Operations for the treatment of varicocele. Surgery for varicocele: what types of operations exist and how are they done? Endoscopy of varicocele

Endoscopic surgery in the treatment of varicocele is an innovative method of surgical intervention, which differs from open operations by minimal risks, a quick recovery period and rare cases of complications. Today, endoscopic operations are usually used by doctors in practice for the surgical treatment of many diseases.

Method features

The main purpose of endoscopic treatment of varicocele, as with traditional, open operations- ligation or complete excision of the damaged vein. Unlike open operations that were used previously, endovascular treatment of varicocele has a number of advantages and is characterized by minimal risks of injury to adjacent, healthy blood vessels and soft tissues.

Endoscopic operations, which is especially important for the patient, have a short rehabilitation period. Thanks to the use of this innovative method of surgical intervention, the man does not have to stay for a long period in the hospital under the supervision of doctors and go through a difficult recovery period.

In the absence of any complications, the patient remains in the hospital for 2-3 days. The use of the endoscopic method makes it possible to successfully carry out simultaneous treatment of varicocele on both testicles, which previously required a lot of time during open operations, and for a man this was fraught with long rehabilitation.

For varicocele, endoscopic surgery is performed using general anesthesia. The pathology goes away immediately as soon as the doctor has bandaged or completely excised the affected area of the vein. What exactly is needed? Ligation or complete removal depends on the degree of damage to the blood vessel and the ability to leave the vein without the risk of possible complications.

Endoscopy surgery does not require a cavity incision. The surgical instrument is inserted through a small puncture in the skin; there will be 2 such punctures in total: the second is intended for the insertion of special equipment - an endoscope equipped with a camera at the end that transmits the image to the screen.

The testicular vein is clamped using special medical clamps made of titanium. After the operation, there will be no trace left on the skin at the puncture site, and the absence of a cavity incision promotes rapid healing and recovery.

Endoscopy surgery does not eliminate the risk of complications, but in comparison with open surgical operations, they are minimal. And risks can be minimized proper preparation to surgery and choosing a qualified surgeon. Among possible complications after endoscopic treatment of varicocele, the formation of dropsy or a recurrence of the disease is noted if the doctor decides to leave the affected vein and simply clamps it with a staple.

In what cases is surgery performed?

In the treatment of any disease surgical intervention, even minimally invasive procedures are postponed until the last minute. First of all, the doctor prefers to solve the problem using conservative methods. And in this case, treatment will be much easier and faster if a person remembers the need for a timely medical examination, and the disease was diagnosed in the early stages of development.

Any surgical intervention, even one as highly effective and safe as endovascular surgery, is always a risk, and the doctor undertakes it only if it justifies itself. In what cases is surgical intervention indispensable:

diagnosable male infertility;
constant pain syndrome;
abnormalities in the structure of the genital organs.

Varicocele, when the disease worsens, can cause male infertility, and the problem can only be solved in a radical way- surgical. Just a few years ago, operations for varicocele were performed even in cases where the signs of the disease were not pronounced and did not bother the patient. It was believed that this was the only way to prevent male infertility.

Today, it has been proven in a practical way that clamping the testicular vein without indications has no prophylactic meaning, but can cause even greater complications if errors are made during the operation. Today, endoscopic treatment of varicocele is carried out only when a thorough diagnosis has confirmed that this pathology is the cause of infertility in a man.

Another indication for surgery is moderate to severe severity of symptoms of the disease. The only way to cure a disease with medicine is to initial stages, but this will only be successful if the disease is diagnosed in the absence of a pronounced clinical picture. If a man has constant pain and other unpleasant manifestations of varicocele, and taking medications gives only a short-term effect, endoscopic surgery is performed.

Varicocele, embolization of which involves artificial thrombosis of the affected vein, is the most effective, modern method surgical intervention, with a number of advantages, the main ones being the absence of complications and a stable successful outcome.

Preparing for surgery and possible difficulties

A favorable outcome from surgery depends on how thoroughly the patient prepares for the surgical procedure. Before the operation, a man must undergo a number of medical tests:

for HIV, AIDS;
determination of blood group and rhesus;
coagulogram;
urine and blood tests;
electrocardiogram;
spermogram.

If the patient has chronic diseases, the doctor can individually prescribe a test additional tests. Before the actual operation, the patient is given an anesthetic injection. There will be 3 punctures in the skin, and the diameter of each does not exceed 1 mm. A puncture for inserting an endoscope is made near the navel. The image of everything that is happening is broadcast on the screen, which allows the doctor to act accurately and without making a abdominal incision in the abdominal cavity.

No matter how safe and highly effective endoscopic surgery is, there is always a risk of complications. It is connected with the fact that when the testicular vein is compressed at the site of its lesion, the pathological process can move to another place. Although it is worth noting that this occurs in rare cases, the patient must be mentally prepared for such a likely outcome.

Among the possible complications, the formation of dropsy cannot be excluded, and it is this complication that occurs more often than a relapse of the disease. Dropsy appears because fluid begins to accumulate between the membranes of the testicle. A complication arises due to the suppression of the reverse flow of blood. After clamping the damaged section of the vein, the blood flow is redirected through other blood vessels. When dropsy forms, it is necessary to perform repeated surgery to eliminate it.

Recurrence of the disease after endoscopy is rare, but such a complication is possible. In rare cases, to eliminate the pathology, the patient has to undergo several operations until the risks of relapse disappear. The reason for the relapse lies in the fact that the doctor did not completely tie up all the venous threads, and even if one remains, this will cause a second round of the disease.

