Which varicocele requires surgery?
Spermatic vein grading: Grade 0: no symptomatic manifestation of varicocele, Valsalva test cannot appear, slight varicocele can be found by ultrasound examination, vein diameter is more than 2mm; Grade 1: not obvious on palpation, but can appear on Valsalva test; Grade 2: dilated vein is extremely palpable on palpation, but cannot be seen; Grade 3: dilated vein can be seen when the patient stands on scrotal skin protrudes like a mass of earthworms and is easily palpable.
Indications for surgery.
1, the presence of abnormal semen, medical history and physical examination did not find other diseases affecting fertility, endocrine examination is normal, female fertility examination no abnormal findings, regardless of the severity of varicocele, as long as the diagnosis is clear should be timely surgery!
2.Severe varicocele with obvious symptoms, such as more standing that the scrotal swelling pain, etc., physical examination found that the testicles are obviously shrinking, even if they have been fertile, there is a desire for treatment can be considered surgery.
3.The clinical finding of prostatitis and seminal vesiculitis, if the above two diseases exist at the same time, and if the prostatitis is not cured for a long time, surgery can also be chosen.
4.For adolescent varicocele, because it often leads to pathological and progressive changes in the testicles, it is currently advocated that surgery should be performed as early as possible for adolescent varicocele with testicular volume reduction.
5.For patients with varicocele, if the semen analysis is normal, they should be followed up regularly, and once the semen analysis is abnormal, the testicle shrinks and the texture becomes soft, they should be operated in time.
6.Contraindications: abdominal infection, history of open pelvic surgery with extensive adhesions.
Q: Is varicocele always the cause of infertility or scrotal discomfort?
Not necessarily, if other common causes are excluded, 60-70% may be.
Q: Is surgery always effective?
The effectiveness rate is usually around 60-70%, and Marc Goldstein, a world-renowned master, only had a pregnancy rate close to 70% two years after surgery. It is often not that the surgery itself is unsuccessful, but that sometimes varicocele is not the cause, and it is very difficult to know if it is the cause before surgery. Likewise, the efficiency of surgery for scrotal discomfort is about the same. I usually present this to patients preoperatively, not to pass the buck, but because medicine has stages and limitations and is not a panacea, which is the state of medicine. We can proudly say that we offer the best technology at this stage, but not the almighty Dan technique. Many patients want their doctors to give a straightforward conclusion: to do or not to do? I believe that in today’s world of much greater education for all, it makes the most sense to give patients the right to be fully informed, to fully understand the current state of medicine and its shortcomings, and to make a choice together.
Q: Now that the new standards for semen are very different from the fourth edition, which one is used?
The new standard of semen parameters and the old standard are used at the same time, and there were no semen parameters for Chinese people when the new standard was formulated, so there is no definite conclusion on which standard is used for Chinese people. It is generally recommended to make a comprehensive judgment in an outpatient clinic before deciding on a treatment plan. For patients who have never had a sexual partner or have not tried to have a baby for more than 6 months, I usually make the indications for surgery more strict, after all, abnormal semen parameters do not mean that the partner cannot get pregnant.
Q: What is the procedure, the number of days in the hospital, the cost, and is it covered by health insurance?
We generally use minimally invasive surgery, the specific time depends on the difficulty of the surgery, and the general hospitalization is 3-5 days.
Q: What are the common complications?
Recurrence, edema and testicular atrophy.
Q: Does the scrotal tortuosity disappear after surgery?
The principle of surgery is to block the venous reflux, not to remove the veins in the scrotum, which would easily lead to edema and testicular atrophy. Therefore, scrotal tortuosity generally decreases gradually after surgery, and some of them can disappear, but not all patients have this effect.
Q: Will the quality of semen decrease after surgery? Is there a possibility that discomfort symptoms will worsen?
Theoretically there will be, but it is extremely rare and may be seen in two situations.
1. post-operative edema and atrophy, which are related to the surgery.
2, Varicocele itself is not the cause, while the cause still exists, such as radiation, environmental hormones, other etiologies, etc.
3. Varicocele is not the cause of scrotal discomfort.
Q: Are there any other treatment options for varicocele? Advantages and disadvantages?
These include laparoscopic technique, microscopic technique (subepidural or transinguinal, we decide the route according to the height of the patient’s epidural ring, transinguinal is usually chosen if the epidural ring is too low), open technique (subepidural, transinguinal, retroperitoneal route), interventional technique (cascade or retrograde approach), etc. Objectively speaking, all these modalities are used by doctors, and it is difficult to determine the absolute advantages and disadvantages, and the surgical modality and results depend on the experience of the operator. As for other treatments than surgery: medication can be effective in some patients, and a small number of patients who do not receive any treatment can also have a pregnancy, but overall studies show that surgery is better than medication and medication is better than no treatment.
Q: Do I have to have both sides of my varicocele?
If there is a problem with semen quality, we do both sides; if you are seen for symptoms, we do the symptomatic side; these refer to the clinical type of varicocele; the subclinical type of varicocele (no findings on examination, only reflux seen on ultrasound) does not advocate surgery, but there is controversy in this area.
Q: What are the precautions for semen examination?
It is generally clinically recommended to abstain from sexual intercourse for 3-7 days, and I suggest that about 4-5 days is best. Patients who may need to have their semen checked in outpatient clinics are advised to calculate their abstinence time so that they will not be unable to be checked during the clinic visit. (Masturbation, seminal emission and sexual intercourse ejaculation are all counted as ejaculation)
Q: Pre-operative routine tests
Such as electrocardiogram, chest X-ray, coagulation status, biochemical situation, common blood-borne diseases, etc. Adults usually do not need a chaperone.
Q: Regarding post-operative issues.
Generally 1 month can resume sexual life, strenuous activities such as running and playing ball are recommended 2 months after surgery. Post-operative local pain and discomfort, etc. is currently difficult to specify the cause, because both can be related to the surgery; some patients have repeated seminal emission, no need to worry.
Q: If not, will it get heavier?
Such as varicocele performance, semen parameters, discomfort symptoms, etc. —- This point is controversial and difficult to be absolutely sure or negative, but my personal opinion is that even if there is progress, it will be a slow process.
Q: Other considerations?
Some patients have secondary seminiferous varicosities, such as those caused by renal tumor compression, which must be ruled out.