Microsurgical Subinguinal Varicocelectomy in Children, Adolescents, and Adults: Surgical Anatomy and Anatomically Justified Technique

Abstract

Microsurgical varicocelectomy has become the gold standard in adults because of low recurrence and postoperative hydrocele rates; it is increasingly applied in children and adolescents. This review aims to provide the surgeon with the necessary surgical anatomy of the spermatic cord and with a step-by-step, anatomically justified description of technique, toward clearer comprehension and improved application. The anatomic compartments of the spermatic cord are delineated by the external and internal spermatic fasciae. Venous drainage of testis-epididymis is accomplished by the internal spermatic, deferential, and external spermatic (cremasteric) veins. All 3 anastomose at the caudal pole of testis, and then via gubernacular veins with the posterior scrotal veins. Another anastomosis exists between a cremasteric branch and anterior scrotal veins, which gives the external pudendal vein. Subinguinal approach offers access to varicose spermatic veins and collaterals. Use of surgical microscope offers identification of small veins, preservation of arteries, lymphatics, and nerves, and appreciation of spermatic cord fasciae, which permits the development of two surgical planes. In the surgical plane of internal spermatic vessels, internal spermatic veins are ligated, whereas the testicular artery and innervation, as well as lymphatics, are preserved. In the plane of cremasteric vessels and vas, cremasteric veins are ligated, whereas the cremasteric artery, vas deferens and its vasculature, lymphatics, and the genital branch of genitofemoral nerve are preserved. Delivery of the testis to ligate gubernacular veins is at the discretion of the surgeon. Finally, venous return is effected by deferential and scrotal veins, or, when gubernacular veins are ligated, by deferential veins only.

Microanatomy of the spermatic cords during microsurgical inguinal varicocelectomy: initial experience in Asian men

“…This anatomy is similar to the subinguinal microanatomy. 9 We speculate whether there is a distinct fascial layer between the vas deferens and the internal spermatic vessels. The third reason may be a racial difference, which requires further studies for support.…”

“…Postoperatively, testicular venous return is via the deferential and scrotal veins. 9 Techniques using optical magnification maximize the preservation of arterial and lymphatic vessels while decreasing the risk of persistent or recurrent varicocele. 10 Compared with the subinguinal approach, the use of the inguinal approach is associated with fewer internal spermatic veins, easier microscopic dissection and clearer identification of the testicular artery pulsation.…”

Isolated thrombosis of right spermatic vein with underlying Factor V Leiden mutation

“…8 Mirilas et al cautioned for a complex system that should be carefully considered when opting for the subinguinal approach and found it necessary to carry out a comprehensive preoperative hemodynamic assessment of the vein reflux to decide on the most suitable surgical technique. 9 The Factor V Leiden mutation and the prothrombin gene mutation are the two most common known genetic mutations that predispose to venous thromboembolism (VTE). 10,11 These mutations account for 20% of first VTE episodes.…”

Reactive Oxygen Species and Sperm Cells

“…Surgical options for varicocele repair include the traditional high retroperitoneal (Palomo) and inguinal (Ivanissevich) approach, laparoscopic high ligation, and microsurgical low ligation via an inguinal or subinguinal incision. Microsurgical low ligation of the spermatic vein by the subinguinal approach is considered the gold-standard technique for varicocele repair because of lower postoperative recurrence and complication rates (e.g., hydrocele, testicular atrophy, and wound pain) compared to other techniques [108]. Several studies indicate that a varicocele repair reduces oxidative stress in seminal plasma and ameliorates sperm DNA damage.…”