Operations for varicocele varieties. Operation varicocele: essence and purpose
13.09.2017
Varicocele - male disease, in which the veins in the seminal canal expand. Pathology begins in adolescence and may not show up for the rest of your life. Signs that may indicate a disease, tubercles on the scrotum, pain in the groin.
The danger of the disease lies in infertility, so it is desirable to cure it. If a person is not bothered by anything, the doctor may decidewhether an operation is neededin this case, but you can get rid of the pathology operational way. The intervention is well tolerated and complications are rare.
Indications and contraindications for surgery
When planning an operation, the doctor takes into account the state of health of the man, his age and desire to have children. To select a treatment method, it is important to determine the stagetesticular varicocele. There are 4 of them, each stage has its own symptoms:
- Expansion of the veins can be determined by ultrasound.
- If the man is standing, the doctor may feel the veins in the pampiniform plexus.
- In any position of the patient, the doctor can feel the deformed veins.
- Swollen vessels are visible to the naked eye.
The earlier donesurgical treatment of varicocele, the more likely it is to maintain the ability to conceive, infertility threatens at the last stage of the disease.
The operation is prescribed according to indications:
- the process of sperm formation is disturbed - the examination indicates that there are few spermatozoa in the seminal fluid, they do not move well. There is blood/pus in the fluid;
- the appearance of the scrotum (tubercles and swollen veins) does not suit the patient;
- worries pain syndrome. Pain begins with 2-3 stages of the disease. In the resting stage, the pain is insignificant, increases with walking and physical exertion;
- testicles are reduced in size.
If there are no symptoms or indications, some doctors consider surgery necessary as a way to avoid infertility. If nothing bothers you, you can not do the operation, but limit yourself to observation by a doctor so as not to miss the worsening of the condition.
The operation is carried out at the age of 18. Statistics confirm that relapses do not often occur in adulthood.
If a patient has a secondary one that develops due to a cyst, tumor or other formation, then the disease must be eliminated, and thensurgical treatment of varicocele.
In addition to indications for surgical intervention, there are a number of contraindications. For example, open operations are not carried out if:
- ailments in the stage of decompensation (diabetes, cirrhosis);
- inflammatory processes in the acute stage.
A contraindication to endoscopic intervention is a history of abdominal surgery.
There are a number of contraindications for surgical intervention.
Sclerotherapy is not carried out in the presence of:
- large anastomoses between vessels, due to which the adhesive can enter healthy arteries and veins;
- high blood pressure in neighboring veins;
- crumbly nature of the veins, which does not allow the use of the probe.
Preparing for varicocele surgery
Regardless of which one is chosentechnique surgical intervention the patient must be prepared for surgery. 10 days before the scheduled day, diagnostics are needed:
- OAM and blood (for coagulability, group, sugar and total);
- fluoroscopy of the lungs;
- ECG;
- tested for hepatitis and HIV.
Before the operation, the patient must pass tests
In addition to these studies, you need to undergo an ultrasound of the scrotum with contrast, so that the doctor has a complete picture of the state of the vessels. Other studies are scheduled as needed.
On the day of the operation, you can not eat or drink in the morning, the patient takes a shower. The abdomen and pubis must be shaved. If the patient is taking medication for chronic diseases, he should tell the doctor about it. You should not worry, if the patient needs it, the surgeon will tell youhow is the operationwhat will he do and why,how long does the operation takeand rehabilitation period.
Options for varicocele surgery
There are different methods of performing operations, the classification of which is based on the technique and method of access to the veins. If we consider the technology, then the operations are with excision and with the preservation of the caval bridge (shunt). This shunt is a bridge between two testicular veins. Because of it, blood stagnates.
The type of operation is chosen depending on the form of the disease.
Another classification is based onhow is varicocele surgery done(what kind of access). Based on this, there are three types of intervention:
- endovascular sclerotherapy;
- laparoscopic intervention;
- open treatment optionVaricocele, types of operations- the method of Palomo, Marmar or Ivanissevich.
During the operation, the veins are not removed - the vessels remain in place. Affected veins are either bandaged or glued (sclerosed).
Endovascular sclerotherapy
This type of intervention is classified as minimally invasive. The essence of the method is in gluing dilated vessels. Hospitalization is not required, the procedure is performed in the angiography room under local anesthesia. As soon as the anesthesia takes effect, the doctor makes a puncture in the wall of the vein on the right thigh, inserts a probe to assess the condition of the blood vessels and deliver a special substance to the site of the vein lesion.
Endovascular sclerotherapy can be performed only at the initial stages of the disease.
As a special substance capable of gluing blood vessels, a 3% thrombovar solution is used. After sclerosis, contrast is injected into the vessels and it is observed whether the diseased part of the vein will be visualized. If not rendered, thensurgery to remove a varicocelewas successful. At this stage, the probe is removed, and a bandage is applied to the puncture.
On the day of the operation, the man is discharged home and given recommendations. Sclerotherapy is carried out in the initial stages of the disease, when there are no obvious symptoms yet.
Laparoscopy
It takes place under general or local anesthesia. The second option is often used. After anesthesia, the surgeon performs a puncture in the navel area, inserts a trocar through it - a needle with a tube. The abdominal cavity is filled with gas so that nothing prevents the doctor from performing manipulations. A tube with a camera and light is placed into the hole in the peritoneum to monitor the progress of the operation.
Laparoscopy is one of the methods of dealing with varicocele
The surgeon makes 2 punctures in the peritoneum, introduces instruments. It is necessary to highlight the lymphatic vessels and arteries so as not to damage them as a result of the procedure. The affected varicocele veins are tied up, then the instruments are removed, the punctures in the peritoneum are sewn up or sealed.
If testicular varicocele surgerywas performed under local anesthesia, then the man can be discharged home on the same day or the next. After applying general anesthesia, they are discharged after 3-7 days. The success of the operation is assessed by ultrasound.
Operation Marmara
Represents a micro surgical intervention with a low degree of invasiveness. The progress of the operation is monitored using a microscope. Suchvaricocele surgerydoes not require general anesthesia, but if the patient insists, then there may be general anesthesia.
Operation Marmara
may be carried out under local anesthesia
The patient may experience a sensation of warmth and a slight tingling sensation. During the procedure, the surgeon makes a small incision above the pubis, gets to the seminal canal and bandages the damaged vein. Then a seam is made, which will be almost invisible over time, after a week you need to go to remove the threads.
Ivanissevich and Palomo method
Both elimination methodsvaricocele in menpractically do not differ. The Ivanissevich procedure is performed both under local and general anesthesia. The essence of the procedure is reduced to the ligation of dilated veins. The surgeon makes an incision above the pubis 6-10 cm long, pushes the muscles to the plexus of the testis, separates the lymphatic vessels. Then it captures and bandages the affected varicocele veins. The final stage of the operation is the stitching of muscles and tissues.
The method of eliminating varicocele Ivanissevich and Palomo is very similar to each other
During the operation according to the Palomo method, the essence of the actions is the same, but the incision is made higher, so the surgeon receives great overview. As a result, the likelihood of relapses is reduced, but the risk of damage to the artery that supplies blood to the seminal canal increases. This blood vessel is located next to the pampiniform plexus, and therefore is damaged.
Forecast
After surgery, patients recover quickly. With minimally invasive operations, the possibility of recurrence is reduced to 2% of cases, with the Ivanissevich method - to 9%.
In 45% of cases, after the operation, the spermogram returns to normal, and in 90% of cases, its performance improves. In patients of the older age group, the indicators are worse, which is associated with age-related changes in the body.
Rehabilitation after varicocele surgery
After any type of surgery, the patient will have a recovery period. To normalize spermatogenesis appoint:
- dietary supplement with zinc and selenium;
- vitamins;
- hormonal preparations short courses under the supervision of a doctor;
- ointments with antibiotics for the treatment of postoperative wounds;
- painkillers.
- on days 1 and 2 after surgery, keep the wound dry. You can apply ice in a plastic bottle to relieve pain;
- more rest, not to be physically loaded;
- wear a testicular bandage;
- within 2 weeks after the operation, you should not overwork and take a bath, have sex.
When the recovery period is over, the doctor determines the possibility of returning to sexual activity. So that a man does not experience pain and pulling sensations during and after intercourse.
Some men believe that the remaining vein in the scrotum is a sign of an unsuccessful intervention. Actually it is not. The vessels are not removed from the scrotum, but the circulation of blood through them is stopped, since they are damaged. A previously diseased vein may be visible and palpable for about 6 months.
Complications
After the operation, a complication arises, no one is immune from this. And although the risk is not so great, you need to know what you can expect after the intervention. The doctor will inform about this, but the complications are:
- inflammatory process. It is characterized by a number of signs and is detected on the control ultrasound. Removed by medicines;
- neuralgic pains. Occurs when nerve endings are damaged. Such pain is difficult to stop, but you can try. Assign physiotherapy and acupuncture;
- lymphedema. They are observed if the lymphatic vessel is damaged as a result of the operation. Treatment may include wearing compression stockings;
- hydrocele. Dropsy occurs in the testicle due to damage lymph nodes. Treatment - wearing a bandage;
- reduction of the testicle. This complication, the reason lies in the damage to the spermatic artery, this situation is difficult to stop;
- . being treated surgically;
- damage to the urinary tract or intestines. This development occurs in inexperienced surgeons;
- blockage of deep veins. happens due to a reaction to contrast or from internal hemorrhage in the puncture zone.
Varicocele can leave a serious mark on a man's health and lead to complications
Summing up the above, it should be noted that varicocele is a pathology that can lead to serious problems with health. The main consequences of varicocele are impotence, infertility, cancer.
Self-medication should not be engaged, this will lead to a worsening of the course of the disease. As soon as the first signs of varicocele appear, you should immediately sign up for a consultation with a doctor.
Varicose veins of the spermatic cord and epididymis is a fairly common disease that affects 17% of men, mostly at a young age. Treatment depends on the stage of the disease and its extent. With obvious clinical signs, when the veins are observed visually, there is pain, surgery is indicated to ligate the inflamed veins, since a serious threat to the development of male infertility is created.
A testicular varicocele is removed - an operation under anesthesia (usually local) and in some cases general anesthesia is needed. About what methods of surgical therapy are used in modern medicine for the treatment varicose veins veins of the pampiniform plexus, what are their features, advantages and disadvantages will be discussed in this article.
Causes of testicular vein varicose veins
The causes of varicocele development are divided into two types: primary and secondary. Primary include venous insufficiency, manifested in the weakness of the venous walls and valves, secondary to all other factors, the action of which causes an increase in blood pressure in the testicular veins, which leads to the development of venous insufficiency. The result of these reasons is the development of varicose veins and deformation of the veins of the scrotum. Let's take a closer look at how this happens.
