Outcomes of Microsurgical Subinguinal Varicocelectomy for Painful Varicoceles
Abstract
Abstract: We assessed the effectiveness of microscopic subinguinal varicocelectomy for the treatment of painful varicoceles. Patients with painful varicocele (n = 81) treated by microsurgical varicocelectomy who attended a 1-year follow-up were retrospectively evaluated. We documented patient age, grade and location of the varicocele, duration and quality of pain, and response to surgical therapy. Telephone interviews and chart reviews were conducted to assess resolution of pain, recurrence of the varicocele, and complications of the procedure. Of the patients, 29 (35.8%) described the soreness as a sharp pain, 35 (43.2%) as a pulling sensation, and 17 (21%) as a dull pain. The varicocele was grade III in 62 patients (76.5%) and grade II in 19 (23.5%). After microsurgical varicocelectomy, 74 patients (91.3%) experienced improvement in their symptoms: 58 patients (71.6%) experienced a complete resolution of pain postoperatively, and 16 patients (19.7%) experienced partial resolution. Seven patients (8.6%) experienced no change. Of the 7 patients with persistent pain, 2 patients had sharp pain, 4 patients had a pulling sensation, and 1 experienced dull pain postoperatively. The resolution of pain was correlated with preoperative varicocele grade (P = .026) but not with quality of pain (P = .807). Subinguinal microsurgical varicocele ligation is an effective treatment for painful varicoceles.
Many scrotal and extrascrotal pathologies can cause chronic scrotal pain. Varicoceles are a cause of pain in men suffering from chronic scrotal pain (Marmar and Kim, 1994). Surgical therapy for varicoceles has been advocated primarily for patients with male factor infertility. Varicocele ligation for the treatment of pain is controversial, with a paucity of literature supporting its use. Pain is an uncommon indication for varicocelectomy; the estimated incidence of pain in individuals with varicocele ranges from 2% to 14% (Maghraby, 2002; Karademir et al, 2005; Al-Buheissi et al, 2007). The most common complaint is dull aching pain, which gets worse after exertion or straining. Various techniques have been used for the surgical ligation of varicoceles, such as high, inguinal, subinguinal, scrotal, and laparoscopic ligations (Palomo, 1949; Ivanissevich, 1960; Nyirady et al, 2002). The subinguinal microsurgical technique has been used in varicocele ligation with minimal complication rates and good outcomes (Marmar and Kim, 1994). We conducted the present study to evaluate the effects of microsurgical subinguinal varicocelectomy on the symptoms of painful varicocele.
Materials and Methods
Patients
The present study included 81 consecutive patients (mean age, 22.4 years; range, 11 to 35 years) who presented with scrotal pain from varicoceles between January 1997 and December 2007 and were available for follow-up evaluation 1 year later. The patients' medical records were reviewed retrospectively to investigate physical examinations, patient age, location and grade of the varicoceles, quality of pain, and color Doppler ultrasound before surgery. The varicoceles were assigned to grades I to III during an examination while the patient was in a standing position according to the criteria of Lyon et al (1982) as follows: grade I was palpable only with the Valsalva maneuver, grade II was palpable without Valsalva, and grade III was visible from a distance. All varicoceles were confirmed by Doppler ultrasonography to detect the actual size. Patients who had other causes of scrotal pain, such as testis trauma, testicular torsion, epididymitis, prostatitis, sexually transmitted disease, urinary tract disease, inguinal hernia repair, stone disease, or any other testicular pathology was excluded. One year after the operation, follow-up evaluation included a physical examination to determine varicocele recurrence and complications and an assessment of pain quality to determine pain resolution. Patient responses after surgery were graded as no response (pain remained unchanged after surgery), partial response (pain persisted but was reduced after surgery), and complete response (pain was absent after surgery). The study procedures complied with guidelines provided by the Declaration of Helsinki.
Operative Technique
The operation was performed with the patient under general anesthesia. The surgical technique for microsurgical inguinal varicocelectomy was a modification of a previously described method (Goldstein et al, 1992); we did not deliver the testis or examine the gubernaculum. We tried to separate and spare the ilioinguinal nerve. A Zeiss operating microscope (Carl Zeiss, Jena, Germany) was brought into the operative field. Under ×10 to ×25 magnification, we could preserve the lymphatics and testicular, vasal, and cremasteric arteries. Briefly, a 2- to 3-cm oblique skin incision was made at the external inguinal ring. The spermatic cord was identified, encircled with a Babcock clamp, elevated out of the incision, and placed over a 1-cm-wide Penrose drain for support. To simplify the procedure and protect the vas deferens and its vessels from potential injury during cord dissection, we separated the internal spermatic vessels from the external spermatic fascia and its associated structure, the cremasteric fiber, the external spermatic vessels, and the vas deferens and its vessels before microdissection. A 1% papaverine solution was dripped onto the spermatic cord to aid in identifying the testicular arteries. All identified arteries were saved, and all veins except for vasal veins smaller than 2 mm were doubly ligated with 4–0 silk ties and divided. At the completion of the procedure, the spermatic cord was returned to the subinguinal level. The fascia of Scarpa was closed with an interrupted 4–0 absorbable suture.
