nk" href="#what-are-the-symptoms-of-varicocele">What are the symptoms of varicocele?

What are the symptoms of varicocele?

Varicocele symptoms are very important for the diagnosis and treatment of the disease. Swelling on the testicle

• and pain in the testicle
• may be the symptoms of varicocele.
• Testicle pain may be a symptom.

The dilatation of the veins may become evident enough to be seen from outside after a while and may take on an varicose-like shape on the legs. Symptoms of varicocele include swelling in the testicles, as well as sweating and a feeling of warmth. The shrinkage of the testicles, which is one of the symptoms of varicocele, can be seen in some patients, although rare.

Why Does Varicocele Occur?

The cause of varicocele is unclear. It is observed in individuals with children in the society at a rate of 15-20% even in adult ages. It is observed in 30-40% of men applying for infertility. In secondary infertility, who have had a child before and who apply again with a child request, it can be up to 60%.

While varicocele is seen 90% in left testicle, 8-9% observed in bilateral. Its rate of being seen only on the right is 1-2%. The appearance of varicocele mostly on the left side depends on a number of anatomical factors.

• The left side testicle is slightly lower than the right side.
• The vein on the left side of the testicle is longer than the right side.
• Anatomical relationship of the left side testicle vein with other neighboring organs in the abdomen.
• Among the features such as the anatomical structure of the left side testicle vein emptying, varicocele is among the reasons why it is seen on the left side.

How to Understand Varicocele?

Careful individuals can identify the varicocele from irregularity, swelling or pain on the testicle when self-examining. Varicoceles are mostly diagnosed during the doctor's examination in applications made with infertility complaints. Also; Pain in conditions requiring effort such as long standing, sports or sexual activity may indicate varicocele. Varicocele examination is performed as part of the genital examination. The patient should be examined in a standing position at a room temperature of 21 -22 degrees. The testicles and genital area are observed while the patient is standing and standing upright. The patient is examined both in the normal position and by straining maneuvers by observation and hand. It should be determined whether there is an expansion in the vascular structure with normal and strain maneuvers. With these procedures, the presence of varicocele is clinically determined. The golden standard is physical examination in diagnosis. In addition, Scrotal Doppler ultrasonography is performed to support clinical diagnosis, to determine the degree of varicocele and to decide on surgery.

How is Varicocele Treatment?

After the diagnosis of varicocele, firstly, whether there is a difference between the testicle sizes and the consistency of the testicle should be checked. Performing semen analysis in which sperm parameters are evaluated is decisive in the treatment. If the patient's sperm parameters do not have a problem, it is controversial whether they should be operated or not.

The factors can disrupt sperm parameters in this kind of patients;

• Eating habits
• Smoking and alcohol
• Exposure to toxic substances

Antioxidant drugs and nutritional methods can be recommended to correct sperm parameters and the environment in which sperm are located. After the diagnosis, the question arises as to which varicocele patients will be operated. It is not a correct approach to make an operation decision by looking at the varicocele grade, that is, the grade value. In some cases, even a 1st degree (Grade 1) varicocele can be operated, while in some cases, surgery may not be decided for 3rd degree (Grade 3) varicocele. Operation decision is a situation that varies according to the patient.  

Supportive therapies may be recommended in the patient group who have been diagnosed with varicocele but have no infertility problem or whose impairment in sperm parameters is limited.Antioxidant agents can be given for patients who have not experienced severe sperm loss, whose sperm motion has not completely disappeared, and sperm deformity is minimal. However, surgery can be recommended in patients who have been diagnosed with varicocele and whose sperm parameters are impaired and who are infertile. In such patients, changes in exercise, diet and lifestyle are not beneficial for the elimination of the disease. 

As a result;

• The patients with normal sperm parameters, only radiological varicocele, no reflux or below normal vascular diameter are not required to be operated.
• Patients with impaired sperm parameters benefit more from surgery.
• It is important to perform clinical follow-up by evaluating testicular sizes and consistency in varicoceles in adulthood.
• Varicocele surgery only due to pain is not a right approach.
• After the surgery, 60-70% sperm parameters improve.
• It is important to perform the postoperative evaluation at the 6th month and to determine the change in sperm parameters.
• The accepted approach in the treatment is interventions made from the groin area by microsurgery.

FREQUENTLY ASKED QUESTIONS ABOUT VARICOCELE

How is varicocele pain?

Varicocele pain is an uncomfortable blunt, distinctive pain in the testicle. This pain can be felt in the groin area and the testicle, as well as from time to time in the leg. Varicocele pain can go away with painkillers. The pain experienced can be confused with different ailments. Besides the presence of varicocele in a patient who applied for testicular pain;

• Hernia
• Urinary tract calculus (kidney calculus) that fall into the urinary tract or bladder
• Orchitis, testicular infection
• It should be evaluated whether the vascular structure of the testicle rotates around itself and causes bleeding.

