No funding sources.

This research is approved by the Affiliated Hospital of the Shanghai Institute for Biomedical and Pharmaceutical Technologies, and the ethics number is 2022001. Written informed consent was obtained from the human subjects to participate in the study. The inclusion criteria were: (1) Diagnosis of varicocele by clinical ultrasound; (2) Age between 20 and 40 years old; (3) Abnormalities detected in semen examination, indicating the need for surgery and consent to undergo the procedure. The exclusion criteria were: (1) Abnormal fever exceeding 38.5 &#176;C within the past 6 months; (2) Presence of major illnesses such as tumors, severe heart, lung, liver, and kidney dysfunction, and mental illnesses. The reagents and equipment needed for this procedure are listed in the Table of Materials.
1. Instrumentation
<ol>
	<li>Ensure the availability of sterilized instruments and other equipment needed for surgery, including the following specific important items: surgical microscope, titanium clips, and microscopic instruments.</li>
</ol>
2. Patient preparation
<ol>
	<li>Perform preoperative skin preparation.
	<ol>
		<li>Apply compound lidocaine cream to cover an area from the anterior superior iliac spine laterally, inferiorly to the level of the pubic tubercle, and superiorly up to 3 cm below the umbilical line 1 h preoperatively (see Figure 1).</li>
	</ol>
	</li>
	<li>Place the patient in the supine position on the operating table. Insert a vein-detained needle into the dorsal metacarpal vein, and use an ECG monitor to monitor the patient&#39;s heartbeat and blood pressure.</li>
	<li>Disinfect the surgical area using Iodophor solution and cover it with sterile drapes.</li>
</ol>
3. Microscopic varicocelectomy
<ol>
	<li>Identify the external inguinal ring above the pubic tubercle by using fingers to palpate the spermatic cord at the base of the scrotum, following it upwards until the external inguinal ring is felt at 1.5 cm above the midpoint of the inguinal ligament.</li>
	<li>Use Hemostatic forceps to grasp the skin to assess the efficacy of anesthesia (Figure 2A), and mark the incision site with methylene blue (Figure 2B).</li>
	<li>Mix Lidocaine (5 mL, 0.1 g) and ropivacaine (10 mL, 0.1 g) in a 1:1 ratio and infiltrate using a 20 mL syringe in layers up to a depth of about 5 cm (see Figure 3).</li>
	<li>Make a 3 cm transverse incision at the external inguinal ring using a scalpel. Sequentially, incise the skin, the Camper&#39;s fascia, and the Scarpa&#39;s fascia using an electrotome.</li>
	<li>Identify the spermatic cord (under direct vision, it appears as a strip with dilated deep blue veins visible, and the vas deferens can be palpated below it) and exteriorize it from the incision with an appendiceal retractor. 
	NOTE: Pay attention to the patient&#39;s heart rate and blood pressure during this step. If a decrease in blood pressure and heart rate is encountered, stop the operation and wait for 3-5 min. If necessary, administer 1 mg of atropine injection and 10 mg of dopamine injection intravenously. Secure the spermatic cord in place (see Figure 4).
	<ol>
		<li>Use an electrotome to dissect the cremaster muscle and the external and internal spermatic fascia of the cord.</li>
		<li>Under 8-10x magnification, observe the pulsation of the arteries to determine their location.</li>
		<li>Carefully identify the spermatic artery (which is surrounded by small veins, has visible pulsation, and a tensed wall). Use micro-scissors and forceps for blunt dissection and mark it with a moistened strip for identification. If available, intraoperative Doppler ultrasound can be used for confirmation (Figure 5).</li>
		<li>Identify and isolate the large spermatic veins. Use micro-titanium clips to clamp both ends before cutting (Figure 6).</li>
		<li>Further dissect and identify small veins adjacent to the spermatic artery. Use micro-titanium clips to clamp them before cutting. For vessels that are difficult to clamp with titanium, use 4-0 coated braided silk to ligate before cutting.</li>
		<li>Ligate all varicose veins, ensuring at least one normal vein is preserved for venous return (Figure 7).</li>
	</ol>
	</li>
	<li>After ligation, suture the cremaster muscle and both the internal and external spermatic fascia using a 6-0 absorbable surgical suture. Close and suture the incision (Figure 8).</li>
</ol>
4. Postoperative care
<ol>
	<li>Apply a 1 kg sandbag for compression and hemostasis 1 h postoperatively.</li>
	<li>Administer oral antibiotics postoperatively (fosfomycin trometamol powder, 3 g) for infection prevention. Administer anti-inflammatory analgesic suppositories rectally if postoperative pain is observed.</li>
	<li>Change the dressing in 3 days and remove the stitches in 7 days.</li>
	<li>Conduct a semen examination after 1 month.</li>
</ol>

