Varicocele is defined as an abnormal dilatation and tortuosity of the pampiniform venous plexus within the spermatic cord and represents one of the most common surgically correctable causes of male infertility. It affects approximately 15–25% of the general male population and is identified in nearly 35% of men with primary infertility and up to 75–81% of men with secondary infertility [1,2]. The condition occurs predominantly on the left side because of anatomical and hemodynamic factors, including the perpendicular drainage of the left internal spermatic vein into the left renal vein, increased venous pressure, and the nutcracker phenomenon caused by compression of the renal vein between the superior mesenteric artery and the aorta [3,4]. The exact pathophysiological mechanism by which varicocele impairs fertility remains incompletely understood; however, several theories have been proposed. Increased scrotal temperature due to impaired countercurrent heat exchange is considered one of the major contributing factors leading to testicular dysfunction and impaired spermatogenesis [5]. Additional mechanisms include hypoxia, reflux of renal and adrenal metabolites, oxidative stress, hormonal imbalance, and impaired Leydig cell function [6]. Previous studies demonstrated that varicocele is associated with deterioration in sperm concentration, motility, and morphology, as well as reduced testosterone production [7,8]. Surgical repair of varicocele has been shown to improve semen parameters and may improve spontaneous pregnancy rates in selected infertile patients [9]. Diagnosis of varicocele is primarily based on clinical examination performed in both standing and supine positions, with or without the Valsalva maneuver. Varicoceles are clinically graded into grade I, II, and III according to their palpability and visibility [10]. Scrotal ultrasonography with Doppler imaging is commonly used to confirm diagnosis, assess venous reflux, and evaluate testicular volume [11]. Several surgical techniques have been developed for varicocele repair, including retroperitoneal, inguinal, subinguinal microsurgical, laparoscopic, and radiological embolization procedures. Open subinguinal varicocelectomy remains one of the most commonly practiced procedures because of its simplicity and effectiveness, while laparoscopic varicocelectomy has gained popularity particularly in bilateral cases because it allows better visualization of the spermatic vessels, artery, and lymphatics through magnification [12]. Despite numerous studies comparing both procedures, controversy still exists regarding the superiority of one technique over another in terms of operative time, postoperative pain, semen improvement, complications, and recovery. Therefore, the present study was conducted to compare open bilateral subinguinal varicocelectomy and laparoscopic bilateral varicocelectomy regarding operative time, clinical outcome, seminal fluid analysis, complications, operation-related pain, hospital stay, and return to normal activity.

This prospective comparative study was conducted at the Urology Department of Al-Imamain Al-Kadhymain Medical City from January 2015 to August 2016. The study included 63 male patients diagnosed with bilateral varicocele. Patients were allocated into two groups according to the surgical procedure performed.

Group I included 30 patients who underwent open bilateral subinguinal varicocelectomy, whereas Group II included 33 patients who underwent laparoscopic bilateral varicocelectomy. All patients underwent detailed clinical evaluation including history taking, physical examination, and semen analysis before surgery. Varicocele diagnosis was established clinically and confirmed by scrotal ultrasonography when necessary

Patients with unilateral varicocele, previous varicocelectomy, severe systemic diseases, or associated scrotal pathology were excluded from the study. Written informed consent was obtained from all participants before surgery.

In the open subinguinal approach, a small subinguinal incision was made below the external inguinal ring. The spermatic cord was isolated, and all dilated veins were ligated while preserving the testicular artery, lymphatics, and vas deferens. In the laparoscopic approach, the internal spermatic veins were identified laparoscopically and clipped or ligated while preserving the artery and lymphatics whenever possible.

