Varicocelectomy: microsurgical subinguinal versus inguinal technique

Abstract

273POINT / COUNTERPOINT I t is reported that 35% to 40% of infertile men have a palpable varicocele (dilated testicular veins), whereas the prevalence of a varicocele in the general male population is about 15%.1-3 Although varicoceles have been associated with impaired male fertility potential, it is also clear that a significant proportion of men with a varicocele (about 75%) are fertile. 2,4,5 As such, a cause and effect relationship between varicocele and male infertility has not been conclusively established. 6 The effect of varicocelectomy on male fertility is also controversial.6-10 Uncontrolled studies have generally shown improved semen quality and pregnancy outcome after surgery.11 On the other hand, the results of randomized controlled studies of varicocelectomy for clinical varicocele (only a few such studies are published) are equivocal. [12][13][14][15] Despite the absence of clear evidence for a positive effect of varicocelectomy, many clinicians consider the data sufficient to support the practice of this surgery, and varicocele is the most commonly treated condition in men with infertility in North America. 8 The benefit of varicocele repair must be balanced by the risk associated with the procedure itself. As such, it is important to select the procedure with the highest success and lowest complication rate. Also, it is important to consider assisted reproductive technologies (ARTs) as an alternative to varicocelectomy in infertile couples. 16 Etiology of varicoceleThe etiology of varicocele is multifactorial. The anatomic differences between the left and right internal spermatic vein (accounting for the predominance of left-sided varicocele), the incompetence of venous valves resulting in reflux of venous blood and increased hydrostatic pressure are the most popular theories. 17,18 Increased intraabdominal pressure during childhood and early adolescence may be a predisposing factor in the development of a varicocele. 19 Mechanisms of varicocele-induced pathologyScrotal and intratesticular temperatures are elevated in humans and in experimental animal models with varicocele, and varicocelectomy may reduce testicular temperature. [20][21][22][23][24] Scrotal hyperthermia likely represents the primary factor by which a varicocele affects endocrine function and spermatogenesis, both sensitive to temperature elevation (testicular proteins exhibit a reduced thermal stability compared with proteins from other organs). [25][26][27] The detrimental effect of hyperthermia may also be exerted on the epididymis. 28 Experimental elevations in epididymal temperature reduce the storage capacity of this organ, resulting in decreased sperm count and quality in the ejaculate. 28Increased hydrostatic pressure in the internal spermatic vein from renal vein reflux may also be responsible for varicocele-induced pathology. Pathophysiology of varicoceleThe adverse effect of varicocele on male fertility is most clearly manifested by the testicular atrophy generally associated with this condition. 4 Using scrota...

Varicocele anatomy during subinguinal microsurgical varicocelectomy in Chinese men

“…Owing to the greater number of vessels encountered at the subinguinal level, the subinguinal approach is more challenging compared with the inguinal approach (Orhan et al ., ; Zini, ). It is necessary to know the subinguinal varicocele anatomy for the surgeons.…”

“…Many and different techniques (conventional inguinal, retroperitoneal, laparoscopic, embolisation, microsurgical inguinal or subinguinal) have been used for varicocelectomy (Zini, ; Mirilas & Mentessidou, ). A microsurgical approach to varicocelectomy has been recommended to identify and ligate the spermatic veins and to preserve the branches of internal spermatic arteries and lymphatics, the outcome is better with a resultant substantial decrease in the incidence of post‐operative hydrocele, recurrence and testicular artery injury (Cayan et al ., ; Ramasamy & Schlegel, ; Al‐Kandari et al ., ).…”

“…According to improvement in post‐operative semen parameters, ratio of achieving pregnancy, complications and operation periods, there are no significant differences between the two approaches (Orhan et al ., ). But, the subinguinal approach is associated with a faster and less painful recovery (Gontero et al ., ; Al‐Kandari et al ., ; Zini, ; Mehta & Goldstein, ).…”

Use of video microsurgery platform in microsurgical subinguinal varicocelectomy with indocyanine green angiography

“…Varicocelectomy is the most common surgery performed for the correction of male factor subfertility . Among the different surgical approaches, microsurgical subinguinal varicocelectomy (MSV) is generally considered the gold standard due to the low risk of complications and recurrence . The subinguinal approach allows exposure of internal spermatic, external spermatic and gubernacular veins via a single incision, and the lack of fascial incision results in less pain postoperatively.…”

Do Not Get Lost in the Spaces of the Spermatic Cord During Subinguinal Microsurgical Varicocelectomy

“…Baazeem and Zini [1] develop two surgical planes within the spermatic cord, as did Zini et al . [2, 3] in previous publications. Those authors did exemplary work as surgeons and arrived very close to the true anatomy.…”