Microsurgical Varicocele Removal Under Local Anesthesia

<ol><li>Alsaikhan, B., Alrabeeah, K., Delouya, G., Zini, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Epidemiology+of+varicocele%5BTitle%5D)+AND+%22Asian+J+Androl%22%5BJournal%5D)">Epidemiology of varicocele.</a> Asian J Androl. 18 (2), 179-181 (2016).</li>
<li>Damsgaard, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Varicocele+is+associated+with+impaired+semen+quality+and+reproductive+hormone+levels%3A+A+study+of+7035+healthy+young+men+from+six+European+countries%5BTitle%5D)+AND+%22Eur+Urol%22%5BJournal%5D)">Varicocele is associated with impaired semen quality and reproductive hormone levels: A study of 7035 healthy young men from six European countries.</a> Eur Urol. 70 (6), 1019-1029 (2016).</li>
<li>Gupta, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Microscopic+varicocelectomy+as+a+treatment+option+for+patients+with+severe+oligospermia%5BTitle%5D)+AND+%22Investig+Clin+Urol%22%5BJournal%5D)">Microscopic varicocelectomy as a treatment option for patients with severe oligospermia.</a> Investig Clin Urol. 59 (3), 182-186 (2018).</li>
<li>Addar, A. M., Nazer, A., Almardawi, A., Al Hathal, N., Kattan, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+yield+of+microscopic+varicocelectomy+in+men+with+severe+oligospermia%5BTitle%5D)+AND+%22Urol+Ann%22%5BJournal%5D)">The yield of microscopic varicocelectomy in men with severe oligospermia.</a> Urol Ann. 13 (3), 268-271 (2021).</li>
<li>Saredi, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Feasibility+of+local+anesthesia+for+varicocele+correction+in+one-day-surgery+setting.+A+single+center+experience%5BTitle%5D)+AND+%22Arch+Ital+Urol+Androl%22%5BJournal%5D)">Feasibility of local anesthesia for varicocele correction in one-day-surgery setting. A single center experience.</a> Arch Ital Urol Androl. 93 (2), 233-236 (2021).</li>
<li>Jensen, C. F. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Varicocele+and+male+infertility%5BTitle%5D)+AND+%22Nat+Rev+Urol%22%5BJournal%5D)">Varicocele and male infertility.</a> Nat Rev Urol. 14 (9), 523-533 (2017).</li>
<li>Baazeem, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Varicocele+and+male+factor+infertility+treatment%3A+A+new+meta-analysis+and+review+of+the+role+of+varicocele+repair%5BTitle%5D)+AND+%22European+Urol%22%5BJournal%5D)">Varicocele and male factor infertility treatment: A new meta-analysis and review of the role of varicocele repair.</a> European Urol. 60 (4), 796-808 (2011).</li>
<li>Maheshwari, A., Muneer, A., Lucky, M., Mathur, R., Mceleny, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+review+of+varicocele+treatment+and+fertility+outcomes%5BTitle%5D)+AND+%22Hum+Fertil+%28Camb%29%22%5BJournal%5D)">A review of varicocele treatment and fertility outcomes.</a> Hum Fertil (Camb). 25 (2), 209-216 (2020).</li>
<li>Çayan, S., Akbay, E., Saylam, B., Kadıoğlu, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Effect+of+varicocele+and+its+treatment+on+testosterone+in+hypogonadal+men+with+varicocele%3A+Review+of+the+literature%5BTitle%5D)+AND+%22Balkan+Med+J%22%5BJournal%5D)">Effect of varicocele and its treatment on testosterone in hypogonadal men with varicocele: Review of the literature.</a> Balkan Med J. 37 (3), 121-124 (2020).</li>
<li>Ulusoy, O., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Successful+outcomes+in+adolescent+varicocele+treatment+with+high-level+laparoscopic+varicocelectomy%5BTitle%5D)+AND+%22J+Pediatr+Surg%22%5BJournal%5D)">Successful outcomes in adolescent varicocele treatment with high-level laparoscopic varicocelectomy.</a> J Pediatr Surg. 55 (8), 1610-1612 (2020).</li>
<li>Mehta, A., Goldstein, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Microsurgical+varicocelectomy%3A+A+review%5BTitle%5D)+AND+%22Asian+J+Androl%22%5BJournal%5D)">Microsurgical varicocelectomy: A review.</a> Asian J Androl. 15 (1), 56-60 (2013).</li>
<li>Marmar, J. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+evolution+and+refinements+of+varicocele+surgery%5BTitle%5D)+AND+%22Asian+J+Androl%22%5BJournal%5D)">The evolution and refinements of varicocele surgery.</a> Asian J Androl. 18 (2), 171-178 (2016).</li>
<li>Wang, X., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Prospective+comparison+of+local+anesthesia+with+general+or+spinal+anesthesia+in+patients+treated+with+microscopic+varicocelectomy%5BTitle%5D)+AND+%22J+Clin+Med%22%5BJournal%5D)">Prospective comparison of local anesthesia with general or spinal anesthesia in patients treated with microscopic varicocelectomy.</a> J Clin Med. 11 (21), 6397(2022).</li>
<li>Al-Kandari, A. M., Shabaan, H., Ibrahim, H. M., Elshebiny, Y. H., Shokeir, A. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Comparison+of+outcomes+of+different+varicocelectomy+techniques%3A+Open+inguinal%2C+laparoscopic%2C+and+subinguinal+microscopic+varicocelectomy%3A+A+randomized+clinical+trial%5BTitle%5D)+AND+%22Urology%22%5BJournal%5D)">Comparison of outcomes of different varicocelectomy techniques: Open inguinal, laparoscopic, and subinguinal microscopic varicocelectomy: A randomized clinical trial.</a> Urology. 69 (3), 417-420 (2007).</li>
</ol>

The author has no conflicts of interest to disclose.