Statistical Analyses
SPSS (version 7.5 for Windows; SPSS, Chicago, Illinois) was used for statistical analyses. Comparison of the patients' preoperative characteristics and postoperative outcomes according to the grade of varicocele and quality of pain was performed by use of Fisher's exact test and t test. Values of P < .05 were deemed to be statistically significant.
Results
Patient characteristics are listed in Table 1. The average patient age was 20.4 years (range, 11 to 35 years). The varicocele was on the left side in 76 men (93.8%) and was bilateral in 5 (6.2%). The varicocele was grade III in 62 men (76.5%) and was grade II in 19 (23.5%). Patients described the pain with testicular discomfort as a dull ache (17, 21%), pulling sensation (35, 43.2%), or sharp pain (29, 35.8%). Overall, 74 patients (91.3%) had improved symptoms: 58 (71.6%) achieved a complete resolution of pain postoperatively, and 16 (19.7%) experienced partial resolution. Seven (8.6%) men reported no change, and ultrasound was performed to confirm varicocele persistency.
| Characteristic or Outcome | Value |
|---|---|
| Age, y | 20.4 ± 3.1 (range, 11–35) |
| Symptom duration, y | 1.9 ± 1.8 (range, 0.2–4.2) |
| Bilaterality, n (%) | |
| Unilateral | 76 (93.8) |
| Bilateral | 5 (6.2) |
| Varicocele grade, n (%) | |
| II | 19 (23.5) |
| III | 62 (76.5) |
| Quality of pain, n (%) | |
| Dull ache | 17 (21.0) |
| Pulling sensation | 35 (43.2) |
| Sharp | 29 (35.8) |
| Pain resolution, n (%) | |
| Complete | 58 (71.6) |
| Partial | 16 (19.7) |
| No change | 7 (8.6) |
| Postoperative result, n | |
| Recurrence | 2 (grade II and III) |
| Hydrocele | 0 (0) |
| Postoperative complications, n | |
| Scrotal hematoma | 1 |
| Wound infection | 1 |
- a Data are presented as x̄ ± SD unless otherwise noted.
Comparison of treatment outcomes in terms of varicocele grade and quality of pain are described in Table 2. Of the 7 patients with persistent pain, 2 had sharp pain (one each of grade II and III), 4 had a pulling sensation (2 each of grade II and III), and 1 had dull pain (grade III) preoperatively. The resolution of pain was correlated with preoperative varicocele grade (P = .026) and was not correlated with quality of pain (P = .807). No intraoperative complications occurred. Postoperative complications consisted of 1 scrotal hematoma, 1 wound infection treated with antibiotics, and 2 varicocele recurrences (grades II and III) without resolution of pain.
| Postoperative Pain Resolution | ||||
|---|---|---|---|---|
| Assessment Criteria | Complete, n | Partial, n | None, n | P Value |
| Varicocele grade | .026 | |||
| II | 9 | 7 | 3 | |
| III | 49 | 9 | 4 | |
| Quality of pain | .807 | |||
| Dull ache | 12 | 4 | 1 | |
| Pulling sensation | 23 | 8 | 4 | |
| Sharp | 23 | 4 | 2 |
Discussion
Most urologists agree that varicoceles are a treatable cause of male infertility, and many reports on this subject suggest improved seminal characteristics and increased pregnancy rates after varicocele correction (Marmar and Kim, 1994; Seftel et al, 1997). Treatment of a painful varicocele traditionally consists of conservative treatment followed by surgical therapy. Commonly used conservative measures, such as scrotal support, nonsteroidal anti-inflammatory drugs, and decreased physical activity, are considered before surgery. Surgical ligation is used in the treatment of painful varicocele, which is an uncommon indication for varicocelectomy, with an incidence of 2% to 14% (Maghraby, 2002; Karademir et al, 2005; Al-Buheissi et al, 2007). However, only limited data exist regarding the outcome of surgical treatment for painful varicocele and the factors that predict success.
