Microsurgical subinguinal varicocelectomy with testicular delivery.

Objective: To demonstrate our approach to the microsurgical subinguinal varicocelectomy with testicular delivery.

Design: An instructional video demonstrating the surgical procedure in a step-by-step manner, highlighting useful surgical techniques.

Setting: Not applicable.

Patient(s): Patients with male factor infertility.

Intervention(s): After appropriate patient selection and counseling, varicocelectomy is performed with a subinguinal approach utilizing the surgical microscope. The patient is under general anesthesia and we employ an operating microscope. The patient is positioned supine.

Main Outcome Measure(s): Not applicable.

Results: A 2.5-cm subinguinal incision was made and the testicle was then delivered. Through the operating microscope at 10-20X magnification, internal spermatic veins were identified and ligated. Smaller veins were taken with electrocautery. The testicular artery was identified using the microdoppler probe. We employ hydrodissection in identifying and isolating the testicular artery. The spermatic cord is then repeatedly examined until no veins other than deferential veins remain. The gubernaculum is also thinned sufficiently so that veins on both sides can be identified and ligated. Testicular delivery was performed and external spermatic veins as well as gubernacular veins ligated.

Conclusion(s): Varicoceles are found in up to 15% of all men, and in up to 40% of infertile men. Varicoceles have negative effects on testicular function. Varicocelectomy improves testicular function and may halt the accelerated rate of decline in testicular function associated with varicoceles. Sperm parameters, serum testosterone levels, and pregnancy rates have all been shown to improve following varicocelectomy. Use of the operating microscope, the microdoppler probe, and black and white sutures aid in efficiency. Testicular delivery is useful to ligate external spermatic veins as well as gubernacular veins.