What is the role of surgery in the treatment of varicocele?

Updated: Jan 02, 2019
  • Author: Wesley M White, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

The primary form of treatment for varicoceles is surgery. Because of the potential to cause significant testicular damage, evaluate the varicocele during the physical examination. The presence of a varicocele does not in itself mean surgical correction is necessary.

The ultimate goals of varicocele repair should include occlusion of the offending varicosity, preservation of arterial flow to the testis, and minimization of patient discomfort and morbidity. Viable options for repair include radiographic obliteration and surgical repair of various approaches. The efficacy of the myriad techniques is nearly equivalent. Therefore, special attention must be paid to the morbidity of the individual procedure and the expertise of the operating surgeon.

Results from a prospective, randomized controlled trial from Saudi Arabia compared subinguinal microsurgical varicocele repair to observation. [23] Inclusion criteria included infertility lasting 1 year or longer, demonstration of a palpable varicocele, and presence of at least one impaired semen parameter (sperm concentration < 20 million/mL, progressive motility < 50%, or normal morphology < 30%). A total of 145 participants had follow-up within 1 year; spontaneous pregnancy was achieved in 13.9% of controls compared with 32.9% of treated men (odds ratio, 3.04). In treated men, the mean of all semen parameters significantly improved in follow-up compared with baseline (p< 0.0001). This study provided an evidence-based endorsement of the superiority of varicocelectomy over observation in infertile men with palpable varicoceles and impaired semen quality.

Surgical techniques for varicocele repair include retroperitoneal, laparoscopic, inguinal, and subinguinal. The microsurgical subinguinal approach is the gold standard. [24] A meta-analysis found that although microsurgical varicocelectomy involves a longer operative time, it has a lower incidence of postoperative complications and recurrence than laparoscopic and open varicocelectomies and a shorter time to return to work, as well as a greater increase in postoperative sperm concentration, better improvement in postoperative sperm motility, and a higher pregnancy rate. [25]

Microsurgical repair of varicocele may improve the patient's erectile and ejaculatory function, along with raising  testosterone levels. In a review by Najari et al of 17 patients with infertility and 13 with symptomatic varicocele associated with hypogonadism, most of whom had bilateral varicoceles and left grade III varicoceles, 15 patients (44%) reported improvement in their erectile function and 18 (53%) reported improvement in ejaculatory function. Serum testosterone levels rose 136.0 ±201.3 ng/dL. [26]

In patients with a left clinical varicocele accompanied by a right subclinical varicocele, the choice of unilateral versus bilateral varicocelectomy has been controversial. However, studies have shown superior improvement in sperm parameters and spontaneous pregnancy rates with bilateral varicocelectomy in these patients. [27, 28]


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