No funding sources.

This research is approved by the Affiliated Hospital of the Shanghai Institute for Biomedical and Pharmaceutical Technologies, and the ethics number is 2022001. Written informed consent was obtained from the human subjects to participate in the study. The inclusion criteria were: (1) Diagnosis of varicocele by clinical ultrasound; (2) Age between 20 and 40 years old; (3) Abnormalities detected in semen examination, indicating the need for surgery and consent to undergo the procedure. The exclusion criteria were: (1) Abnormal fever exceeding 38.5 &#176;C within the past 6 months; (2) Presence of major illnesses such as tumors, severe heart, lung, liver, and kidney dysfunction, and mental illnesses. The reagents and equipment needed for this procedure are listed in the Table of Materials.
1. Instrumentation
<ol>
	<li>Ensure the availability of sterilized instruments and other equipment needed for surgery, including the following specific important items: surgical microscope, titanium clips, and microscopic instruments.</li>
</ol>
2. Patient preparation
<ol>
	<li>Perform preoperative skin preparation.
	<ol>
		<li>Apply compound lidocaine cream to cover an area from the anterior superior iliac spine laterally, inferiorly to the level of the pubic tubercle, and superiorly up to 3 cm below the umbilical line 1 h preoperatively (see Figure 1).</li>
	</ol>
	</li>
	<li>Place the patient in the supine position on the operating table. Insert a vein-detained needle into the dorsal metacarpal vein, and use an ECG monitor to monitor the patient&#39;s heartbeat and blood pressure.</li>
	<li>Disinfect the surgical area using Iodophor solution and cover it with sterile drapes.</li>
</ol>
3. Microscopic varicocelectomy
<ol>
	<li>Identify the external inguinal ring above the pubic tubercle by using fingers to palpate the spermatic cord at the base of the scrotum, following it upwards until the external inguinal ring is felt at 1.5 cm above the midpoint of the inguinal ligament.</li>
	<li>Use Hemostatic forceps to grasp the skin to assess the efficacy of anesthesia (Figure 2A), and mark the incision site with methylene blue (Figure 2B).</li>
	<li>Mix Lidocaine (5 mL, 0.1 g) and ropivacaine (10 mL, 0.1 g) in a 1:1 ratio and infiltrate using a 20 mL syringe in layers up to a depth of about 5 cm (see Figure 3).</li>
	<li>Make a 3 cm transverse incision at the external inguinal ring using a scalpel. Sequentially, incise the skin, the Camper&#39;s fascia, and the Scarpa&#39;s fascia using an electrotome.</li>
	<li>Identify the spermatic cord (under direct vision, it appears as a strip with dilated deep blue veins visible, and the vas deferens can be palpated below it) and exteriorize it from the incision with an appendiceal retractor. 
	NOTE: Pay attention to the patient&#39;s heart rate and blood pressure during this step. If a decrease in blood pressure and heart rate is encountered, stop the operation and wait for 3-5 min. If necessary, administer 1 mg of atropine injection and 10 mg of dopamine injection intravenously. Secure the spermatic cord in place (see Figure 4).
	<ol>
		<li>Use an electrotome to dissect the cremaster muscle and the external and internal spermatic fascia of the cord.</li>
		<li>Under 8-10x magnification, observe the pulsation of the arteries to determine their location.</li>
		<li>Carefully identify the spermatic artery (which is surrounded by small veins, has visible pulsation, and a tensed wall). Use micro-scissors and forceps for blunt dissection and mark it with a moistened strip for identification. If available, intraoperative Doppler ultrasound can be used for confirmation (Figure 5).</li>
		<li>Identify and isolate the large spermatic veins. Use micro-titanium clips to clamp both ends before cutting (Figure 6).</li>
		<li>Further dissect and identify small veins adjacent to the spermatic artery. Use micro-titanium clips to clamp them before cutting. For vessels that are difficult to clamp with titanium, use 4-0 coated braided silk to ligate before cutting.</li>
		<li>Ligate all varicose veins, ensuring at least one normal vein is preserved for venous return (Figure 7).</li>
	</ol>
	</li>
	<li>After ligation, suture the cremaster muscle and both the internal and external spermatic fascia using a 6-0 absorbable surgical suture. Close and suture the incision (Figure 8).</li>
</ol>
4. Postoperative care
<ol>
	<li>Apply a 1 kg sandbag for compression and hemostasis 1 h postoperatively.</li>
	<li>Administer oral antibiotics postoperatively (fosfomycin trometamol powder, 3 g) for infection prevention. Administer anti-inflammatory analgesic suppositories rectally if postoperative pain is observed.</li>
	<li>Change the dressing in 3 days and remove the stitches in 7 days.</li>
	<li>Conduct a semen examination after 1 month.</li>
</ol>