The following parameters were evaluated and compared between both groups:

1. Operative time
2. Clinical outcome
3. Seminal fluid analysis
4. Postoperative complications
5. Operation-related pain using visual analog scale
6. Length of hospital stay
7. Return to normal daily activity

Statistical analysis was performed using SPSS software. Quantitative data were expressed as mean ± standard deviation. Student’s t-test was used for comparison of continuous variables, while Chi-square test was used for categorical variables. A P value less than 0.05 was considered statistically significant

The study showed that the mean age of patients who underwent open bilateral subinguinal varicocelectomy was 28 ± 8 years compared with 25 ± 7 years in the laparoscopic bilateral varicocelectomy group, with no statistically significant difference (P > 0.05). The mean operative time was significantly shorter in the laparoscopic group (45 ± 9 minutes) compared with the open surgery group (50 ± 20 minutes) (P < 0.05). Operation-related pain was significantly lower among patients who underwent open surgery (2.8 ± 1.2) compared with the laparoscopic group (4.1 ± 1.3) (P < 0.05). No statistically significant differences were observed between both groups regarding length of hospital stay, semen analysis improvement, clinical outcome, postoperative complications, or return to normal activity (P > 0.05)

Table 1: Descriptive Data of the Study Comparing Open Bilateral Subinguinal Varicocelectomy and Laparoscopic Bilateral Varicocelectomy

Table 2: Comparison of Seminal Fluid Analysis Parameters Before and After Surgery Between Open and Laparoscopic Bilateral Varicocelectomy

The study showed that postoperative complications were uncommon in both surgical groups. In the open bilateral subinguinal varicocelectomy group, postoperative bleeding occurred in one patient (3.33%), wound infection in two patients (6.67%), and unilateral hydrocele in one patient (3.33%). In the laparoscopic bilateral varicocelectomy group, unilateral hydrocele and recurrence were reported in one patient each (3.03%). No statistically significant difference was found between both groups regarding postoperative complications (P > 0.05).

Table 3: Distribution of Postoperative Complications Among the Study Groups

The study showed that all patients in both open bilateral subinguinal varicocelectomy and laparoscopic bilateral varicocelectomy groups demonstrated clinical improvement after surgery. Improvement in semen analysis was observed in 73.33% of patients in the open surgery group and 78.79% of patients in the laparoscopic group. No statistically significant differences were found between both groups regarding clinical outcome or semen analysis improvement (P > 0.05).

Table 4: Clinical Outcome and Semen Analysis Improvement Among the Study Groups

 The study showed that the mean postoperative hospital stay was one day in both groups with no statistically significant difference (P > 0.05). Patients who underwent laparoscopic bilateral varicocelectomy returned earlier to normal daily activities (2 ± 1 days) compared with those who underwent open bilateral subinguinal varicocelectomy (3 ± 1 days), although the difference did not reach statistical significance (P > 0.05).

Table 5: Comparison of Hospital Stay and Return to Normal Activity Between Study Groups

The study showed that operative time was significantly shorter in patients treated with laparoscopic bilateral varicocelectomy compared with open bilateral subinguinal varicocelectomy (P < 0.05). Conversely, operation-related pain score was significantly lower among patients who underwent open surgery compared with laparoscopic surgery (P < 0.05).

Table 6: Comparison of Operative Time and Operation-Related Pain Between Study Groups

