What is Varicocele?

Varicocele is a disease characterized by enlargement of the testicular veins in the pampiniform plexus, the veins that return the dirty blood of the testicle (ovary) to the heart.

 

Who is more likely to have varicocele in children?

The disease is generally known as a young adult disease, but it is also seen in 1% of children under 10 years of age. Varicocele occurs 90% on the left side, 10% on both sides and 1% on the right side. Varicocele occurs between the ages of 10 and 15, most often at the age of 12, and is seen in about 15 percent of adult men. The incidence rate in infertile men is 20-40%.

Why Varicocele Occurs in Children?

The cause is not completely clear. High pressure in the testicular veins caused by any reason disrupts the valve system in these veins and causes enlargement and varicocele.

The reasons why varicoceles are more common on the left side include the fact that the left spermatic vein enters a higher pressure vein (the left renal vein) at right angles, this vein passes between the aorta and the superior mesenteric artery, the left vein is longer and does not contain a valve.

 

When a varicocele is detected in children younger than ten years of age, a mass obstructing the venous return of the testicle such as Wilms tumor, Neuroblastoma and hydronephrotic kidney should be considered. A retroperitoneal mass should also be considered in right-sided varicocele.

Is there a Varicocele Grading?

Yes, there is, varicocele is divided into 4 degrees according to physical examination and Dopler Ultraasonography:

a) Subclinical Varicocele: Large veins that cannot be detected in physical examination but can only be shown in ultrasonography.

b) 1st degree Varicocele: Large veins that can be felt during examination in situations that increase intra-abdominal pressure such as coughing and straining.

c) Grade 2 Varicocele: Large veins felt during physical examination without any procedure.

d) 3rd degree Varicocele: Large veins that can be seen externally without any procedure during physical examination.

How is Varicocele Diagnosed?

Varicocele is diagnosed by history and physical examination. It is also confirmed by imaging methods and followed up. In the patient's history, there are complaints such as pain in the scrotum, one ovary is small and worm-like structures are noticed in the bag. On physical examination, enlarged veins are seen or palpable.

 

In most age groups, patients with varicocele on the right or in both testicles should be examined with retroperitoneal ultrasonography (the area in the middle and behind the kidneys) to make sure that they do not have a condition such as a mass in the abdomen that compresses the main vessels. Abdominal ultrasonography should be performed to check for a mass that may cause compression.

Scrotal Doppler Ultrasonography confirms the diagnosis and grades the varicose veins.

 

Which Varicoceles Do Not Require Treatment?

Patients with subclinical varicocele or children with varicocele who have no change in testicular volumes do not require surgery. Patients with testicular pain and varicocele should be operated only after it is shown that the cause of the pain is not a condition other than varicocele and after it is observed that they do not benefit from painkillers, the risks of the treatment should be discussed with the patient and surgery should be performed if he/she wishes. These patients are followed up and the patient is examined every 3-6 months and doppler ultrasonography is performed if necessary.

Follow-up visits are recommended for hydrocele, testicular shrinkage and varicocele recurrence.

What are the Treatment Criteria for Adolescent Varicocele?

• The criteria for varicocele surgery are determined as follows;
• Varicocele accompanied by small testicles,
• Presence of varicocele on both sides,
• Deterioration in sperm quality if sperm analysis can be performed in young people in puberty,
• Having complaints due to varicocele,
• Varicocele surgery decision can be made in cases where the testicular volume decreases more than 10% compared to the other or there is more than 2 cm3 difference between the testicles,
• Varicocele surgery decision can be made in the presence of Grade 3 varicocele.

How is varicocele treated?

The treatment of varicocele is surgery. Many surgical methods have been described until today. However, the methods commonly used today are Microsurgery and Laparoscopic Methods.

In addition, treatment can also be performed by introducing various substances into the veins with the use of angiographic techniques.

Varicocele surgery is performed through an incision in the groin area. Here the veins leading to the testicles are found and ligated. The chances of success are much higher when a microscope or optical magnifier is used and the development of unwanted effects (complications) is rare.

What are the Main Surgical Treatment Techniques?

There are mainly 4 techniques.

1. Laparoscopic: The Palomo method is performed laparoscopically. The spermatic artery and cord are clearly seen and protected. In addition to these advantages, it is also easy to differentiate the lymphatics and therefore the rate of hydrocele development after the procedure is lower. Therefore, we prefer this method.

   

   

    

2. Open surgical techniques: It can be performed with normal and microsurgical methods. The veins are accessed through an incision in the groin and the enlarged veins are found and ligated one by one. Today, the most effective and reliable surgical method is microsurgery performed under a microscope.

   

   

    

3. Microsurgery

4. Radiological techniques: Exposure to radiation and high likelihood of recurrence (15%)

•Sclerotherapy
•Embolization

Which of these methods is the most successful?

Recent scientific studies have shown that the most successful and least complicated method is Microsurgery under the Microscope.

How is Microsurgery Performed? What are the Advantages?

As with the open method, an incision of about 2 cm is made in the groin, the veins are turned and suspended. The procedure is then performed under a microscope. The dilated venous vessels are turned one by one and ligated and cut. Since the microscope provides significant magnification, unnecessary tissue damage is avoided.

As for the advantages, arteries, veins and lymphatic system are seen in detail under the microscope, unnecessary tissue damage, arterial and lymphatic damage is prevented. Thus, the risk of testicular damage, edema and hydrocele is minimized. The risk of recurrence of varicocele is also minimized. While the possibility of recurrence decreases from 30-40% to 2-4%, the hydrocele rate decreases from 10-15% to 1%.

On the other hand, studies in adults have shown 60-80% improvement in sperm values.

What Problems Can Varicocele in Children Cause If Untreated?

In cases where varicocele treatment is refused or not applied, progressive damage due to varicocele may continue in the following years, increasing the degree of varicocele, shrinkage in testicular volume, deterioration in serum hormone values and deterioration in sperm parameters. As a result, it may be a cause of infertility.

Why Varicocele in Children Causes Testicular Damage?

The temperature inside the body is normally higher than outside. In order to maintain sperm viability and function, they need to be in a cooler environment than inside the body, which is the scrotum. In the case of varicocele, the enlarged veins cause an increase in temperature in the testicle. This increase in temperature also causes malnutrition due to the incomplete removal of residual substances from the testicles. These two causes cause damage to the testicle.

What are the Risks of Varicocele Surgery?

Life-threatening complications are not expected during and after surgical treatment of this disease. However, the following situations are possible, although very rare. Since the patient will receive General Anesthesia, complications related to it may develop. There may also be complications related to the surgery. The main complications related to the surgery are Testicular Atrophy, Hydrocele and Varicocele recurrence. If the surgery is performed laparoscopically, complications related to laparoscopy may occur, which are very rare complications.

Complications of this surgery:

1. Hydrocele Depending on the preferred surgical method, fluid collection in the scrotum (ovarian sack) may develop after the operation (3-15%).
2. Testicular atrophy: Injury or ligation of the testicular artery may cause testicular atrophy and/or impaired spermatogenesis (14%).
3. Recurrence: Varicocele may recur after surgery (1-45%).
4. Infection may develop at the incision site. Antibiotic treatment may be required.

*** The information provided here, the content of the website is intended to inform the visitor, especially families. No information should be considered as advice by visitors and should not lead to any decision or action. Families should definitely have their patient examined by a pediatric surgery specialist, consult with him/her and make a decision by consulting his/her knowledge one-on-one.