ORIGINAL ARTICLE

Varicocelectomy by means of subinguinal cremasteric compartmentdisruption and venous ligation

A technical critique

PARAG SHAH

Department of Male Infertility, Nowrosjee Wadia Hospital, Mumbai, India

AbstractObjective. To evaluate the efficacy of addition of disruption of the cremasteric compartment to venous ligation in infertilemen with varicocele and abnormal semen parameters. Material and methods. A prospective non-randomized study wasundertaken in 380 infertile men with varicocele and abnormal semen parameters. They were operated on using subinguinalvenous ligation with the addition of cremasteric compartment disruption on an outpatient basis. Results. Following surgery,the median values for each semen parameter were compared preoperatively and 1-year postoperatively using the Wilcoxonsigned rank test. The difference in the median values was significant for all the parameters. Over a minimum 2-year follow-up period, 304 men (80%) contributed to pregnancies leading to live births. Conclusions. The results suggest thatsubinguinal venous ligation with the addition of cremasteric compartment disruption is a physiological, economic and safeoption for varicocele repair in men with abnormal sperm parameters. A high rate of unassisted pregnancy compared toconventional isolated venous obliteration is achievable, with minimal morbidity and recurrence.

Key Words: Varicocele, infertility, cremasteric compartment complex, subinguinal approach, ambulatory surgery, pregnancy

outcome

Introduction

Varicocele is observed in 35�40% of men with

primary infertility [1,2] and in up to 80% with

secondary infertility [3,4]. Varicocele is the com-

monest treatable cause of infertility and its repair has

been demonstrated to improve semen quality and

fertility potential in men with abnormal semen

parameters [5,6].

Various outpatient techniques have been described

for the repair of varicocele, including microsurgery

[7,8], embolization [9,10] and laparoscopy [11,12].

These techniques have generated renewed interest in

the treatment of varicocele because they limit mor-

bidity, decrease recurrence rates and seem to be more

acceptable to patients. However, some investigators

[12�14] were unable to demonstrate improvement

among their own patients following varicocelectomy.

Numerous theories have been suggested for the

development of varicocele [15�18], including in

particular the absence of valves in the spermatic

vein and the so-called nut-cracker phenomenon.

While most of these theories suggest causes above

the deep inguinal ring, none of them explain the

clinical evidence of absence of venous tortuosity

above the deep inguinal ring. I believe that it is not

retrograde flow in the spermatic vein but venous

stasis induced by a tight cremasteric compartment

around the spermatic cord which leads to dilatation

and tortuosity of the spermatic veins. Based on the

above concept, I suggest the addition of complete

disruption of the cremasteric compartment to venous

ligation for the adequate treatment of varicocele.

Material and methods

Between January 1995 and October 2003, a total of

862 patients were referred to an outpatient clinic at a

Correspondence: Parag A. Shah, Shah Surgical Clinic, 11, Yogesh sadan, Hingwala Lane, Ghatkopar (East), Mumbai 400077, India. Tel: �/91 022 25137834.

Fax: �/91 22 25146521. E-mail: parag@maleinfertilityindia.com

Scandinavian Journal of Urology and Nephrology, 2007; 41: 54�57

(Received 11 February 2006; accepted 24 May 2006)

ISSN 0036-5599 print/ISSN 1651-2065 online # 2007 Taylor & Francis

DOI: 10.1080/00365590600863996

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tertiary care unit dedicated to the treatment of

infertile men. A detailed history was obtained and

a complete physical examination was performed. A

minimum duration of infertility of 12 months,

defined as failure to cause pregnancy with appro-

priately timed and unprotected intercourse, was

required for entry into the study. Physical examina-

tion was performed by a single investigator.

The spermatic cords were observed and palpated

while the patient stood upright and performed a

Valsalva manoeuvre and testicular size was docu-

mented. Scrotal ultrasonography with colour Dop-

pler imaging was used to confirm the physical

findings and detect subclinical varicocele. Based on

these findings, the varicoceles were graded as either

large (visible and palpable), moderate (palpable) or

small (detected by Doppler reflux with a venous

diameter �/3 mm). For all patients, semen para-

meters (B/20 million sperm/ml semen; B/50%

motility or B/40% normal morphological forms)

were below threshold levels. Of the 862 infertile

men referred, 412 (42%) were detected to have

varicocele. A total of 517 varicocelectomies were

performed in 380 patients.

Surgical technique

All procedures were performed on an outpatient

basis. Oral atropine (0.6 mg) was given as premedi-

cation. The skin was infiltrated with 3�5 cm3 of a

1:1 mixture of 1% lignocaine and bupivacaine over

the external ring and into the spermatic cord. A

small (2-cm) incision was made over the external

ring, the subcutaneous tissue was separated by

sharp, blunt dissection and small band retrac-

tors exposed the spermatic cord. Local anaesthetic

(1�2 cm3) was injected under the cremasteric fascia

of the exposed spermatic cord. The anaesthetized

exposed segment of the spermatic cord was elevated

out of the incision by gentle traction and sharp

dissection. The band retractor was placed below the

spermatic cord for support, and dilated posterior

cremasteric veins, if present, were ligated and

transected. The cremasteric fascia and muscle en-

circling the exposed spermatic cord were completely

dissected and disposed. The vas deferens and artery

were observed and maintained out of the surgical

field. Only grossly dilated spermatic veins (�/3 mm

in diameter) were isolated, ligated and transected.

