Procedures
Microscopic varicocele surgery (Varicocelectomy) with doppler ultrasound
Althought multiple treatment solutions exist, open subinguinal microsurgical varicocelectomy is currently the gold standard for this condition. The principle this surgery is to block the flow of blood back to the testis. A surgical microscope is therefore used to properly identify the different structures in the spermatic cord. The goal is to only ligate the spermatic veins. An inguinal micro-Doppler is also used to identify the spermatic artery; it ensures its integrity during the intervention. This device also promotes better dissection by ligating more small veins. The risk of recidivism is thus greatly minimized.
Secondary hydrocele: The risk is very low (less than 1%) since dissection of the spermatic cord is done under a microscope. Lymphatic tissues are not severed or ligated. Their ligatures are responsible for the appearance of a hydrocele. It can be corrected later, if necessary.
Persistent veins: It may have a persistence of dilated veins despite improved symptoms.
Recidivism: The risk of recurrence is low because of abnormal venous communications. Re intervention or embolization may be proposed.
Hematoma: A bruise is common, but a hematoma is rare. It may require drainage.
Infection: Wound infections are rare. Infected wounds can become hot, swollen, red, and painful, with significant drainage from the incision site, and patients may develop fever. If wounds become infected (usually 3 to 5 days after surgery), antibiotics may be needed.
Testicular atrophy: It is secondary to testicular ischemia since an arterial branch has been ligated It is exceptional after a varicocele cure by microscopy and micro-Doppler under inguinal. Spermatic arteries are usually all identified.
What are the implications of a varicocele cure by microscopy and micro-doppler under inguinal?
Although microsurgical varicocelectomy involves a longer operative time, it has a lower incidence of postoperative complications and recurrences than laparoscopic or open varicocelectomies. The convalescence is shorter before returning to work. Also, there is a greater increase in sperm concentration, better improvement of postoperative sperm motility and a higher pregnancy rate.
Why opt for an inguinal approach during a varicocele surgery?
The inguinal (groin) approach is performed by an incision at or near the pubic tubercle, which prevents the opening of the external oblique fascia. Benefits of varicocele ligation under inguinal microscopic enlargement, include decreased pain and easier access to the spermatic cord, particularly in obese men and those who have had previous inguinal surgery.
Why use a microscope and a micro-doppler during subinguinal microsurgical varicocelectomy?
The use of the microsurgical technique has advanced the surgical treatment of a varicocele by allowing an optimal visualization. Although the cord isolation approach is no different, 6-25X magnification facilitates the identification of small anastomosing veins that might otherwise be missed. In addition, the risk of testicular ischemia and testicular atrophy due to involuntary ligation of the testicular artery is greatly reduced by this improved visualization. This risk of arterial ligation is further reduced by using a mini-Doppler ultrasound probe with the use of a topical vasodilator.
What are the reasons to perform a subinguinal microsurgical varicocelectomy ?
- Infertility.
- Left scrotal discomfort.
- Testosterone deficiency in older men.
- Dr Marois will take the time to assess the patient and determine if this surgery is needed or an option.
How is a varicocelectomy performed?
The procedure is performed under local anesthesia and a spermatic cord block, in a minor surgery room fully equipped with a high-resolution microscope and a micro-Doppler (in the Montreal clinic).
A short incision of 3 cm is made at the inguinal level to expose the spermatic cord. The spermatic veins are identified under the microscope. They are then ligated. A segment of vein is excised to reduce the risk of re-anastomosis.
A 3 mm micro-Doppler is introduced before the beginning of the fine dissection. The surgical area is copiously irrigated with a 1% Lidocaine solution to fight against vasospasm (although Papaverine dilution may also be used). Dr Marois will then start looking for the artery with the micro-Doppler probe. Once this has been identified, he will take special care to protect it and reconfirm its identity throughout the dissection. The vas deferens and its vascular bundle are then identified and, if possible, brought to the lateral or medial edge of the cord and excluded from the operative field. All lymphatics are identified and preserved to minimize the risk of postoperative hydrocele.
Irrigation of saline water is necessary during the procedure. The skin is closed by resorbable threads and surgical glue. Dressings are applied. The procedure can last about 90 minutes.
A short incision of 3 cm is made at the inguinal level to expose the spermatic cord. The spermatic veins are identified under the microscope. They are then ligated. A segment of vein is excised to reduce the risk of re-anastomosis.
A 3 mm micro-Doppler is introduced before the beginning of the fine dissection. The surgical area is copiously irrigated with a 1% Lidocaine solution to fight against vasospasm (although Papaverine dilution may also be used). Dr Marois will then start looking for the artery with the micro-Doppler probe. Once this has been identified, he will take special care to protect it and reconfirm its identity throughout the dissection. The vas deferens and its vascular bundle are then identified and, if possible, brought to the lateral or medial edge of the cord and excluded from the operative field. All lymphatics are identified and preserved to minimize the risk of postoperative hydrocele.
Irrigation of saline water is necessary during the procedure. The skin is closed by resorbable threads and surgical glue. Dressings are applied. The procedure can last about 90 minutes.
What are the results of a varicocele cure?
Surgery for painful varicocele: Most patients with varicocele will have major improvement in pain or even complete pain relief.
Fertility surgery: Several studies show that the number and motility of spermatozoa improves after varicocele surgery. Some studies suggest that couples with repaired varicocele are 30-50% more likely to become pregnant than couples without repaired varicocele.
Fertility surgery: Several studies show that the number and motility of spermatozoa improves after varicocele surgery. Some studies suggest that couples with repaired varicocele are 30-50% more likely to become pregnant than couples without repaired varicocele.