Surgical treatment of varicocele: shunting, occlusive and endovascular interventions

The frequency of recurrence after surgical treatment of varicocele reaches 29%. This circumstance encourages the medical community to search for the optimal surgical aid to prevent pathological reflux of blood into the venous plexuses of the testicle from the overlying parts of the vascular network. The operation is indicated in case of presence of the clinical symptoms, the development of orchopathy and disorders of spermatogenesis, regardless of the degree of development of varicocele (WHO classification 2010). Operations aimed at eliminating varicocele are divided into 2 large groups: the first group – preserving the renocaval shunt or shunting operations and the second group – not preserving the renocaval shunt or occlusive operations. Shunting operations include the creation of intervenous anastomoses: proximal, distal and bidirectional. Proximal anastomoses are aimed at eliminating renal venous hypertension as the direct cause of the disease. The imposition of bidirectional and distal anastomoses is considered inappropriate, since in the first case, the time of surgical intervention increases, and in the second case, renal hypertension is not eliminated. Occlusive operations are indicated for primary varicocele and the absence of pronounced venous hypertension. According to the level of vein ligation, they are divided into supra-inguinal and sub-inguinal, by selectivity into selective and non-selective, and by operative access into open, laparoscopic and endovascular. The lowest number of relapses and postoperative complications is observed in sub-inguinal selective and endovascular techniques. They are the most universal ones and eliminate all hemodynamic types of varicocele. Supra-inguinal selective techniques show their high effectiveness in the renospermatic type of varicocele and, unlike sub-inguinal operations, there is no risk of damage to the testicular artery during the operation. Thus, a differentiated approach to choosing the type of surgery reduces the risk of postoperative complications and prevents recurrence of the disease.

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