Microsurgical Varicocele Removal Under Local Anesthesia

<ol>
	<li>Alsaikhan, B., Alrabeeah, K., Delouya, G., Zini, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Epidemiology+of+varicocele.">Epidemiology of varicocele.</a> Asian J Androl. 18 (2), 179-181 (2016).</li><li>Damsgaard, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Varicocele+is+associated+with+impaired+semen+quality+and+reproductive+hormone+levels:+A+study+of+7035+healthy+young+men+from+six+European+countries.">Varicocele is associated with impaired semen quality and reproductive hormone levels: A study of 7035 healthy young men from six European countries.</a> Eur Urol. 70 (6), 1019-1029 (2016).</li><li>Gupta, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microscopic+varicocelectomy+as+a+treatment+option+for+patients+with+severe+oligospermia.">Microscopic varicocelectomy as a treatment option for patients with severe oligospermia.</a> Investig Clin Urol. 59 (3), 182-186 (2018).</li><li>Addar, A. M., Nazer, A., Almardawi, A., Al Hathal, N., Kattan, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+yield+of+microscopic+varicocelectomy+in+men+with+severe+oligospermia.">The yield of microscopic varicocelectomy in men with severe oligospermia.</a> Urol Ann. 13 (3), 268-271 (2021).</li><li>Saredi, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Feasibility+of+local+anesthesia+for+varicocele+correction+in+one-day-surgery+setting.+A+single+center+experience.">Feasibility of local anesthesia for varicocele correction in one-day-surgery setting. A single center experience.</a> Arch Ital Urol Androl. 93 (2), 233-236 (2021).</li><li>Jensen, C. F. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Varicocele+and+male+infertility.">Varicocele and male infertility.</a> Nat Rev Urol. 14 (9), 523-533 (2017).</li><li>Baazeem, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Varicocele+and+male+factor+infertility+treatment:+A+new+meta-analysis+and+review+of+the+role+of+varicocele+repair.">Varicocele and male factor infertility treatment: A new meta-analysis and review of the role of varicocele repair.</a> European Urol. 60 (4), 796-808 (2011).</li><li>Maheshwari, A., Muneer, A., Lucky, M., Mathur, R., Mceleny, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+review+of+varicocele+treatment+and+fertility+outcomes.">A review of varicocele treatment and fertility outcomes.</a> Hum Fertil (Camb). 25 (2), 209-216 (2020).</li><li>&#199;ayan, S., Akbay, E., Saylam, B., Kad&#305;o&#287;lu, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effect+of+varicocele+and+its+treatment+on+testosterone+in+hypogonadal+men+with+varicocele:+Review+of+the+literature.">Effect of varicocele and its treatment on testosterone in hypogonadal men with varicocele: Review of the literature.</a> Balkan Med J. 37 (3), 121-124 (2020).</li><li>Ulusoy, O., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Successful+outcomes+in+adolescent+varicocele+treatment+with+high-level+laparoscopic+varicocelectomy.">Successful outcomes in adolescent varicocele treatment with high-level laparoscopic varicocelectomy.</a> J Pediatr Surg. 55 (8), 1610-1612 (2020).</li><li>Mehta, A., Goldstein, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microsurgical+varicocelectomy:+A+review.">Microsurgical varicocelectomy: A review.</a> Asian J Androl. 15 (1), 56-60 (2013).</li><li>Marmar, J. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+evolution+and+refinements+of+varicocele+surgery.">The evolution and refinements of varicocele surgery.</a> Asian J Androl. 18 (2), 171-178 (2016).</li><li>Wang, X., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prospective+comparison+of+local+anesthesia+with+general+or+spinal+anesthesia+in+patients+treated+with+microscopic+varicocelectomy.">Prospective comparison of local anesthesia with general or spinal anesthesia in patients treated with microscopic varicocelectomy.</a> J Clin Med. 11 (21), 6397 (2022).</li><li>Al-Kandari, A. M., Shabaan, H., Ibrahim, H. M., Elshebiny, Y. H., Shokeir, A. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+outcomes+of+different+varicocelectomy+techniques:+Open+inguinal,+laparoscopic,+and+subinguinal+microscopic+varicocelectomy:+A+randomized+clinical+trial.">Comparison of outcomes of different varicocelectomy techniques: Open inguinal, laparoscopic, and subinguinal microscopic varicocelectomy: A randomized clinical trial.</a> Urology. 69 (3), 417-420 (2007).</li></ol>