Varicocele presents a relatively high prevalence in infertile men of reproductive age, reaching 35%-44%6. The impact of this disease on male fertility cannot be overlooked, as it may lead to imbalances in testicular function, instability in blood supply, and thermoregulatory disturbances, subsequently affecting both the quality and quantity of sperm. More severe consequences include potential testicular atrophy and other related complications. Numerous studies have proved the effects of varicocele repair on semen parameters7, pregnancy outcomes8, and reproductive hormones. Besides in infertile patients, varicocelectomy is also performed in adolescent patients with chronic testicular pain and/or testicular growth arrest. Laparoscopic varicocelectomy is the widely accepted method, but hydrocele is a common complication10.
In recent years, microsurgical varicocelectomy has gradually become the &#34;gold standard&#34; treatment for varicocele11. Compared to traditional treatments, this technique has obvious advantages, including fewer postoperative complications, a lower recurrence rate, minimal invasiveness, and rapid postoperative recovery12,13,14. However, many physicians still opt to perform this surgery under general anesthesia. The application of general anesthesia requires patients to fast preoperatively, resulting in a longer postoperative recovery, and the potential drop in arterial blood pressure during anesthesia can increase the difficulty in isolating and protecting the spermatic artery during surgery.
Given these challenges, this study proposes and practices a microsurgical varicocelectomy technique under local anesthesia. The implementation of this method only requires two applications of compound lidocaine cream in the ward for epidermal anesthesia, followed by infiltrative anesthesia in the operating room. This new technique significantly shortens the required surgery time, avoids the complexities and risks of general anesthesia, and offers new surgical opportunities for patients with cardiopulmonary issues who cannot undergo general anesthesia. Furthermore, under local anesthesia, the surgeon can more clearly observe the pulsations of the spermatic artery, enabling more precise isolation and protection. This not only effectively reduces surgical risks but also genuinely promotes the widespread adoption of the surgical technique.
The local anesthesia used in this study also reflects a more patient-centered care approach, reducing postoperative discomfort and economic burden. Postoperative follow-up data indicate that, three months after the surgery, the patient&#39;s semen quality had significantly improved. However, there are limitations to this technique. Patients might still feel a pulling sensation during the surgery, which could potentially impact its completion. Additionally, this study did not directly compare with the traditional microsurgical varicocelectomy technique, representing another significant limitation. Furthermore, the limitations of this surgery require good patient cooperation, making it unsuitable for children under the age of 14 who cannot cooperate. Nonetheless, with further research and practice, this technique will gain broader acceptance and application.
In conclusion, microsurgical varicocelectomy under local anesthesia provides a new perspective for the treatment of varicocele, showcasing its potential value and advantages. In the future, with continued research and technological advancement, this technique holds promise to bring improved therapeutic outcomes and a higher quality of life for more varicocele patients.

With the advancement of modern society, male infertility has gradually emerged as a global health issue, with varicocele being one of the predominant causes. The prevalence of varicocele is estimated at 15% in the general healthy population, 35% in those with primary infertility, and can be as high as 80% in the secondary infertility group1. Not only does varicocele lead to a decline in sperm count and quality2, but it also profoundly impacts the psychological well-being and quality of life of affected men.
Contemporary treatment modalities, such as microscopic varicocelectomy, have been widely adopted3,4. However, their limitations are becoming increasingly evident. Traditional microscopic varicocelectomy requires patients to undergo general anesthesia, which not only necessitates preoperative fasting and postoperative recovery inconveniences but also poses a significant challenge. The hemodynamic changes induced by anesthesia might obscure the pulsations of the spermatic artery, subsequently increasing the intricacy of isolating and preserving the vessel during the procedure5.
In light of these challenges, a method of performing microscopic varicocelectomy under local anesthesia was proposed and implemented. The salient advantage of this unique approach lies in its ability to swiftly and accurately pinpoint the pulsating spermatic artery, thus reducing the risk of injury to the vessel. Furthermore, local anesthesia offers a more patient-centric surgical experience, sidestepping the adverse effects of general anesthesia, and potentially reducing medical costs, presenting a more cost-effective and efficient treatment option. Additionally, considering the practical realities and clinical experiences in China, this innovative method proffers a fresh perspective in the treatment of varicocele and holds promise for broader clinical application. Through this research, a safer and more effective treatment alternative for patients would be provided, aiming to enhance their reproductive capabilities and overall quality of life.