Varicocele has several stages, ranked depending on the degree of deformation of the varicose veins. The earliest one is called subclinical or preclinical because the disease is at the stage of formation, it is latent, has no signs, and it can be detected only with the help of ultrasound diagnostics, which is rather difficult in the absence of symptoms.
At this time, the venous valves cease to close completely, and blood reverses. This phenomenon is called reflux. It leads to an increase in intravascular pressure and negatively affects the functional activity of the testes, since steroid hormones produced by the adrenal glands are delivered to the testicles with the reverse blood flow.
Need to know. In childhood and adolescence, the development of varicocele does not require the presence of factors that cause an increase in venous pressure, since venous insufficiency has a genetic predisposition and is inherited. Therefore, if there have been cases of varicocele in the family, it is important to undergo regular medical examinations boys before the end of puberty.
The appearance of the first signs indicates the progression of the disease and its transition to a clinical form. In the beginning, a man feels weak periodic pain dull or pulling character, which at first occur rarely and usually after significant physical exertion, weight lifting or sexual contact.
These are the symptoms of the first stage of varicocele, in which the inflammation of the veins is still insignificant and they are not only not visible visually, but simply feeling the scrotum is not enough to determine them. To establish the presence of a disease in physical diagnosis is possible only when performing a Valsalva test.
Its essence is that, during palpation, the patient strains the abdominal press or deliberately coughs, while the doctor can detect tension in the veins. For a more accurate diagnosis, the patient is always referred for ultrasound diagnostics using Doppler, which will measure the diameter of the vessels at the sites of vein expansion and establish the intensity of reflux.
The data obtained are important not only for clarifying all aspects of the state of the disease, but their value lies in the fact that, based on the primary data obtained, it is possible to track the course of the disease and monitor the situation in the recovery period after surgical treatment.
Subclinical and first degree varicocele are the least dangerous for men's health, therefore, at this period of the development of the disease, it is possible to use medication and traditional medicine to stabilize varicose veins and maintain spermatogenesis at the proper level.
But in the subsequent stages, extremely unfavorable conditions are already created for the functioning of the testicles and even for their anatomical integrity, therefore, diagnosing the second and especially the third stage of varicocele is a direct indication for immediate surgical intervention.
It is characterized by persistent pain in the scrotum, which can be both periodic and prolonged. They occur not only after physical exertion, but also at the end of the day. At this stage, on palpation, the inflamed veins are already clearly identified, but only in an upright position, lying down, they subside.
The Valsalva maneuver is not required. Visually, the veins can appear in the scrotum, which indicates the progression of the disease and its possible transition to the third degree. Semen analysis shows a significant deterioration in the process of gamete formation.
The most dangerous and easily diagnosed third stage. In the scrotum, an abundant plexus of inflamed veins develops, which is clearly visible visually, due to which the scrotum acquires a bluish tint. Its tissues, as well as the histological structures of the testicles, due to insufficient blood circulation, experience problems with trophism and gas exchange, therefore the skin of the scrotum changes, the diseased testicle becomes smaller and sags.
The pain is constant and quite severe. Laboratory tests show a strong decrease in the synthesis of steroid sex hormones and a deterioration in the spermogram, which requires an urgent operation to eliminate the varicocele. For a complete understanding of what the negative impact on the body of a man is, in the next section, we will briefly dwell on the consecration of this issue.
Harm to men's health caused by varicocele
It does not pose a significant danger to the patient's life and poses the main threat, primarily to reproductive system, and also has a negative effect on endocrine processes, which in turn changes the overall hormonal background, lowering sexual attraction and potency. Table 1 shows the negative consequences that develop due to varicose veins of the spermatic cord and epididymis.
Table 1. Diseases associated with the development of varicocele:
| Pathology | What caused her appearance | |
| Complete or partial loss of fertility | An increase in the total area of the veins in the scrotum due to varicose veins leads to hyperthermia. Violation of histological structures provokes autoimmune reactions and death of spermatozoa. |
|
| Degradation tissue structure testicles | Deceleration of blood circulation, impaired nutritional and respiratory function, stagnant processes, accumulation of active chemical substances negatively affect the cellular structures of the testis |
|
| testicular atrophy | Hypoxia in the third degree of varicocele can lead to severe degradation of the histological structures of the testis |
|
| Decreased blood testosterone levels | Synthetic activity in Leydig cells decreases due to hypoxia, testicular atrophy, and also when reflux of steroid hormones with reversal of venous blood during reflux |
|
| Decreased potency and libido | With a reduced synthesis of male sex hormones, 90% of which are produced in the testes, not only the intensity of spermatogenesis decreases, but also “male strength”. |
|
The most significant effect on the course of spermatogenesis is the change temperature regime in the scrotum upward. The testicles are specially placed outside the peritoneum in order to ensure the optimal temperature at which full-fledged sexual gametes can form, as a rule, this is 34.5 degrees with slight allowable fluctuations.
The scrotum has a special muscle, the cremaster, which is responsible for raising or lowering the testicles, as well as several other muscles responsible for tightening or relaxing the skin layers. This ensures proper thermoregulation. With the development of varicose veins, a significant network of inflamed veins develops around the testicle, so the temperature invariably increases with the development of varicocele.
At the terminal stage, it can reach 37 degrees, while a negative effect is on a healthy testicle, and if the doctor does not intervene during the course of the disease, then the development of infertility occurs in the vast majority of cases. Therefore, the answer to the question of whether surgery is needed for varicocele should be obvious to the reader or not.
In addition to an increase in temperature, the development of germ cells is negatively affected by a slowdown in blood circulation, which worsens metabolic processes in cells and slows down their metabolism. At the same time, oxygen starvation is observed in them.
In areas of deformed veins, stagnant processes are formed, due to which there is an increased concentration of active chemicals (for example, free radicals, nitrogen oxides, etc.) that are the causes of undesirable chemical processes. All this leads not only to a decrease in the work of cells, but also to their lysis; therefore, histological structures degrade.
The hematesticular barrier in the testicles separates the site of gamete synthesis from the aggressive cells of the immune system, which, when thinned, begin to pass through it and destroy spermatozoa, mistaking them for foreign agents. This is how an autoimmune reaction develops, which is responsible for the formation of a stable immune response.
The nutritional function of the hemotesticular barrier is associated with the localization of the so-called nurse cells or Sertoli cells in it, which provide proper trophism for developing and newly formed spermatozoa.
Sex cells, due to their specification, have lost some of the organelles; therefore, with the help of cytoplasmic bridges, they are connected to nurse cells, which are responsible for the metabolic processes of sperm. Accordingly, a decrease in the number of Sertoli cells will negatively affect the quality of male germ cells.
The same processes inhibit the activity of Leydig cells responsible for the synthesis of steroid male sex hormones, the main of which is testosterone, which is responsible for the manifestation of sexual characteristics, muscle growth, potency and sexual desire.
Since many people wonder if everything is so scary, is surgery necessary for varicocele or are there cases in which conservative treatment is possible? Let's consider this question in more detail.
When can surgery to remove a varicocele be delayed?
In itself, the presence of a confirmed diagnosis of varicocele is an indication for surgery, but it is not always performed.
The reason for postponing surgery for more late deadline May be:
- if the disease is early stages in a reliably stable state;
- a short period of illness;
- age of the patient (children and persons old age);
- the presence of other pathologies that do not allow for surgical intervention;
- if for a man the onset of infertility is not terrible, for example, there are already a sufficient number of children;
- categorical refusal of the patient from surgical intervention or lack of financial ability.
On early stages formation of the disease (subclinical and first degree), the negative processes occurring in the testes are small, therefore, as a rule, the spermogram does not show deviations from the norm, and the histological structures remain unchanged.
Therefore, if the doctor is confident in the stability of the patient's condition, a delay is possible until the disease begins to progress. For the patient, treatment is determined and detailed instructions are given about preventive measures. Usually prescribed venotonics, antioxidants and drugs to stimulate meiosis (the process of formation of germ cells).
The patient must adhere to certain restrictions associated with preventing an increase in pressure in the scrotum, move more and adhere to a number of other tips, which are detailed in the section on prevention after varicocele surgery below, as well as in the video in this article.
Surgical treatment may not be carried out at all in the case when the preservation of childbearing function is not relevant for a man, for example, due to advanced age or he has a sufficient number of children and is no longer planned. This option is possible if the varicocele is stable, there is no threat of destruction of the histological structure, and the disease itself does not cause severe discomfort.
Important. If the postponement of surgery to remove scrotal varicose veins concerns men of childbearing age, then it is mandatory constant surveillance at the urologist with statement of the patient on the dispensary account.
A high percentage of postponing the operation is typical for juvenile patients. As a rule, in children and adolescents, varicocele is determined at the first stage in the period of 13-16 years. The delay is due to several reasons.
Firstly, initial stages diseases are not significant. negative impact Second, children are more likely to develop postoperative recurrence because the venous system does not have time to quickly adapt to the rapidly growing youthful body.
The child is constantly observed, he is prescribed medication maintenance therapy aimed at maintaining the disease. The operation is performed at the end of puberty or if a deterioration in the patient's condition is noticed.
But this approach to treating children is somewhat outdated. Previously, for surgical intervention, they used mainly the technique developed by Ivanissevich, which is distinguished by a simple but high probability of developing postoperative complications.
On this moment medicine has made several progressive steps and today in all regions of our country various operations for varicocele are available, which are characterized by low trauma, high efficiency, while the risks of recurrence are minimal.
Therefore, many doctors are inclined to the opinion of reasonableness prompt removal diseased veins of the spermatic cord in the early stages of the disease, which will guarantee the integrity of all histological structures and minimize the risk of infertility in the boy in the future, when he grows up.
When surgery is needed
The most guaranteed way to avoid the loss of childbearing function is early diagnosis and prompt elimination of the detected problem.
There are cases when surgical intervention is required urgently:
- varicose veins of the scrotum 2 or 3 degrees;
- testicle affected by varicose veins;
- pathological changes in spermatozoa or their number in the spermogram;
- in a biochemical blood test, a strong decrease in testosterone levels is detected;
- reduction of the testicle due to degradation of the tissue structure of the testicles.
It must be emphasized once again that there is no alternative to surgical treatment. All other methods of treatment prescribed by the doctor are aimed at maintaining and stabilizing the disease.
It should be understood that at the moment modern medicine does not have and in the foreseeable future will not have conservative ways repair deformed veins and correct malfunctioning valves.
Important! Varicocele is completely cured, but only after an operation to remove the inflamed veins.
