Grade 1:
the veins are palpable only during the straining maneuver.
Andrological microsurgery
Microsurgical correction of varicocele
Recommending surgery begins with a careful assessment.
Assessment and indication
Every decision starts with understanding the case.
Varicocele is the dilation of veins around the testicle. In some men, it is associated with changes in sperm production, difficulty having children or discomfort in the scrotum. In others, it causes no symptoms. Finding a varicocele does not mean, in itself, that it is necessary to operate on it.
01
How do I diagnose
I start with the clinical history and physical examination. I examine the testicles and the veins of the scrotum with the patient standing, at rest and during an exercise maneuver. When the physical examination is not conclusive, Doppler ultrasound can complement the evaluation.
If the consultation is motivated by infertility, I also analyze the spermograms, reproductive history and the couple's context. In selected situations, I consider sperm DNA fragmentation testing. I do not recommend surgery just because the ultrasound showed dilated veins.
Varicocele is clinically classified into three grades:
Grade 2:
the veins are palpable even at rest.
Grade 3:
the veins are visible and palpable at rest.
When it appears on ultrasound but cannot be palpated on physical examination, it is called a subclinical varicocele. The grade describes the finding; does not alone define the need for treatment.
02
When I Consider Surgery
When investigating infertility, I consider correction when I find a palpable varicocele associated with changes in the spermogram. The high fragmentation of sperm DNA can also weigh on this decision, especially when the conventional spermogram does not completely clarify the couple's difficulty. I interpret the test together with the clinical history and other findings, never in isolation.
I also evaluate the possibility of surgery when there is persistent pain that appears to be related to the varicocele. First, I try to investigate other causes of discomfort in the region.
I talk to each patient about the objective of the procedure. We can seek improvement in seminal parameters, reduction of sperm DNA fragmentation or pain relief. The answer varies, and surgery is not a guarantee of pregnancy or the complete disappearance of symptoms.
03
What is the surgery like?
I make a small incision in the groin area, close to the scrotum. Through this access, I identify the spermatic cord and use the operating microscope to work with its enlarged structures.
During the procedure, I treat the veins related to varicocele and try to preserve important structures, especially the testicular artery and lymphatic vessels. It is a surgery that requires continuous attention to detail and experience with microsurgical technique.
The microscope magnifies what I see. Surgical experience guides what I should treat and what I need to preserve.
04
Duration, post-operative period and return to routine
The operation usually lasts around one to two hours, depending on the anatomy and findings of each case. When the varicocele is bilateral, I operate on both sides, and the procedure may take longer. This period does not include preparation or recovery from anesthesia. In general, the discharge occurs on the same day.
It is common for there to be sensitivity, some swelling or purpleness in the region in the first few days. After surgery, I advise care with the dressing and gradual resumption of activities.
Light activities and office work usually resume within a few days. Intense exercise, weight lifting and physical work require more time and are released as recovery occurs. My usual guidance is to avoid sexual activity for 14 days.
Upon return, I examine the healing and adjust these recommendations. The time required may vary, especially when the surgery is bilateral or when the patient's routine requires physical effort.
05
When I repeat the exams
If the aim of the surgery is to improve fertility, I usually request the first spermogram around three months after the procedure. Producing new sperm takes time; an examination done immediately after the operation would not adequately show the answer.
Depending on the reason for the surgery and previous results, I may also re-evaluate sperm DNA fragmentation and repeat the tests in the following months. I interpret this evolution together with the patient, always considering the couple's reproductive project.
Consultation and planning
The indication is defined for each patient.
During the consultation, I evaluate the diagnosis, explain the alternatives and organize treatment and follow-up according to the needs of the case.