Microsurgical Varicocelectomy with denervation for the varicocele and orchalgia.

We had a 22 year old gentleman who came with history of dragging pain in the left testis since 3 years. He did not have anyother complaints. The patient was was examined and found to have grade 3 varicocele on the left. There was no neurological deficit. His investigation profile (Urine and blood ) were unremarkable. He was subjected to Doppler Ultrasound examination which showed grade 3 varicocele with normal sized both testes with normal echotexture.
The patient was given all options including conservative management and the patient chose for the microsurgical varicocelectomy (Having gone through all modalities of the varicocecelectomy- embolisation,open and laparosocopic).He was of the opinion that embolisation would be a minimally invasive option for him(He thus read in the net).He was given the data about success,possible complication and failure rate of each surgical/non-surgical procedure and finally he opted for microsurgical varicocelectomy.(It is important to give best option available rather option suitable for the hospital/treating surgeon-if microsurgical facilities are not available the patient should be duly informed about it.)
The surgery was done with an aid of microscope with varying degrees of the magnification from 10-15X Keenly the lymphatics and the testicular artery was identified and veins of the spermatic cord, external spermatic vein and the gubernacular veins were ligated. The subinguinal approach was taken.The wound was closed after releasing cremasteric fascia and denuding the testicular artery ( as part of microsurgical denervation of the spermatic cord) and subcuticular stitches for the skin.
Surgical Approach to Varicocele:

Surgical repair may be accomplished by various surgical approaches like inguinal (Ivanissevich), subinguinal and retroperitoneal approaches (Palomo), Most experts perform inguinal or subinguinal surgical repair employing loupes or an operating microscope for optical magnification. Techniques using optical magnification help in reliable identification and preservation of the testicular artery or arteries, cremasteric artery and lymphatic channels and reliable identification of all internal spermatic veins and gubernacular veins reducing the risk of persistence or recurrence of varicocele. The introduction of microsurgical technique to varicocelectomy has resulted in a substantial reduction in the incidence of postoperative hydrocele formation and testicular atrophy. The use of magnification enhances the ability to identify and preserves the 0.5 - 1.5-mm testicular arteries, thus avoiding the complications of azoospermia.




Microsurgery only should be offered for varicocele patient
In general laparoscopy should not be assorted for varicocele treatment.
The Gold standard of varicocelectomy is Microsurgical Varicocele Ligation.


Varicocelectomy for pain:
The varicocelectomy for pain is little bit controversial topic while many urologist go for the surgery what we feel that the patient should be fully counseled for the chance that the orchalgia may not fully abate(20% chance).He may need certain other medicines in such cases like Pregabalin, Tegretol.
Our approach- in case of orchalgia with the varicocele has been microsurgical denervation and cremasteric release also which was done in the index case.