Microsurgical subinguinal varicocelectomy in children, adolescents, and adults: surgical anatomy and anatomically justified technique

Abstract

Microsurgical varicocelectomy has become the gold standard in adults because of low recurrence and postoperative hydrocele rates; it is increasingly applied in children and adolescents. This review aims to provide the surgeon with the necessary surgical anatomy of the spermatic cord and with a step-by-step, anatomically justified description of technique, toward clearer comprehension and improved application. The anatomic compartments of the spermatic cord are delineated by the external and internal spermatic fasciae. Venous drainage of testis-epididymis is accomplished by the internal spermatic, deferential, and external spermatic (cremasteric) veins. All 3 anastomose at the caudal pole of testis, and then via gubernacular veins with the posterior scrotal veins. Another anastomosis exists between a cremasteric branch and anterior scrotal veins, which gives the external pudendal vein. Subinguinal approach offers access to varicose spermatic veins and collaterals. Use of surgical microscope offers identification of small veins, preservation of arteries, lymphatics, and nerves, and appreciation of spermatic cord fasciae, which permits the development of two surgical planes. In the surgical plane of internal spermatic vessels, internal spermatic veins are ligated, whereas the testicular artery and innervation, as well as lymphatics, are preserved. In the plane of cremasteric vessels and vas, cremasteric veins are ligated, whereas the cremasteric artery, vas deferens and its vasculature, lymphatics, and the genital branch of genitofemoral nerve are preserved. Delivery of the testis to ligate gubernacular veins is at the discretion of the surgeon. Finally, venous return is effected by deferential and scrotal veins, or, when gubernacular veins are ligated, by deferential veins only.