Varicocele is the dilation of the pampiniform plexus veins (which drain blood from the testicles). It is the main cause of male infertility and hence its importance in the diagnosis and treatment of the couple. It affects approximately 15% of the population, but not all of these men will have infertility as a result of the disease. We estimate that only 15% of men with varicocele will experience some degree of infertility. Varicocele is more prominent on the left, but it is very commonly identified bilaterally.

Due to a failure in the valves of the pampiniform plexus veins, there is reflux of blood that should return to the heart through the renal vein (on the left) or the vena cava (on the right). Thus, the testicular veins are dilated, giving the scrotum the appearance of a “worm bag”.

There are several theories that explain how varicocele generates infertility and among the most accepted, we have:

• Increased temperature of the scrotum (the testicles stay outside the body because they need a temperature 0.5ºC lower than the rest of the body to function properly)
• Difficulty in draining toxic substances from the circulation, due to the failure in circulation caused by varicocele
• Production of reactive oxygen species (free radicals), very toxic to the testicles.

The diagnosis is clinical and no subsidiary exam is necessary for this. An experienced doctor used to dealing with the disease can easily diagnose it by physical examination, which must be done with the patient standing and in a room with good light and heated.

TREATMENT:

Surgical correction of varicocele, with the aim of improving male fertility potential, is currently widely used. For this purpose, there are several surgical approaches, most of which are performed without the aid of a microscope. Although they can be safely performed, all procedures that do not use any optical augmentation feature require the opening of the abdominal muscles, determining a long and relatively painful postoperative period.

The ligation of lymphatic vessels is also a problem when the microscope is not used, as it will generate an accumulation of lymphatic fluid in the scrotum, the so-called hydrocele, which in addition to being aesthetically ugly, can be painful and require further surgery.

The place of choice for the surgical approach is the sub-inguinal (just above the body of the penis).

It is worth remembering that after surgery the veins will continue to be dilated, as they are not removed, but the disease has been treated.

The success rate in eliminating varicocele is 95% in the postoperative period. Semen improves in 75% of cases and pregnancy rates can reach more than 40%. Varicocele should not be operated today without the aid of a microscope.

ADVANTAGES OF MICRO-SURGICAL TECHNIQUE:

• Affects all vessels of the cord
• Preserves lymphatics and arteries, preventing the formation of postoperative hydrocele or testicular failure (for inadvertent ligation of arteries)
• Does not section muscles (less pain in the postoperative period)
• Lower recurrence rate when compared to other techniques
• Very fast post-operative recovery (one day)
  
  

References in medical literature

• Several Authors. Infertilidade Masculina. In: International Braz J Urol. Vol 29, Suppl. 5, 2003.
• Miyaoka, R. & Esteves, S.C., “A critical appraisal on the role of varicocele in male infertility”. In: Advances in Urology, 2012.