Embolization method

Embolization of varicocele is an innovative method of treating pathology, which is by far the safest and most effective. The essence of the method is that the vein is thrombosed artificially. To perform this operation, local anesthesia is used, so recovery after the operation will be easy and quick. To perform embolization, there is no need to make abdominal incisions or large punctures.

How is embolization surgery performed to treat varicocele? First, the doctor injects the patient with a local anesthetic into a vein. There is no pain. After this, a catheter is inserted into the vein, the diameter of which does not exceed 2 mm. The doctor moves the catheter along the vein of the renal blood vessel into the spermatic artery.

The next stage is the injection of a contrast agent into the veins so that the doctor can see the condition of all vessels. When the damaged vein is detected, the immediate operation can begin: a special chemical composition- sclerosant. Its purpose is to glue the walls of a blood vessel together with the further formation of a blood clot. It is at this stage of the procedure that the patient may experience discomfort and mild pain, but it is insignificant and easily tolerated by a man.

The advantage of this type of treatment for varicocele is that the patient does not need to be in a hospital setting. All that is required of the patient is to stay in the hospital for several hours under the supervision of doctors. There is no recovery period.

The only precaution that the patient must take for some period after surgery is to limit physical exercise, since with excessive effort the blood clot can come off, and this is fraught with serious consequences. A month after the operation, the man can return to his usual lifestyle. The ban on physical activity also applies to sex.

Advantages of the method

Embolization for varicocele is an innovative method that has only recently begun to be used in urology, but it is already actively gaining momentum. The main advantage of this type of treatment for varicocele is that there is no need to stay in a hospital. The operation itself is not associated with the risk of bleeding or pain. With local anesthesia, the patient can talk to the doctor during surgery, which is important for maintaining morale. There are no scars after embolization.

There are no cases of relapse after this type of surgical treatment of varicocele. Thanks to the use of a contrast agent, the doctor is able to examine all blood vessels, and if several veins are affected, this is immediately corrected during the operation. There is no risk of damage to the seminal canals.

Another undeniable advantage of the varicocele embolization method is the ability to examine the condition of the renal vein. This is a very important stage in the diagnosis of possible complications that arise against the background of the development of varicocele, but do not have a pronounced clinical picture for a long time. Accordingly, a man may not be aware of his pathological condition.

Despite all the advantages and disadvantages of the varicocele embolization method, this procedure has a significant drawback - high cost. Clinics practice replacing the sclerosing agent by introducing microcoils into the damaged vein, which block the flow of blood through the damaged blood vessel. The use of microspirals is a very reliable and effective technique, but the cost of this method is even higher than the use of a chemical sclerosant.

Varicocele is a disease that can be cured without surgery; to do this, it is enough to undergo medical diagnosis in a timely manner, even if nothing bothers the man. In most cases, the disease is detected in late stages, as it does not have specific symptoms for a long time.

When a man is preparing for an upcoming operation for varicocele, it is natural that the question about the method of eliminating the disease is relevant for him. When choosing, you should take into account a fairly large number of factors, ranging from financial capabilities to small technical details of the operation.

But, perhaps, the most important criterion by which one should judge the advantages of one type of treatment over another is effectiveness with a low probability of complications or relapses. When eliminating the disease, endoscopy is preferable: varicocele surgery will be most useful in the case of a bilateral form of the disease, for overweight patients, in the presence of an inguinal hernia, as well as for those men who have undergone repeated surgical correction.

Quite often, patients themselves insist on laparoscopy, another name for the endoscopic technique for getting rid of varicose veins. In order to evaluate the advantages and disadvantages of endoscopy, one should clearly understand the main aspects relating to this disease, understand the principles of treatment based on the causes of its occurrence, and take into account the most commonly used methods for eliminating the disease.

This article is devoted to a description of the treatment of varicocele using the endoscopic method, taking into account modern surgical practice. The reader will find for himself everything he needs to know about laparoscopy: preparation for surgery, technique, recommendations for rehabilitation and other important points.

What is important for the patient to know

Varicocele is a varicose inflammation of the vessels of the spermatic cord and epididymis, caused by increased pressure in the vessels of the scrotum. This disease is quite common among men, especially at a young age during puberty.

The presence of deformed vessels does not pose a threat to the patient’s life, but can cause significant discomfort due to pain in the scrotum. The main danger lies in processes that significantly aggravate the course of spermatogenesis.

Therefore, stages of the disease, starting from the second, cause the development of infertility, decreased potency and endocrine disorders in the body. More details about pathological processes and their consequences are contained in Table 1.

Table 1. Negative phenomena caused by the disease and their impact on the male body

Pathology	a brief description of	Result of negative impact
Hyperthermia of the scrotum	The presence of varicose vessels affects an abnormal increase in temperature in the scrotum, which affects the processes of meiosis not only in the patient, but also in the healthy testicle.	Suppression of spermatogenesis.
Hypoxia	Reflux, slower blood flow and stagnation in deformed vessels cause deterioration of trophism and disruption of gas exchange in testicular tissue, which leads to destructive processes.	Testicular atrophy.
Violation of hormonal secretion	Hypoxia and, especially, testicular atrophy affect changes in the functional activity of secretory Leydig cells that produce testosterone. With blood reflux, adrenal steroid hormones are delivered to the testes, which also inhibits secretory cells.	Endocrine disorders, decreased potency.
Epithelial cell disorder	Impaired gas exchange, hypoxia, accumulation of active chemical substances lead to disruption of tissue integrity. The spermatogenic epithelium and blood-testicular barrier are affected. Damage to the latter causes the development of autoimmune reactions as a result, sperm are destroyed by the body’s own immune system.	Suppression of spermatogenesis, autoimmune reactions.

