Varicocele anatomy during subinguinal microsurgical varicocelectomy in Chinese men

Clinical effectiveness of microsurgical subinguinal varicocelectomy with enhanced recovery after surgery for varicocele

Background

Varicocele (VC) is one of the most common causes of infertility in men, and microscopic varicocelectomy is currently the major surgical procedure for VC. We assessed the clinical effectiveness of microsurgical subinguinal varicocelectomy (MSV) with enhanced recovery after surgery (ERAS) in the treatment of VC in terms of semen quality improvement rate, pregnancy rate, pain relief rate, recurrence rate, and complication rate after MSV and explored the indications for VC surgery.

Methods

In total, 216 patients undergoing MSV in our center between June 2019 and July 2020 were enrolled in this study. All patients received the surgery under local anesthesia and were admitted and discharged within 24 hours. All patients were followed up for more than 6 months, and the rates of semen quality improvement, pregnancy, pain relief, recurrence, and postoperative complications were recorded. We can evaluate the pain degree of patients through the numerical rating scale (NRS). (I) 0 points for painless; (II) 1-3: mild pain; (III) 4-6: moderate pain; (IV) 7-10 points are severe pain. 0 is the most slightly, indicating comfort, and 10 is the most painful and unbearable.

Results

The sperm concentration, total sperm count, progressive motility rate, sperm viability, and morphology were significantly improved after the surgery (all P values <0.05). The rate of semen quality improvement was 88.2%, and the semen indicators returned to normal in 26.6% of the patients. Among the patients who were followed up for 1 year, the natural conception rate reached 27.1% and was accompanied by a 95.5% pain relief rate, a 0.5% VC recurrence rate, and a 2.3% postoperative complication rate.We obtained data through laboratory examination of semen DNA fragments index (DFI). Compared with preoperative and postoperative DFI, postoperative DFI was improved, and the pregnancy outcome was improved.

Conclusions

MSV under local anesthesia increases the rates of semen quality improvement, pregnancy, and pain relief while lowering the rates of recurrence and postoperative complications. MSV may also help to improve the pregnancy outcomes in patients with VC accompanied by sperm DNA fragmentation or nonobstructive azoospermia, but this should be verified by further investigation.

Microsurgical subinguinal varicocelectomy with spermatic cord double traction and vein stripping

We retrospectively reviewed data for 286 patients with varicocele who underwent microsurgical subinguinal varicocelectomy from March 2015 to May 2017 in Shanghai General Hospital (Shanghai, China). In this surgical approach, the testis was delivered, and the gubernacular and external cremasteric veins were stripped. In addition, the spermatic cord was delivered downward with continuous double traction away from the external ring. The remaining procedure was similar to the conventional approach. We followed patients for at least 3 months and evaluated postoperative semen parameters, pain symptoms, and complications. We excluded data for 32 men due to inadequate follow-up (<3 months). Of the remaining 254 patients, 73 had oligoasthenospermia, 121 had nonobstructive azoospermia, and 60 had symptomatic varicoceles. Total progressive sperm counts increased in the oligoasthenospermic patients from a median preoperative value of 9.15 × 10⁶ ml^-1 to 25.33 × 10⁶ ml^-1 (n= 34), and 35.6% (26/73) initially oligoasthenospermic men contributed to unassisted pregnancies. Sperm returned to the ejaculate in 12.4% (15/121) azoospermia patients. In patients with scrotal pain (n = 60), 43 (71.7%) reported complete resolution of pain, 16 (26.7%) reported partial resolution, and 1 (1.7%) reported no change. No patients experienced varicocele recurrence. This double-traction strategy avoids opening the external oblique aponeurosis, and results in less damage and faster recovery. In addition, the stripping strategy eliminates potential damage to the testis caused by the varicose veins. Our results showed that microsurgical subinguinal varicocelectomy using spermatic cord double traction in conjunction with testicular delivery for vein stripping is a safe and effective approach for varicocele repair.

Positive effects of the inclusion of open-mouth pressure for elimination of blood in microscopic subinguinal varicocelectomy

PURPOSES

Primary varicocele (PVC) may cause testicular hypofunction and scrotal pain. We believe that the currently used procedure microscopic subinguinal varicocelectomy (MSV) can be further improved to provide more benefits to the patients.

METHODS

In total, 100 patients who were diagnosed as having PVC grade II or III with venous reflux based on ultrasound results, along with scrotal pain and visible scrotal varicose veins, were enrolled; they were randomly divided into two groups. When the experimental group underwent MSV, stagnant venous blood in the internal spermatic vein close to the testis was drained using manual pressure, whereas the control group was treated with routine MSV procedure. The patients' psychological condition, symptoms, prognoses, scrotal appearances, and other related indexes were evaluated before and after the surgeries, and the results were compared.

RESULTS

Scores on days 1-3 after the surgeries were significantly different between the two groups (P < 0.05) for the Hamilton Depression Scale (HAMD) after viewing the scrotum immediately after the surgeries, the Hamilton Anxiety Scale (HAMA) after viewing the scrotum immediately after the surgeries, and the average visual analog scale (VAS). No significant differences were found between the groups for other evaluation indexes (P > 0.05).

CONCLUSIONS

The use of open-mouth pressure for elimination of blood reduces postoperative filling of dilated scrotal veins, reduces the visual stimuli to patients immediately after surgery, significantly improves the anxiety and depression of patients, helps to maintain positive mental condition in patients after the surgeries, and increases their confidence in recovery from the disease. It also leads to better pain relief within a short period after the surgery and maximizes surgical benefits for the patients.

