**7. Microsurgery**

In 1985, Marmar et al. proposed combined microdissection of the spermatic cord at the external inguinal ring, ligation of the dilated veins, and controlled sclerosis of small cross-collateral veins (Polidocanol 3%, 2–3 ml) [52]. The procedure was performed with an operating microscope and microsurgical instruments. Out of 71 cases, there were no post hydroceles and two palpable (0.28%) recurrences. In this initial report, the semen parameters demonstrated statistically significant improvement, and the pregnancy rate was 29.9%. However, in 1994, Marmar and Kim reviewed their experience with 466 subinguinal microsurgical varicocelectomies. There was only one permanent hydrocele, a palpable recurrence rate of 0.82%, and a one-year pregnancy rate of 35.6% [53]. In 1992, Goldstein modified the microsurgical subinguinal varicocelectomy, taking a more aggressive approach with arterial and lymphatic microsurgical dissection and venous ligation by an arterial and lymphatic sparing technique that

**Figure 3.** *Single-incision laparoscopic varicocelectomy. Isolation of the bundle and clips application.*

**Figure 4.**

*Lymphatic sparing laparoscopic varicocelectomy with isosulfan blue dye injection into the testicular vaginalis. Lymphatics are colored in blue.*

involved the delivery of the testis and ligature of gubernacular veins. The authors reported a failure rate of 0.6% for all of the procedures, and a pregnancy rate per couple of 43% within 6 months [54].

A microsurgical approach in pediatrics was proposed in the late 80s, although for many authors there is a prevalence of the use of selective laparoscopic ligation [55].