Causes of the disease

The instructions require compliance with the following measures:

Collection of a detailed medical history. It is necessary to establish not only the consequence, but also the cause of varicose veins. The doctor listens carefully to the nature of the patient’s sensations, asks about his activities, inquires about the illnesses of relatives, etc. The more detailed the information, the more accurate the diagnosis and the more effective the treatment;
The examination involves visual inspection and palpation of the veins of the scrotum. Such methods are effective for clinical forms;
Ultrasound and Dopplerography. Ultrasonography allows you to identify varicocele even at the stage of formation. In this case, a quantitative change in the venous lumen will be recorded. The use of Doppler shows the presence of reflux and measures its intensity;
detects pathologies in the formation of male germ cells;
A biochemical blood test determines the hormonal status of a man.

The note. Children do not have the opportunity to perform a spermogram analysis and detect testosterone production since the testes are not yet active. When a boy develops secondary sexual characteristics, which indicates activation of the testicles, which means this diagnosis becomes possible.

After all diagnostic procedures are completed, the doctor decides to prescribe appropriate treatment.

Types of pathology

The diagnosis of varicocele consists of the degree of the disease and its location. Male anatomy causes the lion's share of diagnoses (about 90%).

The least common type of varicose veins is the right testicle, which may indicate tumor formations in the right kidney, so the entire diagnosis must be carried out. genitourinary system. Simultaneous inflammation of the veins on both sides can develop with a 10% probability.

Depending on the level of development, the disease is divided into preclinical and clinical, the latter has three stages:

First stage. Determined using the Valsalva maneuver;
Second stage. The pain is periodic, but clearly expressed. Diseased veins are clearly palpable in an upright position of the patient, they fall down when lying down, and can be visually visible;
Third stage. The pain syndrome is constant and clearly expressed. The veins are visible visually, never collapse, and the morphology of the scrotum and testicle changes.

Preclinical varicocele has no symptoms and is latent, so it is diagnosed only by ultrasound. In this case, they talk about the subclinical stage.

The first and subclinical stages do not require immediate surgical intervention, since their negative impact on the functional activity of the testes is minimal. In other cases, surgical removal of the affected vessels is required.

Important. Modern medicine considers only one way to treat varicocele – surgery. Medications, ethnoscience and others alternative ways may be considered as additional measures.

Surgical treatment

With varicocele, deformation of the veins of the spermatic cord occurs. Stretched veins with non-closing valves that have lost their former elasticity will never regain their lost morphology on their own.

There is no point in using ointments or herbal baths. Such procedures do not have a significant therapeutic effect. If there is a therapeutic effect, it is not associated with clinical positive changes in the venous structure, and the relief is temporary.

Applying compresses, massages, etc. change sensitivity, the patient is psychologically tuned to improvements. Therefore, varicocele can only be cured through surgery. Modern medicine does not know any other way.

However, not in all cases the patient is prescribed surgery.

When is surgery needed?

Depending on the degree of development of the varicocele and several other factors, the operation may be performed immediately or may be postponed.

Surgical treatment is necessary if:

second or third degree diagnosed;
severe pain in the scrotum;
spermogram or hormonal status showed abnormalities;
the morphology of the scrotum or testis is impaired.

Important. For men who plan to have a child in the future, surgical correction should begin as early as possible, regardless of the degree of the disease, which will make it more likely to avoid infertility.

Postponement of surgical treatment is possible in the following cases:

first degree of pathology, no pain or pain is insignificant;
young age of the patient;
if fertility is not relevant for a man and the disease does not progress.

The first or subclinical degree has a minor effect on the activity of the testicles and with normal sperm tests, in agreement with the patient, the operation may not be performed provided the condition is stable. For men who have the desired number of children or elderly people, the threat of infertility is insignificant, so the patient can safely refuse therapy if the varicocele does not interfere with his life.

The approach to treating children has its own characteristics. There is an established opinion among doctors that in boys who have not completed puberty, surgery is postponed until the end of this period.

This decision is explained by the fact that:

the body grows intensively and is rebuilt, which is why frequent relapses and complications arise;
V at a young age there are no threats to spermatogenesis, since the child’s testes are not yet active.

However, it should be taken into account that 30 years ago, the removal of varicose veins was carried out according to Ivanissevich’s method. This operation itself is very traumatic.

Today, with the advent of modern minimally invasive techniques, such as endoscopic surgery to remove varicocele, the likelihood of recurrence of the disease or other consequences of surgical intervention is minimal. Therefore, more and more doctors support the opinion that dilated vessels should be removed at any age, since this will increase the likelihood of maintaining the integrity of cellular structures and minimize the likelihood of developing infertility in the future.

The success of treatment depends on three factors:

timely diagnosis;
chosen method;
surgeon qualifications.

It should be remembered that no method of surgical treatment of varicose veins can guarantee the likelihood of relapse or complications, but there are techniques with minimal risks.

What operations are used

Before moving on to the description of the endoscopic operation stated in the topic, we will name the main surgical techniques common in modern medicine and briefly describe them.

The note. There are approximately 120 surgical techniques for removing varicoceles, and only about 10 of them are actively used today, and there are often cases of combining different methods.

Classic abdominal surgeries

The essence of all operations, regardless of the chosen method, is to stop the blood flow in the testicular vein and its branches. Over time, circulation will be restored in full, but through healthy vessels.

The first whose technique most successfully coped with the task was the Argentine doctor Ivanissevich. In whose honor the corresponding operation was named (in 1924). Veins affected by varicose veins are removed through retroperitoneal access, ligated and cut off.

