Jurnal Siti Rufaidah Volume 3.
Nomor 4.
November 2025 e-ISSN: 3032-1344.
p-ISSN: 3032-1336.
Hal 71-79 DOI : https://doi.
org/10.
57214/jasira.
Tersedia: https://journal.
org/index.
php/JASIRA Microsurgical versus Conventional Inguinal Varicocelectomy: A Systematic Review of Fertility Outcomes and Recurrence Risk Bobby Aksanda Putra1*.
Beny Levi Andreas Sibarani2.
Maeike Grestiana Sinaga3 Faculty of Medicine and Health Science Universitas Bengkulu.
Indonesia *Author Corresprodence: bobbyaksanda@gmail.
Abstract.
Infertility affects approximately 8Ae12% of couples worldwide, with male factors contributing to nearly half of all cases.
Varicocelectomy, particularly the microsurgical subinguinal technique, is now considered the primary treatment that provides superior reproductive outcomes compared to conventional or laparoscopic To evaluate and compare fertility outcomes and recurrence risks between microsurgical and conventional inguinal varicocelectomy, based on recent evidence from 2020 to 2025.
Methods A systematic review was conducted using databases including PubMed.
Scopus.
Cochrane.
ScienceDirect, and Google Scholar.
Out of 371 identified articles, 9 studies met the inclusion criteria.
Results, most studies demonstrated that the microsurgical technique significantly improved sperm concentration, motility, and morphology, as well as higher natural pregnancy rates.
The risks of hydrocele and recurrence were also markedly lower than those observed with laparoscopy.
The average postoperative sperm count increased by 7.
7 A 4.
5 million/mL .
< 0.
Furthermore, the microsurgical subinguinal approach allows for more precise identification of arteries and lymphatic vessels, thereby minimizing vascular injury and facilitating faster recovery.
Conclusion, the microsurgical subinguinal varicocelectomy has proven to be more effective and safer than conventional This technique significantly enhances semen parameters and pregnancy rates, while reducing the risk of hydrocele formation and recurrence.
Keywords: Conventional Inguinal Varicocelectomy.
Fertility.
Microsurgical.
Outcomes.
Recurrence Risk.
INTRODUCTION
Infertility affects an estimated 8Ae12% of couples worldwide, with male factors contributing to roughly half of these cases.
among identifiable male causes, varicocele the abnormal dilation of the pampiniform venous plexus is the most common correctable condition associated with impaired spermatogenesis and subfertility.
Varicoceles have been linked to altered testicular thermoregulation, oxidative stress, and impaired sperm DNA integrity, mechanisms that plausibly mediate declines in semen parameters and spontaneous pregnancy rates (Cannarella et al.
, 2.
Surgical correction .
remains the principal treatment for clinically significant varicoceles in men with abnormal semen parameters and a partner with normal fertility potential.
Multiple operative approaches exist open .
nguinal/retroperitonea.
, laparoscopic, radiologic embolization, and microsurgical subinguinal/inguinal techniques each balancing differing profiles of efficacy, complication rates .
otably hydrocele formation and arterial injur.
,and technical demands.
The microsurgical subinguinal approach has been proposed to minimise inadvertent arterial or lymphatic ligation while improving identification and ligation of all venous channels, thereby reducing recurrence and postoperative hydrocele (Al-said et al.
, 2008.
Mehta and Goldstein, 2.
Naskah Masuk: 14 Juni 2025.
Revisi: 03 Agustus 2025.
Diterima: 21 September 2025.
Terbit: 25 November Microsurgical versus Conventional Inguinal Varicocelectomy: A Systematic Review of Fertility Outcomes and Recurrence Risk Comparative studies and meta-analyses suggest that microsurgical varicocelectomy yields superior improvements in semen parameters and higher natural pregnancy rates while demonstrating lower recurrence and complication rates compared with conventional .
open or laparoscopic techniques.
However, methodological heterogeneity, differences in patient selection .
linical vs subclinical varicocel.
, outcome definitions .
emen parameter thresholds, time to pregnanc.
, follow-up duration, and surgeon experience, limits certainty and generalisability of pooled estimates.