The author has no conflicts of interest to disclose.

Varicocele presents a relatively high prevalence in infertile men of reproductive age, reaching 35%-44%6. The impact of this disease on male fertility cannot be overlooked, as it may lead to imbalances in testicular function, instability in blood supply, and thermoregulatory disturbances, subsequently affecting both the quality and quantity of sperm. More severe consequences include potential testicular atrophy and other related complications. Numerous studies have proved the effects of varicocele...

With the advancement of modern society, male infertility has gradually emerged as a global health issue, with varicocele being one of the predominant causes. The prevalence of varicocele is estimated at 15% in the general healthy population, 35% in those with primary infertility, and can be as high as 80% in the secondary infertility group1. Not only does varicocele lead to a decline in sperm count and quality2, but it also profoundly impacts the psychological well-being and quality of life of affected men.
Contemporary treatment modalities, such as microscopic varicocelectomy, have been widely adopted3,4. However, their limitations are becoming increasingly evident. Traditional microscopic varicocelectomy requires patients to undergo general anesthesia, which not only necessitates preoperative fasting and postoperative recovery inconveniences but also poses a significant challenge. The hemodynamic changes induced by anesthesia might obscure the pulsations of the spermatic artery, subsequently increasing the intricacy of isolating and preserving the vessel during the procedure5.
In light of these challenges, a method of performing microscopic varicocelectomy under local anesthesia was proposed and implemented. The salient advantage of this unique approach lies in its ability to swiftly and accurately pinpoint the pulsating spermatic artery, thus reducing the risk of injury to the vessel. Furthermore, local anesthesia offers a more patient-centric surgical experience, sidestepping the adverse effects of general anesthesia, and potentially reducing medical costs, presenting a more cost-effective and efficient treatment option. Additionally, considering the practical realities and clinical experiences in China, this innovative method proffers a fresh perspective in the treatment of varicocele and holds promise for broader clinical application. Through this research, a safer and more effective treatment alternative for patients would be provided, aiming to enhance their reproductive capabilities and overall quality of life.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>0.9% sodium chloride solution</td>
			<td>Guangdong Otsuka Pharmaceutical Co. LTD</td>
			<td>21M1204</td>
			<td>Preparation for injection of medication during surgery</td>
		</tr>
		<tr>
			<td>20 MHz Microvascular Doppler System</td>
			<td>Vascular Technology, Inc.</td>
			<td>102802</td>