An analogue of this operation is the method developed by Ivanissevich’s student, Palomo. He proposed a technique in which not only veins are cut off, but also the testicular artery. For a long time, these operations were the main ones due to their simplicity, because they can be performed using a regular operating room and local anesthesia.

The low price still leaves classic abdominal surgery in the top methods of surgical correction. But that's where the benefits end.

The negative aspects include a long hospital stay (up to 2 weeks), lengthy rehabilitation, and a high likelihood of complications and relapses. and Palomo should be considered obsolete. Leading urologists and andrologists do not use them.

Microsurgical varicocelectomy according to Marmar

In essence, it does not differ from Ivanissevich’s technique, but there is a significant difference in the method of execution. The advent of an operating microscope or its analogue - special magnifying glasses, made it possible to manipulate blood vessels with much greater accuracy.

At the same time, injuries to the testicular artery and lymphatic vessels are minimal, which significantly reduces the risk of complications such as dropsy and testicular atrophy. The surgeon cuts the testicular vein and its three collectors, and also has the opportunity to review and remove other inflamed vessels, if any.

In this case, the operation is performed on an outpatient basis, under local anesthesia. The method has a short rehabilitation period. The disadvantage is the high cost of treatment.

Testicular vein revascularization

Vein revascularization (bypass) is a rather complex micro-operation in which a section of the testicular vein is removed, and another vessel passing in close proximity is sewn in its place. This creates a shunt that allows you to immediately restore blood flow, which is undoubtedly positive from a physiological point of view.

However, due to the high complexity and likelihood of blood clots forming (at the shunt site), this technique is not widely used.

Embolization (sclerotization)

A minimally invasive and least painless way to eliminate varicocele, which is least similar to surgery. A catheter is inserted into the patient, which delivers a sclerosant through the femoral artery to the testicular vein - a substance or agent that clogs and stops blood circulation in it.

After this, blood communicates with the testis through healthy vessels, and the blocked vein will then resolve. The probability of relapse is estimated at 7-10%. This may be caused by persistence of reflux due to insufficient closure of the vein or placement of sclerosant in the wrong place.

Postoperative complications are practically excluded. When a blocking agent is placed, X-ray equipment is used and the patient receives a specific dose of ionizing radiation.

Endoscopic removal

Before moving on to a detailed coverage of all aspects related to endoscopy, it should be noted that its purpose is the ligation of varicose veins of the spermatic cord, i.e., it pursues the same goals as other surgical techniques. The main difference is the use of endoscopic technology, low trauma and short rehabilitation periods.

Preparing for the operation

A week before treatment, you should visit the clinic and take a test. general analyzes blood and urine. Perhaps there will be a series more laboratory research, for example, ultrasound.

It is important to assess the patient's condition and readiness. Since endoscopic intervention for varicocele is performed under local anesthesia, the anesthesiologist must examine the patient and determine all the nuances of future anesthesia.

You should not eat or drink the evening before and the morning of the operation. As a rule, the patient arrives at the operating department early in the morning, where he is given special pajamas and given preliminary injections.

The hospital stay usually lasts two days. Therefore, you should make sure you have water and light food on the first day.

Execution technique

The patient lies on the operating table on his back.

After putting him under general anesthesia, three small punctures are made in the peritoneum to introduce laparoscopic ports:

in the navel area (an endoscope equipped with a video camera (10 mm) is inserted);
in the iliac region (5 mm);
in the iliac region (5 mm);

As soon as the first tube is inserted, the peritoneal cavity is filled with carbon dioxide, the abdomen is inflated, which gives the surgeon space to manipulate the inguinal area.

An endoscope is a special tube in which a small video camera and a cold light source are mounted, with the help of which the doctor monitors his actions in real time. The enlarged image is projected onto a monitor screen installed in the operating room.

This makes it possible, firstly, to carry out vein ligation with high precision, without affecting neighboring vessels and tissues, and secondly, the surgeon has the opportunity to examine the testicular veins along their entire length. Varicose veins are pinched with titanium clamps and cut off.

Note. When performing an endoscopic technique for removing varicocele, there are no incisions on the patient’s body, and micromanipulators are inserted through holes (5-10 mm). Therefore, the rehabilitation period is about a week, there are no stitches, but three barely noticeable marks will remain at the puncture site.

The duration of the operation can vary from an hour to two. It depends on the specifics of the diagnosis, individual features patient and medical staff experience. For clarity, the main stages of treatment are presented in Table 3.

Table 3. Main stages of endoscopic surgery:

Action	Short description	Photo
Providing general anesthesia and installing trocars	After placing the patient into anesthetic sleep in abdominal cavity microinstruments are introduced and it is filled with carbon dioxide
Identification of pathologically dilated vessels	The doctor looks for veins affected by varicose veins and begins ligating each one individually.
Vessel ligation	In order to stop a vein, it is first clamped using special clips.
Final stage	After manipulation of the veins, the trocars are removed and the wounds are sutured.

Advantages and disadvantages of the method

Like any treatment method, endoscopic surgery for varicocele has its advantages and disadvantages, but the former significantly outweigh the latter, since this is one of the modern and progressive treatment methods.

The main advantages of laparoscopy:

the ability to examine the testicular vein along its entire length;
postoperative complications are minimal, and the probability of relapse is 2%;
weak pain after the anesthesia wears off;
hospital stay for two days;
rehabilitation period is a week, and full recovery from the third week;
elimination of bilateral pathology;
the best method for eliminating relapse;
optimal visualization allows you to identify and ligate all branches of the testicular vein that were not noticed during the preliminary diagnosis;
possibility of treatment of any degree of disease;
After surgery, barely noticeable puncture marks remain on the body.