Several recent systematic reviews and pooled analyses have attempted to synthesise available data but report variation in effect sizes and underline the need for a focused synthesis that examines both fertility outcomes .
emen parameters and natural/assisted pregnancy rate.
and recurrence risk by surgical approach (Majzoub et al.
, 2021.
Yuan et al.
, 2.
Given evolving evidence and persistent heterogeneity in the literature, a rigorous systematic review that explicitly compares microsurgical versus conventional inguinal varicocelectomy with pre-specified fertility endpoints .
perm concentration, motility, morphology.
DNA integrity, natural pregnancy rate.
and recurrence/complication outcomes is warranted.
Such a synthesis will clarify the magnitude and consistency of benefits attributed to microsurgical techniques, identify gaps in trial design and reporting, and inform evidence based counselling of patients and surgical decision-making .
Nayan et al.
, 2.
METHOD
This systematic review utilized secondary data obtained through a literature search.
Journal searches were conducted in electronic database-based publication centers, including PubMed.
Scopus.
Cochrane Library.
ScienceDirect.
Elsevier, and Google Scholar.
The search focused on works published between 2020 and 2025, using keywords such as AuMicrosurgical,Ay AuConventional Inguinal Varicocelectomy,Ay AuOutcomes,Ay AuFertility,Ay and AuRecurrence Risk,Ay arranged with Boolean operators (AND/OR) to refine the search.
After the initial search process, all results were exported and manually curated to remove duplicates and irrelevant The article screening process was carried out in two stages: first, screening of titles and abstracts, followed by a full-text review.
At this stage, several inclusion and exclusion criteria were applied to ensure that the selected articles were directly related to the study focus.
The inclusion criteria were: published between 2020 and 2025, available in full-text English, discussing microsurgical and conventional inguinal varicocelectomy, and addressing outcomes related to fertility and recurrence risk.
The exclusion criteria included: not in English, older Jurnal Siti Rufaidah - VOLUME 3.
NOMOR, 4 NOVEMBER 2025 e-ISSN: 3032-1344.
p-ISSN: 3032-1336.
Hal 71-79 than five years, incorrect outcomes .
ot related to fertility or recurrenc.
, and poor methodology or incomplete data.
RESULT AND DISCUSSION
From a total of 371 identified articles, 9 studies were selected for further analysis based on topic relevance.
The summary of findings is presented as follows:
Figure 1.
Search Framework.
Table 1.
Research Results.
Author Study (Yea.
Design Wang Systematic Review & Metaanalysis .
Review
Silva
HVN,
Kotb Comparativ e surgical Cannar Metaella R, analysis .
Sample Size Intervention / Comparison Microsurgical vs other techniques Fertility Outcomes Pregnancy & semen quality better in Radiologic vs Surgery n=80 Microsurgical pulling vs Varicocele repair vs control Semen Significant Jurnal Siti Rufaidah - VOLUME 3.
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Recurrence Lower in Recurrence Lower in pulling Lower in Follo w-up Varied Varied Microsurgical versus Conventional Inguinal Varicocelectomy: A Systematic Review of Fertility Outcomes and Recurrence Risk Warli SM.
Comparativ e clinical n=120 Microsurgical vs Laparoscopic Teng Systematic Review .
Varicocelectomy vs no Jan
MA,
Aksoy Prospective n=60 Microsurgical Review of Overview of Improved pregnancy in Assisted Significant sperm count General Fertility not Lower in Recurrence not primary Varied Low Recurrence Observatio n=200 Embolization Recurrence 24 Grae agents compared varied by MNM, retrospectiv Surgical intervention for varicocele involves the obstruction of venous reflux drainage to the testis.
Varicocelectomy is the most commonly performed surgical procedure for this condition, with several available techniques.
The operation can be carried out using laparoscopic, open retroperitoneal, or open macroscopic and microscopic approaches.
Both macroscopic and microscopic open techniques can be performed at the inguinal or subinguinal Currently, the microsurgical subinguinal varicocelectomy is regarded as the gold standard treatment for varicocele, offering a better prognosis compared to other therapeutic approaches (Neves et al.
, 2.
The study by Baazeem et al demonstrated that surgical intervention can improve testicular function and sperm quality (Baazeem et al.
, 2.
In the study by Warli et al.
, 2024,
it was found that postoperative complications, including the occurrence of hydrocele, were significantly more frequent in the laparoscopic group compared to the microsurgical group (Warli et al.
