Outpatient Surgery of Varicocelectomy

introduction

Patients who complain of reduced ejaculate volume, attenuated libido, post-coital testicular aching and/or poor parameters of semen analysis usually undergo varicocelectomy - a surgical procedure involving high ligation of an internal spermatic vein or low level approach - provided that the doctor diagnoses the patient with a varicocele and rules out any hormonal dysfunction.

Anesthesia

Topical infiltration of a 0.8% Lidocaine solution is made layer by layer whenever necessary.

Operations (Figure 1)

The cross point of the transverse abdominal crease and the lateral margin of the rectus abdominis muscle is marked (A). This position corresponds to the underlying spermatic cord. It is very helpful to determine the point via palpation when the patient contracts the muscles of his lower abdomen. A rectangular region around 5×1 cm centered with the point is infiltrated with Lidocaine solution via a 10 mL syringe (B). A 3.5 cm wound is made after the anesthetic effect is ascertained. The circumflex branch of the external pudendal vein can be preserved if encountered. The wound is deepened to Scarpa’s fascia, which is opened using a hemostate after it is anesthetized. The aponeurosis (C) of the external oblique muscle is clearly identified, and local infiltration with the injection needle beneath the fascia is performed. A feather-like appearance of the lateral one denotes the exact position, and a slit wound is made in the direction of its fibers with a surgical scalpel, followed by an extension on both ends using scissors. The cut margin is held by a hemostate in order to apply a US-army retractor to expose the underlying muscle (D). Caudally, a fatty tissue, whitish in appearance and delineated by reddish muscle, can be readily identified. Around 3×1 cm area of the muscle 0.5 cm cranially to the margin is infiltrated with Lidocaine solution, and care should be taken not to puncture into the deeper-seated vessels; therefore, aspiration of the syringe is required before attempting any injection. The muscle layer is gently separated through the external oblique, the internal oblique and the transversus abdominis until the whitish paravesical fat is encountered with a pair of retractors. The spermatic cord (E), with its accompanying vas deferens, is hooked out cranial to the internal ring of the inguinal canal with a right-angle hemostate (F). The cord can occasionally be pulled laterally if the blade of the retractor is positioned too deep. If soothe retractor shall be withdrawn then the inferior epigastric artery and vein could be clearly seen and the superior-lateral neighboring cord can be easily identified and then managed. A deeper-blade retractor may be applied cranially, which limits the abdominal content, thus enabling clear identification of the cord. When managing the cord it is unnecessary and unwise to separate any tissue—doing so would cause unpleasant pain to the patient. The entire cord is suspended with a cured-prong hemostate (G). 3 to 4 veins are meticulously dissected and identified in this process. A squeezing maneuver (H) is applied to the pampiniform plexus to enhance visibility of the vein whenever necessary. The transparent lymphatic vessel and a pulsatile (or, rather, erect) artery can exclusively be readily identified. In the management of the bigger veins, a 3 cm segment is removed, while the proximal stump is tied 0.5 cm proximally from its end. The distal stump is allowed to remain open for drainage of the blood pooled in the pampiniform plexus and tied freely afterward. Finally, the two stumps are tied together with two knots separated apart for at least 0.5 cm. This reinforces the strength of the whole spermatic cord and also prevents the veins’ postoperative recanalization. The muscle layer is approximated using 3-0 or 4-0 silk suture with adequate tightness after the cord is returned back to its normal position. Likewise the aponeurisis, Scarpa’s fascia and the subcutaneous layer are subsequently fashioned layer-by-layer with 4-0 silk. Finally the skin layer is repaired with a 4-0 or 6-0 nylon suture.

Figure 1. Schematic illustration of a high ligation of the ISV

The cross point of the transverse abdominal crease and the lateral margin of the rectus abdominis muscle is marked. This is the saddle point along the crease in between the rectus abdominis and the three abdominal muscles: the external oblique, the internal oblique and transversus abdominis.

  1. A 3-cm deep incision centered with the above point is made after the anesthesia is ascertained.
  2. The subsequent topical infiltration is done with an injection of Lidocaine solution via a 10 mL syringe. The anesthetic effect is confirmed by pinching the skin with a toothed forceps.
  3. The wound is dissected and deepened continuously until the aponeurosis of the external oblique muscle is met. A slit wound is made on the aponeurosis and is then extended on both ends using scissors.
  4. Two retractors are applied to expose its underlying muscle. The delineation of the external oblique muscle cranially and the whitish fatty tissue caudally is clearly visible. The muscle is likewise infiltrated and separated bluntly using a hemostate until the paravesical fat is seen.
  5. The spermatic cord (with its accompanying vas deferens) is identified. The retractor should be carefully advanced, otherwise the inferior epigastric vessels that lie medially and Inferiorly will be exposed.
  6. A right-angle retractor is used to hook out the cord Immediately cranially to the internal ring of the inguinal canal.
  7. The cord is held by a cure-prong hemostate that bites the meshed gauges which are good for blood absorption. A squeezing manipulation is performed to facilitate the visibility of the vein (darkish, like an earthworm) and even a transparent, small lymphatic vessel. Note that the testicle is null held inside the palm. Among the internal spermatic veins the biggest one is readily identified and picked up with a mosquito hemostate. In managing the bigger veins, a 3 cm segment was removed, while the proximal stump was tied 1.5 cm proximally from its end with a 3-0 silk suture. The distal stump was allowed to remain open for evacuation of the blood pooled in the pampiniform plexus, which was later tied. Finally the two stumps were tied together with two knots at least 0.5 cm apart. H). The wound is fashioned layer by layer with 4-0 silk suture for layers of muscle, aponeurosis and other fascia; and 4-0 or 6-0 nylon suture for skin repair.