Pain caused by such ailments can be confused with varicocele pain. Some inquiries such as whether the person has a complaint in urination, whether the swelling in the testicle has increased, whether the pain begins suddenly or not, and laboratory methods can provide the differential diagnosis. Not all pain must be varicocele.

Pain can be felt more pronounced after standing for a long time, walking, exercise, sexual activity.

How does the testicle look in the varicocele?

The varicocele does not cause any changes in the testicle. However, in advanced varicocele patients, the veins cab be seen as superficial in testicles, such as varicose veins in the legs. Varicose enlarged veins can be palpable through the skin and can be observed.

Who has varicocele mostly?

The reason for the occurrence of varicocele is unknown. However, there are some risk groups:

• Mostly overweight people
• People doing high-weight sports that increase intra-abdominal pressure
• People suffering from chronic asthma and chronic cough attacks
• People who experience chronic constipation that increases intra-abdominal pressure
• It can be considered as occupational disease as in varicose disease. Occupational groups such as teachers and police, which standing up are more common.

Varicocele is common in people with varicose veins in the legs because it is a vein disease. Inverse of this situation, varicose disease can also be seen in people with varicocele. Since both diseases are related to veins, insufficiency of the valves in these vessels may occur due to factors such as problems in the transmission of blood.

What is Bilateral Varicocele?

While varicocele is 90% seen in the left testicle, 8-9% can be seen on both sides. The occurrence of varicocele in both sides is named as bilateral.

Are there any foods good for varicocele?

Nutrition has nothing to do with varicocele formation or treatment. Only people with chronic constipation can be evaluated in this group. Fiber or olive oil nutrition which helps eliminate constipation may benefit indirectly.

Does varicocele cause infertility?

Varicocele ranks first among the treatable infertility causes. If the varicocele causes male infertility, then an operation decision can be made. However, it should be noted that not every varicocele is the cause of infertility and there may be no improvement in sperm values in each patient after surgery.

Does varicocele prevent erection?

The testicle has two basic functions. Varicocele may cause impairment in the functions of testicles that produce sperm and hormones. Chronic varicocele may lead to a decrease in the production of the male hormone called testosterone, as well as sperm production, by causing a decrease in testicle size in the later periods. If chronic varicocele is not treated, it can cause erection and sexual desire loss along with low testosterone.

What are the varicocele grades?  

According to the examination in the clinical environment, varicocele is evaluated as 3 stages, namely Grade.

1. Grade (Grade 1): This is a situation in which the patient who is examined as standing up does not have any symptoms, however, the varicocele is detected by palpation when the patient strains.
2. Grade (Grade 2): Varicocele can be slightly observed when the patient is standing up. This is a situation in which the veins become visible and palpable after the patient strains.
3. Grade (Grade 3): This is a situation in which the vessels are visible without straining on the patient who is examined as standing up and this image becomes more evident at the end of the straining maneuver.  

For which patients, varicocele surgery decision is made?

In order to decide on varicocele surgery, it is necessary to reveal the presence of varicocele and have infertility in the patient. In patients with this condition, surgery can be decided with the support of the following criteria:

• Shrinkage in testicle size, softening in testicular consistency
• More than 3 mm vascular dilation with Doppler ultrasonography
• Determination of blood backflow in Doppler examination
• Impaired sperm parameters in semen analysis

In addition, in the patients who has varicocele and who have previously undergone assisted reproductive methods but failed, treatment of varicocele may be recommended as a risk factor before a new application if the failure is known to be caused by sperm factor.

It is not correct to make an operation decision in people only with testicular pain.

How is varicocele surgery performed?

Varicocele surgery is performed by microsurgery. The testicle veins are reached by entering through a 2 cm incision in the groin area. Under the microscope, the enlarged veins are separated from other vessels and connected.

How long does varicocele surgery take?

Since varicocele surgery is performed with microsurgery methods, all the vessels in that area must be connected. Depending on whether the operation is unilateral or bilateral and the number of vessels connected, the duration may vary between 1-2.5 hours.

Are there any risks of varicocele surgery?

Since varicocele surgery is performed by microsurgery method, the complication rate is extremely low. The most important risk is the attachment of the testicular artery and associated post-operative testicular shrinkage and impaired blood supply. However, since the surgery is performed by microsurgery, the arterial and vein distinction can be made very clearly. The probability of experiencing such a complication is extremely low today. The likelihood of fluid accumulation around the testicle, namely hydrocele, is also extremely reduced. Apart from this, risks such as postoperative infection development and bleeding formation that may occur in all surgeries should not be ignored. With precautions such as attention to sterilization and hemostasis, possible problems are minimized.