<table><tbody><tr><td>0.9% sodium chloride solution</td><td>Guangdong Otsuka Pharmaceutical Co. LTD</td><td>21M1204</td><td>Preparation for injection of medication during surgery</td></tr><tr><td>20 MHz Microvascular Doppler System</td><td>Vascular Technology, Inc.</td><td>102802</td><td>Doppler ultrasound was used to identify the spermatic artery</td></tr><tr><td>4-0 coated, Braided Silk</td><td>Jiasheng Medical Products Co., Ltd</td><td>1600-31</td><td>Ligation of spermatic vein</td></tr><tr><td>5-0 absorbable surgical suture</td><td>HORCON</td><td>MY313G4</td><td>Skin and fascial suture</td></tr><tr><td>6-0 absorbable surgical suture</td><td>HORCON</td><td>JE1264</td><td>Deep tissue suturing</td></tr><tr><td>Compound lidocaine cream</td><td>Tongfang Pharmaceutical Group</td><td>H20063466</td><td>25mg of propacaine and 25mg of lidocaine per gram for epidermal infiltration anesthesia</td></tr><tr><td>Dianerkang Iodophor Skin Disinfectant</td><td>Shanghai Likang Disinfectant HI-Tech Co,Lid</td><td>31005102</td><td>For skin disinfection and the effective iodine content is from 4.5g/L-5.5g/L</td></tr><tr><td>electrotome</td><td>Shanghai Hutong Electronics Co., Ltd</td><td>GD350-B</td><td>Used to cut open the fascia layer</td></tr><tr><td>Fosfomycin Trometamol Powder</td><td>Shanxi C&amp;amp;Y Pharmaceutical Group Co., Ltd.</td><td>H19994124</td><td>Oral antibiotics for infection prevention</td></tr><tr><td>haemostatic forceps</td><td>SHINVA</td><td>ZH240RN</td><td>Used in surgical procedures</td></tr><tr><td>Lidocaine Hydrochloride Injection</td><td>Shanghai Harvest Pharmaceutical Co., Ltd</td><td>H20023777</td><td>Mixed with Ropivocoine Hydrochloride injection for deep infiltration anesthesia</td></tr><tr><td>methylene blue</td><td>JUMPCAN</td><td>H32025285</td><td>Skin marker</td></tr><tr><td>micro scissors</td><td>SHINVA</td><td>ZF123RN</td><td>Used in surgical procedures</td></tr><tr><td>micro tweezers</td><td>SHINVA</td><td>ZD274RN</td><td>Used in surgical procedures</td></tr><tr><td>needle holder</td><td>SHINVA</td><td>ZM234R/RN/RB</td><td>Used in surgical procedures</td></tr><tr><td>NeutroPhase</td><td>NovaBay Pharmaceuticals,Inc</td><td>CA 94608 USA</td><td>Wound Cleanser</td></tr><tr><td>ophthalmic scissors</td><td>SHINVA</td><td>ZC120R/RN/RB</td><td>Used in surgical procedures</td></tr><tr><td>Ropivocoine Hydrochloride injection</td><td>Jiangsu Hengrui Pharmaceuticals Co., Ltd</td><td>H20060137</td><td>Mixed with Lidocaine Hydrochloride Injection for deep infiltration anesthesia</td></tr><tr><td>Surgical Microscope</td><td>Carl Zeiss Meditec AG</td><td>20162224730</td><td>for microscopic operations</td></tr><tr><td>Titanium Clips</td><td>WECK HORIZON</td><td>002200</td><td>used to clamp vena cava</td></tr><tr><td>Titanium Clips</td><td>WECK HORIZON</td><td>005200</td><td>used to clamp venule</td></tr></tbody></table>

microscopic varicocelectomy under local anesthesia as the treatment of varicocele

Varicocele, characterized by the dilation of veins within the spermatic cord, is a prevalent disease in males, accounting for 35%-40% of infertility cases among men of reproductive age. This condition may disrupt normal neuroregulation, blood supply, and temperature regulation in the testicles, thereby impacting sperm count, quality (morphology, fragmentation rate), and functionality (motility). It may even induce symptoms such as pain and testicular atrophy. The international standard treatment method is microscopic varicocelectomy, typically performed under general anesthesia. This requires patients to fast before surgery and necessitates recovery and fasting care postoperatively. The arterial blood pressure drop caused by anesthesia may obscure the fluctuation of the spermatic artery, making the precise intraoperative isolation and protection of the spermatic artery more challenging. Therefore, this study proposes and implements microscopic varicocelectomy under local anesthesia. This method facilitates rapid and precise identification of the fluctuating spermatic artery, reducing the risk of spermatic artery damage. It also provides more humane care for patients, reduces economic burden, and offers a new perspective on the treatment of varicocele.

From July 2022 to May 2023, a total of 158 patients were diagnosed at our hospital with varicocele accompanied by a decline in semen quality and underwent surgery. The average age of the 158 males was 32.15 years ± 4.8 years (range: 21-51 years). All the males signed informed consent forms to undergo varicocelectomy under local anesthesia, with an average surgery time of 100.11 min ± 9.48 min. Patients experienced no significant pain during the surgery; however, 10 patients developed fat liquefaction postoperatively, with semen quality reassessed in the third-month post-surgery.
In the final statistical analysis, 130 patients (82.4%, 130/158) were included. The preoperative sperm concentration was 21.53 (0.6-125.2) × 106/mL, and the postoperative sperm concentration significantly increased to 41.94 (2-255.2) × 106/mL (p &lt; 0.001). The progressive motility rate (a%+b%) before surgery was 20.23% ± 13.85%, and it increased to 25.84% ± 15.99% postoperatively (p &lt; 0.01) (Table 1). There was a noticeable improvement in semen quality in patients three months after the surgery.
<img alt="Topical patch test setup on skin for dermatological allergy testing." class="xfigimg" src="/files/ftp_upload/66269/66269fig01.jpg" data-altupdatedat="1747911167000" data-alt="Figure 1"> 
Figure 1: Local application of compound lidocaine cream. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/66269/66269fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Surgical procedure preparation with sterile field setup for skin incision in a medical diagram." class="xfigimg" src="/files/ftp_upload/66269/66269fig02.jpg" data-altupdatedat="1747911167000" data-alt="Figure 2"> 
Figure 2: The surgical incision. (A) Hemostatic forceps are used to grasp the skin to assess anesthesia efficacy. (B) Methylene blue is used to mark the incision site. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/66269/66269fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Medical procedure setup, syringe injection for anesthesia, aseptic technique, clinical practice." class="xfigimg" src="/files/ftp_upload/66269/66269fig03.jpg" data-altupdatedat="1747911167000" data-alt="Figure 3"> 
Figure 3: Layer-by-layer infiltration of anesthesia. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/66269/66269fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Surgical procedure on tissue, close-up, medical experiment, wound healing, tissue morphology." class="xfigimg" src="/files/ftp_upload/66269/66269fig04.jpg" data-altupdatedat="1747911167000" data-alt="Figure 4"> 
Figure 4: Fixing the spermatic cord using a ruler. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/66269/66269fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Surgical procedure, tissue dissection using forceps, scalpel; close-up medical operation technique." class="xfigimg" src="/files/ftp_upload/66269/66269fig05.jpg" data-altupdatedat="1747911167000" data-alt="Figure 5"> 
Figure 5: Identifying the spermatic artery with Doppler ultrasound. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/66269/66269fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Surgical procedure with incision and clamp, medical technique, close-up, healthcare practice." class="xfigimg" src="/files/ftp_upload/66269/66269fig06.jpg" data-altupdatedat="1747911167000" data-alt="Figure 6"> 
Figure 6: Usage of the micro-titanium clips to clamp both ends before cutting. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/66269/66269fig06large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Surgical suturing process; wound closure on tissue with sutures visible, medical procedure context." class="xfigimg" src="/files/ftp_upload/66269/66269fig07.jpg" data-altupdatedat="1747911167000" data-alt="Figure 7"> 
Figure 7: Ligature of all varicose veins with one preserved for venous return. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/66269/66269fig07large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 8" class="xfigimg" src="/files/ftp_upload/66269/66269fig08.jpg"> 
Figure 8: Closing of the incision. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/66269/66269fig08large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td colspan="3">Parameters</td>
			<td>Value</td>
			<td>p value</td>
		</tr>
		<tr>
			<td colspan="3">Patients (total) (n)</td>
			<td>158</td>
			<td></td>
		</tr>
		<tr>
			<td colspan="3">Age (years), Mean ± standard deviation (range)</td>
			<td>32.15 ± 4.8 (21-51)</td>
			<td></td>
		</tr>
		<tr>
			<td colspan="3">Operation time (min), Mean ± standard deviation</td>
			<td>100.11 ± 9.48</td>
			<td></td>
		</tr>
		<tr>
			<td colspan="3">Patients included in data analysis, n (%)</td>
			<td>130 (82.4)</td>
			<td></td>
		</tr>
		<tr>
			<td colspan="3">Preoperative sperm concentration (millions/mL), Mean ± standard deviation (range)</td>
			<td>21.53 (0.6~125.2)</td>
			<td rowspan="2">&lt; 0.001</td>
		</tr>
		<tr>
			<td colspan="3">Postoperative sperm concentration (millions/mL), Mean ± standard deviation (range)</td>
			<td>41.94 (2~255.2)</td>
		</tr>
		<tr>
			<td colspan="3">Preoperative progressive motility rate, Mean ± standard deviation (range)</td>
			<td>20.23 ± 13.85</td>
			<td rowspan="2">&lt;0.01</td>
		</tr>
		<tr>
			<td colspan="3">Postoperative progressive motility rate, Mean ± standard deviation (range)</td>
			<td>25.84 ± 15.99</td>
		</tr>
	</tbody>
</table>
Table 1: Characteristics of patients who underwent microscopic varicocelectomy under local anesthesia.

