Is There Any Role for Intraoperative Ultrasound During Varicocele Repair?

  • João Paulo Cardoso
  • Marcello Antonio Signorelli CocuzzaEmail author


Doppler ultrasound assistance has been part of the surgical treatment of varicocele for the past decades. The development of microscopic subinguinal varicocelectomy has provided the surgical management of varicocele with precision, by facilitating less postoperative pain and shorter time for recovery and lower rates of complications and recurrence. Nevertheless, vascular anatomy of the subinguinal access represents a challenge and contributes to the technical difficulty of this approach. Branching of the testicular artery is usually seen at the subinguinal level, and the small spermatic arteries are frequently surrounded by a dense complex of adherent veins, requiring special attention of the surgeons. Optical magnification, precise microsurgery skills, and vascular Doppler have been used at this point to achieve maximal preservation of the arterial blood supply to the testes and to aid in the identification of cord structures. Doppler ultrasound represents a major assistance in preserving testicular arterial inflow and may allow a larger number of veins to be identified and ligated. The clinical implication of these findings can be supported by recent studies showing a significant correlation between the total number of veins ligated and the improvements in total sperm motility and sperm concentration.


Varicocele Varicocelectomy Doppler Ultrasound Microsurgery 


  1. 1.
    Thonneau P, Marchand S, Tallec A, et al. Incidence and main causes of infertility in a resident population (1 850 000) of three french regions (1988-1989). Hum Reprod. 1991;6(6):811–6.CrossRefGoogle Scholar
  2. 2.
    Madgar I, Weissenberg R, Lunenfeld B, Karasik A, Goldwasser B. Controlled trial of high spermatic vein ligation for varicocele in infertile men. Fertil Steril. 1995;63(1):120–4.CrossRefGoogle Scholar
  3. 3.
    The influence of varicocele on parameters of fertility in a large group of men presenting to infertility clinics. World Health Organization. Fertil Steril. 1992;57(6):1289–93.CrossRefGoogle Scholar
  4. 4.
    Dubin L, Amelar RD. Varicocelectomy: 986 cases in a twelve-year study. Urology. 1977;10(5):446–9.CrossRefGoogle Scholar
  5. 5.
    Saleh RA, Agarwal A. Oxidative stress and male infertility: from research bench to clinical practice. J Androl. 2002;23(6):737–52.PubMedGoogle Scholar
  6. 6.
    Agarwal A, Deepinder F, Cocuzza M, et al. Efficacy of varicocelectomy in improving semen parameters: new meta-analytical approach. Urology. 2007;70(3):532–8.CrossRefGoogle Scholar
  7. 7.
    Baazeem A, Belzile E, Ciampi A, et al. Varicocele and male factor infertility treatment: a new meta-analysis and review of the role of varicocele repair. Eur Urol. 2011;60(4):796–808.CrossRefGoogle Scholar
  8. 8.
    Ficarra V, Cerruto MA, Liguori G, et al. Treatment of varicocele in subfertile men: the cochrane review - a contrary opinion. Eur Urol. 2006;49(2):258–63.CrossRefGoogle Scholar
  9. 9.
    Marmar JL, Agarwal A, Prabakaran S, et al. Reassessing the value of varicocelectomy as a treatment for male subfertility with a new meta-analysis. Fertil Steril. 2007;88(3):639–48.CrossRefGoogle Scholar
  10. 10.
    PALOMO A. Radical cure of varicocele by a new technique; preliminary report. J Urol. 1949;61(3):604–7.CrossRefGoogle Scholar
  11. 11.
    Cayan S, Shavakhabov S, Kadioğlu A. Treatment of palpable varicocele in infertile men: a meta-analysis to define the best technique. J Androl. 2009;30(1):33–40.CrossRefGoogle Scholar
  12. 12.
    Marmar JL, DeBenedictis TJ, Praiss D. The management of varicoceles by microdissection of the spermatic cord at the external inguinal ring. Fertil Steril. 1985;43(4):583–8.CrossRefGoogle Scholar
  13. 13.
    Hopps CV, Lemer ML, Schlegel PN, Goldstein M. Intraoperative varicocele anatomy: a microscopic study of the inguinal versus subinguinal approach. J Urol. 2003;170(6. Pt 1):2366–70.CrossRefGoogle Scholar
  14. 14.
    Wosnitzer M, Roth JA. Optical magnification and Doppler ultrasound probe for varicocelectomy. Urology. 1983;22(1):24–6.CrossRefGoogle Scholar
  15. 15.
