V8-07: Microscopic Subinguinal Varicocelectomy with Ligation of Cremasteric Muscle Fibers

Video

Introductions and Objectives
Microscopic subinguinal varicocelectomy reduces hydrocele formation and varicocele recurrence. However, failure to ligate small veins around the testicular artery and those within the cremasteric muscle fibers can cause varicocele recurrence even in the best of hands. We demonstrate our approach to microscopic subinguinal varicocelectomy where cremasteric muscle fibers are ligated with low complication and recurrence rates.

Methods
An IRB approved database was queried for all patients undergoing microscopic subinguinal varicocelectomy between March 2005 and June 2013 by a single surgeon. A 3 cm subinguinal incision was made. The cord structures were then grasped with an atraumatic Babcock clamp and brought out through the wound. Through the operating microscope at 10-20X magnification, cremasteric fibers were dissected and isolated. Internal spermatic fascia was incised. The vas deferens and associated vessels were isolated and separated from the remaining cord structures using a vessel loop. A vascular Doppler probe was used to identify the spermatic artery. Internal spermatic veins were identified and ligated. Individual lymphatic vessels were preserved whenever possible. Cremasteric fibers were then ligated and cauterized. Demographic, clinical, laboratory data, and complications were reported.

Results
A total of 184 patients were identified. Mean age was 32.8 ±4.7. A majority of patients had grade II varicoceles and underwent a bilateral procedure. Mean sperm concentration, sperm motility and total progressive motile sperm significantly improved post-operatively (Table 1). Overall, complication rate was 1%. There were two hydroceles and one spermatic cord hematoma. Testicular atrophy and varicocele recurrence did not occur in any patients.

Conclusions
Microscopic subinguinal varicocelectomy with ligation of the cremasteric fibers offers an effective method in controlling cremastric veins resulting in minimal complications with no evidence of recurrence.

Funding: none