Author Spotlight: Advancing Varicocele Treatment Through Enhanced Surgical Techniques

Varicocele accounts for 35%-40% of infertility cases among men of reproductive age. The international standard treatment method is microscopic varicocelectomy, typically performed under general anesthesia. This study proposes and implements microscopic varicocelectomy under local anesthesia, which provides more humane care for patients and reduces the economic burden.

Microscopic Varicocelectomy under Local Anesthesia as the Treatment of Varicocele

Varicocele, characterized by the dilation of veins within the spermatic cord, is a prevalent disease in males, accounting for 35%-40% of infertility cases ...

microscopic-varicocelectomy-under-local-anesthesia-as-treatment

Universidad San Sebastian

Research

JoVE Journal

Medicine

1.6K Views.  Affiliated Hospital of Shanghai Institute for Biomedical and Pharmaceutical Technologies. Varicocele accounts for 35%-40% of infertility cases among men of reproductive age. The international standard treatment method is microscopic varicocelectomy, typically performed under general anesthesia. This study proposes and implements microscopic varicocelectomy under local anesthesia, which provides more humane care for patients and reduces the economic burden.

Video: Author Spotlight: Advancing Varicocele Treatment Through Enhanced Surgical Techniques

Osteopathic Manipulative Treatment as a Useful Adjunctive Tool for Pneumonia

Pneumonia, the inflammatory state of lung tissue primarily due to microbial infection, claimed 52,306 lives in the United States in 20071 and resulted in the hospitalization of 1.1 million patients2. With an average length of in-patient hospital stay of five days2, pneumonia and influenza comprise significant financial burden costing the United States $40.2 billion in 20053. Under the current Infectious Disease Society of America/American Thoracic Society guidelines, standard-of-care recommendations include the rapid administration of an appropriate antibiotic regiment, fluid replacement, and ventilation (if necessary). Non-standard therapies include the use of corticosteroids and statins; however, these therapies lack conclusive supporting evidence4. (Figure 1)

Osteopathic Manipulative Treatment (OMT) is a cost-effective adjunctive treatment of pneumonia that has been shown to reduce patients&#8217; length of hospital stay, duration of intravenous antibiotics, and incidence of respiratory failure or death when compared to subjects who received conventional care alone5. The use of manual manipulation techniques for pneumonia was first recorded as early as the Spanish influenza pandemic of 1918, when patients treated with standard medical care had an estimated mortality rate of 33%, compared to a 10% mortality rate in patients treated by osteopathic physicians6. When applied to the management of pneumonia, manual manipulation techniques bolster lymphatic flow, respiratory function, and immunological defense by targeting anatomical structures involved in the these systems7,8, 9, 10.

