Open clipping / tying of varicocele

What is the evidence base for this information?

This leaflet includes advice from consensus panels, the British Association of Urological Surgeons, the Department of Health and evidence based sources; it is, therefore, a reflection of best practice in the UK. It is intended to supplement any advice you may already have been given by your urologist or nurse specialist as well as the surgical team at Addenbrooke’s. Alternative treatments are outlined below and can be discussed in more detail with your urologist or specialist nurse.

What does the procedure involve?

This involves tying or clipping the testicular veins causing the varicocele swelling in the scrotum through an incision in the groin.

What are the alternatives to this procedure?

Observation, radiological embolisation, laparoscopic surgery.

What should I expect before the procedure?

You will usually be admitted on the same day as your surgery. You will normally undergo pre assessment on the day of your clinic or an appointment for pre assessment will be made from clinic, to assess your general fitness, to screen for the carriage of MRSA and to perform some baseline investigations. After admission, you will be seen by members of the medical team which may include the consultant, junior urology doctors and your named nurse.

You will be asked not to eat or drink for six hours before surgery and, immediately before the operation, you may be given a pre-medication by the anaesthetist which will make you dry-mouthed and pleasantly sleepy.

Please be sure to inform your urologist in advance of your surgery if you have any of the following:

• an artificial heart valve
• a coronary artery stent
• a heart pacemaker or defibrillator
• an artificial joint
• an artificial blood vessel graft
• a neurosurgical shunt
• any other implanted foreign body
• a prescription for warfarin, aspirin, rivaroxaban, dabigatran, apixaban, edoxaban or clopidogrel, ticagrelor or blood thinning medication a previous or current MRSA infection
• high risk of variant CJD (if you have received a corneal transplant, a neurosurgical dural transplant or previous injections of human derived growth hormone)

What happens during the procedure?

Normally, a full general anaesthetic will be used and you will be asleep throughout the procedure. In some patients, the anaesthetist may also use an epidural anaesthetic which improves or minimises pain post operatively.

The operation is normally performed on the left side through a small incision in or just above the groin. Absorbable sutures are used which do not require removal.

What happens immediately after the procedure?

You may experience discomfort for a few days after the procedure but painkillers will be given to you to take home. Absorbable stitches are normally used which do not require removal. After your operation, you may be given an injection under the skin of a drug (dalteparin) that, along with the help of elasticated stockings provided by the ward, will help prevent thrombosis (clots) in the veins.

The average hospital stay is two days although, if you feel comfortable, you may be able to

return home on the same day as the operation.

Are there any side effects?

Most procedures have a potential for side effects. You should be reassured that, although all these complications are well recognised, the majority of patients do not suffer any problems after a urological procedure.

Please use the check boxes to tick off individual items when you are happy that they have been discussed to your satisfaction:

Common (greater than one in 10)

• Swelling of the scrotum lasting several days
• Seepage of yellowish fluid from the wound several days after surgery
• The external appearance of the varicocele may not change significantly although the symptoms are relieved
• Late recurrence of the varicocele (in approximately 14%)
• Development of fluid around the testis several months after the procedure (15-30%)

Occasional (between one in 10 and one in 50)

• Collection of blood around the testis requiring surgical treatment
• Failure to remove the varicocele completely
• Damage to or shrinkage of the testicle if the blood supply is affected by the operation

Rare (less than one in 50)

• Infection of the incision or the testis requiring further treatment

Hospital-acquired infection (overall risk for Addenbrooke’s)

• Colonisation with MRSA (0.01%, two in 15,500)
• Clostridium difficile bowel infection (0.02%; three in 15,500)
• MRSA bloodstream infection (0.00%; 0 in 15,000)

(These rates may be greater in high risk patients eg with long term drainage tubes, after removal of the bladder for cancer, after previous infections, after prolonged hospitalisation or after multiple admissions.)

What should I expect when I get home?

When you leave hospital, you will be given a discharge summary of your admission. This holds important information about your inpatient stay and your operation. If, in the first few weeks after your discharge, you need to call your GP for any reason or to attend another hospital, please take this summary with you to allow the doctors to see details of your treatment. This is particularly important if you need to consult another doctor within a few days of your discharge.

It will be at least 14 days before healing occurs; you may return to work when you are comfortable enough and your GP is satisfied with your progress.

The varicose veins above your left testicle may become slightly more prominent initially because they thrombose after the surgery. Once things have settled, they will become less obvious. Do not, however, expect the veins to disappear completely because they rarely do so.

What else should I look out for?

If you develop a temperature, increased redness, throbbing or drainage at the site of the operation, please contact your GP.

Are there any other important points?

A follow up outpatient appointment will be arranged for you some six to eight weeks after the operation. You will receive this appointment either whilst you are on the ward or shortly after you get home.

Driving after surgery

It is your responsibility to ensure that you are fit to drive following your surgery.

You do not normally need to notify the DVLA unless you have a medical condition that will last for longer than three months after your surgery and may affect your ability to drive. You should, however, check with your insurance company before returning to driving. Your doctors will be happy to provide you with advice on request.

Privacy and dignity

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high tech equipment and/or specialist one to one care is required.

Hair removal before an operation

For most operations, you do not need to have the hair around the site of the operation removed. However, sometimes the healthcare team may need to remove hair to allow them to see or reach your skin. If the healthcare team consider it important to remove the hair, they will do this by using an electric hair clipper, with a single-use disposable head, on the day of the surgery. Please do not shave the hair yourself, or use a razor for hair removal, as this can increase the risk of infection to the site of the operation. If you have any questions, please ask the healthcare team who will be happy to discuss this with you.

References

NICE clinical guideline No 74: Surgical site infection (October 2008); Department of Health: High Impact Intervention No 4: Care bundle to preventing surgical site infection (August 2007)

Is there any research being carried out in this field at CUH?

There is no specific research in this area at the moment but all operative procedures performed in the department are subject to rigorous audit at a monthly audit and clinical governance meeting.

Who can I contact for more help or information?

Oncology nurses

Uro-oncology nurse specialist
01223 586748

Bladder cancer nurse practitioner (haematuria, chemotherapy and BCG)
01223 274608

Prostate cancer nurse practitioner
01223 274608 or 01223 216897

Surgical care practitioner
01223 348590 or 01223 256157

Non-oncology nurses

Urology nurse practitioner (incontinence, urodynamics, catheter patients)
01223 274608

Urology nurse practitioner (stoma care)
01223 349800

Urology nurse practitioner (stone disease)
07860 781828

Patient advice and liaison service (PALS)

Telephone: 01223 216756
PatientLine: *801 (from patient bedside telephones only)
Email PALS

Mail: PALS, Box No 53
Addenbrooke's Hospital
Hills Road, Cambridge, CB2 2QQ

Chaplaincy and multi faith community

Telephone: 01223 217769
Email the chaplaincy

Mail: The Chaplaincy, Box No 105
Addenbrooke's Hospital
Hills Road, Cambridge, CB2 2QQ

MINICOM System ("type" system for the hard of hearing)

Telephone: 01223 217589

Access office (travel, parking and security information)

Telephone: 01223 596060

What should I do with this leaflet?

Thank you for taking the trouble to read this patient information leaflet. If you wish to sign it and retain a copy for your own records, please do so below.

If you would like a copy of this leaflet to be filed in your hospital records for future reference, please let your urologist or specialist nurse know. If you do, however, decide to proceed with the scheduled procedure, you will be asked to sign a separate consent form which will be filed in your hospital notes and you will, in addition, be provided with a copy of the form if you wish.

I have read this patient information leaflet and I accept the information it provides.

Signature……………………………….……………Date…………….………………….