Varicocele is a common disease in urology, with an incidence of about 10-15% of the male population, mostly in young adults. Many patients do not know enough about this disease, and the treatment is not timely, which causes serious consequences, and the most concerned issues about this disease are explained.
1.What is varicocele?
Varicocele actually refers to the varicose veins in the spermatic cord, which is the abnormal elongation, expansion and tortuosity of the trapezius plexus (venous plexus) of the spermatic cord caused by the reflux and stasis of blood in the veins. In severe cases, they may accumulate in the scrotum in a mass-like manner, causing scrotal swelling and discomfort.
There are three groups of spermatic veins: the internal spermatic veins and the external spermatic veins. The internal spermatic veins are a plexus of veins in the scrotum that converge into 1-2 branches in the inguinal canal and continue upward in the retroperitoneum, with the left internal spermatic vein converging at right angles into the left renal vein. On the right side, it enters the inferior vena cava at an acute angle about 5 cm below the right renal vein; the external spermatic vein is composed of the levator muscle vein, which leaves the plexus at the outer ring of the inguinal canal and enters the inferior abdominal wall vein, the superior abdominal wall vein, the superficial pubic vein and the deep pubic vein, and finally converges into the external iliac vein. The vas deferens vein enters the pelvis with the vas deferens at the internal ring of the inguinal canal and converges into the internal iliac vein.
2.What are the causes of varicocele?
The veins in the spermatic cord are long, so if the valves are poorly developed, damaged or incomplete and the smooth muscle or elastic fiber of the vein wall is weak, it can cause the internal pressure to increase and the blood return flow to be obstructed, and varicose veins can easily occur.
3.Why are most left spermatic varicose veins?
The reasons for the high incidence of varicocele on the left side are
①The left spermatic vein is 8-10cm longer than the right one, and the venous pressure on the left side is greater than that on the right side.
②The left spermatic vein is injected into the left renal vein at a right angle.
③The rate of left spermatic vein valve deficiency in humans is as high as 40%, while the right side is only 3%.
④The left renal vein may be compressed between the abdominal aorta and the superior mesenteric artery, affecting the spermatic vein reflux and creating the so-called proximal clamping phenomenon.
⑤ The left internal spermatic vein may be compressed by a distended sigmoid colon.
(6) Disease of the spermatic vein itself: weakness of the vein wall and its surrounding connective tissue or underdevelopment of the levator muscle.
(7) The upright posture of the person affects the spermatic vein reflux.
Intra-abdominal or retroperitoneal tumors, hydronephrosis, or heterogeneous vessels compressing the superior spermatic vein may also cause poor blood flow, which may lead to varicocele. Especially in the kidney tumor, in addition to its own mechanical compression, but also can occur in the renal vein or inferior vena cava cancer embolism, resulting in secondary varicose veins.
4.Why do I still have scrotal swelling and vague pain after “spermatic vein high ligation”?
Generally speaking, the term “varicocele” refers to the varicocele of the spermatic cord, and the surgical method is the high level ligation of the internal spermatic cord vein, which is a plexus of veins in the scrotum and is gathered into 1-2 branches in the inguinal canal, so the best surgical method is to perform it on the groin, and the opening above the groin is on the inner ring, so the peritoneum on the inner ring is used to find all the internal spermatic veins. Afterwards all the internal spermatic veins are found, cut, and ligated. After surgery, the venous blood from the testes and epididymis returns through the external spermatic veins and the vas deferens veins. This blocks the return of blood from the internal spermatic vein and the return of metabolic waste products such as catecholamines and 5-hydroxytryptophan within the renal venous blood, restoring the normal blood supply to the testicular epididymis in order to maximize the restoration of testicular function.
The high spermatic vein ligation only removes the cause of the disease, the formed varicose veins in the scrotum still exist, not immediately disappear, it takes a long time to slowly shrink, so the symptoms such as scrotal swelling and hidden pain also do not disappear immediately.
The key to recurrence after surgery depends on whether all the internal spermatic veins are ligated during the surgery, if they are completely ligated, there is usually no recurrence after surgery. If there are residual internal spermatic veins, there is a possibility of recurrence after surgery. Generally, we will review the ultrasound after 6 months after surgery to determine whether there is recurrence.
5.Do I have to have surgery if I have varicocele?
Varicocele will cause continuous and irreversible damage to the testicles, and there are traffic branches on both sides of the testicles, so varicocele on the left side will not only affect the left testicle, but also the right testicle. The latest opinion is that in order to prevent irreversible damage to the testicles, varicocele should be operated on as soon as it is detected.
For those who have symptoms such as scrotal swelling and hidden pain, those who have varicocele and have abnormal semen or are infertile, and those who have varicocele combined with prostatitis and vesiculitis should have surgery in time.
In the past, it was thought that some mild patients might have their varicose veins remit on their own after sexual maturity, so mild varicose veins without symptoms and without affecting fertility could not be treated. As the research on subclinical varicocele has intensified, it is believed that subclinical varicocele can also affect testicular function, therefore, patients with various types of varicocele should be treated actively. Some people even advocate that once adolescents are found to have varicocele, they should undergo surgery as early as possible to avoid affecting their future fertility.
6.What is the best surgical procedure for varicocele?
