Practice Pattern of Redo Varicocelectomy for Recurrent Varicocele according to Type of Initial Treatment: Retrospective Analysis of a United States-Based Insurance Claims Database

A varicocele is defined as an abnormal dilatation of the veins within the pampiniform plexus as a result of venous reflux. Varicocele represents one of the most common amenable urologic anomalies that is surgically corrected in adolescent males, with an incidence of approximately 15% [1]. The main indications for surgical treatment are persistent testicular size discrepancy greater than 20%, abnormal sperm parameters, and testicular pain attributable to the varicocele [2, 3].

Surgical treatment includes laparoscopic, open inguinal, open retroperitoneal, microscopic subinguinal, and embolization approaches. The success rate of these types of varicocelectomy is very high; however, a few patients undergo repeated surgical treatments for recurrence.

The redo surgical method depends on the surgeon's preference and the initial type of surgery. For example, when initial surgery was performed via the microscopic subinguinal approach, a laparoscopic or embolization approach may be selected for redo varicocelectomy to avoid adhesion in the surgical field and interruption of the testicular blood supply. Otherwise, a microscopic approach could be chosen because of the higher success rate of microscopic surgery compared with other methods [4, 5, 6].

Elucidation of the practice pattern of redo varicocelectomy can facilitate the selection of the optimal redo approach by physicians and patients. However, to our knowledge, no study has yet reported on the preferred practice pattern of redo varicocelectomy based on the initial methods because of the extremely limited number of patients who undergo such procedures.

Our purpose was to investigate the type of redo varicocelectomy according to the initial surgery type using a large United States population via individual-level insurance data.

The methods of surgical treatment for varicocele include open inguinal (Ivanissevitch), open abdominal (Palomo), laparoscopic, and subinguinal approaches with or without microscopy and embolization. Varicocele recurrence is one of the most common complications associated with varicocele surgery. The success rate of varicocelectomy is very high but not 100%. Recent studies reported the rates of recurrence for laparoscopic (1.2%), open inguinal (1.3%), open retroperitoneal (9.3%), microscopic subinguinal (0.9%–2.5%), and embolization (3.6%–8.9%) [4, 5, 6, 7, 8].

An optimal method for initial varicocelectomy has yet to be established, and the ideal surgical approach for redo varicocelectomy represents another area of controversy. The choice of redo surgical method in clinical practice is dependent on age, surgeon's preference, experience, and previous surgery type.

In this study, open inguinal varicocelectomy was the most popular method used by surgeons in the United States. This may be attributable to surgeons' preference and experience. Microscopic surgery has a lower recurrence rate but is associated with hurdles, such as experience and availability of equipment. Moreover, there is not much difference between the success rates of open and microsurgery.

Our results show a difference in the proportion of microscopic surgery and embolization treatments between initial and redo surgeries. Although inguinal varicocelectomy was still the most commonly used method of redo surgery, the microsurgical approach is likelier to be used in redo than initial surgery and is the second most common method (25%) chosen for redo surgery. For example, 49% of recurrences after inguinal varicocelectomy were treated via the same inguinal approach, whereas microsurgery was performed in 18% of such patients. Furthermore, embolization, which is rarely used for initial varicocelectomy, was the third most common choice for redo treatment. Surgeons who initially perform open varicocelectomy have a tendency to choose a second open varicocelectomy in patients who experience recurrence. This may be because many surgeons find the method easy to perform and are confident in their skills. Surgeons who want to be assured of success might choose microscopic surgery, performed either by themselves or by referral to a specialized center. As a result, the proportion of microscopic surgery rises among redo varicocelectomies.