Immediately after the innovative penile venous stripping granted the USPTO patent in August 2012, we have had a novel approach for bilateral varicocelectomy whereby no abdominal muscle was touched since late 2012. Along the median longitudinal wound for penile venous tripping, and via a subcutaneous tunnel, the left spermatic cord with its accompanying vas deferens was hooked and pulled out medially via a hemostat. Similarly the right spermatic cord was performed (Figure 2A). A squeezing maneuver was applied to the pampiniform plexus to facilitate visibility of the vein whenever necessary. The transparent lymphatic vessel and a more pinkish, pulsatile artery could readily be identified. In the management of larger veins (Figure 2B), 3-5 cm long segment was removed, with the proximal stump tied 0.5 cm proximally from its end. The distal stump was allowed to remain open for evacuation of the blood pooled in the pampiniform plexus and then tied off firmly. Finally, the two stumps were tied together with two knots separated by at least 0.2 cm (Figure 2C). This reinforces the strength of the entire spermatic cord as well as prevents the veins from being re-canalized post-operatively. Similarly the process was repeated on the other side (if required) and both cords released (Figure 2D). A sagging scrotum was not uncommon and could be treated at the same time if necessary. Subsequently, the redundant scrotal skin was properly assessed (Figure 2E), excised and closed using 6-o nylon (Figure 2F) for Dartos layer and then the skin layer (Figure 2G) using 5-0 chromic suture which was also good for repairing finally the pubic wound (Figure 2H). It is paramount that while circumferential and the pubic wounds were fashioned, an assistant should apply constant stretching to the penile shaft. A compression dressing encircling the length of the stretched penile shaft was then put in position.

Figure 2. The photos of varicocelectomy
  1. Both side spermatic cord are positioned by hemostat (white arrows).
  2. Larger veins (arrow) will be identified and skeletonized, a 3-cm-long section is resected and it is tied proximally with an allowance of at least 0.5 cm.
  3. After the blood pooled in the pampiniform plexus had been evacuated, a second knot is made at the distal stump (arrowhead). Inserted illustration is made. 
  4. Both spermatic cords are original anatomical position.
  5. The scrotal reduction is going to make via assessing the adequacy of excision (asterisk) which involves the Dartos fascia.
  6. The redundant skin is excised. The wound is first fashioned on the Dartos fascia using 6-o nylon.
  7. The scrotal wound (arrowhead) is well fashioned with 5-o chromic.
  8. Similarly the pubic (arrow) and circumferential wound (arrowhead) are fashioned.