The objective of this review video-article is three-fold: a) summarize the findings of randomized controlled studies on the efficacy of OMT in adult patients with diagnosed pneumonia, b) demonstrate established protocols utilized by osteopathic physicians treating pneumonia, c) elucidate the physiological mechanisms behind manual manipulation of the respiratory and lymphatic systems. Specifically, we will discuss and demonstrate four routine techniques that address autonomics, lymph drainage, and rib cage mobility: 1) Rib Raising, 2) Thoracic Pump, 3) Doming of the Thoracic Diaphragm, and 4) Muscle Energy for Rib 1.5,11

Pneumonia is one of the top ten leading causes of death in the U.S. Osteopathic manipulative techniques (OMT) may be utilized as an adjunctive therapy in the treatment of pneumonia to enhance biomechanical and immune function; and ultimately, to reduce hospital stay, duration of antibiotics, incidence of respiratory failure, and mortality. In this video-article, we will review randomized controlled studies on the use of OMT in pneumonia patients, as well as demonstrate specific hands-on techniques that are routinely practiced by osteopathic physicians when treating pulmonary infections.

Pneumonia, the inflammatory state of lung tissue primarily due to microbial infection, claimed 52,306 lives in the United States in 20071 and resulted in ...

Isolated Hepatic Perfusion as a Treatment for Liver Metastases of Uveal Melanoma

Isolated hepatic perfusion (IHP) is a procedure where the liver is surgically isolated and perfused with a high concentration of the chemotherapeutic agent melphalan. Briefly, the procedure starts with the setup of a percutaneous veno-venous bypass from the femoral vein to the external jugular vein. Via a laparotomy, catheters are then inserted into the proper hepatic artery and the caval vein. The portal vein and the caval vein, both supra- and infrahepatically, are then clamped. The arterial and venous catheters are connected to a heart lung machine and the liver is perfused with melphalan (1 mg/kg body weight) for 60 min. This way it is possible to locally perfuse the liver with a high dose of a chemotherapeutic agent, without leakage to the systemic circulation.
In previous studies including patients with isolated liver metastases of uveal melanoma, an overall response rate of 33-100% and a median survival between 9 and 13 months, have been reported. The aim of this protocol is to give a clear description of how to perform the procedure and to discuss IHP as a treatment option for liver metastases of uveal melanoma.

Here, we present a protocol how to perform an isolated liver perfusion (IHP) with melphalan and we also discuss IHP as a treatment option for liver metastases of uveal melanoma.

Isolated hepatic perfusion (IHP) is a procedure where the liver is surgically isolated and perfused with a high concentration of the chemotherapeutic ...

Vessel-Sparing Microsurgical Longitudinal Intussusception Vasoepididymostomy to Treat Epididymal Obstructive Azoospermia

The epididymis is a common site of obstruction in obstructive azoospermia (OA). Vasoepididymostomy has become an important method for the treatment of epididymal OA since 2000. There are two challenges in classic microscopic vasoepididymostomy. First, anastomosis of the vas deferens and epididymis is performed with double-needle sutures. However, there is a lack of good-quality and cost-effective double-needle sutures in China, which leads to increased difficulty and poor success rates of anastomosis. Second, the separation of the vas deferens does not retain vasculature, although the vas deferens vasculature plays an important role in the blood supply to the vas deferens, epididymis, and testis. This affects the blood supply to the anastomotic area and epididymis.
Therefore, this team has made innovative improvements to address these problems. Good-quality, cost-effective, single-needle sutures, which are easy to purchase in China and other countries, were used in microsurgical longitudinal intussusception vasoepididymostomy. This can optimize the operation procedure and shorten the operation time while ensuring the success rate of the anastomosis. The surgical method of preserving the vas deferens vessels was innovatively proposed because the etiology of epididymal OA is mostly inflammatory in China. The protection of the blood supply to the vas deferens and epididymis is maximized using microsurgical forceps to separate and protect the vasculature. Patency reached 81.7% in the postoperative follow-up, indicating a better surgical treatment effect.

The present protocol describes a vessel-sparing, longitudinal intussusception vasoepididymostomy using readily available single-needle sutures in China, a safe and effective procedure, which may improve patients' patency and natural pregnancy rates.

The epididymis is a common site of obstruction in obstructive azoospermia (OA). Vasoepididymostomy has become an important method for the treatment of ...

Microvascular Doppler Assisted Microsurgical Denervation of the Spermatic Cord in Treating Chronic Orchialgia

Chronic orchialgia is a common disease in department of urology and andrology. The etiology is complex, and the treatment is difficult. In severe cases, orchiectomy is even necessary. In recent years, microsurgical denervation of the spermatic cord (MDSC) is a minimally invasive and effective surgical method for the treatment of chronic orchialgia. Its greatest advantage is to preserve the testis and epididymis, avoid the possible organ resection. The key of the operation is to dissect all the fibrous tissues in the spermatic cord, while protecting the arteries (especially the testicular arteries) and several lymphatic vessels. Combined with the use of microvascular doppler in the operation, when separating the structure of spermatic cord under the microscope, the testicular arteries can be objectively and accurately protected (pulse &#8220;whistle&#8221; sound can be heard when the microvascular doppler probes the arterial surface), while artery injury and venous missed ligation can be avoided. The postoperative blood supply of the testis is also maximumly safeguarded. At the same time, we can be more fearless to cut the cremaster muscle, fatty and connective tissues surrounding the spermatic cord blood vessels and vas deferens after the arteries and lymphatic vessels being accurately protected under the microscope, finally achieve the spermatic cord completely &#34;skeletonized&#34; (only the testicular arteries, lymphatic vessels and vas deferens remained after the surgery). Thus we can better ensure the clinical curative effect (denervation thoroughly), avoid serious complications (testicular atrophy), and achieve better surgical results.

Here, we present a protocol to treat chronic orchialgia by microsurgical denervation of the spermatic cord. Combined with the use of a microvascular doppler, the procedures can be more easily implemented.