The best surgical procedure is “retroperitoneal spermatic vein high ligation”. The key to the outcome of the surgery is whether the spermatic artery can be found and all the veins can be ligated, because there are three components in the spermatic cord: the spermatic vein (it can be one or more), the spermatic artery and the lymphatic vessels. Finding and preserving the artery and ligating all the veins is the best result of the procedure, preserving the artery and ensuring the blood supply to the testes and the return flow through the external spermatic vein. Ligation of all the internal spermatic veins blocks the return of metabolic wastes such as catecholamines and 5-hydroxytryptophan within the renal venous blood, restoring the normal blood supply to the testes and epididymis in order to maximize the restoration of testicular function. Bilateral varicocele and other cases are suitable to choose laparoscopic approach!
7.Does the spermatic vein recur after high level ligation?
The internal spermatic vein is a venous plexus in the scrotum, which converges into 1-2 branches in the inguinal canal and continues upward in the retroperitoneum, and the left internal spermatic vein enters the left renal vein at right angles. Therefore, theoretically, the possibility of complete ligation of all the internal veins of the spermatic cord is the greatest in retroperitoneal surgery. However, in practice, it is found that in most cases more than two spermatic veins are found during retroperitoneal surgery, and there may be some tiny veins that cannot be identified by the naked eye, or they may not be detected during surgery because they are surrounded by lymphatic vessels, or they are close to the arteries and not easily detected. Therefore, there is a possibility of missing the vein during the actual surgery, and there is a possibility of recurrence if the vein is missed.
8.Why does varicocele cause infertility?
Infertility caused by varicocele may be related to the following factors.
① Blood stagnation in the spermatic vein, which increases the local temperature of the testis and degenerates the spermatogenic tubules affecting spermatogenesis.
(ii) Blood stagnation affecting testicular blood circulation and CO2 accumulation in testicular tissues affecting spermatogenesis.
(iii) blood from the renal vein returning from the left internal spermatic vein brings metabolites secreted by the adrenal glands and kidneys such as steroids, catecholamines and 5-hydroxytryptamine to the testes; steroids can inhibit spermatogenesis, catecholamines can cause chronic toxicity in the testes, and 5-hydroxytryptamine can cause vasoconstriction, resulting in premature sperm shedding.
④ varicocele on the left side can affect the function of the right testis, because there are abundant traffic branches of the veins between the testes bilaterally, and the toxins of the left spermatic vein blood can affect the spermatogenesis of the right testis.
Usually, semen examination should be routinely performed for patients with varicocele in clinical practice. The results show that most patients have decreased sperm count, decreased sperm motility, increased number of immature and acromegalic sperm, and in severe cases, no sperm.
9.Can varicose veins patients have fertility after high spermatozoal vein ligation?
No. Spermatozoal vein ligation only removes the factors that cause damage to the testicles, and after the operation, the blood flow to the testicles will be normalized, and then the fertility will be improved slowly. It takes about 72 days for the sperm to develop and mature, so if it is effective after surgery, it usually takes 3 months after surgery to show up in the semen analysis.
There are many causes of infertility, varicocele being only one of the major factors. The mechanism of infertility caused by varicocele is not well understood, nearly 40% of infertile men have varicocele, and about half of them have improved semen test results after surgery.
10.Why is there no improvement in sperm quality after high spermatic vein ligation?
①There are many reasons for infertility, varicocele is only one of them, and there may be other factors combined.
The mechanism of infertility caused by varicocele is not clear, nearly 40% of infertile men have varicocele, and about half of them have improved semen examination results after surgery. However, not every patient will have improvement after surgery.
③ varicocele will produce continuous raw damage to the testes, and after a long time, the damage to the testicular varicocele sperm duct is heavy to a certain degree, even if the surgery is done, the degree of recovery of the sperm production function of the testes is very limited.
11.Do I need to take medicine after spermatozoal vein high ligation?
For infertility patients with poor semen quality, it is necessary to continue taking spermatogenic drugs after surgery.
12.Why can’t I join the army (military service) if I have varicocele?
Varicocele is caused by dysplastic, damaged or incomplete venous valves and weak smooth muscle or elastic fibers of the vein wall, which cause varicose veins, sperm increase and venous blood reflux. When standing, the seminal vein blood of the testicles return to the heart resistance increases, more easily reflux, the military long-term training will make varicose veins aggravate. So you can join the army only after doing the high ligation of spermatic veins.
13.Do children with asymptomatic varicocele also need surgery?
No. Because varicocele can cause continuous raw damage to both testicles, which will not only affect the development of testicles but also the fertility function in adulthood. Therefore, if varicocele is found in children, it is best to have surgery in time.
14.What about the blood flow in the testes after spermatic vein ligation?
No. The high level ligation of the veins only ligates the internal veins, but there are also external veins and vas deferens veins, so the blood in the testicles can flow back through the external veins of the spermatic cord and the vas deferens veins, and there is no lack of blood.
15.I heard that “ligation” is done for contraceptive purposes, but after “ligation”, one cannot have children, so why do infertile patients need to undergo “ligation” surgery?
The “ligation” we mentioned here refers to “internal spermatic vein ligation”, which is a ligation of the internal spermatic vein, not the vas deferens. The actual fact that the vas deferens is already separated from the spermatic cord at the internal ring and turned to the prostate, will not damage the vas deferens.
The term “ligation” that many people used to hear for contraception refers to “bilateral vasectomy”. The two are completely different concepts.
16.Does varicocele affect sexual function?
The testicular tissue has two components, one is the varicocele and the other is the interstitium. The varicocele is for sperm production, and the interstitium is for androgen production.
In general, varicocele affects the spermatogenic function of the spermatogenic epithelium of the testicular varicocele, causing infertility. The effect on the testicular mesenchyme is less, but there is also the possibility that it may affect androgen production and sexual function. Therefore, patients with clearly diagnosed varicocele should be treated with surgery in time.