A comparison between the efficacy and safety of microscopic inguinal and subinguinal varicocelectomy

OBJECTIVE

To compare microscopic inguinal (MIV) and subinguinal varicocelectomy (MSV) surgeries with respect to efficacy and safety.

MATERIAL AND METHODS

Patients who underwent varicocelectomy between January 2002 and January 2018 were evaluated retrospectively and prospectively. The patients who underwent varicocelectomy until December 2015 were analyzed retrospectively and the cases after January 2016 were analyzed prospectively. In our study, the married infertile male cases were compared on the basis of operation duration, number of ligated veins, number of preserved veins, postoperative pain score (visual analogue scale: VAS), patient satisfaction, surgeon satisfaction, changes in sperm parameters, testicular consistency, pregnancy rates, and complications, such as hydrocele, testicular atrophy, and recurrence of varicocele. Surgical success rates were compared by semen analysis between unmarried infertile male cases because pregnancy rates cannot be tested. The patients were recalled for control examinations every 3 months for 1 year and tested the above-mentioned parameters. Statistical Package for the Social Sciences Version 20 Windows Software was used for data analysis and comparison between the two groups.

RESULTS

The study included a total of 136 adult patients. Mean age of the patients was 28.14 (20-41) years. MSV and MIV were performed in 62 (45.6%) and 74 (54.4%) patients, respectively. No statistically significant difference was detected between the two groups in terms of admission duration, semen parameters within the 1-year follow-up process, hormonal changes, and complication rates. Operation duration was significantly longer in the MSV group. It was determined that a fewer number of veins were ligated, and a fewer number of veins needed to be ligated in the MIV group. The analysis of all the patients revealed that pain scores at 4 and 24 hours postoperatively were significantly statistically lower in the MSV group.

CONCLUSION

MIV and MSV are distinct, efficient, and safe surgical techniques with specific advantages and disadvantages. Their efficacy and safety rates are similar.

Subinguinal microsurgical varicocelectomy with intraoperative microvascular Doppler ultrasound leads to the pain-free outcome after surgery

OBJECTIVE

To determine efficacy of intraoperative microvascular Doppler ultrasound in assisting subinguinal microsurgical varicocelectomy for pain relief in the treatment of painful varicoceles, compared to the microsurgery without Doppler ultrasound.

METHODS

Total 153 patients underwent microsurgical varicocelectomy were randomly allocated to two groups: Groups 1 and 2 included 82 and 71 patients monitored with and without using intraoperative microvascular Doppler ultrasound, respectively. The assessments were compared between two groups, including intraoperative parameters (vessel numbers and operative time) and postoperative outcomes (pain resolution, complications and recurrence).

RESULTS

The average numbers of internal spermatic veins ligated (13.87±6.43 vs 11.72±5.66) and arteries preserved (1.96±0.87 vs 1.73±0.86) were significantly greater in Group 1 with Doppler ultrasound. Precisely, the smaller size of the internal spermatic veins was ligated and the more encircled arteries were also preserved in Group 1. In two groups with and without using Doppler ultrasound, 56 (68.3%) and 36 (50.7%) patients experienced a complete resolution of pain, 21 (25.6%) and 29 (40.9%) patients experienced partial resolution, whereas 5 (6.1%) and 6 (8.5%) patients experienced no change in the chronic pain, respectively. Thus, patients in Group 1 had a better outcome in chronic pain resolution (P = 0.033). The operative time, complications and recurrence rate were not different between the two groups.

CONCLUSIONS

Subinguinal microsurgical varicocelectomy is an effective method to treat painful varicoceles. With the assistance of Doppler Ultrasound monitoring, greater numbers of vessels were identified and a better outcome of pain resolution was achieved.

Anatomical factors affecting the time required for microsurgical subinguinal varicocelectomy

Background

Microsurgical subinguinal varicocelectomy (MSV) is considered an effective and less morbid procedure, but the difficulty in preserving testicular arteries is a limitation of this procedure. We identified the microanatomy encountered during MSV and clarify its significance to the difficulty of the procedure.

Methods

Three hundred and twenty-six patients who underwent left MSV were evaluated. Detailed intraoperative microanatomy was recorded for each case. A classification system was used to assess the anatomical relationship between the internal spermatic artery and the varicose veins as follows: type I (non-adherent to the veins), type II (adherent to the veins), and type III (surrounded by veins). Type III cases were further divided into types III-a (an arterial pulse) and III-b (a blurred arterial pulse). A linear regression analysis of the factors associated with the length of the operation was used to determine the difficulty of the surgery.

Results

A mean number of 8.2 internal spermatic veins were ligated. Internal spermatic arteries were classified as type I in 14 % of patients, type II in 57 %, and type III in 29 % (III-a in 20 % and III-b in 9 %). A large number of internal spermatic veins and higher internal spermatic artery type were observed significantly more often in grade 3 varicoceles (p < 0.05). The types of internal spermatic arteries (ρ = 0.458) and numbers of internal spermatic veins (ρ = 0.431), cremasteric veins (ρ = 0.197), and gubernacular veins (ρ = 0.119) were significantly associated with the length of the operation (p < 0.05).

Conclusions

Anatomical factors were associated with the varicocele grade and surgical difficulty. These findings are helpful to perform MSV.