Are there different treatment methods for varicocele?

Treatment of varicocele is performed by using different surgical and radiological methods.

Varicocele embolization; Interventional radiology methods can be used for entering through the groin and an occlusive substance injection can be made into the enlarged veins. However, in this method, side effects such as mobilization of the occlusive substance, that is, going to other places, loss of effectiveness of the substance over time, pain and allergic reaction can be experienced. This treatment approach is not highly recommended in international guidelines.

There are also surgical methods applied other than microsurgery.There are approaches from the groin area, high groin area or laparoscopic. However, surgery under the microscope from the lower groin area is considered as the golden standard.

Does varicocele reoccur?

There are different treatment methods of varicocele, but the probability of recurrence is almost zero in surgeries performed with microsurgery.

How long is the healing time of varicocele?

After the surgery performed with the microsurgery method, the patient can return to his normal activity within 2-3 days and to routine business life within 1 week and 10 days. It may take 4-6 weeks to perform activities that require heavy effort and exercise.

When do sperm improve after varicocele surgery?

To evaluate the effect of varicocele surgery on sperm, sperm production time should be considered. The time from the main germ cell to the production of mature sperm in the testicle is considered to be an average of 90 days. So sperm parameters are checked every 3 months after surgery. The best recovery in terms of sperm production after varicocele occurs at the 6th month. If there is an improvement in sperm parameters at the 6th month, the 9th and 12th months should be expected when the increase becomes more evident. However, if there is no change in sperm parameters 6 months after the operation, an additional improvement due to the operation should not be expected in the patient. It is necessary to direct the patient to other treatment alternatives. After the operation, an improvement in the sperm parameters of the patient is observed in 60-70%. While 30 - 40% of the patients do not see any improvement, less than 1% of patients may experience worsening after varicocele surgery. This very rare condition occurs mostly in patients experiencing bilateral varicocele.

What are the conditions that patients should pay attention to after the operation?

After varicocele surgery, it is necessary to stay away from sportive activity, heavy exercise and sexual activity by following the doctor's recommendation in the early period. It is appropriate to wait 15-20 days for sexual activity and 4-6 weeks for exercises that require effort ans sports. Apart from these, it is necessary to follow the treatment methods recommended by the doctor.

Is there pain in the testicles after surgery?

In varicocele surgery, which is a surgical procedure, there may be some kind of neuralgia pain, especially due to damage to the nervous tissues in the testicle area. In addition, it is not the right approach to operate patients suffering from only testicular pain. There may be many underlying causes of pain in such patients. Pain continues after surgery in such patients. The most important reason for failed surgery is patients who do not have infertility, but experience pain alone.

Does swelling occur after varicocele surgery?

Post-operative testicular connective tissue release may result in testicular sagging on the operated side. However, swelling is the increase of fluid that is normal around the testicle, that is, the development of Hydrocele. It is a more experienced situation in the methods applied outside the microsurgery method. It is a problem seen less than 1% in operations performed with microsurgery method. Since the lymphatic vessels are clearly demonstrated and no operations such as connection or burning are performed, the lymphatic circulation is not affected, so there is no swelling and swelling around the testicle after surgery.

Can those who have varicocele surgery have children?

After the operation, sperm parameters improve in 60-70% of the patients. If there is no improvement in sperm parameters in the 6th month, it is useful to direct the patient to methods such as vaccination or in vitro fertilization according to the sperm parameters of the patient, taking into account the conditions such as age factor and female factor. If a young patient who comes to the doctor to evaluate the general condition and has a diagnosis of varicocele with impaired sperm parameters and wants to have children in normal ways, varicocele surgery may be recommended. However, in the older patients with the same diagnosis, instead of wasting time with varicocele surgery, it is more appropriate to refer them with to treatments such as IVF or vaccination. Here, the clinical condition and age of the patients are taken into consideration. Infertility should be evaluated bilaterally not only as the condition of the individual but also as the condition of the couple.

What happens if varicocele is not treated?

Varicocele is a chronic condition and does not heal on its own. If left untreated, it can progressively cause decrease in testicle size, enlargement in varicocele size, further decrease in sperm parameters, and hormonal disruption in the testicle in the future. Also, none of these may happen and the patient can have it as standard for life. There is no such thing as the operation of every varicocele.

Does varicocele occur in young people and children?

An important problem of varicocele is its observed in young people. Varicocele, which is less than 1% in the child age group, is observed by 15% in the 13-15 age group. It is very difficult to evaluate the effect of varicocele on the testicle in the 16-17 age group. Since sperm production has not started completely in this age group, it is not very healthy to evaluate sperm function. In addition, it is not ethically correct to perform semen analysis in young people in this age range. In young people whose surgery decision is difficult to make; when evaluating testicle sizes and testicular consistency, it is necessary to determine the degree of varicocele radiologically. Surgery may be considered if the varicocele causes differences and shrinkage in the size of the testicles. However, in young people who do not have a difference in testicle size and consistency, it is more appropriate to decide on surgery by evaluating sperm parameters by semen analysis when the patient at least reaches the age of adolescence.