Surgical treatment of varicocele
At the moment, it is possible to remove inflamed testicular veins in more than a hundred ways, but in real practice, no more than ten methods and their varieties are used. This section will compare operations for varicocele, taking into account their positive and negative characteristics.
Regardless of the chosen technique, the essence of the treatment is to eliminate the blood circulation through the deformed veins, the testicle will be fed through the remaining healthy vessels, which is quite enough to ensure all physiological processes occurring in the testes.
Operations Ivanissevich and Palomo
In 1924, the Argentine surgeon Ivanissevich proposed a technique for the surgical removal of varicose veins through retroperitoneal access. Since then and until today, this type of operations is dominant because positive aspects is the most low price and a simple execution technique, and the operation does not require any special conditions in the operating room or the availability of special tools.
The note. For a long time, the classical method was practically the main method of surgical treatment of varicocele, but in Lately preference is given to more modern techniques carried out mainly through microaccess or using special probes.
Despite the fact that at the moment there are already quite new minimally invasive methods of treatment, classical operations still remain in the first positions, mainly due to the lack of special surgical equipment in most clinics in our country that allows performing modern operations with high precision when working with vessels.
The principle of the operation of varicocele according to Ivanissevich is as follows. On the body in the area of the peritoneum in the left iliac region at the level of the anterior-superior spine ilium skin is excised parallel to the course of the inguinal canal, subcutaneous tissue and muscle tissue.
Through the incision made up to 6 centimeters in size, the surgeon gets to the veins of the spermatic cord and removes them. After that, the diseased veins are clamped with the help of Kocher clamps, ligation, suppression, return of the veins to their former place. Layer-by-layer seams are superimposed on the incision. The duration of the entire operation, as a rule, is within 30-40 minutes.
The negative aspects of the technique general assessment dominate the positive ones. This consists, firstly, in a significant likelihood of relapses and complications, since part of the anastomoses of the testicular vein often go unnoticed and become inflamed again, and secondly, tissue damage, especially muscle tissue, heals for a long time, so the full recovery period lasts at least six months.
The types of operations for varicocele of Ivanissevich and Palomo are quite similar due to the fact that the second was a student of the first. The difference lies in the proposal of Palomo simultaneously with the testicular vein to stop the artery of the same name.
For a long time, this caused controversy between supporters and opponents of this method of removing varicocele, since some believed that the testicle would not receive the necessary blood circulation, others showed the absurdity of the judgment of the former, since there are many anastomoses between the vessels and in practice doctors often bandaged both the artery and the vein, which is not caused negative consequences.
Nevertheless, the technique proposed by Polomo did not receive wide recognition over time, and the Ivanissevich operation became the main operation to remove varicocele until the 90s of the last century.
The note. The high level of complications after operating with these methods forced doctors to modify classical operations and exclude lymphatic vessels during ligation, which reduced the likelihood of postoperative development of hydrocele and testicular edema.
Pay attention to table 2 where in short form a comparative characteristic of classical abdominal operations according to the methods of Ivanissevich and Palomo is given.
Table 2. Positive and negative aspects of the operations of Ivanissevich and Palomo.
| Strengths | Weak sides |
the operation does not require special surgical equipment;
|
|
Varicocelectomy from subinguinal microaccess according to the Marmar method
The technique is essentially similar to the abdominal operations mentioned above, but a different technique is used. The entire operation process takes place under optical magnification, so a special microscope must be installed in the operating room, as an alternative, surgeons use special magnifying glasses.
This allows the doctor to perform manipulations during the ligation of veins much more correctly, while with a high probability the nerve and lymphatic fibers, as well as the testicular artery, remain intact. At the same time, not only the spermatic vein is stopped, but also its collectors, which significantly reduces the risk of relapses.
Subinguine access involves an incision in the area of the external inguinal ring at a distance of about one centimeter from the base of the penis, therefore, in order to get to the veins of the spermatic cord, the muscle tissues of the peritoneum are not damaged, and this reduces the rehabilitation period.
After dissection, a small surgical opening is formed, no more than 4 centimeters, veins are removed through it, which can be examined along the length better than with classical techniques. Before ligation, all other vessels and tissues are necessarily isolated and set aside, which excludes their injury.
After bandaging and suppression of all inflamed veins found, the wound is sutured. The sutures are usually removed after a week, and if the suture is cosmetic, it will resolve itself.
Thus, the technique of surgery for varicocele allows not only to effectively treat varicose inflammation of the veins of the pampiniform plexus, but also to significantly reduce recovery time. During the treatment, hospitalization is not required, and the patient is at home on the evening of the operation. Please refer to Table 3 for the distinctive features of this methodology.
Table 3. Positive and negative aspects of varicocelectomy according to the Marmar method:
| Characteristics of the operating technique | |
| Strengths | Weak sides |
|
|
Important. When operating according to the Marmar method, hospitalization is not required!
Laparoscopic or endoscopic surgery
They began to use in surgical practice recently, about 30 years ago. His appearance made a truly significant breakthrough in medicine, since it became possible to operate without dissecting the tissues of the abdominal cavity, and the accuracy of the manipulations performed increased significantly.
The laparoscope is a tube with a microcamera and a source of cold light at the end, which allows you to display an image on the monitor screen, so the doctor can not only monitor all the work in real time, but also enlarge the resulting image, take screenshots, etc.
At this method general anesthesia is done so the patient will have to go to the hospital for several days. In order to facilitate manipulations and expand the area for the surgeon's actions, carbon dioxide is pumped into the peritoneum, and microinstruments and a laparoscope are inserted through three small holes (the largest hole in the navel is 10 mm, and the other two are 5 mm each on the left and right in the iliac region)
This type of operation has many advantages, which is explained by more detailed visualization, the ability to inspect vessels from both sides along their entire length.
Note. Laparoscopic surgery is the only way to treat a bilateral varicocele at the same time and the best way to treat relapses.
Diseased veins are found and ligated with the help of microinstruments. The whole process lasts an average of about an hour and a half, after which the patient is taken to the ward. As a rule, there are no problems after the withdrawal of anesthesia, since postoperative complications are unlikely and the man leaves the clinic on the second or third day. More details about all the nuances are indicated in table 4.
Table 4. Positive and negative aspects of laparoscopic surgery:
| Characteristics of the operating technique | |
| Strengths | Weak sides |
|
|
Embolization and sclerotization of the testicular vein
The benefit of surgery for varicocele in this way lies in the fundamental difference from all other methods of surgical removal of varicose veins. In this case, the veins are not tied up or stopped, but clogged with the help of special substances or devices (vein-gluing agents, titanium staples, spirals, etc.), so the blood circulation in them stops, and diseased veins resolve over time.
The blood flow is gradually restored through the collaterals in full, sufficient to meet physiological needs testis.
The plugging agent is delivered to desired vein using a special catheter, introduced first into more large vessel, and all manipulations are monitored by X-ray equipment, so postoperative complications are completely excluded.
The proportion of relapses in sclerotization is up to 7%, which can occur for the following reasons:
- insufficient fixation of the plugging agent in the vessel;
- preservation of reflux due to incomplete occlusion of the venous lumen;
- incorrectly selected blockage site.
Surgery for varicocele in adults with this method lasts about 1–1.5 hours without hospitalization and has the shortest rehabilitation time. In table 5 you can find comparative characteristic the described methodology.
Table 5. Pros and cons of testicular vein embolization for varicocele:
| Characteristics of the operating technique | |
| Strengths | Weak sides |
|
|
Important. This technique for the treatment of varicocele has great importance for those men who are contraindicated in surgery.
Revascularization of the testicular vein
The essence of this microsurgical operation is to remove the inflamed vessel and sew in its place a healthy vein passing in close proximity. The epigastric vein is usually used for shunting. The operation is quite technically complicated, it is performed under general anesthesia, since even minimal movement greatly complicates its implementation.
An incision of no more than 6 centimeters is made in the zone of the inguinal canal parallel to the going seminal vessels. After the end, stitches are applied to the wound, which are removed after a week. The rehabilitation period is quite long, and full recovery takes at least three months.
A clear advantage of this technique is the rapid restoration of testicular blood flow in full, which has a positive effect on the physiological side. But due to the high difficulty in carrying out this technique currently rarely used because there are simpler and more effective ways to treat varicocele.
In addition, at the shunting site, there is a possibility of thrombus formation, separation and migration along bloodstream. Table 6 lists the main advantages and disadvantages of this operating technique.
Table 6. Positive and negative aspects of testicular vein revascularization in the treatment of varicocele:
| Characteristics of the operating technique | |
| Strengths | Weak sides |
|
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Bypass or revascularization of the testicular vein
If you do not go into the peculiarities of medical terminology, the essence of the operation is that a shunt is created from the circumcised testicular vein, which is sutured to a closely located vein. In this case, the blood immediately begins to circulate, the blood flow is completely restored, which is good from a physiological point of view.
Micro-equipment is used to manipulate the veins, and all actions are controlled by a camera to ensure high accuracy.
Briefly describe how surgical correction. To access the veins, an incision is made in the peritoneum about 5-6 cm, through which the testicular and epigastric veins are removed for their entire length in order to completely excise the varicose vessel, instead of which the epigastric vein is sutured. After completion of the revascularization, the veins are placed in place, and the incision is sutured in layers.
Note. The main advantage of the operation is the rapid restoration of blood flow to the testicle, which creates good conditions to normalize its functioning. Among negative sides the risk of thrombus formation at the site of the shunt should be noted.
Features of shunting
Like all other methods, testicular revascularization has its own distinctive features:
- For the operation, the patient needs general anesthesia;
- The varicose vein is removed immediately, and does not resolve for some time, so the blood flow quickly normalizes, which is favorable for the physiology of the testis;
- The technique belongs to microsurgical, for its implementation, microinstrumentation and a microscope are needed;
- The prescription of medications in the first few days has general principles, as with other methods: painkillers, antibiotics, anti-inflammatory, immunomodulators and vitamins;
- I put stitches on the incision. In the first days, a sterile bandage is used, which is replaced after two days and so on until healing;
- Usually the stitches are removed on the seventh or eighth day, after the operation, a scar will remain on the body.
Complications may be similar to those in the Ivanissevich method, with the difference that the probability of their occurrence is much lower. There are also prerequisites for the formation of thrombosis.
Due to the complexity of the procedure and the risk of side effects, shunting in the treatment of varicocele is used less and less. The advent of better techniques has further reduced the use of revascularization to eliminate testicular varices.
Briefly, the table summarizes the main characteristics of the described operational methods that are of most interest to patients.
