Varicose Vein Hernia (Varicocele): Surgical Therapy

Surgical indications

  • Infantile varicoceles with testicular atrophy, i.e., when a reduced testis is present in addition to the varicocele. The cutoff value is a testicular atrophy index (TAI) of 20%, meaning that one testis is 20% smaller than the other; another factor is a volume difference of at least 2 ml between the two testes.
  • Large varicocele in adolescents, especially with pathological spermiogram.
  • Pain symptomatology
  • Fertility dysfunction and pathological spermiogram and varicocele.

Surgical procedure

  • Antegrade varicoceles sclerotherapy (according to Tauber):
    • Scrotal spermatic cord exposure (by opening the scrotum (scrotum)).
    • Exposure of the varicoceles vein and injection of the sclerosing agent (sclerosing agent).
  • Retrograde varicoceles sclerotherapy:
    • Retrograde (“retrograde”) via a transfemoral (“via the femoral artery“) access, angiographic embolization (artificial occlusion of blood vessels by e.g. liquid plastics, plastic beads)/sclerotherapy of the internal spermatic vein is performed
  • Suprainguinal surgical procedures (suprainguinal: “located above the groin”; as an open surgical technique; or also laparoscopic or retroperitoneoscopic):
    • Bernardi operation: ligation of the vasa testiculares (paired blood vessels supplying the testis: testicular artery and testicular vein) retroperitoneally (located behind the peritoneum) between the spina iliaca ant. sup. and the renal vein
    • Palomo surgery: transection of the vasa testiculares slightly lower at the level of the spina iliaca superior (anterior superior iliac spine).
    • Vein-selective transection (artery- and lymph vessel-sparing technique); reduces rate of hydrocele; however, recurrence rate is increased
  • Inguinal surgical procedure (usually performed using an operating microscope while sparing the testicular artery, lymphatic vessels, and veins along the vas deferens)
    • Ivanissevich surgery: inguinal spermatic cord exposure and ligation of all veins at the level of the internal inguinal ring.

Varicoceles sclerotherapy is performed under local anesthesia (local anesthesia) or general anesthesia.

Possible complications

  • Varicoceles recurrence (recurrence of a varicocele):
    • Retroperitoneal mass ligation: 1-2%.
    • Sclerotherapy/embolization
      • Antegrade sclerotherapy: 9%.
      • Retrograde sclerotherapy: 10%
      • Selective retroperitoneal ligation and embolization: 4-11 %.
    • Open surgery
      • Inguinal (Ivanissevich) 13 %
      • Suprainguinal: High ligature (Palomo)
  • Hydrocele (water hernia)
    • Suprainguinal: High ligature (palomo): 5-10 %.
    • Retroperitoneal mass ligation: 1%.
    • Selective retroperitoneal ligation and embolization: 7%.
  • Testicular atrophy (“shrunken testis”) due to testicular infarction/tissue infarction (<1%).
    • Wg. antegrade sclerotherapy (obliteration from the testis) due to an arterial malpuncture or in case of extravasation (leakage of blood from a vessel) of sclerosing agent).
  • Postoperative bleeding
  • Wound infections
  • Epididymitis (inflammation of the epididymis) in varicoceles sclerotherapy.
  • Thrombophlebitis (inflammation of superficial (epifascial) veins with secondary formation of thrombosis) in retrograde varicocele sclerotherapy (see above).
  • Postoperative pain