Microsurgical Varicocelectomy: How the Operation Is Performed and Who It Suits
Not every varicocele requires surgery. How microsurgical varicocelectomy differs from other techniques, who it is recommended for, when semen parameters change after the operation, and what recovery involves.
Most men diagnosed with a varicocele are not operated on — and do not need to be. In carefully selected patients, however, microsurgical varicocelectomy is a procedure that can produce measurable improvement in semen parameters and may reduce the need for assisted reproductive treatment. What matters is less the operation itself than the decision about who should be operated on.
What is a varicocele and why does it cause problems?
A varicocele is enlargement of the veins around the testis with backflow of blood. It creates a fullness in the scrotum often described as a "bag of worms" and is found on the left side in the great majority of cases. It is present in roughly 15% of adult men; among men presenting with infertility, that proportion is markedly higher.
Several mechanisms are proposed for how it impairs sperm production: an increase in temperature around the testis, impaired oxygenation due to pooling of blood, and oxidative stress causing damage to sperm DNA. A varicocele may therefore affect not only sperm count but also motility, morphology and DNA integrity.
Should every varicocele be operated on?
No. The presence of a varicocele is not in itself a reason for surgery. The decision is made when the following conditions come together:
- A clinical varicocele detectable on examination — surgery is not recommended for a varicocele seen only on ultrasound and not palpable
- Abnormal semen parameters — a meaningful abnormality in count, motility or morphology
- The couple wishes to conceive and there is no correctable or significant obstacle on the female side
- Reduced testicular volume — particularly in adolescents and young adults
- Pain attributable to the varicocele that affects daily life — a dull ache increasing towards the end of the day is typical
By contrast, in a man with no complaints, normal semen values and no wish to conceive, a varicocele is usually observed.
How does microsurgery differ from other techniques?
A varicocele can be treated by several techniques: open (high) ligation, a laparoscopic approach, radiological embolisation and microsurgical subinguinal varicocelectomy. Among these, the microsurgical technique is the approach accepted as standard today. The difference is that the operation is performed under a surgical microscope, and this magnification allows the structures just below the inguinal canal to be distinguished one by one.
That ability to distinguish has two critical consequences:
- The testicular artery is preserved. Without a microscope the likelihood of inadvertently ligating this artery is markedly higher; preserving it is decisive for the blood supply to the testis.
- The lymphatic channels are preserved. This markedly lowers the rate of hydrocele (fluid collection around the testis), one of the most common unwanted outcomes after the operation.
In addition, because all the enlarged veins can be seen and ligated individually, the recurrence rate of the varicocele is lower with the microsurgical technique than with other methods. These three headings — arterial preservation, hydrocele rate and recurrence — explain why this technique is preferred.
How is the operation performed and how long does it take?
The procedure is usually carried out through a 2-3 centimetre incision just below the groin crease. The spermatic cord is delivered; under the microscope the artery, lymphatics, nerve and vas deferens are separated, and the enlarged veins are ligated individually. Duration varies according to whether the procedure is bilateral, but is typically 45-90 minutes. The choice of anaesthesia (general or regional) is determined by the patient's condition, and the procedure is most often completed with same-day discharge.
What does recovery involve?
- Scrotal support and cold application are recommended in the first 24-48 hours; pain is usually manageable with simple analgesics
- Return to desk work is possible within 2-5 days for most patients
- Heavy lifting and sport are postponed for 2-3 weeks
- Sexual activity is generally resumed after 1-2 weeks depending on comfort
- Temporary bruising, mild swelling and altered sensation around the incision are expected
When do semen parameters change?
This is the most asked and most misunderstood topic. Sperm production completes a cycle of roughly 70-90 days. A semen analysis performed immediately after the operation therefore provides no meaningful information. A follow-up test is generally carried out at 3 months and repeated at 6 months; assessment is usually made over a 6-12 month period.
Expectations should be framed as follows: measurable improvement in sperm count and motility is reported in a substantial proportion of appropriately selected patients, and a reduction in sperm DNA damage in some. However, it cannot be said that every patient will improve or that pregnancy will occur; the outcome depends on factors on the female side, the couple's age, the grade of the varicocele and the pre-operative semen values. The operation should be positioned not as a promise to eliminate the need for IVF, but as a procedure that aims to increase the chance of natural conception and improve the baseline for assisted reproductive treatment.
What are the risks?
Rates of unwanted outcomes are low with the microsurgical technique, but not zero: hydrocele formation, recurrence of the varicocele, infection or bleeding at the incision, impaired blood supply due to injury of the testicular artery (rare with the use of a microscope) and temporary altered sensation. The actual rate of these risks is directly related to surgical experience and the use of a microscope.
Assoc. Prof. Zülfü Sertkaya practises in the field of urology and andrology in Istanbul; varicocele assessment and treatment planning in male infertility are carried out with individualised planning and full confidentiality.