Microscopic Varicocelectomy under Local Anesthesia as the Treatment of Varicocele

Summary

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.

Abstract

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.

Introduction

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 adopted^3,4. 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.

Protocol

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 °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

1. 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.

2. Patient preparation

1. Perform preoperative skin preparation.
   1. 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).
2. 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's heartbeat and blood pressure.
3. Disinfect the surgical area using Iodophor solution and cover it with sterile drapes.

3. Microscopic varicocelectomy

1. 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.
2. 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).
3. 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).
4. Make a 3 cm transverse incision at the external inguinal ring using a scalpel. Sequentially, incise the skin, the Camper's fascia, and the Scarpa's fascia using an electrotome.
5. 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'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).
   1. Use an electrotome to dissect the cremaster muscle and the external and internal spermatic fascia of the cord.
   2. Under 8-10x magnification, observe the pulsation of the arteries to determine their location.
   3. 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).
   4. Identify and isolate the large spermatic veins. Use micro-titanium clips to clamp both ends before cutting (Figure 6).
   5. 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.
   6. Ligate all varicose veins, ensuring at least one normal vein is preserved for venous return (Figure 7).
6. 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).

4. Postoperative care

1. Apply a 1 kg sandbag for compression and hemostasis 1 h postoperatively.
2. Administer oral antibiotics postoperatively (fosfomycin trometamol powder, 3 g) for infection prevention. Administer anti-inflammatory analgesic suppositories rectally if postoperative pain is observed.
3. Change the dressing in 3 days and remove the stitches in 7 days.
4. Conduct a semen examination after 1 month.

Results

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 ± 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 ± 9.48 min. Patients experienced no significant pain during the surgery; however, 10 patients developed fat liquefaction postoperatively, with semen quality reassessed in the third-month post-surgery.

In the final statistical analysis, 130 patients (82.4%, 130/158) were included. The preoperative sperm concentration was 21.53 (0.6-125.2) × 10⁶/mL, and the postoperative sperm concentration significantly increased to 41.94 (2-255.2) × 10⁶/mL (p < 0.001). The progressive motility rate (a%+b%) before surgery was 20.23% ± 13.85%, and it increased to 25.84% ± 15.99% postoperatively (p < 0.01) (Table 1). There was a noticeable improvement in semen quality in patients three months after the surgery.

Figure 1: Local application of compound lidocaine cream. Please click here to view a larger version of this figure.

Figure 2: The surgical incision. (A) Hemostatic forceps are used to grasp the skin to assess anesthesia efficacy. (B) Methylene blue is used to mark the incision site. Please click here to view a larger version of this figure.

Figure 3: Layer-by-layer infiltration of anesthesia. Please click here to view a larger version of this figure.

Figure 4: Fixing the spermatic cord using a ruler. Please click here to view a larger version of this figure.

Figure 5: Identifying the spermatic artery with Doppler ultrasound. Please click here to view a larger version of this figure.

Figure 6: Usage of the micro-titanium clips to clamp both ends before cutting. Please click here to view a larger version of this figure.

Figure 7: Ligature of all varicose veins with one preserved for venous return. Please click here to view a larger version of this figure.

Figure 8: Closing of the incision. Please click here to view a larger version of this figure.

Parameters			Value	p value
Patients (total) (n)			158
Age (years), Mean ± standard deviation (range)			32.15 ± 4.8 (21-51)
Operation time (min), Mean ± standard deviation			100.11 ± 9.48
Patients included in data analysis, n (%)			130 (82.4)
Preoperative sperm concentration (millions/mL), Mean ± standard deviation (range)			21.53 (0.6~125.2)	< 0.001
Postoperative sperm concentration (millions/mL), Mean ± standard deviation (range)			41.94 (2~255.2)
Preoperative progressive motility rate, Mean ± standard deviation (range)			20.23 ± 13.85	<0.01
Postoperative progressive motility rate, Mean ± standard deviation (range)			25.84 ± 15.99

Table 1: Characteristics of patients who underwent microscopic varicocelectomy under local anesthesia.

Discussion

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 repair on semen parameters⁷, pregnancy outcomes⁸, and reproductive hormones. Besides in infertile patients, varicocelectomy is also performed in adolescent patients with chronic testicular pain and/or testicular growth arrest. Laparoscopic varicocelectomy is the widely accepted method, but hydrocele is a common complication¹⁰.

In recent years, microsurgical varicocelectomy has gradually become the "gold standard" treatment for varicocele¹¹. Compared to traditional treatments, this technique has obvious advantages, including fewer postoperative complications, a lower recurrence rate, minimal invasiveness, and rapid postoperative recovery^12,13,14. However, many physicians still opt to perform this surgery under general anesthesia. The application of general anesthesia requires patients to fast preoperatively, resulting in a longer postoperative recovery, and the potential drop in arterial blood pressure during anesthesia can increase the difficulty in isolating and protecting the spermatic artery during surgery.

Given these challenges, this study proposes and practices a microsurgical varicocelectomy technique under local anesthesia. The implementation of this method only requires two applications of compound lidocaine cream in the ward for epidermal anesthesia, followed by infiltrative anesthesia in the operating room. This new technique significantly shortens the required surgery time, avoids the complexities and risks of general anesthesia, and offers new surgical opportunities for patients with cardiopulmonary issues who cannot undergo general anesthesia. Furthermore, under local anesthesia, the surgeon can more clearly observe the pulsations of the spermatic artery, enabling more precise isolation and protection. This not only effectively reduces surgical risks but also genuinely promotes the widespread adoption of the surgical technique.

The local anesthesia used in this study also reflects a more patient-centered care approach, reducing postoperative discomfort and economic burden. Postoperative follow-up data indicate that, three months after the surgery, the patient's semen quality had significantly improved. However, there are limitations to this technique. Patients might still feel a pulling sensation during the surgery, which could potentially impact its completion. Additionally, this study did not directly compare with the traditional microsurgical varicocelectomy technique, representing another significant limitation. Furthermore, the limitations of this surgery require good patient cooperation, making it unsuitable for children under the age of 14 who cannot cooperate. Nonetheless, with further research and practice, this technique will gain broader acceptance and application.

In conclusion, microsurgical varicocelectomy under local anesthesia provides a new perspective for the treatment of varicocele, showcasing its potential value and advantages. In the future, with continued research and technological advancement, this technique holds promise to bring improved therapeutic outcomes and a higher quality of life for more varicocele patients.

Materials

List of materials used in this article

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