Introduction
Varicocele is defined as an abnormal and tortuous dilatation of the pampiniform plexus of veins within the spermatic cord. It is particularly prevalent among the young male population, with a global incidence of approximately 15–20%.1 Clinical presentation commonly includes testicular pain or discomfort, as well as abnormal semen parameters that contribute to infertility. In certain cases, the pain may become sufficiently severe to interfere with daily activities and occupational functioning. Among infertile males, the reported incidence of varicocele ranges from 35–81%, with a higher frequency observed in cases of secondary sterility.2
Historically, open (Palomo) and laparoscopic varicocelectomy were associated with significant limitations, including high recurrence rates, testicular atrophy, and hydrocele formation. These challenges contributed to considerable apprehension among both patients and surgeons. The advent of microsurgical subinguinal varicocelectomy (MSV), now regarded as the gold standard for varicocele repair, addressed many of these complications by improving outcomes and reducing procedure-related risks.3,4
In Bangladesh, urological microsurgery was introduced four years ago in a state-of-the-art manner. Over the past year, the adoption of MSV has expanded rapidly, with 614 cases performed at a single center by one urologist, placing the center among the top five globally in terms of surgical volume. To enhance operative efficiency, a novel technique was developed to facilitate rapid dissection and identification of the spermatic cord, thereby reducing operative time. This technique has been disseminated to urologists internationally and was recently demonstrated at Hackensack University Medical Center, New Jersey, USA, on August 25.
The present study aims to evaluate the effectiveness of microsurgical subinguinal varicocelectomy and to assess the benefits of the newly developed technique compared to the standard approach, particularly in the identification of the spermatic cord and internal spermatic artery.
Methods: During a six-month period spanning from September 2024 to February 2025, a total of 341 microsurgical subinguinal varicocelectomy (MSV) procedures were carried out at Dr. Azfar’s American Standard Urology, Andrology, Microsurgery, and Male Fertility Centers, affiliated with Anwar Khan Modern Medical College and Central Hospital Ltd., Dhanmondi, Dhaka respectively.
Microsurgery Suite 1.5-2.5cm incision over pubic tubercle
All patients who presented to the andrology clinic with symptoms of testicular pain and/or male infertility associated with abnormal semen parameters were considered for inclusion. Each patient underwent a detailed clinical evaluation, including physical examination, followed by Doppler ultrasonography of the spermatic cords.
The inclusion criteria for MSV were:
- Clinically diagnosed AUA grade 2 or grade 3 varicocele, and
- Internal spermatic vein diameter ≥ 3 mm with demonstrable venous reflux on Doppler ultrasonography.
| Usually we ligate 7-14 veins | Large varicocele veins occasionally found |
Preoperative Doppler to identify Internal spermatic artery
All MSV procedures were performed through a 1.5–2.5 cm incision over the superficial inguinal ring, utilizing a modified technique involving invagination of the left index finger through the superficial inguinal ring. This approach allowed the spermatic cord to be lifted within 2–3 minutes, thereby minimizing unnecessary dissection and reducing operative time.
Following exposure, standard MSV was carried out with ligation of all internal spermatic veins. Procedures at Anwar Khan Modern Medical College Center were performed using a Carl Zeiss (Germany) operating microscope, while those at Central Hospital Ltd. employed a Takagi (Japan) microscope, with magnification ranging from six to 30 times.
For efficient identification of the internal spermatic arteries (ISA), systolic blood pressure was transiently elevated to 140–160 mmHg for 15–20 minutes by the anesthesiologist. In selected cases, micro-Doppler ultrasonography and, occasionally, topical papaverine spray were also employed to facilitate ISA identification.
Results:
The outcomes of the MSV procedures were compared with those reported in previous studies in terms of skin incision to spermatic cord pickup time, internal spermatic artery (ISA) identification time, total operating time, postoperative pain resolution (for cases performed for pain), and changes in semen parameters. Overall, the results were comparable to those reported in the literature.
- Recurrence Rate: The recurrence rate of varicocele was 0.95%.
- Skin to Cord Pickup Time: The average time from skin incision to spermatic cord lifting was 2–5 minutes using the modified technique, compared to 12–15 minutes with conventional dissection.
- ISA Identification Time and Total Operating Time: Both ISA identification time and total operating time were significantly reduced with this technique (Table 2).
- Pain-Free Incidence: Postoperative pain resolution at three months demonstrated partial or complete improvement in 84% of patients, consistent with reports from Ryan et al. (2017), who observed over 90% symptomatic relief in carefully selected patients undergoing varicocele repair for pain Ryan et al., 2017.
- Semen Parameters Improvement: Improvement in semen parameters was observed in 67% of cases, aligning with findings from Marmar et al. (2007), who reported significant improvements in semen parameters following varicocelectomy in infertile men Marmar et al., 2007.
Discussion:
- Varicocele is a prevalent condition in the male population and represents a significant cause of work absenteeism among young men. It is a treatable and surgically curable condition with the advent of microsurgical varicocelectomy (MSV). According to the European Association of Urology (EAU) guidelines, MSV is indicated in cases of varicocele associated with testicular hypotrophy (>20%), infertility, symptomatic pain, or pathological sperm quality (EAU Guidelines, 2024).
- Similarly, the American Urological Association (AUA) and the American Society for Reproductive Medicine (ASRM) 2020 guidelines recommend that surgical varicocelectomy should be considered in men attempting to conceive who have a palpable varicocele, infertility, and abnormal semen parameters, excluding azoospermic men (moderate recommendation) (AUA/ASRM Guideline, 2020).
