To the Editor: Varicoceles (VCs) refer to the dilation of the veins of the pampiniform plexus. The primary treatment method for VCs with definite surgical indications is the surgical treatment. With the development of minimally invasive technology, the application of microscopic subinguinal varicocelectomy (MSV) has gradually increased in recent years and has become the standard treatment method for VCs.[1] In the long-term clinical practice of our department, some young people have required surgery for VCs due to physical examination in special industries (e.g., military physical examination). They have wanted the incision to be esthetic, seamless, and concealed. With the expectation of cosmesis, we have made some improvements in the selection of the surgical incision. Using the Scar Cosmesis Assessment and Rating (SCAR) scale,[2] we comprehensively evaluated the cosmetic effects of patients undergoing improved MSV (IMSV) and MSV in this study. This retrospective study was approved by the Ethics Committee of the General Hospital of Northern Theater Command (No. Y[2022]005) and the requirement for written informed consent was waived. Left VC patients treated at the General Hospital of Northern Theater Command from January 2020 to May 2021 were included in this study. We conducted a retrospective observational cohort study involving patients with varicoceles who underwent surgery via IMSV (n= 35) or MSV (n= 26). The inclusion criteria were as follows: (1) the patients with VC who met the criteria of 2019 Edition of Chinese Guidelines for Diagnosis and Treatment of Urology and Andrology Diseases; (2) those who had good treatment compliance. The exclusion criteria were as follows: (1) patients with incomplete data; (2) patients with bilateral and right varicocele. Cosmesis was evaluated using a comprehensive survey administered ≥3 months postoperatively. The indicators included in the analysis were as follows: age; body mass index (BMI); operation time; the number of internal spermatic arteries, veins, and lymphatic vessels; early morning pain score on the first day after the operation (0–10); SCAR scale score (0–15); and postoperative patient satisfaction and comfort score (0–100; very satisfied: 80–100 points; satisfied: 60–79 points; and dissatisfied: < 60 points). Two surgeons performed all preoperative assessments, consultations, and operations. Incision selection: The patients in the IMSV group received an oblique incision 2 to 3 cm in length at the root of the scrotum [Figure 1], whereas the patients in the MSV group received a transverse incision 2 to 3 cm in length under the external inguinal ring [Figure 1]. SPSS 23.0 (SPSS Inc, Chicago, IL, USA) was used for analysis. Continuous variables with normal distribution are shown as the mean ± standard and analyzed with Student's t test. Continuous variables with skewed distribution are presented as the median (Q1,Q3) and analyzed with Mann-Whitney U test. P < 0.05 was considered statistically significant and each analysis was two-tailed.Figure 1: (A) a: Subinguinal incision. b: Incision at the scrotal root. (B) IMSV: Incision at the scrotal root after the operation. (C) MSV: Subinguinal Incision after the operation. (D) IMSV: Scrotal root incision (arrow) three months after the operation. (E) MSV: Subinguinal incision (arrow) three months after the operation. IMSV: Improved microscopic subinguinal varicocelectomy; MSV: Microscopic subinguinal varicocelectomy.The results showed no significant difference in age (IMSV υs. MSV: 22.0 [20.0, 29.0] years υs. 22.0 [19.8, 25.6] years, U= 402.0, P = 0.437) or BMI (IMSV υs. MSV: 23.0 ± 2.7 kg/m2υs. 22.7 ± 2.5 kg/m2, t = 0.439, P = 0.662) between the two groups. The results showed no significant difference in the number of spermatic arteries (IMSV υs. MSV: 2.0 [1.0,2.0] υs. 2.0 [2.0,3.0]), U = 528.0, P = 0.245) or lymphatic vessels (IMSV υs. MSV: 5.1 ± 0.8 υs. 5.3 ± 0.9, t = 0.822, P = 0.414) between the two groups, but the number of veins in the IMSV group was significantly different from that in the MSV group (IMSVυs. MSV: 13.0 [11.0,17.0] υs. 12.0 [9.0,14.0], U = 275.0, P = 0.008). The operation time was longer in the IMSV group than in the MSV group (IMSV υs. MSV: 84.2 ± 10.7 min υs. 74.5 ± 13.1 min, t = 3.179, P = 0.002). The results showed that the early morning pain score was lower in the IMSV group than that in the MSV group (IMSV υs. MSV: 3.0 ± 0.9 υs. 4.2 ± 0.9, t = 5.159, P < 0.001). The SCAR scale score was lower in the IMSV group than in the MSV group (IMSV υs. MSV: 1.0 [1.0, 2.0] υs. 2.5 [1.8, 3.3], U= 658.0, P = 0.002). Compared with those in the MSV group, the satisfaction and comfort scores of patients were significantly higher in the IMSV group (IMSV υs. MSV: 91.6 ± 8.6 υs. 83.0 ± 8.9, t= 3.744, P < 0.001). Previous publications praised the esthetic advantages of the MSV method but did not objectively study the esthetic results. There is no effective survey on the satisfaction of patients with scars after VC surgery. Kantor[2] evaluated beauty using multidimensional surveys, which proved that photos can reliably replace real-time patient assessments. Body image has a great influence on patients’ satisfaction and evaluation of the subjective benefits of surgery. Using Kantor's method, our study investigated VC patients using the SCAR scale score. VCs are the most reasonable cause of surgical correction in male infertility. Presently, the treatment of VCs can be divided into two categories: surgical treatment and interventional treatment. Although each approach has advantages and complications, the incidence of hydroceles and recurrence rate after MSV are the lowest.