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Oganes E. Dilanyan
Urologist, MD, PhD

Marmar Surgery

Reading time: 4 min.
In this article

Marmar Surgery – is a microsurgical intervention aimed at treating Varicocele. Recommended as the safest and most effective procedure by the European and American Urological Associations. In this article we will describe in detail the nature of surgical intervention for our patients and will cover frequently asked questions.


Varicocele and infertility

Extract from European Urology Association recommendations: “Among all causes of male infertility varicocele takes the lead and over 40% primary infertility and over 80% of secondary infertility is caused by this condition.“
Extract from European Urology Association recommendations: “Marmar method microsurgical procedure for treatment of varicocele is the safest and most effective intervention recommended in the presence of varicocele and abnormal semen analysis “.

What is behind this dry quote and all the numbers? Often it is a young married couple longing to start a family but not succeeding. In over half of the cases the husband undergoes semen analysis only after their wife has been thoroughly checked: checks range from endless hormonal profile tests to diagnostic laparoscopy. It can be even worse when the husband already has children from a previous marriage and the “fault” of infertility is firmly placed on the woman. Meanwhile…”80% of secondary infertility cases can be attributed to varicocele”. Having children in the previous relationship is not a guarantee against infertility. 

One might wonder why for decades the medical professionals have stressed the importance of investigating both partners. Clear indication guidelines have been developed for varicocele and it is now very clear that the best and safest way to treat varicocele is the Marmar surgery. But things haven’t budged an inch. In line with an idiotic “tradition” a couple’s infertility it is still considered to be entirely the woman’s “fault”. She is the one left feeling inadequate and is the first to be subjected to multiple and often unnecessary and expensive tests.

Who needs a varicocele operation?

When we say that in our work we are guided by the European Urology Association it is not just us showing off. It is first and foremost the safety of our patients. These recommendations are based on many years of research and have a very strong evidence basis. Should we be “dragging” any man with some testicular vein dilation into the operating theatre? Surely not every single one. There are strict indication guidelines for surgical intervention as well as risk and possible benefits assessment. 

Extract from the EAU recommendations Treatment of varicocele in the presence of male infertility should be carried out in the case of clinical manifestation of the condition (azoospermia, asthenoteratozoospermia, spermacrasia), as well as in cases of infertility lasting over 2 years and unexplained infertility.


What type of varicocele surgery to choose?

A young patients sits before me. In his hands is a folder with structured data and copied questions. I am not the first doctor he is seeing. 
- Doctor, I do understand. You and the other doctors based on the data available have convinced me that I need varicocele surgery. But I have been to see seven doctors and every single one of them praised their own method. Please understand my position, I have no medical training and I am simply trying to understand why Marmar surgery? I have been offered vein hardening procedure in one place and laparoscopic varicocele procedure in two other places. Are you suggesting microsurgery because you are unable to perform a laparoscopy? 
-Let’s sort this out. I have two answers to your question. Firstly Marmar microsurgical procedure is recommended by the European and American Urological Associations as the most effective and safest for the patient. Secondly despite being a laparoscopic surgeon I do not perform laparoscopic surgery for treatment of varicocele based on principle. 
- But why? It is progress, a new method.
- Simple reasons: Your safety and effectiveness of surgical intervention. Look, laparoscopy for varicocele treatment requires general anaesthesia, carries a potential risk of abdominal organ damage, requires 2-3 days of hospitalisation and has a varicocele relapse rate of 17 to 30% based on various data sources  
- Ok I see… 
- The only reason for laparoscopic surgery for varicocele is doing it together with another operation. For example if the patient presents with a hernia or gallbladder stones and varicocele is a co-existing condition. In cases like this the risks are justified.

Extract from the Hinman’s Atlas: Up to this date the indications for laparoscopic intervention for varicocele have not been determined.

Marmar surgery as Varicocele treatment

Marmar Surgery

The point of the Marmar operation is to tighten up the pathologically widened veins of the testicle. Why it needs to be done is explained in detail in this article “Varicocele”

Technically the Marmar method demands that the surgeon performing the procedure has mastered microsurgical procedures and have at their disposal a good pair of magnifying 4x or 5x glasses.

Usually the operation is performed under spinal anaesthesia but the patient can opt for general anaesthesia. In any case the patient can go home the following day and go back to work the day after.

