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Varicocele Ligation

What is a varicocele?

A varicocele is a bundle of enlarged veins in a man`s scrotum, which is the sac that holds the two testicles. The veins are usually visible as lumps on the scrotum and feel like a bag of worms when massaged gently. The veins become enlarged because some of the tiny valves inside the veins don`t close properly. The valves normally prevent blood from draining backwards. When the valves fail, blood pools in the veins, causing them to swell. Many men don`t realise they have a varicocele because the veins typically don`t hurt and don`t change the feeling of orgasm or ejaculation.

How common are varicoceles?

About 20% of the male population have some kind of varicocele. Varicoceles are probably the result of very subtle genetic effects which, at present, remain unknown. Sometimes varicoceles begin to form in the teen years, which is cause for concern. Untreated adolescent varicoceles can result in under-sized testicles, lower semen volumes, and lower sperm counts.

But varicoceles can happen at any age…and in general, the older you are the more likely you are to have a varicocele.

How does a varicocele affect my fertility?

Sperm are made in the testicles, which hang in the scrotum away from the body. This design is required because testicles need to be slightly cooler than normal body temperature to make sperm. Anything that warms the testicles will hurt sperm production. This is what a varicocele does. The extra blood pooling in the enlarged veins warms the nearby testicle unnaturally and cuts sperm production.

How are varicoceles diagnosed?

Since they seldom cause any pain or discomfort, most varicoceles are discovered during routine physical exams, or exams associated with an infertility work-up. Urologist typically diagnose varicoceles by asking the man to stand up, take a deep breath, and bear down while the physician feels the scrotum above the testicle. If a varicocele is suspected, the urologist may order a scrotal ultrasound test.

How can a varicocele be fixed?

Varicocele repair surgery is relatively simple. The goal is to locate the distended veins and tie them off to prevent blood from pooling. There are three main surgical techniques used to correct a varicocele and one non-surgical technique. Which method is best depends on the particulars of a man`s anatomy, the nature and location of the varicocele, whether previous surgery has been performed, and other factors such as surgeon preference and/or amount of experience.


Most commonly, surgery is performed through a single incision in the lower abdomen on the affected by the varicocele or laparoscopically through a 1cm incision inside the umbilicus and 2 more incisions less than 0.5cm in the lower abdomen. Complications from varicocele repair are rare, but include the persistence or recurrence of the varicocele, formation of a fluid-filled space called a hydrocele, and injury to the testicular artery.

The affected veins are ligated, or tied off, to detour the flow of blood into normal veins. Sometimes a laparoscope is used to perform the surgery. Recovery time depends on the type of surgery, but most patients require up to six weeks before heavy lifting and other strenuous activities can be performed. Light activities may be resumed more quickly.

As many times the condition is bilateral, then the laparoscopic approach might be suggested.  A small 1cm incision is made through the belly button and 2 other (0,5cm) one laterally. It is virtually painless and scar-less and the result is the same. Recovery time is less than 1 week.

The non-surgical procedure for varicocele repair is called percutaneous embolisation and it is much less commonly used than surgery. In this procedure a special tube is inserted into a vein in either the groin or neck and guided to the varicocele. Once in position, a tiny coil or balloon is released that blocks the veins.

What are the advantages of varicocele embolisation vs varicocele surgery?

Unlike varicocele surgery, embolisation requires no incision, stitches, or general anaesthesia. Further, embolisation patients almost never require overnight admission to the hospital. In addition, several studies have shown that embolisation is just as effective as surgery. Studies have also shown that with embolisation, patients return to full activities in a day or two, but varicocele surgery patients may need to avoid strenuous activity for several days or even weeks. Some complications of varicocele surgery, such as hydrocele (fluid around that testicle) and infection are virtually unheard of after embolisation. Minor complications such as bruising at the catheter site, nausea or low-grade backache may occur after embolisation but are uncommon.

Do I need any special tests before surgery?

No special preoperative tests are needed before a varicocele repair other than the standard lab tests required by some hospitals.

What type of anaesthesia is used?

Varicocele repair is performed under general anaesthesia because it affords maximum patient comfort during the surgery.

What should I expect after surgery?

Varicocele surgery is usually done as a day case procedure, and recovery is usually rapid. Pain is usually mild. Swelling around incisions usually goes away after several days, and discoloration of the scrotum will resolve in a week or so. You shouldn`t lift anything heavy or exercise strenuously for two weeks, although office work can typically be done one to two days after surgery.

How soon can I have sex after surgery?

It is generally best to wait three weeks after the surgery before resuming any type of sexual activity.

When will I know if the surgery was successful?

If the procedure is performed for infertility, It takes about three months for sperm cells to be created and matured. A follow-up semen analysis is thus usually obtained three to four months after the surgery. The physician will evaluate the number and health of the sperm and compare this with a sample taken before the procedure. Improvement is often seen within six months, but may not be observed until one year after the surgery. Semen quality is improved in about 60 percent of infertile men undergoing correction of a varicocele.

What are my options if the repair doesn`t solve the problem?

If a man`s semen quality does not improve after varicocele repair, and if other potential sources of infertility are ruled out (such as an infection in the reproductive tract) several options remain to allow the man to father children. One option involves taking healthy sperm from a man`s ejaculate and using this for in-vitro fertilization (IVF). If a man has no sperm in his ejaculate, sperm may still be obtained through a minor surgical procedure (sperm retrieval) which extracts sperm directly from the testicles and/or epididymis.