- These guidelines underscore the importance of MSV as a first-line surgical approach for improving fertility outcomes and alleviating symptomatic discomfort in affected individuals.
| Microsurgical Varicocelectomy – Gold Standard | ||||
| Technique | Preservation of artery | Hydrocele formation% | Recurrence rate% | Serious morbidity |
| Retroperitoneal | No | 7 | 15-25 | No |
| Conventional inguinal (without) magnification) | Chance low | 3-30 | 5-15 | No |
| Laparoscopic/ Robotic | Yes | 12 | 3-15 | Yes |
| Radiographic | Yes | 0 | 15-25 | Yes |
| Microsurgical | Yes | 0 | 0.5-1.0 | No |
Table- 1 Comparison of varicocelectomy technique.
| Variable | Group 1 (n= 174) | Group 2 (n= 167) | p-value |
| Arterial identification time (min) | 41.73 + /- 8.62 | 30.74 +/- 11.96 | < 0.05 |
| Unilateral operation time (min) | 75.12+/- 8.64 | 60.57 +/- 3.81 | < 0.05 |
| Number of ISA (n) identified | 1.44 +/- 0.58 | 1.97 +/- 0.45 | < 0.05 |
| Adverse effects; Headache | 0 | 2(1.19%) | – |
| Complications; Hydrocele | 0 | 0 | – |
| Testicular atrophy | 0 | 0 | – |
| Varicocele recurrence | 1.14%(2) | 0 | – |
| ISV identification time and unilateral operative time were significantly shorter in Group 2 than Group 1. Intraoperatively, the number of preserved ISAs was significantly higher in Group 2. Post operative (0 months later) semen parameters were better in both groups than preoperative. But semen parameters didn’t differ significantly between groups. | |||
Table-2: Effect of raising SBP in MSV (our study)
Varicocele results in the reflux of warm blood from the abdomen to the testis, leading to increased intratesticular temperature, hypoxia, and generation of free radicals. These pathophysiological changes contribute to DNA fragmentation in sperm, resulting in oligospermia and asthenozoospermia, which are recognized as significant causes of male subfertility. Clinically, varicocele often presents as a “bag of worms” sensation, associated with heaviness and scrotal pain, which may radiate to the inguinal region and back.
When compared with older techniques such as high ligation (Palomo operation) and laparoscopic varicocelectomy, microsurgical varicocelectomy demonstrates clear superiority in terms of outcomes and complication rates (Table 1).5,6 MSV can be performed via the inguinal or subinguinal approach, with the subinguinal approach preferred due to reduced morbidity and avoidance of dissection through the inguinal canal.
A critical aspect of MSV is the identification and preservation of the internal spermatic artery and its branches. This can be achieved efficiently by intentionally raising the patient’s systolic blood pressure, as demonstrated in the current study (Table 2). In Group 1, procedures were performed under conventional blood pressure, while in Group 2, systolic blood pressure was elevated to 140–160 mmHg to facilitate rapid and reliable identification of the internal spermatic artery.
Conclusion:
Microsurgical subinguinal varicocelectomy (MSV) should be considered the standard of care for varicocele surgery nationwide. The modified operative technique described in this study has the potential to significantly reduce operating time while allowing efficient identification of internal spermatic arteries. Further evaluation through large-scale, long-term, international studies is recommended to validate these findings.
Key Words: Varicocele, Microsurgical subinguinal varicocelectomy, Internal Spermatic Artery
Author of this article:
Azfar Uddin Shaikh,
MD (USA), MS (Urology), Professor of Urology; Head, Department of Urology, Anwer Khan Modern Medical College, Dhanmondi, Dhaka, Bangladesh. E-mail : rimon3k@yahoo.com Mobile : +8801711345060
References:
1. Paick S, Choi WS. Varicocele and testicular pain: A review. World Journal of Men?s Health. 2019;37(1):4-11. doi:10.5534/WJMH.170010
2. Agarwal A, Finelli R, Durairajanayagam D, et al. Comprehensive Analysis of Global Research on Human Varicocele: A Scientometric Approach. World J Mens Health. 2022;40(4):636-652. doi:10.5534/WJMH.210202
3. Yang YY, Huang W, Cao JJ, et al. [Microsurgical subinguinal varicocelectomy with delivery of the testis and ligation of gubernacular veins: Evaluation of clinical effects]. Zhonghua Nan Ke Xue. 2018;24(3):226-230. Accessed October 7, 2025. https://europepmc.org/article/med/30161308
4. Xu EX. A step forward: Translational Andrology and Urology is indexed in PubMed/PMC. Transl Androl Urol. 2016;5(1):162. doi:10.3978/J.ISSN.2223-4683.2015.12.02
5. Al-Kandari AM, Shabaan H, Ibrahim HM, Elshebiny YH, Shokeir AA. Comparison of Outcomes of Different Varicocelectomy Techniques: Open Inguinal, Laparoscopic, and Subinguinal Microscopic Varicocelectomy: A Randomized Clinical Trial. Urology. 2007;69(3):417-420. doi:10.1016/j.urology.2007.01.057
6. Ding H, Tian J, Du W, Zhang L, Wang H, Wang Z. Open non-microsurgical, laparoscopic or open microsurgical varicocelectomy for male infertility: a meta-analysis of randomized controlled trials. BJU Int. 2012;110(10):1536-1542. doi:10.1111/J.1464-410X.2012.11093.X