, 2.
Based on these results, laparoscopic procedures were shown to increase the risk of hydrocele formation by up to 2.
55 times compared to microsurgery.
This finding is supported by the study of Wu et al.
,2017 which reported that microsurgical varicocelectomy reduces the likelihood of hydrocele occurrence (WMD = 0.
95% CI = 0.
01Ae0.
P = 0.
Z = 3.
(Wu et al.
, 2.
The subinguinal microsurgical approach offers several advantages, including preservation of arteries and the lymphatic system, high success rates in improving semen parameters, and a very low risk of hydrocele formation.
Four main benefits of this technique Jurnal Siti Rufaidah - VOLUME 3.
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Hal 71-79 compared to inguinal or retroperitoneal varicocelectomy are: .
the subinguinal incision allows exposure of the spermatic cord without the need to cut abdominal muscles or fascia, reducing postoperative pain and accelerating patient recovery.
clear identification of all dilated veins minimizes the likelihood of varicocele recurrence.
accurate recognition of the testicular, external, and vasal arteries prevents accidental ligation of the testicular artery.
visualization of the testicular veins is enhanced, enabling more thorough and effective ligation (Kaltsas et , 2.
Microsurgical varicocelectomy allows exposure of the spermatic cord without cutting muscles or fascia, while also enabling identification and ligation of small collateral veins to prevent persistent or recurrent varicocele.
Additionally, this technique allows visualization of small arteries, reducing the risk of accidental arterial ligation, as well as lowering the risk of injury and recurrence (Teng et al.
, 2.
During the microsurgical procedure, testicular delivery allows direct visualization of all efferent venous pathways, contributing to a significant reduction in varicocele recurrence A study by Phan et al.
, 2021 which conducted a metaanalysis of 17 studies, aimed to evaluate the efficacy of different surgical varicocelectomy techniques .
icrosurgical inguinal and high ligatio.
in improving semen parameters among infertile men with unilateral or bilateral varicoceles.
The results showed that total sperm count increased by 9.
71 y 10A/mL .
< 0.
and sperm motility improved by 9.
92% .
< 0.
following microsurgical Similarly, in high ligation varicocelectomy, total sperm count increased by 03 y 10A/mL .
= 0.
and sperm motility improved by 11.
72% .
= 0.
(Phan et al.
In line with the study by Jan et al.
, 2025, microsurgical varicocelectomy improves sperm quality.
After microsurgical varicocelectomy, a significant increase in sperm count was Sperm concentration increased significantly from a preoperative value of 12.
5 A 6.
million/mL to 20.
2 A 8.
1 million/mL.
The mean increase was 7.
7 A 4.
5 million/mL, and this difference was statistically highly significant .
< 0.
paired t-tes.
Subgroup analysis showed a significant postoperative increase in sperm count based on varicocele grade, with patients with grade i varicocele showing the highest mean postoperative sperm count at 22.
A 9.
1 million/mL, followed by grade II at 19.
8 A 6.
7 million/mL and grade I at 17.
4 A 5.
million/mL.
This difference was statistically significant .
= 0.
one-way ANOVA) (Jan et , 2.
In line with studies conducted by Cannarela et al.
, 2024, and Wang et al.
,2021 which examined pre and post operative outcomes of varicocelectomy, the results showed that sublingual microsurgical varicocelectomy using the Enhanced Recovery After Surgery Jurnal Siti Rufaidah - VOLUME 3.
NOMOR, 4 NOVEMBER 2025 Microsurgical versus Conventional Inguinal Varicocelectomy: A Systematic Review of Fertility Outcomes and Recurrence Risk (ERAS) approach can significantly improve sperm count, vitality, and morphology.
In this study, sperm concentration increased from 32.
8 million/mL to 38.
8 million/mL, total sperm motility increased from 20.
1% to 25.
9%, and normal morphology improved from 2.
5% to 3.
< 0.
, with the overall semen quality improvement rate reaching 88.
Postoperative complications in this study were approximately 2.
3% .
crotal edema 0.
9%, incisional fat 0.
and testicular pain 0.
5%), while the recurrence of hydrocele was only 0.
No cases of testicular atrophy or vas deferens injury were observed.