Minimal incision size of 1,0 – 1,5 cm guarantees no pain after surgery.

Although the main advantage of Marmar surgery is the highest number of pregnancies occurring following the operation compared to other types of surgeries.


“If a doctor assures you that there can be no complications – find another doctor”
Confessions of a medical heretic.

Marmar Surgery Complications

…- And what are the possible complications doctor? – The patient looks in his note book, he has prepared well for this conversation. –I know that complications after Marmar surgery can include pain, scrotal hydrocele and testicular atrophy. -Not really, you won’t get testicular atrophy after Marmar, this is what is so good about it – I say. As for pain we have not had a single patient agreeing to a pain relief injection after surgery and only 22% asked for a pain relief pill. No one had any lasting pain. As for possible complications it is worth mentioning inflammation, scrotal hydrocele and condition relapses.

Marmar Surgery Complications

A small incision, no bigger than 1,5 cm, and the lack of damage to the muscles as well as pre-operative antibiotics allow the risk of inflammation to be minimised. In our experience this complication occurs no more than in 0.1% of cases.
Scrotal hydrocele
Lymph collecting between the testicle membrane and the testicle itself, otherwise known as hydrocele. Usually caused by lymphatic vessels damage. Use of microsurgical magnifying glasses 5x enables us to save the vessels and prevent hydrocele.
In our experience the number of relapses, when varicocele develops again only make up 0,8%. The reason again is the use of powerful microsurgical glasses. Second reason is experience, which exceeds 1000 operations in the course of the career.


After Marmar Surgery

Recovery after Marmar surgery happens almost unnoticed. The patient is admitted for no longer than 24 hours. They may be discharge on the day following the operation and can go back to work the day after that. They may resume usual physical activity after 7 to 10 days after nearly invisible cosmetic stitches have been removed. 6 months after the surgery a second consultation with semen analysis takes place to assess the effectiveness of the surgery. 

Our guarantees

- We guarantee your safety by using modern and highest quality anaesthesia manufactured in Austria or France. 
-We DO NOT USE low quality equivalents of any drug which significantly lowers the risk of any complications.
-Use of Karl Storz microsurgery microscope guarantees the integrity of the testicular artery for all my patients. 
- Andrology surgical work placements in Austria and Italy together with over 500 Marmar operations ensure absence of complications.   
- We DO NOT REFER our patients to unknown clinics for follow up and further treatment and provide outpatient follow up as well as inpatient treatment. 

Every patient is provided with a discharge summary with detailed recommendations and an official sick leave certificate
Our Advantages

Professional approach: up to date diagnostic methods of male infertility causes.

Our Team: Specialised science based clinical andrology team.

Board of doctors specializing in infertility: Urologist/andrologist, thyroid specialist, reproductive health gynaecologist.

Our equipment:  Karl Storz surgical microscope and KLS Martin microsurgery kits.

Comfort: no queueing or waiting for a consultation and premium inpatient facility.

Safety: Use of methods recommended by professional associations such as EAU and AAU.

Result: Elimination of testicular varicose veins and its complications.

We are also GCP certified, which confirms we provide the highest standards of diagnosis and treatment

Information for foreign patients:

Vitaliy D.

Reviews form Prodoctorov.ru website
I underwent a double-sided Varicocele operation in January 2016. Really pleased with the result. Would recommend Dr Dilanyan as a highly professional doctor in his field of expertise. It was also very easy to arrange coming to Moscow for the operation. Hospital stay was 1 day. The rooms were clean and well equipped. The medical staff were polite and well-disposed.

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Sergey D.

Review from Prodoctorov.ru website

My long-distance acquaintance with Dr. Dilanyan started long before I became his patient. I used to read his Live Journal stories with great interest and always admired his talent for writing. Then I found out that the author of these amazing stories is also a great doctor. In every man’s life there comes a point when your body starts to malfunction. I was no exception. At the first sign of discomfort I decided to see a urologist and had no doubt regarding which one I needed to see. I got hold of his email address and wrote to him describing my situation. I was pleasantly surprised by his warm and welcoming attitude. All the necessary tests and investigations were done very quickly. As a result I was given the diagnosis of double-sided varicocele and the decision was made to operate. Dr. Oganes has performed an intricate operation to eliminate my condition. After spending 2 days in a clean and cosy hospital I was discharged. I never even thought about my condition again. I recommended Dr. Dilanyan to many of my friends some of whom had more serious problems and all of them thanked me for this recommendation. Dr. Oganes is a true professional, an amazing doctor and a great person. He is one of the few doctors that inspire trust and make you feel calm. I could not recommend him enough! 