The most common complaint of these patients is a dull pain that gets worse with straining or exercise (Saypol, 1981). Several techniques have been used in varicocele ligation, including radiographic embolization; open surgical ligation; and laparoscopic, microsurgical inguinal, and subinguinal varicocelectomies. Although the ideal method of varicocele ligation is still a matter of controversy, the microsurgical technique has been advocated as the standard procedure because of the few complications associated with it (Cayon et al, 2000; Ghanem et al, 2004). Al-Buheissi et al (2007) conducted a study to establish the effectiveness of varicocele ligation and to find the most effective surgical technique for the treatment of scrotal pain. They used 3 methods (high ligation, inguinal, subinguinal) of varicocele ligation and found no association between the surgical approach used and failure of pain resolution. Yaman et al (2000) reported the highest success rate among the techniques used in the treatment of pain: specifically, 88% (72/82) of painful varicocele patients who underwent microsurgical subinguinal varicocelectomy had complete resolution of pain, 5% (4/82) had partial resolution, and 6% (5/82) reported no improvement. In the present study, we used microsurgical subinguinal varicocelectomy for scrotal pain and found that 91.3% (74/81) had improved symptoms: 71.6% (58/81) achieved complete resolution of pain postoperatively, and 19.7% (16/81) experienced partial resolution, whereas 8.6% (7/81) showed no change. Karademir et al (2005) indicated that 101 of 121 patients reported improvement on scrotal pain questionnaires after undergoing inguinal or subinguinal varicocelectomies for scrotal pain; of these, 75% had complete resolution of pain and 25% had partial resolution. Maghraby (2002) reviewed the results of the laparoscopic ligation of 58 painful varicoceles and reported complete resolution in 84.5% of cases, with a low complication rate and a success rate similar to that shown with other ligation methods.
Microsurgical varicocelectomy is superior to nonmicrosurgical procedures with respect to the development of complications such as varicocele recurrence (Goldstein et al, 1992; Cayon et al, 2000). Varicocele recurrence most likely accounts for many of the treatment failures after initial varicocelectomy for patients with painful varicoceles (Goldstein et al, 1992; Peterson et al, 1998; Cayon et al, 2000). In this study, we used a modified surgical version of the conventional subinguinal varicocelectomy procedure. We divided the spermatic cord as internal spermatic vessels and others before microdissection to help ease the process of microdissection. We did not deliver the testis out of the scrotum, nor did we ligate the gubernacular vein. Zini et al (2006) also reported a modification in the technique of microsurgical varicocelectomy. They used early division of some cord structures before microdissection, which resulted in a significant decrease in the operation time compared with the standard procedure and did not compromise the surgical outcome. One study estimated that gubernacular veins were presumed to exist in 7% of cases of varicocele recurrence (Steckel et al, 1993). However, the contribution of these gubernacular veins to postoperative recurrence remains unclear. Varicocele recurrence in our current study was seen in only 2 patients and was probably due to unligated small veins of gubernacular origin.
Successful surgical treatment of painful varicoceles has been reported to depend largely on proper patient selection—specifically, patients with chronic, dull, non-radiating pain—and on avoiding complications, such as varicocele recurrence. Al-Buheissi et al (2007) attempted to determine predictors of success after surgical ligation of painful varicoceles. In that study, most patients (76.5%) experienced a marked or complete resolution. Those authors insisted that a dull aching pain quality was the only predictor of successful pain resolution; patients with sharp pain failed to benefit from varicocele ligation. Peterson et al (1998) reported that duration of preoperative pain, patient age, varicocele grade, length of conservative management, and surgical approach did not accurately predict outcomes of varicocele ligation performed for pain. In the present study, we observed that the resolution of pain was correlated with preoperative varicocele grade. Treatment failure after microsurgical varicocelectomy could be due to underlying pathology, such as epididymitis, idiopathic orchalgia, or a surgical complication (Chawla et al, 2005). In the present study, recurrence of varicoceles was confirmed in only 2 patients who had persistent pain; varicoceles did not recur in the other 5 cases of persistent pain. This result also suggests that the persistence of pain was probably not related to varicocele recurrence. We believe that our results represent the effective outcome of microsurgical varicocelectomy for patients with painful varicocele. However, we do not exclude the possibility that varicocelectomy for presumed varicocele-related scrotal pain might, in some cases, be an inappropriate form of treatment. A prospective, randomized study with long-term follow-up that compares the surgical management of painful varicoceles by means of different surgical techniques is needed to reach a more definite conclusion.
Conclusions
We found that microsurgical subinguinal varicocele ligation in patients with painful varicocele was successful in the treatment of varicocele and scrotal pain. Preoperative high-grade varicocele might predict surgical outcome of pain resolution in these patients.