Publish by Memorial 9 December 2020

Treatments

Kidney transplantation is the most effective treatment of chronic kidney failure which is the result of permanent loss of kidney function. The patients with chronic kidney failure can return to their lives as healthy individuals in a short time upon a successful transplant and post-operation follow-up process. The "Da Vinci Robotic Surgery" method applied in Memorial Bahçelievler Kidney Transplant Center offers opportunities to reduce many risks during surgery as well as to improve the quality of life of the patient after surgery.

• KIDNEY IS TRANSPLANTED WITH ROBOTIC METHOD
• THINGS TO KNOW ABOUT "DA VINCI ROBOTIC SURGERY" METHOD

KIDNEY IS TRANSPLANTED WITH ROBOTIC METHOD

Kidney transplant is a versatile process that requires proper pre-operation preparations, an experienced team using advanced technology during transplant process, a professional team to manage the post-transplant care and treatments.  Good and proper management of this process is important for the patient's future quality of life and reducing the risk of possible complications. The "Da Vinci Robotic Surgery" method applied in Memorial Bahçelievler Kidney Transplant Center provides important privileges to the physician as well as the patient during and after the kidney transplant process. Thanks to the image zooming system that increases the vision quality of the surgeon 15 times during the surgery, even the thinnest veins can be seen in all details. In addition, it does not cause tiredness and loss of concentration since the surgeon can sit for the long period of surgery. In case of possible hand tremor of the surgeon, the risk of developing complications is also minimized by the anti-tremor system in the device. In addition, in these operations in which the kidney is completely attached to the recipient by the robotic method, the risk of developing post-operative infections is much lower compared to the open method by providing a quick healing of the scar thanks to the only 4 cm incision opened in the patient. In addition, immunosuppressive drugs that suppress the immune system administrated to the patient after open surgery can delay the healing of the large scar area in open surgery. The small incision in the robotic surgery method greatly reduces this risk.

There are 3 parts in the Da Vinci System in which the surgeon moves the arms of the robot as his/her hands with 3D image:

Surgical console section where the surgeon sits during operation,

Patient console section next to the patient and including robotic arms prepared under sterile conditions,

Camera system unit providing advanced imaging system.

In the Da Vinci Robotic System, the camera and the accompanying three robotic arms are proceeded into the abdomen through tunnels with a diameter of 0.8 cm or 1 cm placed on the wall of the abdomen from certain points. Thanks to the thin and gentle surgical robotic arms, the joining (anostomosis) of the veins of the kidney which is placed into the abdomen through a small incision, is performed. In order to increase safety, the incision in the lower part of the abdomen from where the kidney will be removed, is performed at the beginning of the surgery. Since the surgeon's hand can enter through this incision during the surgery, there is the advantage of feeling and the chance to intervene in an emergency.

THINGS TO KNOW ABOUT "DA VINCI ROBOTIC SURGERY" METHOD

Robotic kidney transplant surgery requires high surgical experience and advanced technology. Surgery for the kidney donor is now performed as standard with the laparoscopic method. Robotic surgery provides additional benefits in terms of kidney recipient's quality of life and reduction of complications.

Robotic kidney transplant surgery has important advantages for both surgeon and patient. One of the most important of these concerns the surgeon's quality of vision during the operation. Laparoscopic kidney transplantation methods with standard camera provide only two-dimensional images. In the Da Vinci Robotic Surgery system, 3D images can be obtained thanks to high resolution cameras that transmit seperate images to each eye. In addition, since these cameras can zoom in 15 times, surgery can be performed with an ideal view.

The ends of the surgical instruments at the tip of the robot's arms rotate around their axes at total of 540 degrees in all planes. This technology enables the surgery to be performed even in the deepest parts of the body, beyond the mobility capacity of the human wrist.

The "tremor scaling" feature in the Da Vinci Robotic Surgery system prevents the surgeon from transmitting possible hand tremors to the devices during the surgery.

In classical surgeries, surgeons perform the surgeries by standing up and this may cause difficulties due to tiredness in prolonged surgical interventions. In robotic surgery, since the surgeon works by sitting, his/her concentration is higher and the risk of stress due to tiredness decreases.

The operation continues meticulously, as the robot moves according to the surgeon's wrist movements. Especially in suturing and suturing tissues, a much greater advantage is provided compared to the laparoscopic system.

After the operations performed with robotic surgery, the patient can recover in a much shorter time and the length of hospital stay is also shortened.

Memorial Publish 2021