Varicocelectomy
Varicocele is a varicose disease that affects the vascular system of the testis. It is characterised by the dilation and incontinence of the testicular (or spermatic) veins that can drain blood from the testicle. When these veins are dilated, blood reflux from above to the testicle occurs, which causes its temperature to increase and is an unfavourable environmental condition for normal spermatogenesis.
Testicles receive blood from the genital artery (testicular artery) through the inguinal canal that connects the scrotum to the abdomen. The testicular veins (superficial and deep) come together. After collecting the veins of the epididymis, they rise and become part of the spermatic cord, where they constitute the pampiniform plexus.
From this originates the testicular vein, which on the right flows into the inferior vena cava, on the left instead reaches the left renal vein. Such veins, in humans, can become incontinent and dilate, thus preventing the outflow of venous blood from the testicle to the upper part of the body. It then creates a condition of reflux and stasis of blood towards the testicle.
Varicocele is quite common in 30–40% of men with fertility problems. It affects about 10–20% of the general male population, typically between 15 and 25 years old. It can occur in pre-adolescence (found in 2-2.5% of boys between 7 and 10 years), but the era in which it usually manifests itself is that of sexual maturation, between 11 and 16 years.
The constitution of the young should not be underestimated: varicocele affects long-limbed and tall subjects more frequently. It should be diagnosed early in adolescence when it has not yet had time to cause reproductive damage, even in its minor forms. Because the two vascular pathways are in different places in the body, they primarily affect the left testicle (95%) and sometimes the right testicle (5%).
The pathogenesis of varicocele is unknown; it is thought to be determined by a congenital weakness of the venous walls associated with incontinence of the valves. The blood pressure determined by the standing position determines the long-term dilation of the veins. More than 95% of varicocele conditions are related to an idiopathic situation (the so-called primary forms).
It is possible that constitutional factors, similar to what occurs in the veins of the lower extremities, condition a weakness of the venous wall with progressive exhaustion of the same; this leads to consequent valvular incontinence with the appearance of retrograde blood reflux, a salient feature of varicocele. It should be noted, however, that any retroperitoneal or expansive pelvic processes compromising the venous structures can cause an obstacle to venous outflow and the appearance of varicocele (in particular, the formation of varicocele in adulthood or at the right site must suggest the exclusion of any extrinsic compressive pathologies – secondary varicocele).
What is the treatment of varicocele?
Varicocele repair may not be needed, but it could be if the disease causes pain, testicular shrinkage, or infertility.
Whether correcting varicocele results in improved fertility is still a matter of debate. However, a Cochrane review of the scientific evidence showed that varicocele treatment is associated with an increase in the pregnancy rate compared with no treatment. Varicocele repair has relatively few risks, which could include: accumulation of fluid around the testicles (hydrocele), relapses, infection, and damage to an artery. The surgery aims to close off the damaged vein so that blood can flow through healthy veins instead.
Several varicocele repair methodologies include surgery and interventional radiology.
Lymphatic-sparing microsurgery has the lowest rate of complications and the highest rate of success, but it takes much experience to do well.
Radiological techniques are done outside of a hospital and benefit from a short recovery time, but they also expose the patient to X-rays, which is not ideal.
Varicocele embolization
Varicocele embolisation is an outpatient procedure performed under local anaesthesia to selectively close the blood vessels responsible for excessive blood collection within the testicle.
Varicocele is a purely male condition characterised by the dysfunction of some small valves present in the veins of the testicle whose purpose, in physiological functions, is to make the blood progress towards the heart and prevent its reflux towards the testicle. If these valves do not work, the blood goes back to the testicle, and the small veins increase in size, giving rise to this disorder.
Varicocele embolisation is an outpatient procedure to selectively close the blood vessels responsible for excessive blood collection within the testis. In recent years, it has largely replaced the use of classical surgery, representing a less invasive and equally decisive intervention technique. Under radiological control, the catheter through which the embolism agents (or sclerosing agents) are put in is in place.
The operation takes place in the angiography room in sterile conditions. After giving the local anaesthesia in the skin area chosen for the catheter insertion, a vein in the arm or groyne is cannulated. Under the guidance of X-rays, the catheter is then made to reach the dilated veins of the testicle. The contrast medium is then injected, which allows the veins of the testicle to be viewed.
Finally, they are released selectively within the veins to occlude particular embolic substances or small metal spirals to block blood flow. After ensuring that the devascularisation is successful, the doctor removes the catheter and places a compressive dressing at the point of entry of the catheter into the skin (no sutures are required). The whole procedure takes about 20 minutes. The patient is observed for a few hours and discharged the same day. The surgery only takes a few hours to heal, and the patient can usually return to his regular work the next day.
The risks associated with undergoing this procedure are pretty rare. These include local reactions of the testicle such as swelling, redness and pain sensation; bleeding due to traumatic rupture of a vein (very rare); allergic reactions to contrast medium, local anaesthetic or sclerosing substance (very rare).
There are several advantages related to embolisation: the same, if not more significant, the effectiveness of traditional surgical treatment in terms of pain reduction and increased fertility; absence of surgical incisions and administration of general anaesthesia; lower complication rate compared to surgery standard; shorter hospitalisation times than traditional surgery; lower recurrence rate than conventional surgery.
Is varicocele embolisation dangerous or painful?
Being a procedure that involves the insertion of a catheter, embolisation of the varicocele can cause discomfort. However, it is considered a minimally invasive procedure compared to the classic so-called "open" surgery (which was the only option for removing varicocele) before the use of embolisation.
Which patients can embolism varicoceles?
There are particular contraindications to the catheter placement for the embolisation of varicocele for people suffering from problems related to blood clotting, for patients being treated with anticoagulant drugs, and for people with cardiovascular disease, diabetes, or hypotension. Particular attention must be paid to subjects with hypersensitivity to the contrast medium used to monitor the catheter insertion (which takes place under radiographic guidance).
Varicocele embolization
After embolisation, modest pain in the lower abdomen may appear (also associated with other symptoms such as nausea and fever), which requires appropriate painkilling treatment. The patient will have to undergo some checks established by the doctor based on the outcome of the surgery and the patient's general physical and health conditions.
Before this test, the patient must have been fasting on solid food for at least 8 hours. It can drink small amounts of liquids (still water or tea). The patient will go to the X-ray room with peripheral venous access.