Comparative table of operations to eliminate varicocele
| View | Hospitalization (days) | Recovery period (weeks) | Probability of relapse | Photo |
| Ivanissevich or Palomo | 8 to 14 | 2-4 | 30% |
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| Marmara | 1-2, or no hospitalization | 2 | 5-7% |
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| 2 | 2 | 1-2% |
|
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| Shunting | 3 | 2 | 5% |
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Other methods of surgical treatment of varicocele
The above operations are the most popular and most frequently used in modern medicine, but there are several more methods for the surgical removal of varicocele that should be mentioned. Previously, they were more widespread, but today they have been successfully superseded by modern and less traumatic methods.
Such operations include:
- Ligation surgery for varicocele. This method is also known as the Goldstein operation for varicocele. Treatment in this case involves ligation of not only the testicular vein, but also the cremasteric one. The bottom line is the evacuation of the testicle through surgical wound, the size of which will depend on the size of the testis, after which the seminal duct and its artery are released, and all the veins and their inflamed collectors are drained. In this case, special attention is paid to the isolation of nerves and lymphatic ducts to prevent their injury. The operation requires magnifying equipment (operating microscope or special glasses). After the end of the operation, the wound is sutured in layers and an antiseptic dressing is applied to it. The risks of recurrence or complications are about the same as with varicocelecomia from the subinguinal micro-access.
- Yakovenko operation for varicocele. Her technique was proposed in 1955. The bottom line is the ligation of the cremasteric vein. According to the technique of the operation, the operation is not complicated, it does not last long under the influence of local anesthesia, but there is a high probability of developing a postoperative relapse or complication. The incision is made directly on the scrotum from the side of the diseased testicle, after which the spermatic cord is removed into the surgical wound, and the inflamed cremasteric vein is identified. Ligation is performed at the beginning and end of the deformed area, then the varicose veins are excised. In this case, it is important to select all the inflamed branches and do the same manipulations with them. After completion, the wound is sutured tightly.
- Kocher operation for varicocele. In fact, it resembles the operation of a varicocele according to the Yakovenko method, but with the difference that all inflamed veins are tied up, and the scrotal incision is made not from the side, but along the central commissure of the scrotum, which is covered by the penis, which is more advantageous from the aesthetic side. The operation is performed under local anesthesia and, as a rule, is performed in those cases in which there is no other way to get to the inflamed veins, although with the advent of modern techniques this is no longer relevant.
Possible Complications
No surgical technique provides an absolute guarantee of protection against the development of postoperative complications. This applies to a greater extent to open-cavitary classical operations and less to endoscopic methods of treating varicocele.
At the core are various reasons both through the fault of the doctor, for example, ligation of not all collectors, weak ligation of veins, passion for the cosmetic side, etc., and through the fault of the patient who does not comply with the rules of postoperative recovery.
Among the most likely negative consequences may be:
- Relapse occurs when there is insufficient ligation of the veins or when branches of the testicular vein go unnoticed. Sometimes a doctor can confuse and mistakenly bandage completely the wrong vessels;
- Dropsy of the testicle (hydrocele) is formed in case of damage to the lymphatic vessels due to impaired lymph circulation;
- Testicular atrophy is possible with damage to the testicular artery;
- Numbness of the skin area, usually on the inner surface of the thigh. This happens when the innervating nerve is cut.
Complications appear in a short period of time after completion of treatment, and relapses can occur both immediately and after longer periods. Both are treated surgically, with a hydrocele it is possible to eliminate the pathology with the help of a puncture.
The immediate reason for contacting a doctor for help will be the manifestation of the following signs:
- the appearance of temperature;
- the occurrence of edema, redness, swelling or liquid discharge of a cloudy nature with an unpleasant odor at the incision site;
- the appearance of blood smudges or an ongoing increase in hematoma;
- signs of inflammation of the scrotum, its increase in size;
- increased pain or other discomfort that causes concern.
Features of rehabilitation
The terms of the rehabilitation period and full recovery depend primarily on the operating technique and less on the patient's compliance with the prescribed instructions. Most of the time for rehabilitation will be spent after the classic open cavity methods of treatment according to the methods of Ivanissevich and Palomo.
Patients feel most comfortable after endoscopic and microsurgical interventions. It all depends not so much on the establishment of a constant blood flow and healing of the veins, but on the restoration of other tissues, the dissection of which was required to gain access to diseased veins.
The operated patient must strictly follow the rules of rehabilitation. In order to prevent a relapse or the integrity of the seams is not violated, the main thing is to prevent loads and increase intra-abdominal pressure.
To do this, you should refuse:
- any heavy physical activity;
- until the doctor allows you to lift heavy objects more than 10 kg should not be;
- light sports are allowed, but you should refrain from long or intense running, as well as from riding a bicycle and a horse;
- prevent constipation or diarrhea as it creates a load on the veins;
- avoid colds and prevent diseases respiratory tract with prolonged cough.
The first few days the patient should observe bed rest. After a short time, you can and should move more, walk or do athletics, which will increase blood circulation in the pelvic organs. Rejection of bad habits is required.
There are no special dietary requirements, but it is advisable to exclude fatty cholesterol-containing foods for the period until complete recovery, and give preference to seafood, chicken, vegetable food rich in vitamins and fiber. And most importantly, do not forget to visit the doctor in a timely manner to monitor the recovery process.
Conclusion
Thus, when comparing surgical techniques for the removal of varicocele, the most optimal is varicocelectomy from a mini-access according to the Marmar method and laparoscopic surgery.
All open abdominal operations performed in the classical way stand out with the greatest likelihood of developing postoperative complications and relapses. The effectiveness of treatment depends not only on the chosen method of removing varicocele, but to a greater extent on the characteristics of the diagnosis, the stage and duration of the disease.
Varicocele - a disease in which, due to impaired blood flow in the vessels of the scrotum, the veins of the pampiniform plexus of the spermatic cord expand.
Varicocele was described by Celsius in the 1st century AD, and only in the 19th century, the connection between varicocele and testicular failure was proven. Infertility is a severe complication of varicocele.
The problem of infertile marriages has recently become very relevant. 40% of infertile marriages are caused by male infertility. According to studies, almost 30% of men suffer from varicocele. It has also been proven that 40-80% of patients with varicocele were found to have reduced fertility.
The incidence by age groups is not homogeneous: thus, in preschool age, the incidence does not exceed 0.12%, and between the ages of 15 and 30 it becomes 3-30%. Especially often this disease develops among athletes and manual workers.
Anatomy and physiology of the testicles
The testicles are a paired glandular organ oval shape. The testicles are located in the scrotum. The testicle is approximately 4 cm long and 3 cm across. The mass of the testicle is approximately 20 grams. The testicle consists of lobules (250-300). Each lobule consists of 2-3 seminiferous tubules (straight and convoluted tubules).The testicle as a gland performs:
- Exocrine function (sperm production in convoluted tubules)
- Intrasecretory function (production of male sex hormones - androgens)
Causes of varicocele
To date, varicocele is considered not as an independent pathology, but as one of the manifestations genetic anomaly development or acquired during the life of the disease of the inferior vena cava and renal veins.The flow of blood in the opposite direction (retrograde) is called reflux. It is primary and secondary.
Primary reflux develops with:
- Congenital anomaly in the testicular vein (lack of valves in the vein)
- Genetic predisposition to weakness of the venous wall.
The main causes leading to renal venous hypertension are:
- Narrowing of the lumen of the renal vein
- Location of the left renal vein behind the aorta
- annular renal vein
- Arteriovenous fistula
Any pathological conditions of the scrotum, inguinal canal, abdominal cavity (hernia), which lead to compression of the spermatic cord, can cause venous reflux (reverse blood flow) and, as a result, lead to varicocele.
Factors leading to violations of spermatogenesis (the process of sperm formation):
- Increased testicular temperature
- Violation of the barrier between blood and testicular tissues (which can lead to the production of antisperm antibodies)
- Overproduction of the hormone hydrocortisone
- Disruption in the production of various pituitary hormones
Varicocele symptoms
In the early stages, varicocele is very often asymptomatic (patients do not complain about anything). A number of patients note the severity and pain in the scrotum on the affected side. The pain has a moderate intensity and a pulling character. The pain may radiate to the groin. As a rule, the pain increases with walking and physical activity. Taking hot bath, patients may notice an increase in veins on the affected part of the scrotum.
But the main complaint that makes patients see a doctor is infertility (the inability to conceive a child).
According to the WHO classification ( world organization health care) distinguish 3 degrees of severity of varicocele.
- Grade 1 - dilated veins of the scrotum are not visible and not palpable; they can only be determined by the Valsalva test
- Grade 2 - the veins are not visible, but are well palpated (palpable)
- Grade 3 - dilated veins are visible, as they protrude through the skin, are very well palpated
- Reno-testicular (reflux from the veins of the kidneys into the testicular veins)
- Ileo-testicular (reflux from the iliac veins into the testicular veins)
- Mixed type (combination between the two types described above)
Diagnosis of varicocele
Feeling the scrotumA mandatory procedure that allows you to determine the severity of varicocele.
ultrasound (ultrasonography). Ultrasound is always combined with dopplerography (a technique for determining the quality of blood supply) of the renal vessels (arteries and veins) and testicular vein.
The study is carried out in the position of the patient standing (orthostasis) and lying down (clinostasis) with the measurement of the blood flow gradient in these positions.
During the ultrasound, it is necessary to carry out Valsalva test:
- An increase (varicose) of the testicular vein in size with a vertical position of the body.
- In the position of the body, lying down, the vein subsides (decreases in size).
With a varicocele of the first degree, the diameter of the testicular vein becomes 2 millimeters larger than normal and a positive (up to 3 seconds) reflux is determined. Severe reflux indicates a more severe stage of the disease.
Ultrasound also allows you to determine the hemodynamic variant of the varicocele, as well as to identify renal venous hypertension (if any).
General urine analysis before and after physical activity (marching test). A positive march test - the appearance of a small number of red blood cells in the urine (microhematuria) and the presence of protein in the urine (proteinuria) indicates renal venous hypertension.
X-ray methods.
X-ray methods include:
- Antegrade phlebotheticulography or retrograde renal phlebography - these methods of research are performed after a preliminary injection of a contrast agent into the veins of the scrotum.
Semiological research(semen study) - most patients have pathospermia (a decrease in the number of motile forms of spermatozoa and an increase in the number of pathological forms) of varying degrees.
Treatment of varicocele
Non-drug treatmentConservative treatment of varicocele is not effective.
Medical treatment
Drug treatment is prescribed only after surgery to stimulate spermatogenesis. Most often, a complex of vitamins, biologically active food supplements (containing selenium and zinc) are prescribed. Sometimes hormonal drugs (androgens, chorionic gonadotropin), they are used under strict laboratory control.
