Intraoperative Varicocele Anatomy: A Macroscopic and Microscopic Study

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Abstract
Varicoceles are found in approximately 15% of all men in the general population and up to 41% of all infertile men. However, the exact location and relationship of internal and external spermatic arteries, veins and lymphatics within the inguinal portion of the spermatic cord have not been previously well described in infertile men. The results of detailed intraoperative macroscopic and microscopic surgical dissections of the spermatic cord and gubernaculum of 83 infertile men with 115 palpable varicoceles are described. Enlarged veins exiting the testis and traversing the gubernaculum were present in 48% of the dissections. Enlarged external spermatic veins were detected in 74% of all spermatic cords. Typically, small internal spermatic veins drained into a large vein more proximally in the spermatic cord. An average of 3.6 lymphatics per spermatic cord was identified and preserved during the dissections. A solitary testicular artery was observed in 69% of the dissections. The testicular artery was adherent to the posterior surface of a large internal spermatic vein in 50% of the dissections and was surrounded by a dense complex of closely adherent veins in 30%. To decrease the incidence of postoperative varicocele recurrences we suggest a surgical approach that addresses all identifiable dilated and connecting veins. These findings suggest that surgical approaches that include intraoperative access to and ligation of low inguinal (external spermatic) and gubernacular veins may cause fewer recurrences, unligated small internal spermatic veins may be a cause of varicocele recurrence, and large internal spermatic veins should be individually identified, dissected and ligated since the testicular artery and lymphatics are often adherent to these veins. Optical magnification is important to facilitate identification of lymphatics, testicular arteries and small internal spermatic veins.