Microsurgical varicocelectomy
Varicoceles are identified as the most prevalent surgically treatable cause of male infertility. Nonetheless, the repair of varicoceles is frequently performed for various reasons beyond infertility, such as low testosterone levels, testicular hypotrophy, and poor quality of sperm DNA.
Literature describes several techniques for the repair of varicoceles. Surgical approaches include conventional inguinal (Ivanissevich) and high retroperitoneal (Palomo) methods, as well as laparoscopic and microsurgical repair through inguinal or subinguinal incisions. Additionally, varicocele embolization presents a non-surgical alternative.
While there are no definitive guidelines regarding the optimal surgical technique for varicocelectomy, microsurgical varicocelectomy is widely regarded as the gold standard for this procedure in both adults and adolescents. This is attributed to its lower rates of postoperative recurrence and complications in comparison to other methods. Recent studies have also indicated that microsurgical varicocelectomy correlates with higher spontaneous pregnancy rates after surgery in men with clinically detectable varicoceles who are experiencing infertility.
Microsurgical varicocelectomy can be conducted through either an inguinal or subinguinal incision. In both cases, the incision follows Langer’s lines and varies in size from 1.5 cm to 3 cm. These techniques facilitate the elevation of the spermatic cord for enhanced visualization of its structures, allow access to the external spermatic and gubernacular veins, and enable the delivery of the ipsilateral testicle for biopsy or microscopic examination. The subinguinal incision avoids the necessity of opening any fascial layers, which can theoretically result in a quicker and less painful recovery.
The use of an operating microscope enhances the precision of the procedure through magnification, enabling careful hemostasis, the identification and preservation of testicular arteries and lymphatics, and the prevention of unintended iatrogenic injuries. During the operation, dilated veins are carefully dissected and ligated.
Typically, the surgery lasts around 30 minutes and is performed under spinal anesthesia. Recovery is generally swift, with patients often returning to their regular activities within a few days, although it is recommended to refrain from strenuous physical activity for approximately one month.
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