    Goldstein M, Gilbert BR, Dicker AP, Dwosh J, Gnecco C. Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique. J Urol. 1992;148(6):1808–11.CrossRefGoogle Scholar
  16. 16.
    Silber SJ. Microsurgical aspects of varicocele. Fertil Steril. 1979;31(2):230–2.CrossRefGoogle Scholar
  17. 17.
    Mehta A, Goldstein M. Microsurgical varicocelectomy: a review. Asian J Androl. 2013;15(1):56–60.CrossRefGoogle Scholar
  18. 18.
    Cayan S, Kadioglu TC, Tefekli A, Kadioglu A, Tellaloglu S. Comparison of results and complications of high ligation surgery and microsurgical high inguinal varicocelectomy in the treatment of varicocele. Urology. 2000;55(5):750–4.CrossRefGoogle Scholar
  19. 19.
    Chan PT, Wright EJ, Goldstein M. Incidence and postoperative outcomes of accidental ligation of the testicular artery during microsurgical varicocelectomy. J Urol. 2005;173(2):482–4.CrossRefGoogle Scholar
  20. 20.
    Steinberger E, Tjioe DY. Spermatogenesis in rat testes after experimental ischemia. Fertil Steril. 1969;20(4):639–49.CrossRefGoogle Scholar
  21. 21.
    Yaman O, Soygur T, Zumrutbas AE, Resorlu B. Results of microsurgical subinguinal varicocelectomy in children and adolescents. Urology. 2006;68(2):410–2.CrossRefGoogle Scholar
  22. 22.
    Minevich E, Wacksman J, Lewis AG, Sheldon CA. Inguinal microsurgical varicocelectomy in the adolescent: technique and preliminary results. J Urol. 1998;159(3):1022–4.CrossRefGoogle Scholar
  23. 23.
    Grober ED, Chan PT, Zini A, Goldstein M. Microsurgical treatment of persistent or recurrent varicocele. Fertil Steril. 2004;82(3):718–22.CrossRefGoogle Scholar
  24. 24.
    Grober ED, O'brien J, Jarvi KA, Zini A. Preservation of testicular arteries during subinguinal microsurgical varicocelectomy: clinical considerations. J Androl. 2004;25(5):740–3.CrossRefGoogle Scholar
  25. 25.
    Matsuda T, Horii Y, Yoshida O. Should the testicular artery be preserved at varicocelectomy? J Urol. 1993;149(5 Pt 2):1357–60.CrossRefGoogle Scholar
  26. 26.
    Student V, Zátura F, Scheinar J, Vrtal R, Vrána J. Testicle hemodynamics in patients after laparoscopic varicocelectomy evaluated using color Doppler sonography. Eur Urol. 1998;33(1):91–3.CrossRefGoogle Scholar
  27. 27.
    Belani JS, Yan Y, Naughton CK. Does varicocele grade predict vein number and size at microsurgical subinguinal repair? Urology. 2004;64(1):137–9.CrossRefGoogle Scholar
  28. 28.
    Taylor KJ, Holland S. Doppler US. Part I. basic principles, instrumentation, and pitfalls. Radiology. 1990;174(2):297–307.CrossRefGoogle Scholar
  29. 29.
    Greenberg SH. Doppler ultrasound for localization of testicular artery during varicocelectomy. Urology. 1981;17(5):480.CrossRefGoogle Scholar
  30. 30.
    Ramadan AE, Eldemiry MI. Doppler-controlled varicocelectomy. Br J Urol. 1984;56(4):432–3.CrossRefGoogle Scholar
  31. 31.
    Cocuzza M, Pagani R, Coelho 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(7):2396–9.CrossRefGoogle Scholar
  32. 32.
    Pasqualotto FF, Lucon AM, de Góes PM, et al. Relationship between the number of veins ligated in a varicocelectomy with testicular volume, hormonal levels and semen parameters outcome. J Assist Reprod Genet. 2005;22(6):245–9.CrossRefGoogle Scholar
  33. 33.
    Shindel AW, Yan Y, Naughton CK. Does the number and size of veins ligated at left-sided microsurgical subinguinal varicocelectomy affect semen analysis outcomes? Urology. 2007;69(6):1176–80.CrossRefGoogle Scholar
  34. 34.
    Guo L, Sun W, Shao G, et al. Outcomes of microscopic subinguinal Varicocelectomy with and without the assistance of Doppler ultrasound: a randomized clinical trial. Urology. 2015;86(5):922–8.CrossRefGoogle Scholar
  35. 35.
    Watanabe M, Nagai A, Kusumi N, Tsuboi H, Nasu Y, Kumon H. Minimal invasiveness and effectivity of subinguinal microscopic varicocelectomy: a comparative study with retroperitoneal high and laparoscopic approaches. Int J Urol. 2005;12(10):892–8.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • João Paulo Cardoso
    • 1
  • Marcello Antonio Signorelli Cocuzza
    • 1
    Email author
  1. 1.Department of UrologyHospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São PauloSao PauloBrazil

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