Subinguinal Microsurgical Varicocelectomy: A Technical Critique and Statistical Analysis of Semen and Pregnancy Data

Abstract

A total of 606 modified subinguinal microscopic varicocelectomies was performed on 466 outpatients using local anesthesia and sedation. The patients selected for these procedures were infertile for at least 12 months and had at least 1 semen parameter below threshold level: less than 20 million per ml., less than 50% motility or less than 40% normal morphological forms. The lymphatics, spermatic artery and vas were preserved, whereas all refluxive veins were transected or obliterated. Postoperative complications were limited to transient epididymal discomfort in 5.5% of the patients, ecchymosis at the wound site in 3.4% and wound inflammation in 2.4%. There was only 1 permanent hydrocele. The palpable recurrence rate was 0.82% per procedure. The median values for each semen parameter were compared preoperatively and postoperatively by the Wilcoxon signed rank test. The differences in the median values were significant for all parameters. As an alternative statistical model, the average preoperative semen value was subtracted from the average postoperative semen value for each parameter. The median differences were 10.8 million sperm per ml. for sperm density, 13.9% for motility and 3.8% for normal morphological forms. These differences were significantly greater than zero by the Wilcoxon signed rank test. The intra-quartile ranges for these differences suggested that postoperatively more than 75% of the patients had a difference of greater than zero for sperm density and per cent motility, and 63% had a difference of greater than zero for normal morphology. The 1-year pregnancy rate was 35.6% for 186 varicocelectomy patients compared to 15.8% for 19 medically treated men with varicocele. The difference between the true 1-year pregnancy rates was 19.8% and the 95% confidence intervals estimated bounds of 1.91 to 37.5%. These data suggest that outpatient subinguinal microscopic varicocelectomy has minimal morbidity and recurrence, and may be beneficial for select patients.