Chronic orchialgia is a common disease in department of urology and andrology. The etiology is complex, and the treatment is difficult. In severe cases, ...

A Modified Vessel-Sparing Microsurgical Vasoepididymostomy

Microsurgical vasoepididymostomy (MVE) is the main surgical treatment for epididymal obstruction. The vasal vessels are ligated during MVE. However, preserving the vasal vessels during MVE might better simulate the normal physiological structure and be meaningful for patients who have undergone varicocelectomy. Nevertheless, preserving the vasal vessels might elevate the risk of increasing the tension of anastomosis, affecting the patency rate and leading to delayed postoperative bleeding. Therefore, we developed a novel vessel-sparing MVE to make it safer. Here is a summary of the improvements to the procedure. 1) The retrograde dissociation of the vasal vessels on the proximal testicular side was adopted as the main method, and the anterograde dissociation of the vasal vessels on the distal testicular side was adopted as a supplement to dissociate the vasal vessels to be preserved. This improvement ensures the blood supply to the vas deferens that will be used for anastomosis and also provides longer vasal vessels, which reduces the tension of anastomosis. 2) By fixing the vas deferens to be anastomosed and the broken end of the vas deferens, the free vasal vessels get fixed, which resolves the problem of transmission of vas tension to the vasal vessels and reduces the risk of vasal vessel hemorrhage. 3) Dissociation of the vas deferens after opening the tunica vaginalis increases the mobilization of the vas deferens, which also makes the new procedure easier to complete. The evaluation of the outcomes of this new procedure showed that no significant postoperative complications occurred in the patients, and the patency rate was no different from that of the conventional procedure. Therefore, this new, improved procedure can be considered safe, with satisfactory postoperative results.

Here, we present a protocol to preserve the vasal vessels in microsurgical vasoepididymostomy. The surgical security is enhanced by preserving the vasal vessels using a retrograde-anterograde dissociation and fixing the vasal vessels.

Microsurgical vasoepididymostomy (MVE) is the main surgical treatment for epididymal obstruction. The vasal vessels are ligated during MVE. However, ...

Microscopic Cyst Resection for the Treatment of Patients Diagnosed with Epididymal Cyst

Epididymal cysts mostly occur in men aged 20-40 years old. Previous reports have covered concerns about postoperative complexes, including postoperative asoedema, hematoma, sustaining pain, and seminal tract obstruction in patients who have undertaken nonmicroscopic epididymal cyst resection or epididymal resection. Nonmicroscopic epididymal cyst surgery is suggested for patients with childbirth plans as a precaution. The treatment of male epididymal cysts via microtechnology is obviously a beneficial option; we took the lead in carrying out microscopic epididymal exploration and cyst resection surgery in China. From September 2017 to April 2021, 41 young and middle-aged male patients diagnosed with epididymal cysts underwent microtechnology treatment in a program titled &#34;microscopic epididymal exploration and cystectomy&#34;. The postoperative follow-up lasted for 3-50 months. The results confirmed that, as microscopic manipulation largely improved visualization of the subtle tissue structures of the epididymis, the cyst could be clearly dissected apart and completely removed intact under the microscope. Bleeding during the operation was significantly reduced (2-3 mL) and wound drainage was not required. According to follow-up data, microscopic treatment significantly reduced the incidence of postoperative scrotal hematoma, edema, and long-term postoperative pain, thereby promising a higher surgical success rate as well as recurrence prevention. Besides, preliminary experience and reflection suggest that microscopic epididymal exploration and cystectomy provide efficient preservation of the epididymal patency through refined treatment, while a better prognosis can be achieved. We recommend that surgery be carried out before the epididymal cyst develops to 0.8 cm in diameter, for fear that a larger epididymal cyst (&#62;0.9 cm in diameter) could cause the complete destruction of all tubules of the ipsilateral epididymis - a more severe case with damage to the testicular output network.

Here, we present a protocol to treat patients diagnosed with an epididymal cyst using microscopic cyst resection. Based on microscopic manipulation, a largely improved visualization of the subtle tissue structures of the epididymis was obtained, so the cyst could be clearly dissected apart and completely removed intact.

Epididymal cysts mostly occur in men aged 20-40 years old. Previous reports have covered concerns about postoperative complexes, including postoperative ...

Combination of High Ligation and Intraoperative Embolization using Polidocanol for Treatment of Varicoceles

Varicoceles are dilated veins within the pampiniform plexus and are relatively common in the general male population. The spermatic vein has many branches in the scrotal segment and then gradually merges into 1-2 trunks after passing through the internal inguinal ring. The key to a successful varicocelectomy is to ligate all the spermatic veins while protecting the testicular arteries and spermatic lymphatic vessels from damage. The small veins, including the branches of spermatic veins and collateral veins, are easily missed for ligation during conventional high ligation of varicocele, which has been suggested as a major cause of postoperative recurrence. Although microsurgery effectively reduces the risk of missing ligation of the spermatic veins during surgery, it has several shortcomings, such as long operation time and a steep learning curve. More importantly, this technique is difficult to carry out in primary hospitals due to the requirement of specialized equipment. Therefore, an attempt to modify the traditional high ligation aiming to reduce the postoperative recurrence rate has been carried out here. The protocol here combines traditional high ligation with intraoperative embolization to seal off the branches of the spermatic vein and collateral veins. We rapidly injected foamed sclerosant into the internal spermatic vein under direct observation after separation of the spermatic vein and then ligated all the veins. The foamed sclerosant through the varicose vein hampers endothelial cell growth, promotes the growth of thrombus and fibrosis, and ultimately forms fibrous streaks that permanently fill the venous. The results showed a more satisfactory effect on reducing the postoperative recurrence rate compared with traditional high ligation. Since this protocol is simple to carry out and has better results in reducing the recurrence rate, this can be an alternative surgical method for the treatment of varicocele, especially in primary hospitals.