[3] Based on MSV, some improvements were made using the natural folds of the scrotal skin, and some unexpected benefits were obtained. There was no significant difference in age between the two groups. According to Park et al's[4] research on the selection of a kidney operation method, young people have higher beauty standards. However, our research does not show the trend of Samuel's research. The reason for this may be that the onset age of VC patients is relatively young. In the clinical practice of our hospital, surgical incisions of IMSV are made at the skin fold at the root of the scrotum and are oblique incisions approximately 2 to 3 cm in length. Compared with MSV, our technique can alleviate the postoperative pain of patients. A possible reason for this is that our surgical technique avoids damaging the inguinal canal. Additionally, the spermatic cord is more superficial, the subcutaneous fat layer is thinner, the surrounding connective tissue is looser, and there is less pulling of the spermatic cord. All operations were carried out using a microscope at 8 to 10 × magnification. After exposing the internal spermatic vein, the arterial pulsation area was carefully observed to find the most vital arterial pulsation point. The testicular artery was confirmed and protected by arterial pulsation. At the same time, delicate operation principles should be followed when separating spermatic vessels. There are usually 1–3 arteries,[5] which are in line with our observations. To preserve the artery to the maximum extent, tying the remaining spermatic vessels in bundles after finding one artery is not recommended. Lymphatic vessels are transparent and easy to identify under a microscope. After finding arteries and lymphatic vessels, they are marked and protected with silk thread, and the veins are ligated one by one. Usually, the higher the position of the spermatic vein is, the lower the number of branches,[5] as found in our study. In the whole operation, ligation was performed on the same plane perpendicular to the spermatic cord to avoid missing veins and damaging arteries. Because the surgical incision is located at the scrotal skin fold and to achieve a better cosmetic effect, we usually use subcutaneous sutures. Over time, the natural folds of the scrotum, growth of pubic hair, pigmentation of the scrotum, and self-healing of the incision conceal the surgical incision. We evaluated this result objectively with the SCAR scale score which was higher in the IMSV group. A custom-made 100–point questionnaire revealed that the satisfaction and comfort scores of patients were higher in the IMSV group than in the MSV group. Unfortunately, the IMSV slightly prolonged the operation time. We thought about this problem and analyzed it. In fact, the operation time can be shortened by the operator's more skilled operation and by ligating veins in a cluster. Maybe there are other ways for us to further shorten the operation. In addition, we discussed some other advantages. Because the incision is located closer to the testicle, the ligation of VCs can be performed simultaneously with other procedures, such as ligation of the leading testicular vein, sperm extraction by a testicular incision under a microscope, and removal of testicular hydroceles, without the need for an additional incision. We are aware of some limitations of our research. First, this study is a small nonrandom analysis conducted at a single institution, introducing possible bias in baseline data and views on cosmetic appearance. In addition, the IMSV is not a complete improvement; this was also not our original intention. The main research direction of this study was esthetics. Finally, we did not use Doppler to explore all the arterioles. Usually, we can determine the location of arteries by arterial pulsation. When arterial pulsation disappears, the location of arteries can be judged by the alternating strength of blood vessels. If this does not work, we usually use the surface instillation of papaverine to restore arterial pulsation. Despite these limitations, there is no doubt that these findings provide valuable insights into the cosmetic effect of treatment in VC patients. Multicentre and large-sample prospective studies will be needed to further evaluate and/or confirm these findings. In summary, IMSV has a better cosmetic effect than MSV. Considering the greater scar satisfaction achieved with IMSV, we infer that this surgical method is better for patients with higher cosmetic standards. Funding This work was supported by the grant from 2018 National Key Research & Development Plan Foundation (No. SQ2018YFC10002704). Conflicts of interest None.