Is There Any Role for Indocyanine Green Angiography in Testicular Artery Preservation During Microsurgical Subinguinal Varicocelectomy?

  • Chak-Lam Cho


Varicocelectomy is the most commonly performed surgery for the correction of male factor subfertility. Microsurgical subinguinal varicocelectomy (MSV) is generally considered the gold standard nowadays in view of the lower risk of complications and recurrence. To achieve complete ligation of veins while preserving testicular artery during the procedure remains challenging despite the application of high-power optical magnification and micro-Doppler ultrasonography. The application of indocyanine green (ICG) angiography with infrared fluorescence operative microscope in MSV potentially lowers the incidence of testicular arterial injury by providing high-contrast real-time images on vascular anatomy. Arteries of 1 mm diameter or less are demonstrated on angiographic images. Testicular, cremasteric, and deferential arteries are clearly visualized within 1 min upon ICG injection. The short half-life and low risk of adverse reaction of ICG allow repeated administration without compromising the quality of images. The administration of ICG is simple and quick. The interpretation of angiography is often straightforward. The clear angiographic images are particularly helpful for documentation and training purposes. Technical advances in intraoperative ICG angiography includes ICG dynamics and novel operating platforms. The innovations may prove their role in clinical application in the near future. In summary, the use of intraoperative ICG angiography facilitates early testicular artery visualization and may potentially decrease the incidence of testicular artery injury during varicocelectomy. The technique represents a valuable adjunct to the procedure of varicocelectomy and may shorten the learning curve of novice surgeons.


Varicocele Varicocelectomy Microsurgery Indocyanine green Angiography 


  1. 1.
    Clarke BG. Incidence of varicocele in normal men and among men of different ages. JAMA. 1966;198:1121–2.CrossRefGoogle Scholar
  2. 2.
    Gorelick JI, Goldstein M. Loss of fertility in men with varicocele. Fertil Steril. 1993;59:613–6.CrossRefGoogle Scholar
  3. 3.
    Witt MA, Lipshultz LI. Varicocele: a progressive or static lesion? Urology. 1993;42:541–3.CrossRefGoogle Scholar
  4. 4.
    Sabanegh E, Agarwal A. Male infertility. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. Campbell’s urology. 10th ed. Philadelphia: WB Saunders; 2012. p. p616–47.CrossRefGoogle Scholar
  5. 5.
    Diegidio P, Jhaveri JK, Ghannam S, Pinkhasov R, Shabsigh R, et al. Review of current varicocelectomy techniques and their outcomes. BJU Int. 2011;108:1157–72.CrossRefGoogle Scholar
  6. 6.
    Hopps CV, Leder ML, Schlegel PN, Goldstein M. Intraoperative varicocele anatomy: a microscopic study of the inguinal versus subinguinal approach. J Urol. 2003;170:2366–70.CrossRefGoogle Scholar
  7. 7.
    Marmar JL, Kim Y. Subinguinal microsurgical varicocelectomy: a technical critique and statistical analysis of semen and pregnancy data. J Urol. 1994;152:1127–32.CrossRefGoogle Scholar
  8. 8.
    Al-Kandari AM, Shabaan H, Ibrahim HM, Elshebiny YH, Shokeir AA. Comparison of outcomes of different varicocelectomy techniques: open inguinal, laparoscopic, and subinguinal microscopic varicocelectomy: a randomized clinical trial. Urology. 2007;69:411–20.Google Scholar
  9. 9.
    Zini A. Varicocelectomy: microsurgical subinguinal technique is the treatment of choice. Can Urol Assoc J. 2007;1:273–6.PubMedPubMedCentralGoogle Scholar
  10. 10.
    Chan PT, Wright EJ, Goldstein M. Incidence and postoperative outcomes of accidental ligation of the testicular artery during microsurgical varicocelectomy. J Urol. 2005;173:482–4.CrossRefGoogle Scholar
  11. 11.
    Wosnitzer M, Roth JA. Optical magnification and Doppler ultrasound probe for varicocelectomy. Urology. 1983;22:24–6.CrossRefGoogle Scholar
  12. 12.
    Oettle AG, Harrison RG. The histological changes produced in the rat testis by temporary and permanent occlusion of the testicular artery. J Pathol Bacteriol. 1952;64:273–97.CrossRefGoogle Scholar
  13. 13.
    Silber SJ. Microsurgical aspects of varicocele. Fertil Steril. 1979;31:230–2.CrossRefGoogle Scholar
  14. 14.
    Matsuda T, Horii Y, Yoshida O. Should the testicular artery be preserved at varicocelectomy? J Urol. 1993;149:1357–60.CrossRefGoogle Scholar
  15. 15.
    Raman JD, Goldstein M. Intraoperative characterization of arterial vasculature in spermatic cord. Urology. 2004;64:561–4.CrossRefGoogle Scholar
  16. 16.
    Cocuzza M, Pagani R, Coelha R, Srougi M, Hallak J. The systematic use of intraoperative vascular Doppler ultrasound during microsurgical subinguinal varicocelectomy improves precise identification and preservation of testicular blood supply. Fertil Steril. 2010;93:2396–9.CrossRefGoogle Scholar
  17. 17.
    Beck EM, Schlegel PN, Goldstein M. Intraoperative varicocele anatomy: a macroscopic and microscopic study. J Urol. 1992;148:1190–4.CrossRefGoogle Scholar
  18. 18.
    United States Food and Drug Administration. Approval of “IC-Green”. [Online]. Accessed August 2018.
  19. 19.
    Hope-Ross M, Yannuzzi LA, Gragoudas ES, Guyer DR, Slakter JS, et al. Adverse reactions due to indocyanine green. Ophthalmology. 1994;101:529–33.CrossRefGoogle Scholar
  20. 20.
    Alander JT, Kaartinen I, Laakso A, Patila T, Spillmann T, et al. A review of indocyanine green fluorescent imaging in surgery. Int J Biomed Imaging. 2012;2012:940585.CrossRefGoogle Scholar
  21. 21.
    Bates AS, Patel VR. Applications of indocyanine green in robotic urology. J Robotic Surg. 2016;10:357–9.CrossRefGoogle Scholar
  22. 22.
    Shibata Y, Kurihara S, Arai S, Kato H, Suzuki T, et al. Efficacy of indocyanine green angiography on microsurgical subinguinal varicocelectomy. J Investig Surg. 2016;0:1–5.Google Scholar
  23. 23.
    Cho CL, Ho KL, Chan WK, Chu RW, Law IC. Use of indocyanine green angiography in microsurgical subinguinal varicocelectomy - lessons learned from our initial experience. Int Braz J Urol. 2017;43:974–9.CrossRefGoogle Scholar
  24. 24.
    Boni L, David G, Mangano A, Dionigi G, Rausei S, et al. Clinical applications of indocyanine green (ICG) enhanced fluorescence in laparoscopic surgery. Surg Endosc. 2015;29:2046–55.CrossRefGoogle Scholar
  25. 25.
    Brahmbhatt JV, Gudeloglu A, Liverneaux P, Parekattil SJ. Robotic microsurgery optimization. Arch Plast Surg. 2014;41:225–30.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Chak-Lam Cho
    • 1
  1. 1.S.H. Ho Urology Centre, Department of SurgeryPrince of Wales Hospital, The Chinese University of Hong KongShatinHong Kong

Personalised recommendations