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Ivan T.

Review from Prodoctorov.ru website
I would like to thank Dr. Oganes and his team for performing such intricate work during my surgery on double-sided varicocele. I suffered with chronic prostatitis for 2 years and no one could diagnose me correctly. I came across a web article “ varicocele as a cause for chronic prostatitis” by accident and realised there was a connection despite many urologists being of the opinion that there is no connection between varicocele and prostatitis. I took a very long time choosing the right doctor. And chose Dr. Dilanyan due to his most modern approach to surgery (Marmar Operation) and minimally invasive procedure. It helped and I am now extremely happy! A big thank you to you and your team!

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Olga K.

Review from Prodoctorov.ru website
My family has known Dr. Dilanyan for 6 years. I say “family” because I am able to use this term only thanks to him. He was recommended to me by another great doctor, a gynaecologist, E. Govorkova. I had very high white blood cell count in the urine, which almost permanently remained at 17000 mark and sometimes more. I had cystitis which did not only start from intercourse with my husband once in the blue moon but no longer went away at all, and got worse following intercourse. I was 33, it was 2010. My attempts to get pregnant were unsuccessful and gynaecologists could not help me due to my urine test results and constant inflammation. I saw 3 urologists, who looked at me with a dull expression, sighed and wrote “other chronic cystitis” in my notes and prescribed “Phytolysin”, herbs and antibiotics never even offering a follow up consultation while they sat in their huge leather chairs behind the oak desks with palm trees in the office and little fountains in the waiting rooms. Not a single one of them examined me even once. My gynaecologist advised me to see Dr. Dilanyan and I am grateful to her ever since. I rang him. His consultations took place very far away in the middle of nowhere in an old aviation hospital in Sokolniki where he occupied an old and simple consultation room. He examined me, performed an ultrasound scan and explained in great detail what was wrong with me. He sent me for a CT scan to a specific specialist and explained what I needed to do. As a result all the tests were done very quickly and with no hassle and another potential serious problem was quickly ruled out. Diagnosis was made of advanced gaping urethra. The solution was surgery with urethral transposition. While I was getting ready for my surgery my husband continued to be investigated for fertility issues by urologists and andrologists. Semen analysis, ultrasounds and other tests. His semen analysis results were not great and every subsequent one was worse than the one before. Ultrasound did not show anything. I mentioned this to Dr. Dilanyan during one of my consultations. He asked my husband, who was waiting for me outside to come in and see him. 10 minutes later I hear him exclaim “bingo” and varicocele diagnosis was made. My husband had his surgery before me.  My husband is 31. Intricate Marmar operation was performed under spinal anaesthetic. After the operation I immediately received a phone call to inform me the operation went well. He stayed in hospital for 1 night in a clean room with very friendly medical staff. Recovery took 1.5 days. He was fully recovered after about 6 months. Sperm quality gradually improved over this period of time and was back to normal after 6 months. My operation for urethral transposition was also performed under spinal anaesthetic and I spent 1 day in hospital. The staff were very attentive and the food was very good too. The operation was not the easiest as my case was quite complicated as they come.  I recovered very well with no post-operative pain.  Mucous membranes recovery went well under doctor’s control and he also kept in touch with my gynaecologist and gastroenterologist as I have an ulcer. I was fully recovered 7 months later. I have not had a single relapse and my sex life is great. And I had a baby at last. I still call Dr. Oganes with any questions I have. I will never use any other urologist. Over the past 6 years I recommended this great doctor to my friends several times. They are all very grateful for the chance to know this doctor.  Thank you Dr. Oganes for our family! You are a very skilful and attentive professional. Precise work, quick diagnosis and no unnecessary tests. Dr. Oganes does not make his patients run around and deals with a lot of things over the phone. He is very polite. He explains everything in simple terms. He is a very attentive doctor and never abandons his patients after the surgery has been done. He always rings to check up on them.

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