To reduce the postoperative recurrence rate of varicocelectomy, we combined high ligation of varicocele with intraoperative embolization. We injected polidocanol from the spermatic vein during surgery to embolize the branches of the spermatic vein and collateral veins. This is an alternative surgical method for the treatment of varicocele.

Varicoceles are dilated veins within the pampiniform plexus and are relatively common in the general male population. The spermatic vein has many branches ...

Grade III Varicocele Surgical Treatment using Spermatic Vein-Superficial Abdominal Vein Shunt

Microsurgical varicocelectomy is the most commonly used method for the treatment of varicocele (VC) in recent years. However, it is technically demanding with the risk of damaging the normal anatomical structure of the spermatic cord, such as the cremaster muscle, testicular artery, and vas deferens during the pampiniform plexus ligation. Also, traditional varicocelectomy hinders the drainage of the stagnant venous blood of the affected testicle, resulting in a persistent scrotal appearance of varicose veins and slower remission of swelling sensation in postoperative patients with grade III VC. Therefore, we developed a retroperitoneal varicocelectomy with a microscopical spermatic venous-superficial vein of the abdominal wall bypass procedure. The spermatic vein was transected and ligated proximally through the retroperitoneal space. Then, the distal spermatic vein was freed and passed through the internal ring; under the skin of the groin, a microscopic vascular anastomosis was performed to build the bypass of the distal spermatic vein and proximal inferior epigastric vein. The high ligation facilitates the protection of the normal anatomy of the spermatic cord, and the venous bypass allows rapid testicular blood drainage, which can effectively improve the degree of varicocele, testicular pain, and even spermatogenic function. In conclusion, the present protocol describes a promising way to reconstruct the spermatic return through high retroperitoneal ligation of the spermatic vein and anastomosis of the spermatic vein-inferior epigastric vein, which resulted in faster and more obvious improvement in symptoms and better prognosis of grade III VC.

Here, we present a protocol for grade III varicocele surgical treatment that aims to rebuild the venous drainage of the spermatic cord by a spermatic vein-superficial abdominal vein shunt performed under the microscope.

Microsurgical varicocelectomy is the most commonly used method for the treatment of varicocele (VC) in recent years. However, it is technically demanding ...

Electrical Stimulation Therapy: Non-Surgical Remedy for Varicocele-Induced Pain

Transcutaneous Neuromuscular Electrical Stimulation for Treating Varicocele-Induced Scrotal Pain

Varicocele is a prevalent vascular disorder affecting the male reproductive system, leading to scrotal pain and testicular dysfunction. Epidemiological studies have shown that varicocele occurs in approximately 10% to 15% of adult males, while scrotal pain affects 2% to 10% of the population. Currently, clinical treatment options for varicocele-induced scrotal pain include general therapy, medication, and surgery. Among these, surgical intervention is considered the most effective method, boasting a success rate of 80%. However, it carries risks such as postoperative bleeding, infection, and recurrence, making it less desirable for some patients. In recent years, transcutaneous neuromuscular electrical stimulation has gained wide acceptance for treating various andrological conditions, including erectile dysfunction and premature ejaculation, yielding positive outcomes. This non-invasive technique offers a promising alternative for managing varicocele-induced scrotal pain, potentially reducing the need for surgical intervention and its associated risks. Its growing popularity underscores the need for further research and clinical trials to validate its efficacy and safety in treating this condition.

Author Spotlight: Advancing Varicocele Treatment with Neuromuscular Electrical Stimulation

This protocol outlines the use of transcutaneous neuromuscular electrical stimulation for treating varicocele-induced scrotal pain. It compares visual analog scale (VAS) scores and imaging changes before and after treatment to assess effectiveness. Results indicate that patients experienced improved scrotal pain symptoms following the treatment.

Varicocele is a prevalent vascular disorder affecting the male reproductive system, leading to scrotal pain and testicular dysfunction. Epidemiological ...

Combined Supine and Standing Imaging for Varicocele: An Improved Diagnostic Approach

Varicocele, one of the main diseases affecting male reproductive health, relies heavily on angiographic diagnostic techniques for disease-related examination and assessment. Traditional varicocele angiography often employs a supine position to facilitate the relaxation of the groin area muscles, the insertion of the angiography catheter, and imaging. However, the supine position may cause blood reflux, thus underestimating the clinical incidence of varicocele, particularly resulting in missed diagnoses of right-sided or bilateral varicoceles. To address this issue, this study proposes the combined use of supine and standing positions for varicocele imaging. The standing position increases lower abdominal pressure, making the degree of varicosity more prominent in the images. Compared to the sole use of the supine position, the method employed in this study effectively reduces the misdiagnosis rate of right-sided or bilateral varicoceles. This approach aims to facilitate the early detection, diagnosis, and treatment of varicocele, effectively reducing the potential threat of the disease to male reproductive health. It also helps improve the accuracy of disease assessment, providing more references for selecting subsequent treatment plans.

Varicocele relies heavily on angiographic diagnostic techniques for disease-related examination and assessment. In order to diagnose varicocele better, we combined supine and standing positions for varicocele imaging, and contrast-enhanced ultrasound is used for patients with inconspicuous reflux. This approach facilitates the early detection, diagnosis, and treatment of varicocele.