ADU~ UROLOGY INCIDENCE OF EXTERNAL SPERMATIC VEINS IN PATIENTS UNDERGOING INGUINAL VARICOCELECTOMY ERIK T. GOLUBOFF, M.D. DAVID T. CHANG, B.A. ANDREWJ. KIRSCH, M.D. HARRY FISCH, M.D. From the Department of Urology and Squier Urological Clinic, Columbia University College of Physicians and Surgeons, New York, New York ABSTRACT--Objectives. To determine the incidence of external spermatic veins at in- guinal varicocelectomy. Methods, A prospective study was performed by" making intraoperative observations on 78 varicocelectomies (47 patients) performed by a single surgeon. All patients were referred for evaluation of male infertility and had a palpable varicocele present when ex- amined while performing a Valsalva maneuver in the upright position. Varicocelectomies were performed via the inguinal approach using ×2.5 loupe magnification. Presence of external spermatic veins was defined as visualization (with ×2.5 Ioupe magnification) of veins on the floor of the inguinal canal traveling posterolateral to the spermatic cord that then subsequently exited the spermatic cord before passing through the internal in- guinal ring. Age, anesthetic technique, and need for incision of the external inguinal ring were also recorded for each patient. Results. One third of patients had undergone left-sided varicocelectomies, while two thirds had undergone bilateral procedures. External spermatic veins were identified in 15% of left-sided varicoceles and 19% of right-sided ones. Of 31 patients undergoing bi- lateral varicocelectomies, 19% had at least 1 external spermatic vein. Of these patients, only 2 (7%) had a unilateral right external spermatic vein, none had a unilateral left ex- ternal spermatic vein, and 4 (13%) had bilateral external spermatic veins. Overall, of all patients studied, 16% had at least 1 external spermatic vein. Follow-up at 1 year showed no evidence of clinical recurrence in any patient. Conclusions. These results emphasize the importance of distal gonadal venous anatomy in the surgeon's choice of the proper approach to varicocele repair, since exter- nal spermatic veins are only accessible via an inguinal approach. Varicoceles, which are found in approximately 15% of the general population and in as many as 40% of infertile men,~,2 are caused by abnormal ret- rograde venous flow to the testicle. Varicocele ther- apy aims to occlude the involved venous channels, with common indications for intervention includ- ing male infertility, pain or discomfort, undesirable cosmetic appearance, and, in the adolescent, dis- crepancy in testicular size. Successful varicocele repair leads to improved semen parameters in 60% Submitted: March 31, 1994, accepted (with revisions): July 8, 1994 of infertile patients. 3 Recent work has addressed the inherent advantages offered by the various sur- gical and percutaneous embolization treatment op- tions, each of which have reported postoperative re- currence rates between 5% and 20%. 4-8 The outcome of any varicocele repair is highly de- pendent upon the gonadal venous anatomy, which is complex and can have many variations TM (Fig. 1). Testicular venous drainage occurs primarily through the internal spermatic veins, but collat- eral channels often exist both proximal and distal to the inguinal rings. Proximally, collaterals to the spermatic vein from the renal vein, the capsular UROLOGY ~ / DECEMBER 1994 / VOLUME 44, NUMBER 6 89S