Comparison of Success Rate and Complications of Open Inguinal and Subinguinal Varicocelectomy: A Randomized Controlled Trial

Comparison of Success Rate and Complications of Open Inguinal and Subinguinal Varicocelectomy: A Randomized Controlled Trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison of Success Rate and Complications of Open Inguinal and Subinguinal Varicocelectomy: A Randomized Controlled Trial Sadrollah Mehrabi, Fataneh shojaeizadeh, Leila Manzouri, Amir Mehrabi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-597318/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Varicocele is the most common surgically correctable cause of infertility in men. The aim of this study was comparing the success rate and complications of open inguinal and subinguinal varicocelectomy. Methods: This randomized clinical trial was conducted from March 2017 to 2018. Sixty six patients that met inclusion criteria for varicocelectomy (persistent pain or impaired spermogram) were sequentially randomly allocated to inguinal and subinguinal varicocelectomy. Sperm analysis was performed in all patients before surgery. One week, one and three months after the operation patients were visited and evaluated for pain intensity (using visual analog scale) and complications( recurrence, hematoma, scrotal swelling, infection, hydrocele formation and numbness). Follow- up spermogram was done three months after varicocelectomy to evaluate the success of operation. Results: Mean time of operation was17.33±2.18 and 22.48± 4.45 minutes in the subinguinal and inguinal varicocelectomy method, respectively (p=0.001, CI 95% =3.41-6.89). Semen analysis three months after surgery showed that there was no significant differences between semen volume (p=0.85), sperm count (p=0.09), sperm density (p=0.13), normal morphology (p=0.07) and motility (p=0.47) in both groups. There was no significant difference in pain density one week (p=0.51), one (p=0.29) and three months (p=0.67) after surgery between two groups. There wasn't any significant difference between two groups regarding recurrence of varicocele (p=0.67). Conclusions: In this study subinguinal varicocelectomy was superior to inguinal method due to less time of operation. However, there was no significant difference in postoperative complications and improvement of spermogram. Further studies with longer period of follow-up are recommended to compare fertility rate in inguinal and subinguinal varicocelectomy. Trial registration: IRCT, IRCT201710131323N12, Registered 20 October 2017, Retrospectively registered , https://www.irct.ir/trial/581 Urology & Nephrology complication semen analysis varicocele varicocelectomy Figures Figure 1 Introduction Infertility is one of the most important health issues of society, which is observed in 15% of young couples of reproductive age and imposes many psychosocial, emotional and economic effects on community health. [ 1 , 2 ] Varicocele is the most common surgically correctable cause of infertility in men which may be familiar and, in some studies, had some relation to prostate cancer. [ 3 , 4 ] Early diagnosis and treatment of varicocele, as the major cause of male infertility, can play an important role in improving infertility and reducing harmful effects on testes and also related costs. [ 5 , 6 ] There are several methods for the surgery of varicocelectomy, including microscopic surgery (inguinal and subinguinal), laparoscopic, open surgery and interventional radiology. [7– 10 ] Inguinal and subinguinal methods are recently developed as surgical techniques that in both methods, during operation all veins except the vassal vein are ligated, while lymphatic and if possible testicular arteries are preserved. Consequently, it reduces recurrence and complications. [ 1 , 11 ] In this study, we compare success rate and complications of open inguinal and subinguinal varicocelectomy. Methods It was a simple blind randomized clinical trial that was conducted from March 2017 to 2018. This study was approved by ethics committee of Yasuj University of Medical Sciences. After obtaining informed consent, 66 eligible patients that met inclusion criteria(persistent pain and/or impaired spermogram ) enrolled study and were randomly allocated (sequential) in one of two groups of inguinal and subinguinal varicocelectomy(Fig. 1). In both groups, after taking history and physical examination, diagnosis of varicocele were confirmed by examination and ultrasonography. Then sperm analysis was performed and sperm parameters were recorded in all patients. All operations were performed by a single surgeon with two