil Steril 60:693-697, 1993

9. MacLeod J: Seminal cytology in the presence of varicocele. Fertil Steril 16:735-757, 1965

10. Steckel J. Dicker AP, Goldstein M: Influence of varicocele size on response to microsurgical ligation of spermatic veins. J Urol 149:769-771, 1993

11. Braedel HU, Steffens J, Ziegler M, et al: A possible ontogenic etiology for idiopathic left varicocele. J. Urol 151:62-66, 1994

12. Palomo A.: Radical cure of varicocele by a new technique: Preliminary report. J Urol 61:604, 1949