No attempt was made to ligate all vessels and

spermatic veins. No sclerosing agent was used and

surgery was done without the use of an operative

microscope. The spermatic cord was replaced in its

bed and the incision was closed with an absorbable

suture.

Results

A total of 517 procedures were performed in 380

patients. There were 362 cases of primary and 18 of

secondary infertility. The mean9/SD age of the

patients was 28.79/6.3 years (range 21�46 years).

The varicocele were left-sided in 152 patients (40%),

right-sided in 91 (24%) and bilateral in 137 (36%).

The mean9/SD duration of infertility was 26.39/

16.5 months (range 12�120 months). The varico-

cele were large in 136 cases (36%), moderate in 194

(51%) and small in 50 (13%). A history of smoking

was reported by 23 patients (6%) and these patients

were advised to stop smoking. Although all patients

reported a reduction in the number of cigarettes per

day, none of them completely abandoned smoking.

A total of 15 couples (4%) had concomitant female

factor infertility which was independently treated.

All operations were performed on an outpatient

basis and the mean operative time was 15 min (range

10�25 min) per side. In 53 patients (14%) only

cremasteric compartment disruption was performed

as these patients did not have grossly dilated veins

(�/3 mm in diameter).

The commonest problem was transient local

discomfort, which was reported by 26 patients

(7%). There were only two cases of hydrocele; no

recurrence was palpable over a 2-year follow-up

period and there was no testicular atrophy. Semen

specimens were collected and evaluated according to

WHO criteria [19]. The median values for each

semen parameter were compared preoperatively and

1 year postoperatively using the Wilcoxon signed

rank test. The differences in the median values were

significant for all parameters (Table I). The 1-year

pregnancy rate was 64% (n�/244), and this in-

creased to 80% (n�/304) over a 2-year period.

Discussion

Varicocele is the commonest identifiable, surgically

correctable lesion associated with male infertility.

Surgical correction of varicocele, whether uni- or

bilateral, results in improvement not only in semen

parameters but also in spontaneous and assisted

pregnancy rates. The results of this study showed

that semen parameters were improved for most men

and that 80% contributed to an unassisted preg-

nancy. Infertility and oligoasthenozoospermia were

the main criteria in selecting patients with varicocele

for surgery. The grade of varicocele was considered

to be of secondary importance. Subclinical varico-

cele probably indicated a tight cremasteric compart-

ment. Venous dilatation may evolve in such patients

with time.

Technical critique of varicocelectomy 55

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In this study, a decision was taken to perform

surgery on an outpatient basis under local anaesthe-

sia, as this is associated with less risk than the general

anaesthesia required for the laparoscopic and retro-

peritoneal approaches [11,12,20]. I believe that a

tight cremasteric compartment encircling the sper-

matic cord causes venous stasis and subsequent

tortuosity of the spermatic veins in a localized area

up to the deep ring. Histochemical study of the

human cremasteric compartment in patients with

long-standing varicocele showed small group atro-

phy due to local tissue hypoxemia and denervation

[21,22]. I believe that atrophy of the cremasteric

compartment occurs as nature’s response to long-

standing varicocele and this emphasizes the need for

complete disruption of the cremasteric fascia and

muscle in order to achieve the desired results.

In this study, only abnormally dilated veins were

transected, with no emphasis being placed on

complete venous occlusion. As major dissection is

not required, the chances of damaging the artery,

with subsequent testicular atrophy (0% in this

series), or damaging the lymphatics, with subsequent

formation of hydrocele (0.3% in this series),

are minimized. Others [20] have reported an in-

cidence of hydrocele formation of up to 7.2% after

varicocelectomy using the inguinal and retroperito-

neal approach. The commonest complaint following

modified subinguinal varicocelectomy was wound

discomfort; this was easily managed by means

of conservative measures such as administration

of non-steroidal anti-inflammatory drugs. The pa-

tient usually returned to work within 24 h after

surgery.

The morbidity associated with this procedure was

less than that with the inguinal or retroperitoneal

approaches, which require dissection of the muscle

layers of the inguinal canal. Laparoscopic varicoce-

lectomy may have lowered the morbidity rate but the

technique requires intraperitoneal exploration and

has the potential for significant complications, such

as bowel perforation and bleeding [23,24]. The

operative time in the present series was 15 min per

side, which was significantly less than in some

laparoscopic cases, for which the operative time has

been reported to be as long as 177 min [11]. The

high ligation and retroperitoneal approaches are

subject to high recurrence rates ranging from 1%

to 8% [24�26]. As meticulous dissection and liga-

tion are not advocated in the present approach it

might be concluded that there would be a high rate

of recurrence; however, no palpable recurrences

were demonstrated over a 2-year follow-up period.

Analysing the reports of different investigators, it

was observed that those who used the subinguinal

approach for varicocele repair had better pregnancy

rates (30�60%) compared to those who adopted

other approaches (6�8%) [25�27]. It is inferred that

subinguinal varicocelectomy results in partial or

complete disruption of the cremasteric fibres, lead-

ing to better results. Theoretically, cremasteric

compartment disruption without venous ligation

would be the best surgical option for eliminating a

tight cremasteric compartment. The venous dilata-

tion which occurred subsequent to a tight cremas-

teric compartment would regress spontaneously.

However, in the absence of a suitable animal model,

with a standing posture, for varicocele, it is not

possible to document this prior to human experi-

mentation.

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