Treatment of Varicocele Using a Single Scrotal Access: Our Experiance on 55 patients
Antonio Cutrupi*, M. Barbalace, C. Covani , S. Malavenda. PMDC, Policlinic Hospital Mother of Consolation, Reggio
Department of Paediatric Surgery.
Paediatric and Neonatal Surgery Unit, Paediatric Urology.
In this study, we present our experience on 55 patients affected by varicocele and treated underwent surgery with a scrotal access. 55
patients were enrolled with clinical palpable and infraclinical (ultrasonic Doppler scanning) varicocele. They all underwent scrotal
varicocelectomy under general anaesthesia. At 6 months, no other complications were reported. No case of testicular atrophy was
observed. None had recurrence of varicocele. Scrotal access with general anaesthesia is a safe and useful technique to treat patients
with varicocele in the paediatric population.
Varicocele, Scrotal Access, Infertility, Paediatric population.
Varicocele is a common abnormality with the following
andrological implications: failure of ipsilateral testicular
growth and development, male infertility symptoms
of pain and discomfort. It is commonly believed that this
condition may begin with the onset of puberty, at around the
prepubertal – pubertal age.All varicoceles are left-sided,
and this is explained by turbulent venous flow related to the
right angle insertion of the left testicular vein into the left
The exact association between reduced male fertility
and varicocele is unknown, but a meta-analysis showed that semen
improvement is usually observed after surgical correction
  Varicocele is associated with increased sperm DNA damage,
and this sperm pathology may be secondary to varicocele
-mediated oxidative stress. Physical examinations and scrotal
ultrasounds remain the most commonly used methods. Varicocele
is graded at the time of the initial physical examination according
to the Dubin – Amelar grading system (I–III) .Several
surgical approaches to varicocelectomy exist, each with its own
advantages and drawbacks:
varicocele embolization, the traditional inguinal
(Ivanissevich), or high retroperitoneal (Palomo) approaches,
laparoscopic repair and microsurgical repair via an inguinal,
or subinguinal incision. Complications of varicocele repair
include hydrocele formation, persistence or recurrence of the
varicocele, and rarely testicular atrophy  .Although no specific
recommendations exist as to the optimal surgical technique
for varicocelectomy, the use of magnification to preserve
lymphatics and testicular arteries is recommended.
We strongly believe that microsurgical varicocelectomy
is the gold-standard technique for varicocelectomy in
adolescents, due to lower postoperative recurrence and complication
rates compared to other techniques .However, surgery
via a scrotal approach was not widespread due to the
difficulty of preserving the arterial supply of the testis because
the pampiniform plexus of veins encoils the testicular artery
at the level of the scrotum. By the way we think that scrotal
access is useful in the management of varicocelectomy in
order to avoid two surgical incisions and it can be a valid
2. Materials and Methods
We enrolled in our study, from July 2012 to December 2014, 55 adolescents’ patients with clinical palpable and infraclinical
(ultrasonic doppler scanning) varicocele. They underwent scrotal microsurgical varicocelectomy. Before surgery all the patients
underwent a complete physical examination, including supine and standing scrotal examition and a color doppler ultrasound examination.
Under general anesthesia, a single incision was made on the ipsilateral scrotum. (Figure1).
Figure 1: A scrotal incision was done.
Dartos fascia was open, and left testis was exposed by opening the tunica vaginalis, a resection and eversion of the tunica vaginalis
Figure 2: Exposure of left testis. Figure 3: A resection and eversion of the tunica vaginalis was performed.
The left spermatic cord was exposed more proximally until the external inguinal ring and at this level the cremasteric and internal
spermatic fascia were opened longitudinally with the exposure of the testicular vein. In this case we performed an en block ligation
of the anterior spermatic venous plexus using an absorbable suture (2.0 vicryl) (Figure 5-6). In our opinion preserving the
cremasteric and deferential arteries is enough to supply vascularization to the testis in cases wher the testicular artery is damaged.
The patients were discharged on the following day unless any complications occurred in which case discharge was delayed. Complications
if any were recorded. Follow up was advised at 1 week, 1 month, 3 and 6 months. Skin was closed using 5 stiches in
absorbable suture 4.0 Vicryl R. Surgery for testis lasted 30 minutes.
Figure 5-6: Ligation of the anterior spermatic venous plexus
3. Results and Discussion
All patients were evaluated at 1 week, at 1, 3 and 6
months after the operation by means of physical examination,
scrotal Doppler ultrasound, and sperm analysis ( where possible).None
of the patients reported pain at 3-month followup.Edema
of the spermatic cord occurred in 9pts with spontaneous
regression aftert 2,5 - weeks follow up.At 6 months
no other complications were reported.No case of testicular atrophy
was observed.None had recurrence of varicocele.In our
opinion scrotal ( sub inguinal )varicocelectomy is the best approach
for unilateral varicocele because it has the advantage of
allowing the spermatic cord structures to be pulled up and out
of the wound so that the testicular artery, lymphatics, and small
periarterial veins may be more easily identified and preserved.
However, anatomic studies have proved that the diameter of
the testicular artery is the main blood supply to the testis being
greater than the diameter of the deferential artery and cremasteric
artery combined .
In addition, subinguinal approach allows access to external spermatic
and even gubernacular veins, which may bypass the spermatic
cord and result in recurrence if not ligated.
4. Conclusions :
In our opinion varicocele repair must be proposed in young
adult men with impairment of seminal parameters. Patients
with varicocele prefer a single incision. When the incision is
made on the scrotum, no unaesthetic scars remain. The single
approach reduces invasiveness and increases patients and relatives
- Dubin, L., Amelar, R.D.( 1971) Etiologic factors in 1294
consecutive cases of male infertility. Fertil Steril.;22:469–474.
- Diamond, D.A., Paltiel, H.J., DiCanzio, J. et al, (2000) Comparative
assessment of pediataric testicular volume: orchidometer
versus ultrasound. J Urol.;164:1111–1114.
- Castro-Magana, M., Angulo, M., Canas, A., Uy, J.(1990)
Leydig cell function in adolescent boys with varicoceles. Arch
- Haans, L.C., Laven, J.S., Mali, W.P., te Velde, E.R., Wensing,
C.J.(1991)Testis volumes, semen quality, and hormonal
patterns in adolescents with and without a varicocele. Fertil
- Sayfan, J., Siplovich, L., Koltun, L., Benyamin, N.(1997)
Varicocele treatment in pubertal boys prevents testicular
growth arrest. J Urol.157:1456–1457.
- Kass, E.J., Marcol, B.(1992) Results of varicocele surgery
in adolescents: a comparison of techniques. J Urol.
- Marsuda, T., Horii, Y., Yoshida, O (1993) Should the
testicular artery be preserved at varicocelectomy?. J Urol. 149:1357–1360.
- Goldstein M, Gilbert BR, Dicker AP, et al.(1992) Microsurgical
inguinal varicocelectomy with delivery of the testis: an artery
and lymphatic sparing technique. J Urol Dec;148(6):1808-11.
- Barbalce M, Cutrupi A, Salcuni M, Albanese G, Scafidi R,
Romeo A, Zema D, (2003)adiologic embolization for paediatric
varicocele: Should we abandon traditional and mininvasive
surgical approach? BAPS Leeds Annual Meeting.