Varicocelectomy remains the standard treatment for clinically significant varicocele associated with infertility, pain, or abnormal semen parameters. Several operative approaches have been developed over the years, including open inguinal, subinguinal microsurgical, retroperitoneal, laparoscopic, and radiological embolization techniques [1,2]. Despite numerous advances in surgical techniques, controversy still exists regarding the optimal procedure that provides the best clinical outcomes with minimal complications [3]. In the present study, laparoscopic bilateral varicocelectomy demonstrated a significantly shorter operative time compared with open bilateral subinguinal varicocelectomy. This finding is consistent with the study conducted by Sun et al. [4], who reported shorter operative duration in laparoscopic procedures because of easier access to bilateral spermatic veins through the same ports and better visualization of the operative field. Similar findings were also observed by Franco [5], who emphasized that laparoscopic magnification facilitates rapid identification and ligation of spermatic veins. The current study showed no statistically significant difference between the two procedures regarding postoperative semen analysis improvement. Both approaches resulted in significant postoperative increases in sperm concentration and motility. These findings agree with the observations of Shamsa et al. [6], who demonstrated comparable improvements in semen parameters following both laparoscopic and open subinguinal varicocelectomy. Previous studies have confirmed that varicocele repair improves testicular function by reducing scrotal hyperthermia, oxidative stress, and venous reflux [7,8]. Regarding postoperative pain, the present study demonstrated significantly lower pain scores in the open subinguinal group compared with the laparoscopic group. This finding differs from several previous reports that suggested reduced postoperative discomfort after laparoscopic surgery [9]. The difference may be attributed to variations in surgical technique, postoperative analgesic protocols, and surgeon experience. Complication rates were low in both groups, with no statistically significant difference. Hydrocele formation and recurrence were uncommon in both procedures. Similar results were reported by Al-Kandari et al. [10], who found comparable complication rates between laparoscopic and open techniques. Preservation of lymphatics and testicular arteries during surgery plays an essential role in minimizing postoperative hydrocele and testicular atrophy [11]. Hospital stay was equal in both groups, averaging one day, which is comparable to findings reported in previous international studies [12,13]. In addition, laparoscopic surgery showed a slightly faster return to normal activity, probably due to smaller incisions and less tissue dissection [14]. The present findings support the growing evidence that laparoscopic varicocelectomy is an effective and safe option for bilateral varicocele management. The magnification provided by laparoscopy allows better identification of vascular structures and facilitates bilateral treatment through minimal access surgery [15]. Nevertheless, open subinguinal varicocelectomy remains an effective procedure with excellent outcomes and low complication rates, especially when performed by experienced surgeons [16]. Several authors have compared recurrence rates among different techniques and found lower recurrence with microsurgical and laparoscopic approaches due to improved visualization of collateral veins [17–19]. Other studies emphasized the importance of artery and lymphatic preservation in reducing postoperative complications [20,21]. Improvement in sperm quality following varicocelectomy has been consistently demonstrated in many clinical trials and meta-analyses [22–24]. Increased postoperative testosterone levels and improved Leydig cell function were also reported after varicocele repair [25,26]. Furthermore, early surgical intervention may prevent progressive deterioration in testicular function and fertility potential [27]. Although laparoscopic surgery offers several advantages including shorter operative time and earlier recovery, it requires general anesthesia and specialized laparoscopic equipment [28]. Open subinguinal surgery, on the other hand, is technically less demanding and can be performed safely with excellent outcomes in experienced hands [29]. Overall, the present study confirms that both open bilateral subinguinal varicocelectomy and laparoscopic bilateral varicocelectomy are effective procedures for the treatment of bilateral varicocele, with each technique having specific advantages and limitations [30].

Both open bilateral subinguinal varicocelectomy and laparoscopic bilateral varicocelectomy were effective in the treatment of bilateral varicocele. Both techniques improved clinical outcomes and semen analysis parameters with low complication rates. Laparoscopic surgery showed shorter operative time and earlier return to normal activity, while open surgery was associated with lower postoperative pain scores. No significant differences were found regarding hospital stay, complications, or semen analysis improvement. Laparoscopic varicocelectomy is a safe and effective option for bilateral varicocele and may be preferred when laparoscopic facilities and expertise are available.

Limitations of the Study

The sample size of the study was relatively small and conducted in a single center, which may limit the generalization of the results. The follow-up period was short, and long-term recurrence and fertility outcomes were not fully evaluated. Pregnancy rates and postoperative hormonal changes were not assessed in this study. Differences in surgeon experience and operative technique may have affected some outcomes

