Subinguinal Varicocelectomy With Loupes Only, Sans Surgical Microscope

I would like to comment Abdelrahman and Eassa on their important paper on the assessment of loupe-assist­ ed subinguinal varicocelectomy in infertile men (1). Methodology was complete, including a group of pa­ tients and another of controls, of adequate sample size, defined with valid inclusion and exclusion criteria, and followed-up at 3 and 6 months with measures of seminal count/morphology and relevant hormones. As for surgical anatomy and technique, the authors cor­ rectly approached internal spermatic veins after opening the internal spermatic fascia. They correctly mention a ‘compartment of the vas’ internal to the internal spermat­ ic fascia. Many experts, however, erroneously state that the vas sits outside the internal spermatic fascia (2). The vas indeed lies internal to the internal spermatic fascia (i.e. in the spermatic cord’s internal compartment) but is further ensheathed by a membranous layer continuing from the respective layer of the abdominopelvic extraperitoneal tissue. The internal spermatic vessels, nerves and lymphatics all within the internal compartment are similarly packed by another membranous sheath (3). The authors preserved the veins of the vas, “except when abnormally engorged veins were evident”. My preference is not to ligate these, but instead cremasteric veins plus their anastomoses with the external pudendal vein. The cremasteric veins are found between the internal and external spermatic fasciae, i.e. in the cord’s external com­ partment. Intact veins of the vas serve for venous flow after ligation of the internal spermatic and cremasteric veins. Gubernacular veins were not ligated; consequently the testis was not delivered. I concur: if sacrificed, tes­ ticular venous return relies only on the small deferential veins (3). With loupes only (sans surgical microscope), 0% recur­ rence and 0% hydrocele were achieved; admirable rates, totally comparable with those of subinguinal varicoce­ lectomy under microscope -better than rates of others using loupes [2.9% hydrocele, 2.9% reccurence (4)]. Com­ plication rates of subinguinal varicocelectomy without loupes— 15% hydrocele, 10% recurrence seem higher than