What is the best approach for open varicocelectomy without a microscope?

From the Guidelines

The best approach for open varicocelectomy without a microscope is the subinguinal or inguinal approach with loupe magnification, as it offers a good balance between efficacy and complication rates. When performing open varicocelectomy, it is essential to prioritize techniques that minimize scarring, blood loss, and complications, similar to the updated surgical techniques for varicose veins that use small incisions and limit removal of the superficial axial veins 1. The procedure involves making a 2-3 cm incision at the external inguinal ring (subinguinal) or over the inguinal canal, identifying and isolating the spermatic cord, then carefully separating and ligating the dilated veins while preserving the testicular artery, lymphatics, and vas deferens. Some key points to consider when performing this procedure include:

• Using at least 2.5x to 3.5x surgical loupes to enhance visualization of the testicular artery and lymphatic vessels
• Utilizing intraoperative Doppler ultrasound to help identify the testicular artery when a microscope isn't available
• Performing the procedure under general or spinal anesthesia, with patients typically discharged the same day
• Providing postoperative care, including scrotal support for 1-2 weeks, limited physical activity for 2-3 weeks, and pain management with NSAIDs like ibuprofen 400-600mg every 6-8 hours as needed. This approach is supported by the principle of using small incisions to reduce scarring, blood loss, and complications, as seen in the treatment of varicose veins 1. The subinguinal approach is particularly advantageous as it avoids opening the external oblique aponeurosis while still allowing access to both internal and external spermatic veins. Recurrence rates and hydrocele formation risk should be considered, with reported rates of 5-15% and 7-10%, respectively. Overall, the subinguinal or inguinal approach with loupe magnification is a viable option for open varicocelectomy without a microscope, prioritizing morbidity, mortality, and quality of life as the outcome.

From the Research

Open Varicocelectomy Without Microscope

The best open varicocelectomy without a microscope is a topic of interest in the field of urology. Several studies have compared the outcomes of different varicocelectomy techniques, including open, microsurgical, and laparoscopic approaches.

• The study by 2 compared the efficiency of microsurgery over conventional techniques of varicocele repairs and found that microsurgical varicocelectomy had better sperm test outcomes and lower postoperative complications compared to open varicocelectomy.
• Another study by 3 compared the postsurgical outcome of laparoscopic and open inguinal varicocelectomy and found that both procedures had equivalent postoperative outcomes regarding improvement in semen parameters and postoperative complications, but open inguinal procedure had a shorter operating time.
• The study by 4 compared the outcomes of open surgery, laparoscopic Palomo varicocelectomy, and embolization in children with varicocele and found that laparoscopic Palomo varicocelectomy was a safe and efficient approach with a low recurrence rate.
• A study by 5 compared the intraoperative difference between macroscopic and microsurgical varicocelectomy and found that microsurgical varicocelectomy could preserve more internal spermatic arteries and lymphatic and ligate more veins, which may interpret the superiority of microsurgical varicocele repair.

Key Findings

• Open varicocelectomy without a microscope may not be the most effective approach, as it may miss internal spermatic veins and lymphatics, and may have a higher recurrence rate compared to microsurgical varicocelectomy.
• Laparoscopic varicocelectomy may be a viable alternative to open varicocelectomy, with equivalent postoperative outcomes and a shorter hospital stay.
• The use of loupe magnification during open inguinal varicocelectomy may improve the outcomes and reduce the recurrence rate.

Comparison of Techniques

• Open varicocelectomy: may have a higher recurrence rate and more postoperative complications compared to microsurgical varicocelectomy.
• Microsurgical varicocelectomy: may have better sperm test outcomes and lower postoperative complications compared to open varicocelectomy.
• Laparoscopic varicocelectomy: may have equivalent postoperative outcomes and a shorter hospital stay compared to open varicocelectomy.