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 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.
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.
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
2. Patient preparation
3. Microscopic varicocelectomy
4. Postoperative care
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.
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 recovery12,13,14. 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.
The authors have nothing to disclose.
No funding sources.
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 |