Microscopic Surgical Techniques for Varicocele Repair

The varicocele is a common condition afflicting postpubertal men, a subset of whom will develop subfertility and/or androgen deficiency. Varicocele repair is associated with improved semen parameters, sperm DNA integrity, androgen levels, and fertility outcomes. Multiple treatment modalities exist for the varicocele, each carrying a differing set of advantages and disadvantages. The appropriate treatment for a given patient depends upon the patient’s anatomy, his values and goals, the resources available, and the experience of the surgeon. Beyond the treatment modality ultimately selected, the success of varicocele repair is most dependent upon appropriate patient selection in whom the indications are clear. In this review, the subinguinal microsurgical varicocelectomy will be discussed in detail. Overriding principles, outcomes, and complications of this technique will first be addressed with a critical overview of existing literature. The technical aspects to effectively and safely perform a subinguinal microsurgical varicocelectomy are outlined in a stepwise fashion. Additionally, controversial elements of the repair, mainly delivery of the testis and the benefits of arterial preservation, will be presented based upon available data. The remainder of the technical description will address the unique obstacles and strategies required when the reproductive urologist faces the recurrent varicocele. Finally, it cannot be emphasized enough that formal microsurgical training should be considered a requirement for offering the subinguinal microsurgical varicocelectomy. A call for better and more standardized training regimens concludes this review, as uniform and high-quality varicocele repair is the ultimate gold standard the medical community must strive for.