Varicocele is the number one killer of male infertility as announced by the World Health Organization (WHO), and fertility is a major male problem, and the testes are an important male organ, and varicocele is the most important disease causing male infertility that requires surgical correction, so surgical treatment should not be ignored.
Microscopic low ligation of varicocele is a complex and challenging surgery in male surgery, which is performed under a microscope with a magnification of 10-40 times and can clearly see various tissues that are invisible to the naked eye. It requires the surgeon’s excellent surgical skills and patience and meticulous operation to ligate more than 10 or even 20 varicose veins in order to achieve the best results, which cannot be achieved by other surgical methods.
In the current domestic and international research status and my clinical experience, summarize a need to understand the knowledge as follows.
I. What is varicocele.
In the summer, some men will find their testicles one high and one low, the low side of the testicle, sometimes like a pendulum, hanging there very uncomfortable. Some men can sometimes see blood vessels on the skin of the scrotum, which can appear as curved as earthworms. Some men can touch a worm-like swelling in the scrotum with their hands, and sometimes, after standing for a long time, they can feel a feeling of swelling and discomfort in one side of the scrotum. Most of these symptoms occur on the left side. Varicocele is an abnormal expansion, elongation and tortuosity of the trapezius plexus in the spermatic cord.
Second, the harm of varicocele.
1, the relationship with fertility: research shows that varicocele exists in 15% of normal men, the incidence is 40% in primary infertility patients, 75% in secondary infertility patients, with testicular discomfort symptoms for 15 – 20%, previous history of fertility, about 70% of currently infertile men, varicocele is its basic cause. The World Health Organization also reports that about 25.4% of patients with abnormal semen tests have varicocele, while only 11.7% of patients with normal semen have varicocele.
The World Health Organization considers varicocele to be the primary factor causing male infertility. A lot of clinical and experimental studies have been conducted on the mechanism of male infertility caused by varicocele, which is usually considered to be related to abnormal semen, decreased testicular volume, decreased testicular perfusion and testicular spermatogenic dysfunction, etc. Meanwhile, studies have shown that varicocele is related to DNA damage of semen, and surgery can significantly change the DNA quality of sperm, improve the quality of semen and increase testosterone levels. Studies have shown that varicocele is a progressive lesion that causes testicular growth disorder and gradual decline of testicular function leading to infertility, and varicocele repair surgery can stop or even reverse this progression, and 80% of infertile men can improve semen quality through varicocele repair.
2.Relationship with pain: the incidence of varicocele pain is 2%-10%.
3, the relationship with androgen: some studies believe that the serum testosterone level of varicocele patients is more, there are also reports in the literature to improve the androgen level of patients after treatment, the latest a randomized controlled study proved that varicocele can significantly reduce the serum total testosterone level of patients, after surgery, the serum total testosterone has a significant increase.
Third, the best treatment for varicocele.
Varicocele is the most important disease causing male infertility that needs surgical correction. The current surgical methods of varicocele at home and abroad are
1.Open surgery.
(1) High ligation of the spermatic vein.
(2) Transinguinal spermatic vein ligation.
2.Laparoscopic spermatic vein ligation
3.Microscopic spermatic vein ligation.
(1) Transinguinal microscopic spermatic vein ligation.
(2) Microscopic spermatic vein ligation under the external ring.
4.Interventional treatment: Most foreign and domestic studies have concluded that microsurgical approach is the most suitable for infertility, with less trauma, faster recovery, higher postoperative conception rate, and least postoperative complications, which can achieve the best results, just like the difference between inverter air conditioner and fixed frequency air conditioner, “inverter air conditioner” can make sperm more comfortable.
The European Association of Urology has compared the results of various treatment modalities: pregnancy rate, recurrence rate, incidence of syringomyelia, testicular volume, and the best prognosis with microscopic spermatocele ligation: microscopic spermatocele ligation is recommended.
(1) best prognosis and least complications
(2) long operation time (3 hours/bilateral)
IV. Surgical complications.
1.Oedema
Oedema is the most common complication after spermatic vein ligation, with an incidence of 3 to 39%, and lymphatic vessel injury or misligation is the main cause of oedema. Theoretically, the embolization technique does not produce edema, and microscopic spermatic vein ligation has a low rate of edema. Testicular syringomyelia occurs in individual patients after surgery, and some of them can subside on their own after several months, while the opposite requires surgical treatment.
2.Testicular artery injury
Most of the postoperative testicular atrophy occurs due to ligation or injury to testicular artery during surgery, and the overall incidence of testicular atrophy is about 0.2%. Since the testicular blood supply also includes the vas deferens artery and the levator muscle artery, the preservation of the testicular artery remains controversial. However, the American Urological Association clearly recommends the use of magnification techniques during spermatic vein ligation to better protect the testicular arteries.
3. Persistence or recurrence of varicocele
The recurrence rate after spermatic vein ligation is 0.6 to 45%. Reports vary from author to author and from procedure to procedure. The available studies show a low recurrence rate of microscopic spermatic vein ligation by the subcircular route.
4.Other
Laparoscopic surgery can lead to serious complications such as pelvic and abdominal organ and vascular injuries.
5. Postoperative semen quality does not improve or decreases.
V. Post-surgical treatment
1. Stay in bed for 24 hours after surgery and try to rest in bed for 1 week.
2. Reduce activities within 1 month after surgery, and no strenuous activities.
3. You can start to have intercourse after 1 month after surgery.
4. Moderate activities can be performed within 3 months after surgery, avoiding strenuous activities.