1. Mehta A, Goldstein M. Microsurgical varicocelectomy: a review. Asian J Androl. 2013;15:56-60.
2. Serefoglu EC, Saitz TR, La Nasa JA Jr, et al. Adolescent varicocele management controversies. Andrology. 2013;1:109-115.
3. Gargollo PC, Diamond DA. Current management of adolescent varicocele. Curr Urol Rep. 2009;10:144-149.
4. Sun H, Liu Y, Yan M, Li Z, Gui X. Comparing three different surgical techniques used in adult bilateral varicocele. Asian J Endosc Surg. 2011;5(1):12-16.
5. Franco I. Laparoscopic varicocelectomy in the adolescent male. Curr Urol Rep. 2004;5(2):132-136.
6. Shamsa A, Mohammadi L, Abolbashari M, et al. Comparison of Open and Laparoscopic Varicocelectomies in Terms of Operative Time, Sperm Parameters, and Complications. Urol J. 2009;6(3):170-175.
7. Feng HL, Sandlow JI, Sparks AE. Decreased expression of heat shock protein is associated with infertility. Fertil Steril. 2001;76:1136-1139.
8. Lima SB, Cenedeze MA, Bertolla RP, et al. Expression of HSPA2 gene in adolescents with varicocele. Fertil Steril. 2006;86:1659-1663.
9. Hirsch IH, Abdel-Meguid TA, Gomella LG. Postsurgical outcomes assessment following varicocele ligation. Urology. 1998;51(5):810-815.
10. Al-Kandari AM, Shabaan H, Ibrahim HM, et al. Comparison of outcomes of different varicocelectomy techniques. Urology. 2007;69(3):417-420.
11. Goldstein M, Gilbert BR, Dicker AP, et al. Microsurgical inguinal varicocelectomy with delivery of the testis. J Urol. 1992;148(6):1808-1811.
12. Donovan JF, Winfield HN. Laparoscopic varix ligation. J Urol. 1992;147(1):77-81.
13. May M, Johannsen M, Beutner S, et al. Laparoscopic surgery versus antegrade scrotal sclerotherapy. Eur Urol. 2006;49(2):384-387.
14. Kobori Y, Okada H, Ota S, et al. LESS-V versus subinguinal microscopic varicocelectomy. ASRM Annual Meeting. 2013.
15. Glassberg KI, Poon SA, Gjertson CK, et al. Laparoscopic lymphatic sparing varicocelectomy. J Urol. 2008;180(1):326-330.
16. Marmar JL, Kim Y. Subinguinal microsurgical varicocelectomy. J Urol. 1994;152(4):1127-1132.
17. Barbalias GA, Liatsikos EN, Nikiforidis G, et al. Treatment of varicocele for male infertility. Eur Urol. 1998;34(5):393-398.
18. Lemack GE, Uzzo RG, Schlegel PN, et al. Microsurgical repair of adolescent varicocele. J Urol. 1998;160:179-181.
19. Cayan S, Kadioglu TC, Tefekli A, et al. Comparison of results and complications of high ligation surgery and microsurgical varicocelectomy. Urology. 2000;55(5):750-754.
20. Szabo R, Kessler R. Hydrocele following internal spermatic vein ligation. J Urol. 1984;132(5):924-926.
21. Raman JD, Goldstein M. Intraoperative characterization of arterial vasculature in spermatic cord. Urology. 2004;64(3):561-564.
22. Li F, Yue H, Yamaguchi K, et al. Effect of surgical repair on testosterone production. Int J Urol. 2012;19:149-154.
23. Zohdy W, Ghazi S, Arafa M. Impact of varicocelectomy on gonadal function. J Sex Med. 2011;8:885-893.
24. Abdel-Meguid TA, Farsi HM, Al-Sayyad A, et al. Effects of varicocele on serum testosterone. Urology. 2014;84:1081-1087.
25. SathyaSrini V, BelurVeerachari S. Varicocelectomy and gonadal function. Int J Endocrinol. 2011;2011:916380.
26. Masson P, Brannigan RE. The varicocele. Urol Clin North Am. 2014;41:129-144.
27. Zampieri N, Cervellione RM. Varicocele in adolescents: longitudinal study. J Urol. 2008;180:1653-1656.
28. Kaufman SL, Kadir S, Barth KH, et al. Mechanisms of recurrent varicocele. Radiology. 1983;147(2):435-440.
29. Beck EM, Schlegel PN, Goldstein M. Intraoperative varicocele anatomy. J Urol. 1992;148(4):1190-1194.
30. Saad DF, Abbas FM. Laparoscopic varicocelectomy for bilateral varicocele in infertile males. Iraqi Postgrad Med J. 2011;10:317-322