			<td>Doppler ultrasound was used to identify the spermatic artery</td>
		</tr>
		<tr>
			<td>4-0 coated, Braided Silk</td>
			<td>Jiasheng Medical Products Co., Ltd</td>
			<td>1600-31</td>
			<td>Ligation of spermatic vein</td>
		</tr>
		<tr>
			<td>5-0 absorbable surgical suture</td>
			<td>HORCON</td>
			<td>MY313G4</td>
			<td>Skin and fascial suture</td>
		</tr>
		<tr>
			<td>6-0 absorbable surgical suture</td>
			<td>HORCON</td>
			<td>JE1264</td>
			<td>Deep tissue suturing</td>
		</tr>
		<tr>
			<td>Compound lidocaine cream</td>
			<td>Tongfang Pharmaceutical Group</td>
			<td>H20063466</td>
			<td>25mg of propacaine and 25mg of lidocaine per gram for epidermal infiltration anesthesia</td>
		</tr>
		<tr>
			<td>Dianerkang Iodophor Skin Disinfectant</td>
			<td>Shanghai Likang Disinfectant HI-Tech Co,Lid</td>
			<td>31005102</td>
			<td>For skin disinfection and the effective iodine content is from 4.5g/L-5.5g/L</td>
		</tr>
		<tr>
			<td>electrotome</td>
			<td>Shanghai Hutong Electronics Co., Ltd</td>
			<td>GD350-B</td>
			<td>Used to cut open the fascia layer</td>
		</tr>
		<tr>
			<td>Fosfomycin Trometamol Powder</td>
			<td>Shanxi C&#38;Y Pharmaceutical Group Co., Ltd.</td>
			<td>H19994124</td>
			<td>Oral antibiotics for infection prevention</td>
		</tr>
		<tr>
			<td>haemostatic forceps</td>
			<td>SHINVA</td>
			<td>ZH240RN</td>
			<td>Used in surgical procedures</td>
		</tr>
		<tr>
			<td>Lidocaine Hydrochloride Injection</td>
			<td>Shanghai Harvest Pharmaceutical Co., Ltd</td>
			<td>H20023777</td>
			<td>Mixed with Ropivocoine Hydrochloride injection for deep infiltration anesthesia</td>
		</tr>
		<tr>
			<td>methylene blue</td>
			<td>JUMPCAN</td>
			<td>H32025285</td>
			<td>Skin marker</td>
		</tr>
		<tr>
			<td>micro scissors</td>
			<td>SHINVA</td>
			<td>ZF123RN</td>
			<td>Used in surgical procedures</td>
		</tr>
		<tr>
			<td>micro tweezers</td>
			<td>SHINVA</td>
			<td>ZD274RN</td>
			<td>Used in surgical procedures</td>
		</tr>
		<tr>
			<td>needle holder</td>
			<td>SHINVA</td>
			<td>ZM234R/RN/RB</td>
			<td>Used in surgical procedures</td>
		</tr>
		<tr>
			<td>NeutroPhase</td>
			<td>NovaBay Pharmaceuticals,Inc</td>
			<td>CA 94608 USA</td>
			<td>Wound Cleanser</td>
		</tr>
		<tr>
			<td>ophthalmic scissors</td>
			<td>SHINVA</td>
			<td>ZC120R/RN/RB</td>
			<td>Used in surgical procedures</td>
		</tr>
		<tr>
			<td>Ropivocoine Hydrochloride injection</td>
			<td>Jiangsu Hengrui Pharmaceuticals Co., Ltd</td>
			<td>H20060137</td>
			<td>Mixed with Lidocaine Hydrochloride Injection for deep infiltration anesthesia</td>
		</tr>
		<tr>
			<td>Surgical Microscope</td>
			<td>Carl Zeiss Meditec AG</td>
			<td>20162224730</td>
			<td>for microscopic operations</td>
		</tr>
		<tr>
			<td>Titanium Clips</td>
			<td>WECK HORIZON</td>
			<td>002200</td>
			<td>used to clamp vena cava</td>
		</tr>
		<tr>
			<td>Titanium Clips</td>
			<td>WECK HORIZON</td>
			<td>005200</td>
			<td>used to clamp venule</td>
		</tr>
	</tbody>
</table>