Important. Only endoscopic techniques allow simultaneous treatment of bilateral varicoceles. With other methods, the operation should be done separately on each side.

The disadvantages of laparoscopy include:

general anesthesia;
high cost;
the presence of expensive unique equipment that requires certain surgeon skills.

It is for these reasons that such operations are carried out in modern clinics equipped with high-tech equipment, which, as a rule, are only available in large cities of our country. Contraindications include the presence of purulent processes of any location, tumors in the peritoneum or pelvis, and a history of repeated endoscopic operations in the past.

Forecast

Varicocele is one of those diseases that can be completely cured by surgery. If before the operation the spermogram did not show serious abnormalities and there were no signs of testicular atrophy, then the likelihood of problems associated with reproductive function does not exceed 30%. Otherwise, the risks of developing infertility increase.

Important. With successful treatment, spermogram indicators will begin to show positive dynamics a month after the operation. After a year, sperm analysis can be assessed as satisfactory, and only after three years should spermatogenesis be restored to its original state.

Since the muscular aponeurotic layer is minimally injured, rehabilitation after endoscopy does not last long, which even applies to restrictions on physical activity. However, there are certain instructions that must be followed.

To eliminate pain at first, it will be enough to use simple (non-narcotic) analgesics. A couple of hours after the anesthesia wears off, you are allowed to drink; you can eat in the late afternoon.

It is advisable to limit physical activity for as long as possible. It is important not to lift weights in the first week. You can have sex already on the fourth day; if there is pain, then you should wait. Full recovery occurs in 20-30 days.

Possible Complications

During endoscopy, the occurrence is practically excluded since all manipulations occur under magnification and are monitored on the monitor. There is a slight chance of damage to small and almost transparent lymphatic vessels. If lymph drainage is impaired, testicular hydrocele (hydrocele) develops.

Relapse is more likely, but the risks are small (2%). This may happen due to insufficient visualization of the veins with loose-type varicocele, when not all inflamed vessels are detected.

Prevention

Since the disease has a genetic basis, there are no preventive measures, the use of which would avoid the manifestation of congenital causes of varicocele. But it should be remembered that primary causes often appear after the occurrence of secondary ones that provoke them. Therefore, it is important to exclude factors that cause increased pressure in the lower peritoneum and veins of the pelvic organs.

These include:

lifting weights;
regular physical activity;
bodybuilding, abdominal pumping, cycling and equestrian sports, intense or long running;
diseases accompanied by prolonged cough, chronic diarrhea, constipation and others.

Important. If varicocele has a secondary etiology, additional diagnostics of the body should be performed, since varicocele of the scrotum may be the result of another disease, for example, a tumor of a nearby organ.

Conclusion

Endoscopy (laparoscopy) is a modern and reliable method for eliminating varicocele. The operation involves a short hospital stay, quick recovery time with a low probability of complications and relapses.

The technique is suitable for treating patients of any age, regardless of the degree of the disease. A full return to normal life is possible after three weeks.

In comparison with other methods of treating varicocele, endoscopy has greatest number positive characteristics. The disadvantage should be considered the high cost. More details about this technique are shown in the video in this article, where experienced urologists share their experience and interesting details.

Varicose veins of the spermatic cord and testicle today considered one of the most common male diseases. According to WHO statistics, this disease is diagnosed in more than 16% of the male population.

In 2% of cases, there is a right- or bilateral varicocele, in 98% - a left-sided one..

The degrees of varicocele vary depending on the intensity of the venous expansion.

Subclinical varicocele: testicular veins are not detectable by palpation, varicocele can be detected only on the basis of ultrasound results.

Grade 1: dilated veins can be felt with hands only in a standing position.
Grade 2: Varicocele can be easily detected by palpation in any position of the body.
Grade 3: a visual examination is sufficient to detect dilated veins.

In most cases, varicocele progresses rapidly and, having reached a specific stage, stops in development.

Subclinical and first stage varicocele does not require treatment. To eliminate negative phenomena, it is enough to eliminate stagnant processes localized in the pelvic organs.

The list of such measures includes abstinence from alcohol consumption, normalization of stool, regular sex life, balanced physical tension.

Such elementary actions can reduce dilated veins and prevent the disease from progressing.

Elderly people whose disease has frozen for early stage Wearing a jockstrap will be helpful.

During the second degree of varicocele, if the disease is characterized by pain, surgery is necessary.

An inevitable measure is surgery for third-degree varicocele. Now we have dealt with the question of whether surgery is needed for varicocele and at what stages it should be done.

Varicocele can lead to other, more annoying problems, such as infertility..

It is this diagnosis in 40% of men suffering from. The fact is that dilated veins contribute to an increase in temperature in the scrotum, and this leads to violations of the morphology, motility of spermatozoa and their number.

Operation for varicocele: types, types, methods, methods (how do they do it?)

The essence of all types of operations is the elimination of the affected areas of the veins. Operations differ among themselves in terms of the method of carrying out, the degree of injury, effectiveness and possible complications.

Traditional operations

There are 3 types of traditional surgery- By Ivanissevich, Marmar and Palomo.

Operation Ivanissevich

This operating technique is one of the very first developments in the elimination of varicocele. Today she recognized as one of the most inefficient, because recurrence rate reached 40%.

Operation in progress under local anesthesia. An incision up to 5 cm long is made in the left part of the iliac region. In depth, the incision reaches the walls of the inguinal canal, in which the veins and spermatic cord pass. The discovered veins are crossed and the wound is sutured.