Preparation for surgical treatment involves the delivery of tests before the operation (to exclude decompensation of any organ or organ system). The following analyzes are required:
- Complete blood count (to determine the state of hematopoiesis)
- Blood group and Rh factor (for blood transfusion if needed)
- Urinalysis (to check kidney function)
- Biochemical blood test (glucose, creatinine, urea)
- ECG (electrocardiogram) - to determine the work of the heart
- Radiography chest(to rule out lung pathology)
Currently, there are more than 120 types of surgical treatment for varicocele.
All operations can be divided into two groups:
- Group I - operations in which a message is stored with renal artery.
- Group II - operations in which communication with the renal artery is interrupted
Classic surgery for varicocele
One of the most common operations according to Ivanissevich. It consists in ligation and further resection of the left testicular vein. This leads to the elimination of reflux from the renal vein into the pampiniform plexus. But with this operation, there is a risk of developing a renocaval anastomosis due to difficulty in the outflow of venous blood from the kidney.
Microsurgical treatments for varicocele
Laparoscopic clipping of the testicular vein
Laparoscopic varicosectomy is an endoscopic and minimally invasive treatment for varicocele.
 |
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| Indications for laparoscopic clipping of the testicular vein | Advantages of the laparoscopic method over classical operations | Contraindications for laparoscopic clipping of the testicular vein |
| Varicocele 1, 2, 3 degrees | Possibility of vein clipping in case of bilateral lesion | Operations on the abdominal cavity in the past. |
| Reno-testicular type varicocele | Reducing the risk of postoperative complications | |
| Ileo-testicular type varicocele | The length of stay in the hospital is reduced to 2-3 days | |
| Mixed type varicocele | Almost complete absence of pain in the wound | |
| No pain when walking on the first day | ||
| good cosmetic effect | ||
| Good performance spermograms after surgery | ||
The operation is performed under general anesthesia (the patient is put into anesthesia). A trocar is inserted near the umbilicus, examined abdominal cavity. Then they find the veins of the testicle, carefully separate the artery and lymphatic vessels from the veins. Then the veins are clipped (applying special clips) and the operation is completed.
Endovascular phlebosclerosis
The method consists in clogging the testicular vein with various substances or special devices.
| Indications for the use of endovascular phlebosclerosis | Advantages of endovascular phleboskerosis | Contraindications for endovascular phlebosclerosis |  |
| Reno-testicular type varicocele | The operation is performed under local anesthesia (the patient is conscious) | Large reno-testicular collaterals, which can lead to the drug getting into systemic circulation |
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| Absence of renal vein stenosis | Length of hospital stay is reduced to 2 days | Renal venous hypertension |
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| No venous hypertension | The absence of surgical intervention as such (there are no incisions with this method) | Loose vein type |
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| This method avoids such complications as hydrocele. | |||
| Possibility of re-occlusion of the vein in case of recurrence of the disease |
Endovascular obliteration (occlusion) of the testicular vein is performed in both adults and children. Various substances are used for occlusion:
- Spiral emboli
- fabric glue
- Wire Umbrella Devices
- Various cylinders
- Drugs that cause vein sclerosis
Possible complications after surgery
Complications developing after classical operations.Hydrocele (hydrocele) - a complication in which fluid accumulates in the membranes of the scrotum. In this case, the hydrocele appears due to a violation of the outflow of lymphatic fluid. Violation of the outflow of lymph occurs due to the ligation of the lymphatic vessels together with the testicular vein during the operation.
This complication is treated, as a rule, either by puncture of the affected part with fluid pumping out or by surgery with restoration of lymph outflow.
testicular atrophy. A very rare but serious complication is testicular atrophy. Testicular atrophy is characterized by a decrease in testicular size and a significant decrease in its function. According to statistics, this complication develops in 1:1000 operated patients for varicocele.
postoperative pain occurs due to overfilling of the epididymis with blood and, as a result, stretching of its capsule. But most often in patients after surgery, there is a decrease pain sensitivity.
Complications that develop after laparoscopic clipping of the testicular vein.
Complications develop extremely rarely. The most common complication is mild abdominal discomfort after surgery due to pneumoperitoneum (air filling of the abdomen). It is performed during endoscopic surgery for better visualization of organs. Over time, the air is sucked in and the discomfort goes away.
Complications that develop during embolization of the testicular vein:
- Allergic reactions to contrast agent. Can be avoided by administering desensitizing drugs before surgery
- Thrombophlebitis of the veins of the pampiniform plexus. Can be avoided with thromboprophylaxis.
- Perforation of vessel walls.
Prognosis for varicocele
According to the research, recurrence of the disease is detected in 2 - 30% of cases.In 90% of patients after surgery, an increase in the number of actively motile forms of spermatozoa is observed. But only in 45% of cases, spermatogenesis indicators approach normal values. The longer the disease lasts and the older age patient, the less often spermatogenesis indicators approach normal.
Prevention of varicocele
Prevention is to eliminate congestion in the pelvis. For this you need:- Correction of constipation (constipation)
- Exclusion of a long physical tension
- Regular sex life (implies regular sex)
- Sports activities (best athletics and swimming)
- Sufficient rest (includes proper sleep and walks)
FAQ
When can I have sex after surgery?
After surgical treatment of varicocele, it is recommended to abstain from sex for three weeks. This time is just enough for the body to recover after the operation. Failure to comply with the abstinence period leads to the appearance of painful sensations on the side where the operation was performed.Patients' concerns and fears that erectile function decreases after surgery to eliminate varicocele are not justified. Studies have shown that the operation does not affect the quality of sex.
How much does varicocele surgery cost?
On average, an operation to eliminate a varicocele, together with the cost of a bed, costs from 20,000 to 90,000 rubles. The cost of the operation depends on the clinic and the method by which the problem of varicocele is solved. For example, in Moscow, surgical treatment according to the Ivanissevich method costs 32,000 rubles, and endoscopic treatment of varicocele costs 50,000 rubles.Operation to remove varicocele - reviews
Alexander 30 years oldI have a heaviness in the left side of the scrotum. Has addressed to the doctor to the urologist. He prescribed an ultrasound of the prostate and other organs, then passed a couple more tests. The doctor diagnosed a varicocele of the 2nd degree and prescribed an operation. He said that I can choose the method myself and told me what and how much it costs. I chose the Ivanissevich operation, it cost 27,000 rubles. Endoscopic surgery, but almost 50,000 rubles. I had surgery, according to my doctor professionals. I felt good after the operation. After 5 days I was discharged. It's been almost a month and I feel great, no problems.
Vladimir 23 years old
Was with a friend for company at the urologist. The urologist said I have a grade 2 varicocele. I didn't believe it at first. But then he explained what was happening and said that it could lead to infertility. I was slightly puzzled. The doctor reassured me and suggested endoscopic surgery. He explained that the seam would be almost invisible and would recover quickly. I agreed, went to the operation. They took all the tests I needed and did an ultrasound. Then there was an operation under general anesthesia. Released on day 2. I felt good. Yes, I only had one. cosmetic seam, which I will tell you, healed very quickly and was almost invisible. I was very pleased with both the doctors and the operation itself.
Marmar operation for varicocele, what is the effectiveness of such a microsurgical operation?
Medicine is increasingly striving for low-traumatic surgical operations for various diseases. Surgeons can develop in this direction due to the improvement of high-precision medical equipment, namely endoscopic and computer technologies. So in the treatment of varicocele in countries with developed medicine, classical operations are performed quite rarely. It is not the first year that the treatment of varicocele has been preferred all over the world. microsurgical varicocelectomy or Marmar surgery, this operation is considered the standard in the treatment of varicocele .Indications for microsurgical varicocelectomy:
- varicocele 1-3 degree , both one-way and two-way process;
- soreness in the testicle , a feeling of heaviness in the scrotum, a decrease in the volume of the testicle;
- bad spermogram - Violation of sperm formation, infertility.
1. Temporary contraindications:
- blood clotting disorder;
- exacerbation of chronic diseases;
- sharp infectious diseases(SARS, tonsillitis, sinusitis and others);
- infections genitourinary system(cystitis, urethritis, pyelonephritis), including sexually transmitted diseases;
- severe concomitant diseases that are in the stage of decompensation (for example, diabetes mellitus with complications and uncontrolled glucose levels).
Microsurgical varicocelectomy technique:
1.
The operation is performed under local anesthesia.
2.
The incision is made in the area of the outer ring of the inguinal canal, its dimensions are very small, only about 20 - 30 mm in diameter.
3.
They reach the inguinal canal, where the varicose vein is located.
4.
This vein is tied up in two places, in the area of transition to a healthy vessel, then stitched; all this happens under the control of a microscope, the image is fed to the computer screen.
5.
The affected vein is excised using special tools.
6.
The postoperative wound is sutured.
7.
The duration of the operation, on average, with preparation, is half an hour.
Recovery after surgery using the Marmar method:
- After a few hours, the patient can be discharged home;
- complete restoration of normal general well-being and the cessation of pain in the postoperative wound occurs within 2 days;
- removal of stitches occurs on the 7-8th day;
- having sex and resuming physical activity is possible immediately after the stitches are removed, that is, after a week.
Benefits of the Marmara operation:
1. Low-impact surgery:
there is no need to enter the abdominal cavity, cut muscles and fascia, there is no risk of injury to other blood and lymphatic vessels, nerves.
2. Fast and painless surgical manipulation.
3. General anesthesia
– there is no risk of complications associated with general anesthesia and tracheal intubation.
4. Low risk of complications
during the surgical intervention.
5. Fast recovery period
there is no need for a long stay in the hospital, and you can return to your usual rhythm in a week.
6. Small postoperative scar
, which is located in the scalp, hides under underwear. Almost all men are embarrassed to talk about their gentlemanly health problems, and a large scar always gives rise to unnecessary questions.
7. Virtually no postoperative complications
in the form of hydrocele, relapses
occur extremely rarely, 5-25 times less than with other methods. And more serious complications do not occur at all.
8. Greater percentage of reproductive system recovery
(fertility), normalization of spermatogenesis and the ability to conceive a child.
Disadvantages of microsurgical varicocelectomy:
The main disadvantage of the Marmara operation is its cost. - the cost of the operation averages from 300 to 1300 c.u. e.
When can pregnancy be planned in the family after varicocele surgery?
Varicocele This is one of the most common causes of male infertility. A third of all cases of primary, and four out of five cases of secondary infertility are associated in one way or another with varicocele. Causes of infertility with varicocele:
1.
Impaired blood supply to the testicle
- with varicose veins, both blood flow and its outflow worsen. As a result, there is a lack of nutrients and oxygen for the formation of spermatozoa and the accumulation of harmful substances.