Varicocele Embolistion

Introduction

This leaflet tells you about the procedure known as varicocele embolisation, explains what is involved and what the possible risks are. It is not meant to be a substitute for informed discussion between you and your doctor, but can act as a starting point for such discussion. The varicocele embolisation is likely to be done as a pre-planned procedure, and you should have had plenty of time to discuss the situation with your urologist and the radiologist who will be doing the procedure, and perhaps even your own GP, before you sign the consent form.

What is a varicocele embolisation?

A varicocele is an abnormality of the veins that take blood away from the testicle. he veins become bigger and more obvious, rather like varicose veins in the leg. Embolisation is a way of blocking these veins, and therefore making them less obvious and causing the varicocele disappear, without an operation.

Why do I need a varicocele embolisation?

Varicocele can cause various problems, including intertility. In the past, an open operation would have been necessary to get rid of the varicocele, but now it can be treated by the technique of embolisation.

Who will be performing the varicocele embolisation?

A consultant interventional Radiologist. Radiologists are trained in using x-ray equipment, and also in interpreting the images produced. They need to look at these images while carrying out the procedure.

Where will the procedure take place?

In the x-ray department, in a special "screening" room, which is adapted for specialised procedures.

How do I prepare for varicocele embolisation?

You need to be an in-patient in the Surgery Day Case Unit. You will probably be asked not to eat for four hour before hand, though you may be told that it is alright for you to drink some water. You may receive a sedative to releave anxiety. You will be asked to put on a hospital gown. As the procedure is generally carried out using the big vein in the groin, you ma be asked to shave the skin around this area. If you have any allergies, you must let your doctor know. If you have preiviously reacted to intravenous contrast medium, the dye used for kidney x-rays and CT scanning, then you must also tell your doctor about this.

What actually happens during varicocele embolisation?

You will lye on the x-ray table, generally flat on your back. You will have a monitoring device attached to your chest and finger, and may be given oxygen through small tubes in your nose The radiologist will keep everything as sterile as possible, and will wear a theatre gown and operating gloves. The skin near the point of insertion, probably the groin, will be swabbed with antiseptic, and then most of the rest of your body covered with a theatre towel. The skin and deeper tissues over the vein will be anacsthetised with local anaesthetic, and then a needle will be inserted into the large vein in the groin. Once the radiologist is saticfied that this is correctly positioned, a guide wire is placed through the needle, and into the vein. Then the needle is withdrawn alowing a fine plastic tube, called a catheter, to be place over the wire and into the vein. The radioogist uses the x-ray equipment to make sure that the catheter and the guid wire are moved into the right posistion, into the variococele, and then the wire is withdrawn. The radiologist can block the abnormal veins, either by injecting a special fluid down the catheter, or by passing down small metal coils. These metal coils are like small spings, and cause the blood around then to clot and conciquently block the vein. The radiologist will inject small amounts of special dye, called contrast medium, down the catheter, to check that the abnormal veins are being block satisfactorily. Once they are blocked completely, the catheter will be removed. The radiologist will then press firmly on the skin entry point for several minutes, to prevent any bleeding.

Will it hurt?

When the local anaesthetic is injected, it will sting to start with, but this soon passes off, and the skin and deeper tissues should then feel numb. After this, the procedure should not be painful. There will be a nurse, or another member of staff, standing next to you and looking after you. If the procedure does become uncomfortable for you, then they will be able to arrange for you to have some pain killers through the needle in your arm. You will be awake during the procedure, and able to tell the radiologist if you feel any pain, or become uncomfortable in any other way.

How long will it take?

Every patient situation is different, and it is not always easy to predict how complex or straightforward the procedure will be. Generally, the procedure will be over in about half an hour, but you may be in the x-ray department for about an hour or so.

What happens afterwards?

You will be taken back to your ward on a trolley. Nurses on the ward will carry out routine observations, such as taking your pulse and blood pressure, to make sure that there are no untoward effects. They will also look at the skin entry point to make sure that there is no bleeding from it. You will generally stay in bed for a few hours, until you have recovered. You may be allowed home on the same day, or kept in hospital overnight.

Are there any risks or complications?

Variococele embolisation is a very safe procedure, but there are some risks and complications that can arrise. There may occasionally be a small bruise, called a haematoma around the site where the needle has been inserted, and this is quite normal. If this becomes a large bruise, then there is the risk of it getting infected, and this would then require treatment with antibiotics. Very rarely, some damage can be caused to the vein by the catheter, and this may need to be treated by surgery or another radiological procedure. Unfortunatley, there is always the possibility that although the variococele seems to have been cured to start with, months or even years later, it may come back again. If this happens, then the procedure may need repeating, or you may be advised to have an operation. Dispite these possible complications, the procedure is normally very safe, and is carried out with no significnt side effects at all.


Finally....

Some of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion about your treatment with the doctors looking after you. Do satisfy yourself that you have receive enough information about the procedure, before you sign the consent form.

Varicocele embrolisation is considered a very safe procedure, designed to prevent you having a larger operation. There are some slight risks involoved, and although it is difficult to say exactly how often these occur, they are generally minor and do not happen very often

Attention! The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with your physician for further evaluation.

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