Minimally invasive varicocele

Numerous different surgical techniques are available for varicocele. Their common principle is that of closing the pathological venous circuit allowing for the subsequent development of collateral circuits through the circuits of the deferential vein and the external gonadal vein.

Surgical techniques can be classified into 3 groups:

  1. Abdominal techniques
  2. Inguinal and sub-inguinal techniques
  3. Radiologically guided techniques

Abdominal techniques:

These techniques involve the ligature of the gonadal vein within the abdomen and thus require opening of the abdomen by either open abdominal or laparoscopic means. They are generally carried out under general or spinal anesthesia. They are somewhat invasive techniques (opening of the abdomen, general or spinal anesthesia) and subject to complications, such as hydrocele (collection of liquid around the testicle) in 8-10% of cases, requiring a second surgical intervention.

Inguinal and sub-inguinal techniques:

these techniques involve the closure of veins upstream of the gonadal vein, the pampiniform plexus veins. Access is via incision of the skin of the inguinal, sub-inguinal (external ring) or high scrotal regions.

Radiologically guided techniques:

These techniques involve closure of the gonadal vein via the insertion of catheters (thin tubes) into a vein in the arm. The advantage of these techniques is that they do not entail any incisions. We carry out retrograde sclerosis, preferably via a vein in the fold of the arm. This technical modification offers the advantage of being less invasive than the transfemoral approach and offers easier access to the renal-spermatic region not only on the left, but also on the right, because the catheter advances from the top down. A small quantity of local anesthetic at the puncture site through which the catheter is inserted is sufficient for the entire procedure. Once the spermatic vein is reached, under radioscopic guidance, the sclerosing substance is injected. During the same session, if the varicocele is bilateral, it is possible to treat both the right and left sides. The patient is allowed to rest for a few hours and is discharged the same day.

Anterograde sclerosis

Following local anesthesia of the inguinal region, an incision of around 1cm is made at the root of the scrotum and one of the veins forming the varicocele is isolated and cannulated. After radiological guidance showing the course of the vein, the sclerosing substance is injected. The vein is then tied and the small wound is sutured with reabsorbable sutures. The patient is discharged as a day case. Again, in this case, we have introduced a few technical modifications, which make this procedure preferable in pre-pubertal or early-pubertal boys.

Surgical Technique

Local Anesthesia: applied between the external inguinal ring and the root of the scrotum around the spermatic cord using a thin insulin needle.

Cutaneous incision: around 2.5cm to the upper part of the scrotum.

Exteriorization of spermatic cord: the cord is the structure that allows the passage of the testicular blood vessels and nerves in addition to the vas deferens (the seminal canal).

Exposure of the external spermatic fascia:
the external spermatic fascia is then incised to reach the veins

The different elements of the spermatic cord are explored: the vas deferens and the 3 venous plexi of the testicle are identified:

  1. The pampiniform plexus
  2. The deferential plexus
  3. The cremasteric plexus

A dilated vein from the pampiniform plexus is isolated
Gonadal phlebography is performed:
phlebography allows the continuity with the gonadal vein to be confirmed.

The sclerosing liquid is injected:
The liquid will cause fibrotic retraction, leading to closure of the lumen of the cannulated vein, the collateral branches of the pampiniform plexus and the gonadal vein downstream.

The incised structures are then closed, that is, the spermatic fascia, subcutis and cutis.