A study examines the detailed vascular anatomy of the spermatic cord during subinguinal microscopic varicocelectomy and to assess the outcome of the cases about varicocele recurrence and hydrocele formation. Varicocele is found in ∼15% of the general male population. The European Association of Urology recommends varicocele repair for adults with clinical varicocele with infertility or abnormal semen quality and adolescents with progressive failure of testicular development.

The best treatment method should include the elimination of the varicocele and should carry a low risk of complications. Therefore, the ideal technique should involve ligation of all internal and external spermatic veins with preservation of spermatic arteries and lymphatic vessels. Conventional varicocelectomy is complicated by a postoperative recurrence rate of 5–20% in patients with varicocele. The use of microscopy has significantly improved the outcome of varicocelectomy.

Microsurgical varicocelectomy is considered the ‘gold standard’ technique for treating varicocele in both adults and adolescents, due to relatively more favourable outcomes and lower postoperative recurrence and complication rates. Optical magnification allows identification of all spermatic cord structures with inguinal and subinguinal approaches to varicocelectomy. 

In the subinguinal approach, the external oblique aponeurosis is not opened, and the cord is isolated by dissection at the level just inferior to the external inguinal ring. So, the subinguinal approach is associated with less pain and a rapid recovery in comparison with the inguinal approach. In the inguinal canal, the pampiniform plexus is drained by three or four veins, which run into the abdomen through the deep inguinal ring.

According to a study, a total of 11.1 internal spermatic veins per dissection were identified sublingually. A mean of 0.4 internal spermatic veins of ≥5?mm in diameter per cord was identified sublingually. A corresponding increase in the mean number of internal spermatic veins of ≤2?mm in diameter was noted with 7.9 at the subinguinal level. In the present study, the mean number of spermatic veins was 14 on both sides.

Microscopic subinguinal varicocelectomy accurately evaluated the detailed vascular anatomy of the spermatic cord, achieving an excellent surgical outcome with minimal varicocele recurrence and hydrocele formation. Microscopic subinguinal varicocelectomy should be the ‘gold standard’ for varicocelectomy.

Internal spermatic arteries at the subinguinal level are covered in a dense complex of veins compared with when they are identified at the inguinal level. This relationship requires greater surgical expertise to separate them. Dissection of this complex places the artery at greater risk of being damaged. The limitation of our study is the lack of the semen analysis outcome data. However, the aim of the present study was to report vascular anatomy details and the relationship with recurrent varicoceles and hydrocele formation.