microscopic varicocelectomy under local anesthesia as the treatment of varicocele

Varicocele, characterized by the dilation of veins within the spermatic cord, is a prevalent disease in males, accounting for 35%-40% of infertility cases among men of reproductive age. This condition may disrupt normal neuroregulation, blood supply, and temperature regulation in the testicles, thereby impacting sperm count, quality (morphology, fragmentation rate), and functionality (motility). It may even induce symptoms such as pain and testicular atrophy. The international standard treatment method is microscopic varicocelectomy, typically performed under general anesthesia. This requires patients to fast before surgery and necessitates recovery and fasting care postoperatively. The arterial blood pressure drop caused by anesthesia may obscure the fluctuation of the spermatic artery, making the precise intraoperative isolation and protection of the spermatic artery more challenging. Therefore, this study proposes and implements microscopic varicocelectomy under local anesthesia. This method facilitates rapid and precise identification of the fluctuating spermatic artery, reducing the risk of spermatic artery damage. It also provides more humane care for patients, reduces economic burden, and offers a new perspective on the treatment of varicocele.

Author Spotlight: Advancing Varicocele Treatment Through Enhanced Surgical Techniques

Microscopic Varicocelectomy under Local Anesthesia as the Treatment of Varicocele

Varicocele is linked to 35%to 40%of male infertility cases during reproductive years. The globally accepted approach for treating this condition is through a microscopic varicocelectomy conducted under general anesthesia. This protocol demonstrates this surgery using local anesthesia to improve patient comfort and reduce financial costs.This new one should significantly shorten the required surgery time and offers opportunities for patients who cannot undergo general anesthesia. Under local anesthesia, we can more clearly observe the positions of symptomatic arteriole, which helps us make more a precise resolution and protection. We will focus on the changes in the small non-encoding RNAs after the surgery, because many patients seem to improve after surgery but still cannot conceive naturally.Based on our preliminary research, we speculate that small non-encoding RNAs may play an important role in this process.

From July 2022 to May 2023, a total of 158 patients were diagnosed at our hospital with varicocele accompanied by a decline in semen quality and underwent surgery. The average age of the 158 males was 32.15 years &#177; 4.8 years (range: 21-51 years). All the males signed informed consent forms to undergo varicocelectomy under local anesthesia, with an average surgery time of 100.11 min &#177; 9.48 min. Patients experienced no significant pain during the surgery; however, 10 patients developed fat liquefaction postoperat...

Varicocele accounts for 35%-40% of infertility cases among men of reproductive age. The international standard treatment method is microscopic varicocelectomy, typically performed under general anesthesia. This study proposes and implements microscopic varicocelectomy under local anesthesia, which provides more humane care for patients and reduces the economic burden.

Varicocele, characterized by the dilation of veins within the spermatic cord, is a prevalent disease in males, accounting for 35%-40% of infertility cases ...

microscopic-varicocelectomy-under-local-anesthesia-as-treatment

Research

JoVE Journal

Medicine

Surgical Intervention Under Microscope for Treatment of Varicocele

To begin, place the patient in a supine position on the operating table. Insert a vein detained needle into the radial vein, and use an electrocardiogram monitor, to track the patient's heartbeat and blood pressure. Then use fingers to palpate the spermatic cord at the base of the scrotum, following it upwards until the external inguinal ring is felt at 1.5 centimeters above the midpoint of the inguinal ligament.After injecting local anesthesia, use hemostatic forceps to grasp the skin to assess the efficacy of anesthesia, and mark the incision site with methylene blue. Using a scalpel, make a three centimeter transverse or longitudinal incision at the external inguinal ring. Sequentially, incise the skin, the Campers fascia, and the Scarpas fascia, using an electrotome.Identify the spermatic cord, which under direct vision appears as a strip with dilated deep blue veins and the vas deferens palpable below it. Exteriorize the spermatic cord from the incision with an appendiceal retractor. Use an electrotome to dissect the cremaster muscle, and the external and internal, spermatic fascia of the cord.Under 8 to 10 x magnification, observe the pulsation of the arteries to determine their location. Carefully identify the spermatic artery, which is surrounded by small veins, has visible pulsation, and a tensed wall. Use micro scissors and forceps for blunt dissection and mark the artery with a moistened strip for identification.Identify and isolate the large spermatic veins. Use micro titanium clips to clamp both ends of the vein before cutting. Further, dissect and identify small veins adjacent to the spermatic artery.Clamp them with micro titanium clips before cutting. For vessels that are difficult to clamp with titanium clips, use 4-0 coated braided silk to perform ligation before cutting. After ligation, suture the cremaster muscle, and both the internal and external spermatic fascia, using a 6-0 absorbable surgical suture.Using this protocol, varicocelectomy was performed on 158 males, aged 21 to 51 years, diagnosed with varicocele and decreased semen quality. The average surgery time was 100.11 minutes. Post-surgery, there was a significant overall improvement in semen quality by the third month.The progressive motility rate also increased from 20.23%to 25.84%

812 Views.  Affiliated Hospital of Shanghai Institute for Biomedical and Pharmaceutical Technologies.  Varicocele accounts for 35%-40% of infertility cases among men of reproductive age. The international standard treatment method is microscopic varicocelectomy, typically performed under general anesthesia. This study proposes and implements microscopic varicocelectomy under local anesthesia, which provides more humane care for patients and reduces the economic burden.

Microsurgical Varicocele Removal Under Local Anesthesia

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