The purpose of the operation is to ligate absolutely all veins in one procedure. There is a high degree of risk that one or more blood vessels will be missed, which may lead to re-development diseases.

The level of skill of the operating doctor and the quality of his work determine the likelihood that the testicular artery will be ligated by mistake, and this threatens to disrupt spermatogenesis.

The operation to remove testicular varicocele according to Ivanissevich was recognized as the most traumatic, the recovery period after it can be about 3 weeks.

Operation Marmara

Among the surgeries recognized as the most effective. During the operation, the veins of the spermatic cord are doped through the inguinal access.

The operation has several advantages:

minimal invasiveness, since the length of the incision is 2-3 cm, it can be compared with laparoscopic;
postoperative recovery in a short time;
the minimum number of recurrences of the disease and complications;
high cosmetic effect. The seam (scar) after such an operation is small and is located lower than the level of wearing underwear begins.

During the surgical operation, the testicular artery is primarily localized, after which all large and small veins of the spermatic cord are sequentially localized.

After the operation, the patient will need to spend about 4-7 hours in the clinic at the day hospital. After this time, he can be sent home under the supervision of relatives.

Operation Palomo

This procedure is an improved version of the Ivanissevich operation. The difference is that the incision site is located higher than in the first case. The vein is ligated in the retroperitoneal tissue.

Laparoscopic surgery (endoscopic)

Minimally invasive and modern treatment method.

During the operation, punctures up to 5 mm in diameter are made in the anterior abdominal wall, into which instruments and a laparoscope will subsequently be inserted.

During laparoscopic surgery for varicocele, the veins and arteries of the testis are isolated, and titanium staples are applied to the former or they are tied with a surgical thread.

This operation is performed under general anesthesia.. Remarkably, she surgery to remove a varicocele can take about 15-40 minutes. The duration of the operation may vary.

So, the later stage of the disease, the less time will be spent on the operation due to the fact that the varicocele is already pronounced by this time.

During the operation, based on the image provided by the laparoscope, the doctor locates and cuts the testicular vein. After this operation, the patient must spend a maximum of two days in the clinic. For now laparoscopy is considered the most effective method varicocele treatment, as the devices allow you to inspect the entire length of the testicular vein.

Laparoscopic surgery to remove a varicocele is also good because it allows one-stage operation of a bilateral varicocele. The probability of recurrence after endoscopic surgery does not exceed 2%.

Microsurgical revascularization

The result of this operation is normalization of blood flow in the testicular vein. Surgery is performed using general anesthesia.

An incision is made in the lower abdomen (5 cm), the testicular vein is brought into the wound along its entire length from the place where it flows into the renal vein to the testicle. In parallel, there is a section of the epigastric vein. The testicular vein is completely removed, and the epigastric vein is sutured instead.

Considered a physiological operation, since blood circulation in the scrotum can be restored immediately after the operation, which reduces the risk of complications.

X-ray endovascular surgery

Surgery is performed under x-ray control..

A catheter is inserted into the body through a puncture in the femoral vein, delivering a sclerosing drug into the testicular vein that clogs the testicular vein.

One of the least effective operations - after it there is a high probability of recurrence.

Men who have undergone varicocele surgery you will have to abstain from sexual intercourse for three weeks. For some time after varicocele surgery during sex pain or discomfort may occur.

Preferably within the next month after traditional varicocele surgery avoid physical activity and sports. After endovascular or endoscopic surgery, it will be possible to start physical activity much earlier.

In general, for the first few days after surgery, the patient should wear a suspensorium, which is a special scrotal bandage designed to relieve tension on the tissues of the spermatic cord and scrotum.

The operation for varicocele with the same success is carried out at any age, as in children, it is especially detected in adolescence, and in adults, but the recommended age is at least 9 years.

If the operation is performed immediately after detection, the male's reproductive function will be preserved. This suggests that a man who has undergone surgery to remove a varicocele remains fertile. The presence of this disease in many cases is just a temporary reason that a couple cannot have children.

In the later stages of varicocele, there is a high likelihood of infertility and erectile dysfunction.

As for nutrition, it is desirable to adhere to a sparing diet for the entire period of the rehabilitation period after the operation to remove the varicocele.

3 months after the operation, it is necessary to do an analysis - a spermogram. If the test results are bad, andrologist treatment is prescribed to restore childbearing function after surgery to remove the varicocele.

Postoperative period: how to rehabilitate and what are the consequences (complications) after the operation?

The question is, what can and should be done after the operation? If a man underwent surgery to remove a varicocele, then after that various complications can occur, and the most common is dropsy of the testicle. In this case, serous fluid accumulates between each of the testicular membranes.

The occurrence of dropsy contributes to impaired blood circulation in the testicle caused by surgery. After some time, a venous collateral outflow is formed in the male reproductive system, allowing blood to flow through other scrotal veins.

Complications may occur if you are sexually active in the first weeks after surgery.. Until the rehabilitation process after the varicocele cured by the operation is completed, should refrain from having sex with a partner and masturbation - these are the restrictions.

Also there is a possibility of a relapse even following all the rules of rehabilitation. The main cause of recurrence is a pampiniform vein or twig missed by the surgeon. In addition, after an unsuccessful operation, damage to the iliac artery, an infectious process in the wound, bleeding, hypertrophy, atrophy or azoospermia of the testicle is possible.

In some cases, repeated repetition of operations to remove a varicocele is possible, until the damaged veins are completely ligated.

After varicocele surgery there may be pain in the testicles, but in 90% of cases they quickly pass. In the event that the pain does not stop, you should consult your doctor.