methods of inguinal and subinguinal varicocelectomy. In both methods after operation, patients transferred to recovery and were discharged in the absence of any complication. One week after operation patients were visited again and evaluated for pain intensity using visual analog scale, hematoma formation, scrotal swelling and infections of operation site by surgeon. One and three month later, patients were revisited and evaluated for pain intensity, varicocele recurrence, hydrocele formation and presence of numbness in the site of operation by examination and/or ultrasonography, again. After three months, Follow up spermogram was done for all patients to assess the success of operation. A sample size of 80 patients was calculated using comparing two mean formulas counting 10% attrition rate. It was estimated to yield 80%power (type II or beta error of 0.20%) and type I error of 0.05 (µ 1 = 48 = Mean of sperm motility in open inguinal varicocelectomy, µ 2 = 52 = Mean of sperm motility in microscopic subinguinal varicocelectomy, S 1 = 4 = S.D. of sperm motility in inguinal varicocelectomy, S 2 = 6 = S.D. of sperm motility in microscopic subinguinal varicocelectomy). [ 6 ] Ethical considerations ‎‏ The research followed the tenets of the Declaration of Helsinki. Informed consent was obtained .The research was approved by the ethical committee of Yasuj University of Medical Sciences (Ethic code: ir.yums.REC.1395.220) and was registered in the Iranian Registry of Clinical Trial (IRCT) with code number of IRCT201710131323N12. ‎ Statistical analysis Data were analyzed by SPSS 21 software using descriptive (frequency, mean and standard deviation) and analytical (independent sample T test, chi-square) statistics. P value < 0.05 was considered as the significant level. Results Sixty six patients completed the study. Demographic characteristics of participants are summarized in Table 1 . Table 1 Demographic characteristics of participants based on surgical method variables Method of varicocelectomy P-value CI 95% Inguinal Subinguinal Lower limit Upper limit Age (year) : - 21–29 - 30–39 13(39.4%) 20(60.6% ) 20(60.6%) 13(39.4%) 0.08 a - - Varicocele side : - Right - Left 0(0%) 33(100%) 1(3%) 32(97%) 1 c - - Varicocele grade : - 1 - 2 - 3 8(24.24%) 17(51.52%) 8(24.24%) 2(6.1%) 17(51.5%) 14(42.4%) 0.07 a - - b Semen analysis : - Volume(ml) - Count - Density - Normal morphology - Normal motility 4.4 ± 1.8 68.6×10 6 ±49.21×10 6 15.36 ± 12.42 57.78 ± 26.98 45.66 ± 24.99 3.74 ± 1.66 72.09×10 6 ±43.87×10 6 19.73 ± 12.00 48 ± 23.54 45.63 ± 18.89 0.12 0.76 0.15 0.12 0.99 -0.19 -26.42 -10.37 -2.66 -10.86 1.51 19.43 1.63 22.24 10.92 a Chi−Square test was used for analysis b Independent samples T test was used for analysis c Fisher's Exact test was used for analysis Mean time of operation in the subinguinal and inguinal methods was 17.33 ± 2.18 and 22.48 ± 4.45 minutes respectively (P = 0.001,CI 95% =3.41–6.89). Three months after surgery, there wasn’t any significant differences between two groups in result of semen analysis (Table 2 ). Table 2 Semen analysis three months after varicocelectomy based on method of surgery Semen analysis Method of varicocelectomy P-value a CI 95% Inguinal Subinguinal Lower limit Upper limit - Volume(ml) - Count - Density - Normal morphology - Normal motility 3.83 ± 1.87 69.73×10 6 ±47.43×10 6 19.31 ± 13.84 65.15 ± 21.79 54.36 ± 21.08 3.76 ± 1.14 92.56×10 6 ±57.65×10 6 24.07 ± 11.85 55.45 ± 20.87 57.48 ± 13.12 0.85 0.09 0.13 0.07 0.47 -0.69 -48.23 -11.09 -0.79 -11.78 0.83 3.69 1.58 20.19 5.54 a Independent samples T test was used for analysis In inguinal varicocelectomy, there was significant difference before and after surgery in sperm density(P = 0.008), normal morphology(P = 0.0001) and normal motility( P = 0.0001) in semen analysis but there wasn't any significant difference in semen volume(P = 0.14) and sperm count(P = 0.88). In subinguinal varicocelectomy, there was significant difference before and after surgery in sperm count (P = 0.017), sperm density (P = 0.0001), normal morphology (P = 0.0001) and normal motility (P = 0.0001) in semen analysis but there wasn't any significant difference in semen volume (P = 0.96). There was no significant difference in pain intensity one week (p = 0.51), one (p = 0.29) and three months (p = 0.67) after surgery between two groups. There wasn't any report of hematoma formation, scrotal swelling and infections one week after surgery in both groups. There wasn't any report of pain, hydrocele formation and paresthesia in the site of operation, one and three months after surgery in both groups. There wasn't any significant