Microsurgical Varicocelectomy

MARC GOLDSTEIN

Varicocele is by far the most commonly performed operation for the treatment of male infertility. Varicocele is found in approximately 15% of the general population, 35% of men with primary infertility, and in 75% to 81% of men with secondary infertility (1,2). Animal and human studies have demonstrated that varicocele is associated with a progressive and duration dependent decline in testicular function (1,2,3,4,5,6,7,8,9).

Repair of varicocele will halt any further damage to testicular function (5,6) and in a large percentage of men result in improved spermatogenesis (10,11,12) as well as enhanced Leydig cell function (13,14). The potentially important role of urologists in preventing future infertility and/or androgen deficiency underscores the importance of using a varicocelectomy technique that minimizes the risk of complications and recurrence.

DIAGNOSIS

Varicoceles are defined as dilations of the veins of the testicular pampiniform plexus, which are believed to be caused by absent or incompetent valves in the internal spermatic veins. The diagnosis of a clinically significant varicocele is generally made on physical examination of the scrotum and its contents. The patient is examined in the supine and standing position with the scrotum warmed first with a heating pad. This promotes relaxation of the scrotal dartos muscle and facilitates accurate evaluation for varicocele. The scrotum should be inspected carefully for any easily visible dilated veins. The spermatic cord should be palpated between thumb and forefinger for palpable tortuous veins. Both spermatic cords should be palpated while the patient performs a Valsalva maneuver in the upright position.

Varicoceles are graded I through III using the system outlined in Table 53.1. Grade I varicoceles are small, grade II moderate, and grade III large. Varicoceles should collapse in the supine position. If the varicocele remains prominent with the patient supine, this finding suggests a mechanical obstruction to testicular venous outflow from a retroperitoneal mass (sarcoma, lymphoma, or a renal tumor with venous thrombus). An abdominal ultrasound or computerized tomography scan should be obtained to evaluate the retroperitoneum in these men.

Scrotal ultrasonography with color flow Doppler imaging with the patient upright and supine may prove useful in equivocal cases or in patients with a body habitus that makes accurate physical examination of the scrotum impossible. Using ultrasonography, the diameter of the internal spermatic vein can be measured and retrograde flow through the vein during Valsalva maneuver documented. Veins that are greater than 3.5 mm can generally be detected on physical exam. Those that are 2.5 mm or less are usually not palpable and have been termed subclinical varicoceles (15). The need for diagnosing and treating subclinical varicoceles is controversial (16). Recent studies have indicated that repair of subclinical varicoceles is of questionable value (17). However, other reports have indicated that repair of small palpable or subclinical right varicoceles may be beneficial if present in conjunction with a larger left-sided varicocele (18,19,20).

A recent meta-analysis by Marmar et al. (12) clearly shows a significant increase in pregnancy rates after microsurgical varicocelectomy.

INDICATIONS

The indications for repairing varicoceles in adolescents include the following:

Palpable (especially grade III) left varicocele with associated ipsilateral testicular atrophy (with the volume of the left testis being at least 20% less than that of the right)
Palpable (especially grade III) varicocele with abnormal semen analysis results
Large (grade III) symptomatic (painful) varicocele
Bilaterally palpable varicocele with testicular atrophy

Although prophylactic treatment of adolescent varicocele for the prevention of future infertility and androgen deficiency is controversial, the author feels that it is much easier to prevent future infertility and androgen deficiency than to treat it once it has occurred. In view of the high success rate and low morbidity of microsurgical repair, the author feels that repair of grade III varicoceles is the conservative therapy since it conserves testicular function.

TABLE 53.1 CLINICAL VARICOCELE CLASSIFICATION

Classification		Definition
Clinical (palpable)
	Grade III (large)	Easily visible
	Grade II (moderate)	Dilated tortuous veins palpable through the scrotal skin when standing (without Valsalva maneuver)
	Grade I (small)	Impulse palpable with Valsalva maneuver, full cord when standing, collapses when supine
Subclinical		Vein larger than 2.5 mm on ultrasound, reflux with Valsalva maneuver on color flow Doppler

Based on the Best Practice Policies for Male Infertility of the American Urological Association (21), varicocele treatment should be offered to the male partner of a couple attempting to conceive when all of the following are present:

A varicocele is palpable.

The male partner has one or more abnormal semen parameters or sperm function test results.

The couple has documented infertility.

The female partner has normal fertility or potentially correctable infertility.

In addition, testicular pain associated with varicocele (in the absence of other pathology), psychological concern regarding future fertility, and cosmetic reasons are all relative indications. Varicocele repair is not indicated in men with normal semen analysis, sperm function assays, or only a subclinical (nonpalpable) varicocele.

ALTERNATIVE THERAPY

Several approaches exist for varicocelectomy, including retroperitoneal and inguinal open techniques, microsurgical inguinal and subinguinal approaches, laparoscopic repairs, and radiographic embolization. The microsurgical varicocelectomy, low inguinal (22) or subinguinal, as first described by Marmar et al. (23), is preferred because it is associated with higher success rates and lower morbidity and recurrences than nonmicrosurgical techniques (22,24).

Microsurgical Inguinal and Subinguinal Operations: The Preferred Approaches

Subinguinal varicocelectomy is currently the most popular approach. It has the advantage of allowing the spermatic cord structures to be pulled up and out of the wound so that the testicular artery, lymphatics, and small periarterial veins may be more easily identified. In addition, an inguinal or subinguinal approach allows access to the external spermatic and even gubernacular veins (25), which may bypass the spermatic cord and result in recurrence if not ligated. Lastly, an inguinal or subinguinal approach allows access to the testis for biopsy or examination of the epididymis for obstruction or repair of hydrocele (26).