Painless
During the operation, pain relief is performed - regional anesthesia or anesthesia.
Effectively
The operation can be performed in the traditional way (through an incision in the anterior abdominal wall) or laparoscopically (three punctures of the anterior abdominal wall with a size of 5-10 mm are performed - in the navel, as well as in the left and right iliac regions).
With laparoscopic access, an 8-fold increase on the monitor screen is achieved, which allows you to see even small accompanying veins, which also intersect, which greatly reduces the possibility of varicocele recurrence. Also, the increase helps to diagnose the lymphatic vessels accompanying the vein and not to injure them during the operation, which makes it possible to avoid such fairly frequent consequences of this operation as the formation of hydrocele.
According to our statistics, recurrence in traditional operations (Ivanissevich's operation, Marmar's operation) different sources reaches from 2 to 10%. In our clinic, the relapse rate over 15 years is less than 1%. Also, when using the laparoscopic method, the amount of formation of hydrocele after the operation is significantly reduced.
Safely
We prefer to use the least traumatic laparoscopic (endoscopic) approach. During the operation, the endoscopic picture is projected onto the monitor with an increase in the image. Due to this, as well as the applied scheme of punctures, the most detailed examination of the operation area is achieved. Using an endoscope, the surgeon examines the dilated testicular vein. Titanium brackets are applied to all branches of the vein, while the vessels between the brackets are dissected. This technique contributes to faster recovery in the postoperative period and, compared with other types of operations, allows to achieve the lowest percentage of relapses.

Why do they trust us and choose the CELT clinic?

We were one of the first to perform endoscopic operations for varicocele since 1995.
Comfortable stay without pain during surgery and in the postoperative period.
The absence of queues for treatment allows you to appoint and carry out the operation as quickly as possible.

The clinic has a unique experience in the treatment of varicocele - we successfully apply all methods of treatment - laparoscopic, traditional operations, as well as varicocele embolization.

What is important for the patient to know

Table 1. Negative phenomena caused by the disease and their impact on the male body

Pathology	a brief description of	Result of negative impact
Hyperthermia of the scrotum	The presence of varicose vessels affects an abnormal increase in temperature in the scrotum, which affects the processes of meiosis not only in the patient, but also in the healthy testicle.	Suppression of spermatogenesis.
Hypoxia	Reflux, slower blood flow and stagnation in deformed vessels cause deterioration of trophism and disruption of gas exchange in testicular tissue, which leads to destructive processes.	Testicular atrophy.
Violation of hormonal secretion	Hypoxia and, especially, testicular atrophy affect changes in the functional activity of secretory Leydig cells that produce testosterone. With blood reflux, adrenal steroid hormones are delivered to the testes, which also inhibits secretory cells.	Endocrine disorders, decreased potency.
Epithelial cell disorder	Disturbed gas exchange, hypoxia, accumulation of active chemicals lead to a violation of tissue integrity. The spermatogenic epithelium and blood-testicular barrier are affected. Damage to the latter causes the development of autoimmune reactions as a result, sperm are destroyed by the body’s own immune system.	Suppression of spermatogenesis, autoimmune reactions.

Causes of the disease

The instructions require compliance with the following measures:

Collection of a detailed medical history. It is necessary to establish not only the consequence, but also the cause of varicose veins. The doctor listens carefully to the nature of the patient’s sensations, asks about his activities, inquires about the illnesses of relatives, etc. The more detailed the information, the more accurate the diagnosis and the more effective the treatment;
The examination involves visual inspection and palpation of the veins of the scrotum. Such methods are effective for clinical forms;
Ultrasound and Dopplerography. Ultrasound examination can detect varicocele even at the stage of formation. In this case, a quantitative change in the venous lumen will be recorded. The use of Doppler shows the presence of reflux and measures its intensity;
detects pathologies in the formation of male germ cells;
A biochemical blood test determines the hormonal status of a man.

The note. Children do not have the opportunity to perform a spermogram analysis and detect testosterone production since the testes are not yet active. When a boy develops secondary sexual characteristics, which indicates activation of the testicles, which means this diagnosis becomes possible.

After all diagnostic procedures are completed, the doctor decides to prescribe appropriate treatment.

Types of pathology

The diagnosis of varicocele consists of the degree of the disease and its location. Male anatomy causes the lion's share of diagnoses (about 90%).

The least common symptom is varicose veins of the right testicle, which may indicate tumor formations in the right kidney, so the entire genitourinary system must be diagnosed. Simultaneous inflammation of the veins on both sides can develop with a 10% probability.

Depending on the level of development, the disease is divided into preclinical and clinical, the latter has three stages:

First stage. Determined using the Valsalva maneuver;
Second stage. The pain is periodic, but clearly expressed. Diseased veins are clearly palpable in an upright position of the patient, they fall down when lying down, and can be visually visible;
Third stage. The pain syndrome is constant and clearly expressed. The veins are visible visually, never collapse, and the morphology of the scrotum and testicle changes.

Preclinical varicocele has no symptoms and is latent, so it is diagnosed only by ultrasound. In this case, they talk about the subclinical stage.

Important. Modern medicine considers only one way to treat varicocele – surgery. Medications, traditional medicine and other alternative methods may be considered as additional measures.

Surgical treatment

However, not in all cases the patient is prescribed surgery.

When is surgery needed?

Depending on the degree of development of the varicocele and several other factors, the operation may be performed immediately or may be postponed.

Surgical treatment is necessary if:

second or third degree diagnosed;
severe pain in the scrotum;
spermogram or hormonal status showed abnormalities;
the morphology of the scrotum or testis is impaired.