2.
testicular atrophy
can develop with a long course of varicocele, while the testicle is significantly reduced in size and partially loses its functions.
3.
immune process
- there is always an inflammatory process in the wall of varicose veins, as a result - immunity sends to the inflammation site a large number of cells. These immune cells interfere with the formation of sperm, and an autoimmune reaction may develop.
4.
venous congestion
in the testicle leads to a violation of thermoregulation, and the quality of sperm and potency are directly dependent on temperature. Everyone knows that with hypothermia, as with overheating, a man can have "gentleman's punctures."
5.
With a significant expansion of the vein can compress the seminiferous tubules and interfere with normal ejaculation.
But besides varicocele, other factors not related to varicose veins (sexually transmitted diseases, hormonal disorders, prostatitis and prostate adenoma, wrong image life and many others). And up to half of cases, infertility is caused by a whole range of causes and factors.
With a varicocele, there may not be a violation of fertility in men. Yes, and infertility associated with varicocele is not yet a sentence, and after surgical treatment, many men manage to restore fertility and give their soul mate a long-awaited pregnancy.
The most important thing is not to start the process of varicocele and not to refuse treatment at any stage, both surgical and conservative. You can't give up!
It must be noted that success in the treatment of infertility in varicocele depends on the method of treatment. So, conservative treatment makes it possible to conceive a child only in 10-15% of cases. While surgical treatment makes it possible to become pregnant in half of the cases in the first year after surgery, and up to 70% in the second year. And in another 20% of cases, there is an improvement in the quality of spermatozoa, but this is not enough to conceive a child.
But many operations in every tenth case, on the contrary, worsen the spermogram, which is most likely due to postoperative complications or development adhesive process in the testicles and seminiferous tubules.
Also, the restoration of fertility after surgery is affected by:
- the age of the man;
- duration of the course and stage of varicocele;
- spermogram results before varicocele treatment;
- the presence of concomitant pathologies of the male reproductive system.
Planning for pregnancy after surgery for varicocele:
- In 6 months after surgical treatment, and after Marmara operation after 3 months conduct a spermogram . If the sperm is of high quality, and the activity of spermatozoa is good, then you can get down to business.
- If after 6 months the spermogram has not recovered to normal, then the analysis is repeated 8 and 12 months after surgical treatment. And during this time they spend additional methods examination of the male reproductive system, and, if necessary, are treated for concomitant conditions.
- Pregnancy is possible at normal spermograms. Poor-quality spermatozoa can fertilize an egg, but there is a risk genetic disorders The child has.
As you can see, the chances of becoming a father in patients with varicocele are not just there, they are quite high.
Is it possible to go in for sports and are they recruited into the army after surgery for varicocele?
You can return to sports after an average of 1 month, after the Marmar operation - immediately after the removal of sutures, and after the Ivanissevich operation - after 3 months.
Before the permitted period, it is better to minimize physical activity, it is impossible to lift weights of more than 4-5 kg. At the end of the recovery period, physical activity should be started small, gradually increasing to the usual or desired.
Do not forget that excessive physical activity and heavy lifting in itself can cause varicose veins of the scrotum before surgery, and after surgery, this can lead to the development of a recurrence of varicocele. So you have to be careful with weights.
Important! If during sports a man feels discomfort in the scrotum, then physical activity should be excluded for a while, and it is better to contact your urologist with this question.
Do they take in the army with a varicocele?
Varicocele often affects adolescents and young people of military age. Therefore, the issue of military service is very important. I want to remind you that the decision on the suitability of a young person is made only by a doctor of the medical unit at the military commissariats.
Absolute contraindication to military service:
- varicocele of the 3rd degree;
- two relapses in the form of 2nd degree varicocele after surgery.
- An operation for the 1st or 2nd degree, a delay is given for 6 to 12 months, then they are sent to serve.
- 2nd degree varicocele - surgical treatment is recommended, but the conscript may refuse the operation, then the last word is up to the urologist or andrologist. Usually such young people are not called up for military service, but in the event of martial law, mobilization cannot be avoided.
- varicocele of the 1st degree;
- varicocele of the 2nd degree 6-12 months after effective surgical treatment (including after the treatment of the first recurrence).
What to do if the varicocele remains after the operation (recurrence has developed) or the pain in the testicle persists?
Pain in the testicle after surgery for a varicocele can normally persist for a week. After this period, discomfort after physical exertion, sexual intercourse or masturbation is possible for 3 weeks. If after the removal of the sutures, that is, after 7-8 days, the pain in the scrotum persists, it is urgent to consult a doctor, because this may be the result of surgical errors or complications of the operation. Causes of pain after surgery for varicocele:
| Causes of postoperative pain in the testicle | Why do they arise? | What to do, how to treat? |
| Stretching of the epididymis by varicose veins | This is the most common cause of postoperative pain that persists for a long time. This condition occurs due to late treatment for varicocele, at 3-4 stages. | Gradually, pain and discomfort completely disappear on their own. |
| Damage to the ovarian artery | Sometimes, due to their inexperience or inattention (or due to the use of imperfect equipment), the surgeon can confuse the vein and artery, and during the operation, instead of varicose veins, he can bandage the artery. In this case, the patient is worried about pain, discomfort and a gradual decrease in the size of the testicle. This is extremely rare, but it can be costly for the patient. severe consequences. Damage to the ovarian artery threatens testicular atrophy. In this case, the testicle is partially destroyed and ceases to fully perform its functions, disrupting the hormonal background (decrease in testosterone levels) and the formation of active spermatozoa. | Usually, blood flow to the testicle is restored over time due to bypass vessels (collaterals). If testicular atrophy has developed, then hormone therapy is needed to stop the atrophy process. In severe cases, they resort to the removal of the destroyed gonad. |
| Damage to the lymphatic vessel | It is the cause of dropsy of the testicle (hydrocele), manifested in addition to pain by an increase in the scrotum, more often on one side. | Treatment of dropsy of the testicle is possible only surgically. |
| Damage to the spermatic cord | During classical operations it is rare, but it can be. This complication is associated with the anatomical proximity of the blood vessels and the spermatic cord. | In this case, the surgeon usually immediately sees his errors and can restore the integrity of the seminiferous tubule by stitching. But if the damage was not immediately noticed, then sometimes it is necessary to form a stump and remove the testicle from the damaged side over time. |
After any operation, you may also experience relapses of the disease. In microsurgical and laparoscopic operations, the risk of varicocele recurrence is much lower, while in classical abdominal operations, relapses are quite common, up to 40% of all surgical interventions.
Recurrent varicocele- the appearance of all symptoms of varicocele some time after the operation (from 1 week to several months and even years), while varicocele is confirmed by various instrumental diagnostic methods (ultrasound, angiography).
9 out of 10 recurrences are the result of surgeon errors during the operation.
Causes of recurrence of varicocele associated with errors during the operation:
1.
Error in the diagnosis of vascular anastomoses(the formation of additional thin vessels that bypass varicose veins), if these vessels are not removed during surgery or only partially removed, they can cause the re-formation of varicocele.
2.
Surgical treatment in childhood and adolescence(that is, the operation was performed too early), which is associated with the anatomical features of the testicular vessels and with the peculiarity of the course of the disease itself. For the treatment of varicocele in children and adolescents, it is necessary to find the optimal time for surgery, because with late treatment various complications and relapses may also occur.
3.
During the operation, the wrong vessel was tied or all necessary varicose vessels were not blocked .
4.
Failure of clips, seams and other methods of blocking varicose veins.
5.
outflow disturbance(extremely rare) through the veins of the pelvis or external spermatic vein.
6.
With embolization of the ovarian vein, it is possible emboli migration(an embolus is a substance (air, fat, specially created chemical compounds), which block the lumen of the vessels, like a cork bottle).
Risk of complications can be reduced by choosing the correct and effective method of surgery and a detailed examination of the vessels of the testis using various instrumental methods(angiography, CT, Doppler ultrasound and others).
Treatment of recurrent varicocele performed only surgically. It is much more difficult to re-operate on a varicocele. For the treatment of relapses use the same surgical operations, as in the primary treatment of varicocele, while microsurgical and laparoscopic operations are preferred.
If and after reoperation developed a relapse , then the risk of developing testicular atrophy, infertility and dropsy of the testicle in such a patient increases significantly. Treatment of repeated recurrence is also carried out surgically. And, probably, it makes sense to choose another doctor or clinic, because such relapses are a mistake of the surgeon.
Varicocele in children and adolescents, what are the causes, features and what to do?
In childhood, varicocele is a fairly common phenomenon; 10-15% of boys aged 11 to 17 years have this vascular pathology. Basically, the first manifestations of pathology appear from the age of 11, and by adolescence, by the age of 14-15, obvious symptoms, in very rare cases, varicocele is detected in preschool children. Causes of varicocele in childhood:
- The most common cause of testicular varicose veins in children and adolescents is a congenital cause. or anatomical features, that is, a child is born with this, and does not acquire;
- weight lifting - feeling their strength and trying to become men faster, the boys, without much preparation, begin to lift weights, which contributes to an increase in intra-abdominal pressure and the development of varicocele;
- heavy physical activity ;
- frequent or chronic diseases respiratory tract accompanied by a strong cough;
- lack of sexual intercourse at sexual arousal(quite common in teenagers) increases pressure on varicose veins;
- constipation and other factors.
Usually, in boys, varicocele is detected during an annual medical preventive examination, especially when examined by referral from the military registration and enlistment offices.
Manifestations of varicocele in adolescence similar to those in adults. In young men, there may also be changes in spermogram, a decrease in sperm activity.
In boys, the gonads are only going through a stage of development and maturation, in which it is very important to supply enough oxygen and nutrients. In case of violation of the venous outflow, the gonads suffer from their lack, therefore, there is increased risk of complications in the form of testicular atrophy and / or seminal canal, and as a result - male infertility in future. For the purpose of prevention and timely detection possible pathology boys should be taught to visit a urologist, just as girls should be observed by gynecologists.
In addition to varicose veins, many children with congenital pathology there is a violation of blood flow in other vessels (renal vein, mesenteric vessels, and others). Therefore, children and adolescents with signs of varicocele must undergo angiography and Doppler ultrasound to determine blood flow in the pelvic vessels.
Interesting! In children, congenital varicocele is often accompanied by anomalies connective tissue, for example, flat feet or clubfoot, scoliosis, physiological phimosis and other diseases.
Treatment of varicocele in adolescents, as well as in adults, provides only for the surgical removal of testicular varicose veins or blocking the blood flow through them. In pediatric practice, the same surgical techniques are used, but microsurgical and laparoscopic operations are preferable, which are less traumatic, with a small risk of complications and relapses.
