The presence of a varicocele is determined by physical examination but Doppler sonography must confirm the persistence of a retrogade flow during the Valsalva maneuver since only refluant varicoceles deserve surgery. If a fertility problem is evocated, a refluant varicocele deserves a treatment anyway since the result of the cure is neither dependant upon the size of the veins nor upon the degree of the retrograde flow. The skin is horizontaly incised medial to the anterior superior iliac spine, the external oblique muscle is incised, the internal oblique muscle is retracted and the peritoneum is teased away. At this level the vein is generaly unique and easy to ligate. The surgical approach on the right side may also be more difficult because the right gonadic vein drains in the inferior vena cava.
Inguinal ligation is performed through a low inguinal incision.
The aponeurosis of the external oblique is incised and the spermatic cord isolated. The spermatic fascia is incised and the dilated veins are dissected, ligated and excised. This allows a complete stop in the internal drainage. After puncture and catheterization of one of the femoral veins, the radiologist identifies the refluant spermatic vein by injecting a iodine dye during a Valsalva maneuver. Then, during a new maneuver he injects a sclerotizing solution, a wire coil or a detachable ballon.