Important. For men who plan to have a child in the future, surgical correction should begin as early as possible, regardless of the degree of the disease, which will make it more likely to avoid infertility.

Postponement of surgical treatment is possible in the following cases:

first degree of pathology, no pain or pain is insignificant;
young age of the patient;
if fertility is not relevant for a man and the disease does not progress.

This decision is explained by the fact that:

the body grows intensively and is rebuilt, which is why frequent relapses and complications arise;
at a young age there are no threats to spermatogenesis, since the child’s testes are not yet active.

However, it should be taken into account that 30 years ago, the removal of varicose veins was carried out according to Ivanissevich’s method. This operation itself is very traumatic.

The success of treatment depends on three factors:

timely diagnosis;
chosen method;
surgeon qualifications.

It should be remembered that no method of surgical treatment of varicose veins can guarantee the likelihood of relapse or complications, but there are techniques with minimal risks.

What operations are used

Before moving on to the description of the endoscopic operation stated in the topic, we will name the main surgical techniques common in modern medicine and briefly describe them.

The note. There are approximately 120 surgical techniques for removing varicoceles, and only about 10 of them are actively used today, and there are often cases of combining different methods.

Classic abdominal surgeries

The low price still leaves classic abdominal surgery in the top methods of surgical correction. But that's where the benefits end.

Microsurgical varicocelectomy according to Marmar

In this case, the operation is performed on an outpatient basis, under local anesthesia. The method has a short rehabilitation period. The disadvantage is the high cost of treatment.

Testicular vein revascularization

However, due to the high complexity and likelihood of blood clots forming (at the shunt site), this technique is not widely used.

Embolization (sclerotization)

Postoperative complications are practically excluded. When a blocking agent is placed, X-ray equipment is used and the patient receives a specific dose of ionizing radiation.

Endoscopic removal

Preparing for the operation

A week before treatment, you should visit the clinic and undergo general blood and urine tests. There may also be a number of laboratory tests, for example, ultrasound.

The hospital stay usually lasts two days. Therefore, you should make sure you have water and light food on the first day.

Execution technique

The patient lies on the operating table on his back.

After putting him under general anesthesia, three small punctures are made in the peritoneum to introduce laparoscopic ports:

in the navel area (an endoscope equipped with a video camera (10 mm) is inserted);
in the iliac region (5 mm);
in the iliac region (5 mm);

As soon as the first tube is inserted, the peritoneal cavity is filled with carbon dioxide, the abdomen is inflated, which gives the surgeon space to manipulate the inguinal area.

Note. When performing an endoscopic technique for removing varicocele, there are no incisions on the patient’s body, and micromanipulators are inserted through holes (5-10 mm). Therefore, the rehabilitation period is about a week, there are no stitches, but three barely noticeable marks will remain at the puncture site.

The duration of the operation can vary from an hour to two. This depends on the specifics of the diagnosis, the individual characteristics of the patient and the experience of the medical staff. For clarity, the main stages of treatment are presented in Table 3.

Table 3. Main stages of endoscopic surgery:

Action	Short description	Photo
Providing general anesthesia and installing trocars	After immersing the patient in anesthetic sleep, microinstruments are inserted into the abdominal cavity and it is filled with carbon dioxide
Identification of pathologically dilated vessels	The doctor looks for veins affected by varicose veins and begins ligating each one individually.
Vessel ligation	In order to stop a vein, it is first clamped using special clips.
Final stage	After manipulation of the veins, the trocars are removed and the wounds are sutured.

Advantages and disadvantages of the method

The main advantages of laparoscopy:

the ability to examine the testicular vein along its entire length;
postoperative complications are minimal, and the probability of relapse is 2%;
mild pain after the anesthesia wears off;
hospital stay for two days;
rehabilitation period is a week, and full recovery from the third week;
elimination of bilateral pathology;
the best method for eliminating relapse;
optimal visualization allows you to identify and ligate all branches of the testicular vein that were not noticed during the preliminary diagnosis;
possibility of treatment of any degree of disease;
After surgery, barely noticeable puncture marks remain on the body.

Important. Only endoscopic techniques allow simultaneous treatment of bilateral varicoceles. With other methods, the operation should be done separately on each side.

The disadvantages of laparoscopy include:

general anesthesia;
high cost;
the presence of expensive unique equipment that requires certain surgeon skills.

Forecast

Important. With successful treatment, spermogram indicators will begin to show positive dynamics a month after the operation. After a year, sperm analysis can be assessed as satisfactory, and only after three years should spermatogenesis be restored to its original state.

To eliminate pain at first, it will be enough to use simple (non-narcotic) analgesics. A couple of hours after the anesthesia wears off, you are allowed to drink; you can eat in the late afternoon.

Possible Complications

Relapse is more likely, but the risks are small (2%). This may happen due to insufficient visualization of the veins with loose-type varicocele, when not all inflamed vessels are detected.

Prevention

These include:

lifting weights;
regular physical activity;
bodybuilding, abdominal pumping, cycling and equestrian sports, intense or long running;
diseases accompanied by prolonged cough, chronic diarrhea, constipation and others.

Important. If varicocele has a secondary etiology, additional diagnostics of the body should be performed, since varicocele of the scrotum may be the result of another disease, for example, a tumor of a nearby organ.

Conclusion

The technique is suitable for treating patients of any age, regardless of the degree of the disease. A full return to normal life is possible after three weeks.

In comparison with other methods of treating varicocele, endoscopy has the greatest number of positive characteristics. The disadvantage should be considered the high cost. More details about this technique are shown in the video in this article, where experienced urologists share their experience and interesting details.