The venous return system of the testes primarily consists of the internal spermatic vein, the deferential vein, and the external spermatic venous system, which includes the cremasteric and gubernacular veins.
Lymphatic vessels are usually transparent, and when the main veins are ligated, these vessels can undergo compensatory thickening to enhance lymphatic flow.
Injury to these lymphatic vessels may trigger an increased incidence of hydrocele due to impaired scrotal fluid drainage (Cannarella et al.
, 2024.
Wang et al.
, 2.
Theoretically, the risk of hydrocele formation is higher in laparoscopic surgery compared to low ligation, due to lymphatic obstruction along the spermatic cord.
In high en bloc ligation, which is commonly performed in laparoscopic procedures, disruption of blood vessels and lymphatics can occur, leading to an imbalance between fluid absorption and secretion in the tunica vaginalis.
If varicocelectomy is followed by hydrocelectomy, the risk increases in the event of injury to the internal testicular artery, as the remaining collateral blood supply to the testis may be compromised.
Hydrocele formation after varicocele repair can also result in a fluid layer around the testis, which may impede the restoration of the testisAos natural cooling function postoperatively.
To date, it remains unclear whether this fluid layer also contributes to additional disturbances in spermatogenesis, potentially leading to delayed testicular growth (Warli et al.
, 2.
The study Da Silva et al.
, 2022 compared microsurgical and laparoscopic The results showed that microsurgical varicocelectomy had significant advantages over laparoscopy in terms of lower recurrence rates, fewer hydrocele complications, and greater improvements in semen parameters, although it required a longer operative time.
Overall, both methods are effective in improving sperm quality and pregnancy rates, but microsurgical varicocelectomy is still considered more efficient and safer in the long term (Neves et al.
, 2.
From an efficacy standpoint, this study found that laparoscopic varicocelectomy has a recurrence rate 5.
84 times higher than microsurgical varicocelectomy.
This finding aligns with a 2017 meta-analysis, which also demonstrated that the microsurgical technique is superior in Jurnal Siti Rufaidah - VOLUME 3.
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p-ISSN: 3032-1336.
Hal 71-79 reducing recurrence rates (Wu et al.
, 2.
This difference is thought to be related to the findings of Moon KH et al.
, 2021, who reported that the high recurrence rate in laparoscopic surgery is mainly due to residual collateral veins from the internal and external spermatic veins that join in situ vitrification (ISV) at higher levels, which are difficult to identify via venography (Moon et al.
, 2.
In addition to ISV collaterals at the subinguinal level, there are other small collateral veins, such as periarterial plexus, cremasteric veins, and extratesticular and gubernacular collaterals, which, if not identified, can dilate postoperatively and cause varicocele recurrence (Wu et al.
, 2.
These findings are further supported by Pajovic et al.
,2015 who stated that although laparoscopic surgery can preserve the spermatic artery and lymphatic vessels, the identification and preservation of these structures are performed more accurately and consistently using the microsurgical approach (Pajovic et al.
, 2.
In this study, among 70 evaluated patients, 100% of those in the microsurgical group successfully preserved the testicular artery, compared to 1% in the laparoscopic group.
The high success rate is attributed to the use of 10Ae25y microscopic magnification, which allows for more precise identification of the artery and helps avoid inadvertent ligation.
Therefore, although the testis also receives additional blood supply from the vasal and cremasteric arteries, the testicular artery remains the primary source of blood flow to the testis and must be optimally preserved to maintain its physiological function (Pajovic et al.
, 2.
CONCLUSIONS
Varicocelectomy is the primary surgical intervention for treating varicocele, aiming to restore testicular function and improve male fertility.
Various surgical techniques can be However, the microsurgical subinguinal varicocelectomy has been proven to yield the best outcomes compared to laparoscopic, retroperitoneal, or conventional approaches.
The superiority of the microsurgical technique lies in the 10Ae25y optical magnification, which allows precise identification of the testicular artery, small collateral veins, and lymphatic vessels, thereby minimizing inadvertent ligation and preventing persistent or recurrent Jurnal Siti Rufaidah - VOLUME 3.
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Microsurgical versus Conventional Inguinal Varicocelectomy: A Systematic Review of Fertility Outcomes and Recurrence Risk
REFERENCES