It is important to schedule the operation at the right moment when the testicles are fully formed, but the 3rd degree varicocele has not yet developed. This task is difficult for the surgeon, in some cases it is difficult to find a middle ground. Surgical treatment for growing gonads very often gives recurrences of varicocele, as well as with delayed treatment of the disease.
Varicocele in children and restoration of fertility(ability to reproduce).
Due to the violation of the maturation of the sex glands in childhood, it is important to restore spermatogenesis, because even an operation performed in young men does not always give a complete recovery. The potential before surgery is very important in this, a poor spermogram before treatment significantly increases the risk of remaining infertile (50%). Also, to increase the effectiveness of the operation, conservative therapy is recommended immediately before the operation and in the postoperative period for 3 months, which increases the chance of fertility restoration by more than 20%.
Drug treatment of varicocele in adolescents aimed at restoring fertility:
- antispasmodics (No-shpa, papaverine);
- angioprotectors (Detralex, Pentoxifylline, Etamzilat and others);
- membrane stabilizers (phenytoin, quinine);
- antioxidants (vitamins, ozone therapy);
- prostaglandin inhibitors - anti-inflammatory drugs (Prednisolone, Nimesulide, Indomethacin and others).
Can varicocele be cured without surgery? Are there any means of conservative and traditional medicine? Can a varicocele go away on its own without treatment at all?
Varicocele is a problem not only for men, but also for women, because they often lose the joy of motherhood because of this male pathology. And in many ways, the fertility of men depends on themselves. Only with careful attention to their male health, men can overcome infertility associated with varicocele. Therefore, it is very important for him to go for all the methods of treatment recommended by doctors. And official medicine claims that the only effective method of treating varicocele are various surgical operations that give a great chance of restoring the ability to conceive a child. If a gentleman refuses surgery for fear of the operation itself, possible complications or refuses to go to a male doctor at all, then he must understand that conservative treatment of varicocele is ineffective. It might make sense to use drug therapy, if the varicocele is just beginning, that is, in the I degree of the disease. This therapy can stop the process, but it is not able to cure a man of varicocele. And if there are negative changes in the spermogram, then drinking pills and herbs is generally pointless, they will not restore masculine qualities in any way.
It also makes sense to use conservative therapy in preparation for surgery and in the postoperative period.
- venotonics: Detralex, Ginkgo Biloba, Aescusan, Venolek, Vasoket;
- vitamins: ascorbic acid (C), retinol (A), tocopherol (E);
- drugs that improve blood circulation : Trental, Nicotinic acid, Pentoxifylline and others;
- anticoagulants: Heparin, Aspirin, Troxevasin, Ibustrin, Gepatrombin and others.
Daily regimen and nutrition for varicocele:
1.
avoid lifting weights
and heavy physical exertion
2.
walking and swimming
well tones the blood vessels,
3.
daily exercise
, especially effective lifting on socks,
4.
hardening
also have a positive effect on vascular tone, water procedures low temperatures you need to start gradually, increasing the area of impact and lowering the temperature of the water,
5.
refrain from going to the bath or sauna,
6.
to give up smoking
, alcohol or drug abuse,
7.
diet :
the diet should contain a large number of various fruits and vegetables, seafood, cereals, dried fruits, bee products,
8.
plentiful drink:
at least 2 liters pure water, the use of green tea, juices, fruit drinks is welcome,
9.
food restriction:
food should be frequent and fractional, exclude fatty, fried, smoked, spicy and salty foods,
10.
regular sex life
(not often, but by no means rare).
Also there are traditional methods varicocele treatment, which can have a positive effect in the first degree of the disease, as well as in support of surgical treatment:
All these folk remedies improve vascular tone and have an analgesic effect.
Varicocele - photo, what does it look like before and after varicocele surgery?
Photo: angiography of testicular varicose veins with varicocele on the left.
Varicocele 3rd degree : varicose veins of the testicle on the left are visible to the naked eye.
And it looks like this postoperative suture after Marmara operation .
Varicocele complicated by lymphedema , which led to swelling of the scrotum, dilated veins are clearly visualized.
Photo of the genitals of a man with varicocele complicated by dropsy of the testicles (hydrocele). Dilated veins are visualized on the scrotum.
And this is how they look varicose veins in classical abdominal surgery (according to Ivanissevich).
Photo varicose veins of the testicles during laparoscopic surgery, recurrence of the varicocele. Dilated veins are visible against the background of postoperative sutures. Relapse occurs due to errors during surgery.
At the moment, such surgery is considered one of the worst treatment options., since it is almost 40%. And also various complications are possible, up to infertility (with bilateral varicocele).
How is such an operation carried out? A sufficiently large incision is made in the iliac region, after which all damaged ovarian veins are tied off. This is the main drawback of the operation.
With such an incision and in such an area, the surgeon does not have full access to the venous ligament, so it is almost impossible to bandage absolutely all deformed and damaged veins (their processes).
Therefore, there is a tendency to relapse. The result directly depends on the stage of the disease at which the patient sought qualified medical help.
Operation Palomo is carried out in a similar way, only the incision is made already above the frontal region, under the peritoneum. In this case, there is no need to bandage each process of the ovarian vein - the entire ligament is blocked by one tightening.
The chance of relapse remains(because the vascular clamps can stretch over time), but significantly lower than when operating according to the Ivanissevich method. To date, the Palomo operation is performed quite rarely due to the complexity of its execution.
The hormonal background is also partly disturbed, production decreases. All this in the amount reduces his attraction to women. And some men have complexes against the background of all this.
Who decides which operation will be performed on the patient? Of course, the decision is up to the patient himself, but it should be understood that only Ivanissevich's operation is performed free of charge in state clinics.
For more modern and optimal methods of treatment, you will have to pay a certain amount of money. Even better - without wasting time to contact private clinics. It will cost more, but the reproductive function of a man after the operation will in no way be impaired.
Is it possible to carry out an operation under the MHI policy?
The compulsory medical insurance policy includes a wide range of free operations, but only according to the Ivanissevich method and laparoscopy (punctures in the peritoneum).
That is, the compulsory health insurance policy covers only the most radical methods of treating varicocele. This is only suitable in cases where the patient no longer plans to have children in the future, or if the varicose veins are unilateral.
Does the patient experience pain during the procedure?
Operations to eliminate varicocele are performed under local anesthesia, since there is no need for general anesthesia. And the doctor needs to monitor the patient's condition during the procedure. Does he feel anything during the operation?
The most painful thing is the implementation of the primary incision or puncture. But the operation is carried out quickly enough, so no complications after this can occur. The main thing is to follow the rules for processing the seam in order to prevent the connection of infection, otherwise the incision will have to be opened again.
But the place where the operation was performed will hurt after the anesthesia stops working. And even then - the very next day the patient can be discharged from the hospital.
Longer rehabilitation and hospitalization will be required only if the surgery was performed according to Ivanissevich, or the patient has the following complications:
- increased body temperature;
- signs infection seam;
- low hemoglobin;
- recurrence of the varicocele.
How to process a seam?
Treatment postoperative suture involves carrying out 2 times a day of mandatory dressing.
First of all, it is treated with a solution of furacilin for disinfection, then Levomekol ointment is applied to it. From above, everything is covered with cotton wool and wrapped with a bandage.
After 3-5 days, instead of Levomekol, any wound healing ointment which also contributes to tissue scarring.
On average, the suture is processed approximately 7-10 days after the operation, after which the sutures or staples are removed (depending on the treatment method used).
On the 5th-6th day, a second examination is carried out by the attending physician (surgeon). If necessary, the doctor will prescribe additional procedures for the treatment of the seam.
rehabilitation period
Full rehabilitation takes 3 weeks (21 days) from the date of surgery. If a person is doing power types sports, then you can restore your shape only after 30 days, while starting with minimal loads.
If an operation was performed according to Ivanissevich or Palomo, then there the rehabilitation lasts exactly until the seam heals.
It should be noted that the healing of blood vessels occurs much faster than the epithelium. That is, when the seam has already disappeared, the veins are guaranteed to restore the nominal blood flow. After all this, it is recommended to take blood tests to determine the concentration of hormones - this way the work of the testicles and the prostate gland is controlled.
The shortest rehabilitation period is introduced with endoscopy or microsurgery. There, no suture treatment is required (after the operation, an ice bubble is only applied in order to prevent soft tissue swelling and bleeding).
Physical activity is allowed from day 12, but you should be guided by the assurances of the attending physician.
In summary, varicocele is best treated with surgery. What to perform the operation should be in the early stages of detection of the disease. The optimal method is microsurgery followed by vein suturing. After such an operation, the functions of the testicle are completely restored, as is the reproductive function of a man (but only if there was no atrophy before). But the operation on Ivanissevich should be abandoned. It has not been carried out in most countries of the world for a long time due to the high trauma and the likelihood of relapse.
Varicocele in men does not pose a threat to the life of the patient, but affects fertility and contributes to the development of infertility. If the operation is performed on time, testicular varicocele can be cured and terrible consequences can be avoided. Moreover, surgery for varicocele is the only truly effective way get rid of the consequences of the disease.
The essence of all operations for varicocele is to turn off the varicose veins of the pampiniform plexus from the bloodstream. The operation of varicocele can now be performed in various ways. These are the classic variants of Ivanissevich and Marmar, endoscopic operations, innovative intravascular methods, as well as microsurgical methods and mini-interventions.
Do teenagers with varicocele need surgery?
If a varicocele is detected in a child before or during puberty, then it is recommended that he postpone the operation until the age of 18.
This is due to the fact that early surgery removes varicocele, but after that, complications are possible in the form of impaired function of the unripe testicles. It should be remembered that the consequences of surgical treatment are irreversible, while the varicocele itself in the first stages causes reversible changes in testicular function. Also, with early surgery, there is a high probability of recurrence of the disease. For the period before surgery, the patient is prescribed maintenance drug therapy.
Is surgery necessary for varicocele?
If a young man wants to preserve or restore his fertilizing function, then surgical treatment is indispensable. The operation can be omitted if the problem of paternity for a man today and in the future is irrelevant.
WE ADVISE! Weak potency, a flaccid penis, the absence of a long-term erection is not a sentence for a man's sexual life, but a signal that the body needs help and male strength is weakening. There are a large number of drugs that help a man get a stable erection for sex, but they all have their drawbacks and contraindications, especially if the man is already 30-40 years old. help not only to get an erection HERE AND NOW, but act as a prevention and accumulation of male power, allowing a man to remain sexually active for many years!
