Laparoscopic Varicocelectomy Complications

[Hilary Laite]

Despiteextensive information being available on varicoceles and many studies on different surgical solutions, the ideal method of varicocele ligation is still a matter of controversy. The ideal technique would have low recurrence and complication rates [4].

Different approaches have been applied for the treatment of varicocele, including open surgery, sclerotherapy, and, recently, laparoscopy [5,6,7]. The Palomo technique was associated with a relatively high incidence of postoperative discomfort [8] and for this reason the modified Palomo procedure was often preferred [9].

Ivanissevich described a procedure where the testicular vein is tied at the inguinal ring and the testicular artery is spared [8]. In 1991 Aaberge et al. introduced laparoscopic varicocelectomy as the new and less invasive treatment for varicocele [10].

In recent years laparoscopic varicocele ligation (LV) had been popularized and had gained growing acceptance. The built-in magnification of the laparoscope facilitates identification of the spermatic veins and artery, potentially reducing the risk of recurrence of the varicocele and of ischemic damage to the testis. Magnification also allows the surgeon to preserve lymphatics and the genital branches of the genitofemoral nerve that runs along the spermatic vessels, which may reduce lymphocele formation and postoperative pain [11].

Laparoscopic management of varicoceles in adults may reflect the excellent visibility of the posterior abdominal wall achieved using the laparoscope, which allows a thorough search of sites known to be responsible for recurrent varicoceles, viz., renal, vas associated, pelvic, and retropubic cross-over veins [11].

The conventional technique of laparoscopic varix ligation is to ligate the vessels with clips and then transect them in between the clips [12,13,14]. Sasagawa reported that they successfully transected the internal spermatic vessels purely using a harmonic scalpel, which comes only in diameters of 5 and 10 mm [15].

Preoperative semen analysis should be carried out in all patients aged 18 years and above. Pre-anesthetic checkup was done. After the patients were considered fit for surgery, they were informed in their native language about the nature of the disease process, the procedure, the possible complications of the procedure, the possibility of conversion of laparoscopic surgery to open in cases of difficulty and about the hematoma, wound infections, pneumoscrotum, hydrocele, prolonged pain, and recurrence.

Operation theater setup is done as shown in Fig. 1. The procedure is performed under general anesthesia. A prophylactic intravenous antibiotic (third generation cephalosporins IV) is given at induction prior to the incision. The patient is placed in a supine position.

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Considering the relatively high incidence of this condition, it is important to mention that there are many treatment options available. There are effective non-surgical and surgical options that have been proven effective for the treatment of infertility and pain when compared to conservative approaches.2,3

This is a surgical operation using a camera to find and close the varicocele. The surgeon makes several incisions on the abdomen to place a camera and small instruments to perform the operation. Once the abdomen is inflated with gas, the surgeon can visualize inside the abdomen to try and locate the abnormal veins. This is done under general anesthesia and usually an outpatient procedure.

The main goal of this procedure is to locate and ligate (tie) the affected veins to restore proper blood flow to the scrotum. All of this, without damaging other important structures like arteries and components of the ejaculatory complex.

There are different variations of this technique depending on the approach of how the tissues are dissected in the pelvis. It can also be guided by ultrasound for better results and fewer complications.

Additionally, it can be further divided into artery-preserving and artery-ligating procedures depending on whether the testicular artery is tied off or not. Some studies have found that the chance of recurrence is lower when these arteries are ligated.4 The downside of artery ligation is that it can lead to infertility and shrinkage of the testicle. This is not a good option for someone wanting to preserve fertility.

Since this is the most invasive of the treatment options, it carries a higher risk of complication. The most common complications associated with this surgery are recurrence, fluid build-up in the scrotum (known as a hydrocele), and damage to the vessels and structures in the area.

Other complications like nerve damage, intestinal or organ injury, and even peritonitis (infection/inflammation of the abdomen) have been reported. Nerve injury would cause scrotal numbness. Additional complications due to general anesthesia must be considered as well.8

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Surgery usually takes less than two hours. After leaving the OR, the patient is put into observation for a couple of hours until the anesthesia wears off. After that, the patient is usually discharged home unless there is a complication requiring hospital stay.

After surgery, it is normal to experience pain or discomfort at the surgical incisions, as the incisions pierce through the abdominal muscles. This pain may require narcotics until the muscles and tissues heal. Bruising and swelling might also appear in the groin area and on the incision sites, which may take several weeks to resolve.

Most patients are allowed to return to work after 3 to 5 days. Full recovery may take 2-4 weeks and sexual activity can be resumed in 1 to 2 weeks; open surgical recovery can take 3 to 6 weeks. A supportive jock strap may be recommended.

Laparoscopic varicocelectomy is still surgery involving general anesthesia, with risks of bleeding, infection, tissue or vascular damage. Is non-surgical embolization treatment a better option? Embolization does not require creating a major surgical incision on your abdomen or groin, or dissection of the tissues. Since there is no cutting, there is no risk of damaging the testicular artery, nerve or lymphatics. There are no major incisions or sutures. Lastly, varicocele embolization has a 90% success rate.

Varicocele can be treated by an embolization procedure or surgery. Embolization is a non-surgical, outpatient, minimally invasive technique that uses x-ray guidance to place tiny coils and embolic fluid in the abnormal blood vessels causing them to close down.

Request an Appointment to meet with our varicocele specialist who will review your imaging, labs and history to determine if you are candidate for the procedure, and the outcomes you can expect. Each person is an individual and should discuss the potential risks and benefits of embolization and other treatments with our doctor to decide which option is best.

Appointments are available via an online video telehealth platform or in person at one of the offices in Los Angeles, Orange County or San Diego. Why should you choose us? Read here

The above information explains what is involved and the possible risks. It is not meant to be a substitute for informed discussion between you and your doctor, but can act as a starting point for such a discussion.

Please note that although we strive to protect and secure our online communications, and use the security measures detailed in our Privacy Policy to protect your information, no data transmitted over the Internet can be guaranteed to be completely secure and no security measures are perfect or impenetrable. If you would like to transmit sensitive information to us, please contact us, without including the sensitive information, to arrange a more secure means of communication.

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