Anesthesia

If the testis is delivered, as described in the following text, regional or light general anesthesia is preferred. If only the cord is delivered, local anesthesia with a 50/50 combination of 0.25% bupivacaine and 1% lidocaine is satisfactory with adjunctive intravenous heavy sedation. After infiltration of the skin and subcutaneous tissues, the cord is infiltrated prior to delivery. Blind cord block carries with it a small risk of inadvertent testicular artery injury (27). A 30-gauge needle should therefore be employed for cord block to minimize the risk of injury and hematoma.

Inguinal and Subinguinal Approaches

The introduction of the subinguinal approach, just below the external inguinal ring (23), obviates the necessity for opening any fascial layer and is associated with less pain and a rapid recovery comparable to laparoscopic procedures. At the subinguinal level, however, significantly more veins are encountered; the artery is more often surrounded by a network of tiny veins which must be ligated and the testicular artery has often divided into two or three branches, making arterial identification and preservation more difficult (28).

TABLE 53.2 INDICATIONS FOR INGUINAL (EXTERNAL OBLIQUE OPENED) VERSUS SUBINGUINAL (FASCIA INTACT) VARICOCELECTOMY

Inguinal	Subinguinal
Prepubertal children	Prior inguinal surgery
Solitary testis	Obesity
Tight, low external ring	Lax, capacious external ring
	High external ring
Short cord, high lying testis	Long cord with low lying testis
Less experienced with microsurgical repair	Very experienced with microsurgical repair

Subinguinally, the arterial pulsations are often dampened by compression on the edge of the external ring, making its identification somewhat more difficult than when the external oblique is opened. Table 53.2 summarizes the criteria for performing the operation inguinally (external oblique opened) versus subinguinally (fascia intact). In general, it is best to use a subinguinal approach in men with a history of any prior inguinal surgery. Under these circumstances, the cord is usually stuck to the undersurface of the external oblique and opening the fascia risks injury to the cord. A subinguinal approach is easier in obese men in whom opening and closing the fascia is difficult through a small incision. A subinguinal approach is easier in men with high, lax, capacious external rings and in men with long cords and low-lying testes. In these men, the level of the external ring is fairly proximal to the testis and opening the fascia will not result in a significant diminution in the number of veins to be ligated or in the branching of the testicular artery.

I recommend always opening the external oblique in prepubertal children without prior inguinal surgery. In children, the testicular artery is very small and systemic blood pressure is low, making identification of the artery very difficult in a subinguinal approach. The fascia could also be opened in men with a solitary testis in whom preservation of the artery is critical. Exposure of the cord more proximally (at the inguinal level) allows identification of the artery before it has branched, where clear pulsations are more readily observed.

Consider opening the fascia in men with prior failed subinguinal varicocelectomy in order to dissect proximal to the prior scarred ligation area. The microdissection will be quicker and easier. A subinguinal operation is significantly more difficult than a high inguinal operation and should only be used by surgeons who perform the operation frequently. Less experienced microsurgeons should start out doing inguinal operations because it is easier. An inguinal operation is employed when simultaneous ipsilateral hernia repair is performed.

Before making the incision, the location of the external inguinal ring is determined by invagination of the scrotal skin
and is marked. The size of the incision is determined by the size of the testis when delivery of the testis (see in the following text) is planned. Atrophic testes can be delivered through a 2- to 2.5-cm incision. Larger testes require a 3-cm incision. The incision is made within Langer lines to minimize scarring.

FIGURE 53.1 Subinguinally, a 2- to 3.0-cm incision is placed in the skin folds right over the external inguinal ring. Inguinally, a 3.5- to 4-cm incision is begun at the external ring and extended laterally along Langer lines.

If the decision is made to perform an inguinal operation and thus to open the fascia, the incision is begun at the external ring and extended laterally 2 to 3.5 cm along Langer lines (Fig. 53.1). If the operation is to be performed subinguinally, the incision is placed in the skin folds right over the external ring (Fig. 53.2).

FIGURE 53.2 The index finger is then hooked under the external inguinal ring, retracting it cephalad. A small Richardson retractor is slid along the back of the index finger and retracted caudad over the cord toward the scrotum.

FIGURE 53.3 The relatively avascular internal spermatic fascia is opened with scissors as high as possible and held open with the straight mosquito forceps.

Camper fascia and Scarpa fascia are divided with the electrocautery between the blades of a Crile clamp. The superficial epigastric artery and vein, if encountered, are retracted or alternately, may be clamped, divided, and ligated. If an inguinal approach is selected, the external oblique aponeurosis is cleaned and opened the length of the incision to the external inguinal ring in the direction of its fibers. A 3-0 absorbable suture placed at the apex of the external oblique incision facilitates later closure.

The spermatic cord is grasped with a Babcock clamp and delivered through the wound. The ilioinguinal and genital branches of the genitofemoral nerve are excluded from the cord which is then surrounded with a large Penrose drain. If a subinguinal incision was made, Camper and Scarpa fascia are incised as described previously. An index finger is introduced into, around and along, the cord as it passes into the scrotum. The
index finger is then hooked under the external inguinal ring, retracting it cephalad. A small Richardson retractor is slid along the back of the index finger and retracted caudad over the cord toward the scrotum (see Fig. 53.2). The spermatic cord will be revealed between the index finger and retractor. The assistant grasps the cord with a Babcock clamp and delivers it through the wound. The cord is surrounded with a large Penrose drain.