Indications and preparation for varicocele surgery
A timely operation of testicular varicocele helps to eliminate the negative conditions for the maturation of spermatozoa. It is carried out in a surgical clinic. Depending on the method of surgical intervention chosen by the doctor, it can be performed both under general anesthesia and under local anesthesia.
In case of varicocele, the indications for surgery are reduced to the presence of varicocele, which is accompanied by a dysfunction of spermatogenesis, pulling pain in the groin area and along the spermatic cord, either when playing sports and lifting weights, or permanently, as well as an increase in the scrotum. These signs correspond to 1 and 2 degrees of the disease. The operation can also be performed before the age of 18, if there are initial signs of testicular atrophy.
The indication for surgery is also a recurrence of varicocele after a previous operation.
What is the best surgery for varicocele?
The volume and tactics of surgical intervention are determined only by the doctor, taking into account the general condition of the patient, the state of the testicular venous system and the severity of the lesion, as well as taking into account the capabilities of the clinic.
A contraindication to the operation may be serious condition patient, comorbidities, bleeding disorders. There are limitations if the patient is diabetic, as this dramatically reduces the healing of the postoperative wound.
Also, surgery to remove the varicocele should be appropriate. With signs of testicular atrophy, when fertility is irreversibly impaired, the operation, unfortunately, will no longer be able to restore the function of spermatogenesis.
Before the operation, the cause of stagnation in the testicular veins should be clearly identified, and its primary nature should be proven.
Types of operations for varicocele: operation according to Ivanisevich, Marmara, Paloma, laser and endoscopic
With varicocele, the types of operations are currently represented quite widely. This traditional operations with direct access, laparoscopic interventions, microsurgical and innovative methods.
The most common Ivanissevich operation for varicocele is ligation of the orifice of the testicular vein through direct access in the inguinal region. In this case, a longitudinal-oblique incision is made in the inguinal region, the venous inguinal plexus is highlighted.
The operation is performed under local anesthesia, but childhood or with other features, general anesthesia is possible. The mouth of the dilated testicular vein is ligated and then divided. After that, the wound is sutured in layers, followed by skin sutures.
During the Ivanissevich operation, there is a high risk of damage to the femoral artery, as well as other anatomical structures that are part of the neurovascular bundle passing in the inguinal canal.
Operation Palomo
The Palomo operation for varicocele also consists in crossing the varicose testicular vein, but unlike the Ivanissevich operation, with this technique, the incision is made over the inguinal canal, which significantly reduces the risk of damage to the neurovascular bundle. As well as the Ivanissevich operation, it can be performed both under local and general anesthesia.
In both cases, the sutured wound is superimposed sterile dressing. The patient is discharged on the second day, and the sutures are removed on the 8-9th day.
Surgical intervention according to the Palomo method differs from the operation according to the Ivanissevich method in that the incision is made above the inguinal canal. After cutting the tissues, the surgeon gains access to the testicular vein, after which it is ligated and removed. According to the Palomo method, surgery is performed both under local and general anesthesia.
note
Varicocele surgery under local anesthesia is preferable to surgery under general anesthesia because it avoids the complications of general anesthesia, which is especially important for patients who have contraindications for intravenous or endotracheal anesthesia.
Operation Marmara
The Marmara microsurgical operation is also based on the ligation of the testicular vein.
With this method, the incision is made along the outer edge of the inguinal canal, below the linen level, where the testicular vein lies under the skin. The incision itself is less than 2 cm long.
If the Marmar operation was performed with a varicocele, the doctors' reviews indicate a low number of postoperative complications.
At the same time, the frequency of relapses has been proven to be less than in the case of the Ivanissevich and Palomo operation.
Endoscopic surgery
Endoscopic varicocele surgery allows you to cure without incisions in the area inguinal fold. This modern technique takes advantage of the laparoscopy technique.
It is carried out using a special long instrument - an endoscope, or a laparoscope, which has an optical assembly and mini-tools at its free end.
Through a small incision, it is introduced into the abdominal cavity, its intra-abdominal end is brought to the mouth of the testicular vein, then it is clipped with a titanium clip and crossed.
It is worth noting
Its peculiarity is the presence of three postoperative scars in the umbilical region, since three small incisions are required for endoscopic surgery, but they are not more than 1 cm.
Endoscopic operations are associated with less tissue trauma, postoperative scars after them heal quite quickly due to their small size.
This type of operation is not performed under local anesthesia, since the abdominal cavity is involved, and is possible only under general anesthesia, intravenous or endotracheal. Laparoscopic surgery is excellent for treating bilateral lesions as it allows both testicular veins to be transected without additional incisions.
laser operation
With varicocele, laser surgery, or laser ablation, is performed using modern technologies without an incision in the groin.
The intervention is performed using an intravascular endoscope. With the help of fiber optics, the place of expansion of the vessel is located, which is then coagulated from the inside with a laser beam and switched off from the bloodstream. This efficient view interventions can be performed without anesthesia.
Endovascular embolization
There is also endovascular embolization of the testicular vein, when a thin intravascular endoscope up to 2 mm thick is inserted under x-ray control and passed through femoral vein into the ovary. Next, the veins are examined using a radiopaque substance, and then a sclerosant drug is injected into the lumen of the varicose veins, which embolizes and glues the lumen of the vessels. The operation is performed without anesthesia.
The advantages of intravascular operations are significant, they are minimally invasive, do not require anesthesia, and are also easier to tolerate by the patient. The number of complications and relapses after their implementation is much less.
How long do you stay in the hospital for varicocele surgery?
If this is a Palomo, Ivanissevich or Marmar operation, then a hospital stay can take from two days in the absence of complications. On the 8-9th day, it will be necessary to appear to the surgeon to remove the sutures, and within a month after the operation - to the urologist. With intravascular intervention, the operation can be performed on an outpatient basis.
How long does varicocele surgery take?
Depending on the method and method of surgical intervention, it can last from several tens of minutes to several hours.
How is varicocele surgery performed: stages
When an operation is performed for varicocele, its course is highly dependent on the method of surgical intervention.
If this is a conventional operation with an incision in the inguinal fold, above or below, then the first stage of the operation is anesthesia.
- Next, the surgeon dissects the tissue in layers and widens the incision in order to isolate the testicular vein, which is then ligated and crossed. Also, as part of the operation, if necessary, excision of varicose nodes is performed through mini-incisions in the skin of the scrotum.
- After the manipulations, the wound is sutured in layers, with suturing on the skin. A sterile bandage is applied to the surface of the wound.
In the case of endoscopic surgery, anesthesia is performed first.
- After that, three small incisions, up to 1 cm, are made in the abdomen in the navel area, a special device is inserted through one of them, which pumps the abdominal cavity with a gas mixture.
- Further, endoscopic instruments are introduced into the resulting cavity, they reach the mouth of the renal vein and clamp it with a special titanium clip. How a varicocele operation is performed is broadcast in real time on a special video screen.
- Next, the instruments are removed, the gas mixture is removed through the incisions, and the incisions themselves are sutured.
In the case of intravascular surgery, anesthesia is not performed.
- A puncture is made in the inguinal region, a thin endoscope or a catheter no more than 2 mm thick is inserted into the femoral vein.
- Under visual or X-ray control, it is carried out to the affected vessels, where the necessary manipulations for sclerosis, embolization or laser ablation are performed.
- After performing the manipulations, the endoscope is removed and a pressure bandage is applied to the wound channel.
Is varicocele surgery dangerous?
There are several ways to perform operations on a varicocele - from abdominal to microinvasive. The danger of each such operation depends on the professionalism of doctors and the correctness of its implementation. With a clear and well-coordinated conduct of all proper manipulations, such an operation is no more dangerous than any other surgical intervention.
The effectiveness of varicocele surgery and reviews
The effectiveness of varicocele surgery is quite high. Due to the exclusion of varicose veins from the bloodstream, their gaps subside, and the local temperature normalizes. The outflow of blood occurs through the venous collaterals, as a result of which the toxic effect blood stasis, carbon dioxide is excreted. After some time, the function of the testicle begins to recover, and the conditions for spermatogenesis improve, as a result of which fertility is restored.
The operation performed for varicocele has different reviews, depending on the technique and the presence of complications. During operations with access to the inguinal canal, symptoms of lymphostasis, development of hematoma, testicular dropsy are possible. As a rule, everything passes within a month. The patient may complain of pain at the incision site, along the spermatic cord.
note
In most cases postoperative period runs smoothly total number complications after operations for varicocele does not exceed 10%. The postoperative scar, subject to all the rules of asepsis and antisepsis, heals by primary intention within 2 weeks.
Intravascular operations have the least number of complications and do not leave a postoperative scar.
The varicocele scar in the area of the inguinal fold is a small light cord, from 5 to 2 cm, depending on which operation was performed. After laparoscopy, three pinpoint scars remain just below the navel.
Overview of prices for varicocele surgery in different cities
The cost of the operation to eliminate varicocele varies depending on the city, the level of the clinic, the method of surgical assistance.
Prices for Ivanissevich's operation in Moscow are on average at the level of 18,000 rubles. The Marmara operation will cost more, from 28 to 48,000 rubles with a unilateral lesion. An endoscopic surgical aid in Moscow costs an average of 44,000 rubles.
IN Novosibirsk Ivanissevich's operation costs 10,000 rubles, and Marmar's operation costs 18,000 rubles.
Prices in Saint Petersburg for Ivanissevich's operation are in the range from 5 to 20 thousand rubles, and for endoscopic surgery at the level of 16-25,000 rubles, excluding anesthesia and hospital stay.
Does it hurt to remove stitches after a varicocele?
Hardly ever. Removal of sutures occurs quickly enough. There may be slight pain during hypersensitivity skin in the groin area.
The prices for the Ivanissevich operation by Russian cities were distributed as follows: Nizhny Novgorod- 6300 rubles, Saratov- 8000 rubles, Permian 6600 rubles, Tula,Odessa,Chelyabinsk,Ufa,Voronezh- from 5 to 8000 rubles. Endoscopic surgery in Thule costs 12000 rubles.
Ivanissevich's operation Kyiv And Kharkov costs from 1400 to 3000 hryvnias, and the embolization operation from 3000 to 5000 hryvnias. Surgery with a laser Dnepropetrovsk will cost 4500 hryvnia.
IN Novosibirsk Ivanissevich's operation costs 10,000 rubles, and Marmar's operation costs 18,000 rubles. Krasnodar provides these services at a price of 13,500 rubles.
IN Yekaterinburg the price of the Marmara operation is 18,500 rubles, and the endoscopic operation is 20,000 rubles.
Marmara surgery cost Odessa is 55,000 rubles, together with anesthesia.