Discussion

  1. During the entire procedure neither a Bovie nor suction apparatus is applied, since there is no excessive blood generated from this operation. Any vessel stump can be readily identified and ligated with a 6-0 nylon suture. Likewise, a drain tube is not necessary in routine use because vessel trauma can be avoided completely in this procedure. In our thousand operations, 11 patients regularly took aspirin as victims of the coronary artery disease and 2 patients were taking Coumadin daily for their valvular replacement. They all experienced this ‘almost nonexistent’ surgery without requiring any special care after the operation.
  2. Painful injection may be expected in this sensitive region, but a slow injection as well a quick puncture through the skin is acceptable. Surgeons should try to avoid making a wheal (a typical result of subcutaneous injections) so as to not cause any further pain or anxiety to the patient.
  3. Prior to operation, the spermatic cord’s position should be just above the internal ring of the inguinal canal, where it is 0.5 cm allowance and unnecessary to dissect any tissue, so it is a relatively painless surgery. With the surgery—which creates an opening merely 0.5 cm long—local anesthesia on outpatient basis becomes possible since the overlying fatty layer is always very thin, even in a male with central obesity. This operation area has the advantages of being low enough to apply local anesthesia and high enough to avoid multiple venous channels.
  4. We advise physicians to shorten and then enhance the major internal spermatic vein after the pooled blood is squeezed out. The venous trunk is strong enough to sustain the increased suspension force to the ipsilateral testicle, this could solve the problem of testicular ptosis in which the testicle may touch the ground when patient squats. In 35 patients the measurement of the venous strength of a single internal spermatic vein is 0.32 to 1.68 Kgf (mean 0.91 Kgf, Simpo DFG-20), which is more than strong enough to support a testicle. In contrast, if the bigger ISVs were simply severed the patient would experience an overall decrease in the strength of the spermatic cord.
  5. A squeezing manipulation during the operation of the pampiniform plexus is very helpful in increasing the visibility of the smaller veins and expelling the venous content. Interestingly, a yellowish phlebolithiasis was expelled out with those pooled blood in 1995. At the time, the preoperative colic pain that was not commensurate with that of the varicocele is elusive. It is important that the assistant hold rather than squeeze the testicular proper, otherwise the patient may experience intolerable pain.
  6. Postoperative wound pain is usually reported by patients; however, oral intake of anesthetic medication is sufficient to alleviate any unpleasant feelings. Patients are instructed to apply a clenched fist to compress the wound whenever a sneeze or cough arises. It is inadvisable to repair the muscle layer too tightly, otherwise an extreme postoperative pain may result since chronic ischemia can lead to fibrosis of these muscles. Care should be taken not to encase or traumatize either the iliohypogastric or ilioinguinal nerves, otherwise iatrogenic numbness over the inguinal region is irreversible. These concerns can be free from the innovative method (Figure 2) although it is technique challenging. These concerns can be free from the innovative method (Figure 2) although it is technique challenging.  
  7. Varicocele is traditionally believed to adversely affect spermatogenesis, being responsible for low sperm count, poor motility, and bizarre morphology. It mostly occurs in fertile young patients; however in our practice it plays an important role in sexual functions, such as stimulating libido, increasing the amount of ejaculate, advancing coital frequency, etc. Further investigation on varicocele is mandatory. The reason we never hesitate to perform this surgery on suitable patients is that it does not negatively impact erectile function.
  8. Routinely 5 to 6 pieces of acupuncture needles are applied to cover 3 to 5 standardized acupoints. This is very helpful in relieving the patient of what may otherwise be intolerable pain. Although this measure did not reduce the verbal pain scale, a pethidine injection is no longer required, and we believe that acupuncture can increase pain tolerance among patients.
  9. Some may question the feasibility of this surgery because it is such a complex operation. Skeptics may rest assured that the surgery is indeed possible when performed by capable hands, although its difficulty is amplified when done on obese patients. In fact, in our experience operating on hundreds of patients, we were only presented with an extremely difficult case when we performed the surgery on a very overweight gentleman who not only required a spinal anesthesia but also implored us to exhaust virtually every option to complete the operation. Based on that experience, and due to the complications that may arise, we regrettably discourage obese men from seeking this type of treatment.

Suggested Readings

  1. Cayan S, Kadioglu TC, Tefekli A et al: Comparison of results and complications of high ligation surgery and microsurgical high inguinal varicocelectomy in the treatment of varicocele. Urology 2000; 55: 750-754.
  2. Coolsaet BL. The varicocele syndrome: venography determining the optimal level for surgical management. J Urol 1980; 124: 833-839.
  3. Green KF, Turner TT and Howards SS. Varicocele: reversal of the testicular blood flow and temperature effects by varicocele repair. J Urol 1984; 131: 1208-1211.
  4. Kim ED, Leibman BB, Grinblat DM et al. Varococele repair improves semen parameters in azospermic men with spermatogenic failure. J Urol 1999; 162: 737-740.
  5. Nadelson EJ, Cohen M, Warner R et al. Update: varicocelectomy--a safe outpatient procedure. Urology 1984; 24: 259-261.
  6. Pap anikolaou F, Chow V, Jarvi K et al. Effect of adult microsurgical varicocelectomy on testicular volume. Urology 2000; 56: 136-139.
  7. Yaman O. Ozdiler E, Anafarta K. et al. Effect of microsurgical subinguinal varicocele ligation to treat pain. Urology 2000; 55: 107-108.
  8. Leach GE. Local anesthesia for urologic procedures. Urology 1996; 48: 284-288.
  9. Pierik FH, Abdesselam SA, Vreeburg JT et al. Increased serum inhibin B levels after varicocele treatment. Clin Endocrinol 2001; 54: 775-780.
  10. Younes AK. Low plasma testosterone in varicocele patients with impotence and male infertility. Arch Androl 2000; 45: 187-195.
  11. Cayan S, Kadioglu A, Orhan I. et al. The effect of microsurgical varicocelectomy on serum follicle stimulating hormone, testosterone and free testosterone levels in infertile men with varicocele. BJU Int 1999; 84: 1046-1049.
  12. Hsu GL, Ling PY, Hsieh CH, Wang CJ, Chen CW, Wen HS, Liu LJ, Huang HM, Einhorn EF, Tseng GF. Outpatient varicocelectomy performed under local anesthesia. Asian J Androl2005; 7: 439-444. (Correspondent and Principal author)
  13. Hsu GL, Molodysky E, Liu SP, Hsieh CH, Chen HC, Chen YH. A Combination of Penile Venous Stripping, Tunical Surgery and Varicocelectomy for Patients with Erectile Dysfunction, Penile Dysmorphology and Varicocele under Acupuncture-aided Local Anesthesia on Ambulatory Basis. Surgery: current research. 2013; S12: 008. doi:10.4172/2161-1076.S12-008 (Correspondent and Principal author)
  14. Hsu GL, Zaid UX, Hsieh CH, Huang SJ. Acupuncture assisted regional anesthesia for penile surgeries. Transl Androl Urol. 2013; 2: 291-300. doi: 10.3978/ j.issn.2223-4683.2013.12.02 (Invited, correspondent and Principal author)