Patent internal spermatic veins are the most common cause of persistent or recurrent varicocele after surgery [9, 10]. Microsurgical inguinal varicocelectomy provides direct visual access to all forms of testicular venous drainage and results in a significant decrease in the incidence of varicocele recurrence [6, 11]. Redo surgery may be a burden to surgeons and patients afraid of recurrence, and represents one of the factors associated with increased use of the microscopic approach in redo surgery. One study demonstrated the effectiveness of microscopic subinguinal redo varicocelectomy. Most of the patients (84%) initially underwent inguinal or abdominal surgery and no recurrence was seen after redo microscopic surgery [12]. Our study showed that 83% of patients (34/41) who had recurrence of varicocele following initial microscopic surgery underwent redo microscopic surgery. A few physicians were concerned about the risk of arterial injury; however, most surgeons who are experienced with microscopic surgery preferred microsurgery [12].

Open inguinal surgery often leaves a scar or adhesion in the surgical field that prevents easy identification of the remaining or recurrent small vessels. Embolization may be a good option in such cases and our study shows that 18% of patients underwent embolization for recurrence after inguinal varicocelectomy. Kim et al [13] evaluated the effect of embolization for recurrent varicocele after laparoscopic, retroperitoneal, or inguinal ligation. Embolization was technically feasible in 93% of cases, and 80% showed complete resolution on physical examination.

Unlike inguinal surgery, only 8% of cases of initial laparoscopic or abdominal surgery were treated with embolization for recurrent varicocele. Two-thirds of patients (62%) underwent redo open inguinal surgery, probably because the surgeons believed that laparoscopy or abdominal surgery do not affect the inguinal surgical field.

Almost all of the patients who underwent embolization initially underwent redo embolization. It is possible that these patients had contraindications for open surgery, or that physicians who preferred embolization as the initial method strongly preferred radiological interventions.

This study has several limitations. First, we could not evaluate a patient's symptoms or varicocele grade during the initial or redo surgery. In this study, we analyzed redo surgical cases but not recurrent cases. Recurrence should be evaluated and defined according to symptoms or clinical findings. However, our data did not completely reflect the patients' clinical status. Therefore, we could not compare effectiveness or recurrence rate according to the initial and redo surgical methods.

Second, inconsistent or incorrect reporting of insurance codes during the study period by the hospitals limited the reliability of our evaluations of surgical choice. The microsurgical approach was adopted in only 3% of cases, which was similar to the proportion seen in another United States-based population study [7]. Lack of experience and non-availability of microscopic equipment are significant hurdles to the microscopic approach. Also, use of the microscopic approach might be underestimated by the underutilization of CPT code 69990; a similar explanation was given in another study [7].

Third, the data in this study do not present adolescent and adult varicocele separately. Treatment patterns may differ between adolescent and adult varicocele patients. When we did divide the patients into adolescent vs. adult groups, we found no significant differences because of the small number of patients who underwent redo surgery. This represents another limitation of this study.

Fourth, the data in this study was from a United States insurance company. The choice of redo surgery depends on the physician's evaluation and patient's status as well as insurance status. In addition, the availability of specialized facilities in the hospital, including microscopy and radiology, also affects the choice of redo surgery type. Therefore, these results may not represent the situation in other countries.

Notwithstanding these limitations, this study is notable as it is the first large population study to examine the type of redo varicocelectomy according to initial surgical type. Our results may be helpful to physicians and patients considering redo varicocelectomy. For treatment of recurrent varicocele after open varicocelectomy, microscopic surgery or embolization are not always necessary. About half of recurrences following open surgery were treated by redo open surgery. In addition, we assumed that embolization is performed mostly to avoid arterial injury when varicocele recurred after microscopic varicocelectomy. However, almost all cases of recurrent varicocele following microsurgery were treated by redo microscopic surgery. Redo microscopic varicocelectomy after initial microscopic varicocelectomy seems to be a feasible method.

Compared with the type of initial varicocelectomy, there were changes in the proportions of each type of surgical approach in redo procedures. A redo open inguinal approach was most commonly used after initial open inguinal, open abdominal, and laparoscopic approaches.

Although inguinal varicocelectomy is still the most commonly used method in redo operations, microsurgical interventions and embolization rank second and third, respectively, in redo cases. This suggests that microscopic varicocelectomy or embolization is selectively preferred compared with initial treatment.