difference in varicocele recurrence three months after surgery in inguinal and subinguinal varicocelectomy, respectively (12.1% vs. 6.1%, P = 0.67). Discussion Varicocele is the most common correctable cause of male infertility that may cause severe oligospermia and even azoospermia in some patients. [ 12 – 14 ] .Recently two systematic reviews concluded that there isn’t sufficient evidence regarding treatment of varicocele and its relation to fertility to warrant their repair. [ 14 , 15 ] However many studies reported fertility rate of 30–50% after different type of operation. [ 2 , 6 , 16 ] At present inguinal, subinguinal, microsurgical and laparoscopic methods are performed with different success rate and complications. [ 7 , 9 , 17 ] This study was performed for comparison of success rate and complication of open inguinal and subinguinal varicocelectomy. According to our results, there was no significant difference between two groups regarding patients' age, site and grade of varicocele and semen analysis parameters before operation. Mean time of operation was significantly lower in subinguinal varicocelectomy. In study by Watanabe and his colleagues, mean age of patients was 33.1 ± 5.9 year and grade 2 was the most common type of varicocele. Mean time of operation was 28.4 ± 3.86 minutes that was less than other studies. [ 1 ] Results of our study are similar to this study regarding mean age of patients and varicocele grades but the mean time of operation was lower in our study. In AL-kandari study the mean time of operation in subinguinal method was longer than laparoscopic and open group. [ 6 ] Also in Shiraishi study and his colleagues, the time of operation in subinguinal method was more than laparoscopic and open methods and postoperative pain in subinguinal method was less than other methods. [ 7 ] These results are in contrast to our results and mean time of operation in subinguinal group was less than inguinal method in our study. This difference may be due to type of anesthesia that in some patients was regional or inappropriate answers of patients to questionnaire. Regarding recurrence rate and complications in Shiraishi study, subinguinal method showed lower rate than other methods which is in concordance with our results. [ 7 ] Three months after operation sperm analysis revealed that there was no significant difference between two groups regarding semen volume and sperm parameters such as count, density, morphology and density. On the other hand, intergroup comparison showed that in both methods sperm density, morphology and motility improved after operation and sperm count improved more in subinguinal method (p = 0.017). These results are similar to Watanabe and Shiraishi studies, [ 1 , 7 ] but in contrast to these studies, in the present study both sperm density and motility improved with higher improvement in subinguinal varicocelectomy. Regarding postoperative complications there was no case of hematoma, scrotal swelling, infection, pain and inguinal paresthesia one week to 3 month after operation in both groups. In this study, there wasn't any significant difference in varicocele recurrence, three month postoperatively between two groups. These results are similar to Watanabe et al, except that in their study there was no recurrence in subinguinal method but we have two cases of recurrence in this method that may be due to non-microscopic method. [ 1 ] Regarding postoperative pain, other studies reported different results; but in all of them, pain intensity was higher than our study, [ 1 , 6 – 7 ] which may be due to small incision in our study. With regard to importance of infertility in our society we suggest further studies with loner duration of follow up to compare fertility rate in inguinal and subinguinal varicocelectomy. Conclusions In this study subinguinal varicocelectomy was superior to inguinal method due to less time of operation. However, there was no significant difference in postoperative complications and improvement of spermogram, the necessity of further studies with loner duration of follow up to compare fertility rate in inguinal and subinguinal varicocelectomy is felt. Declarations Ethics approval and consent to participate: The research was approved by the ethical committee of Yasuj University of Medical Sciences (Ethic code: IR.YUMS.REC.1395.220). Informed consent was obtained from all participants. Consent for publication: Not applicable Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests: ‎ ‏ The authors declared that they have no competing interest. Funding: Deputy of research of Yasuj University of Medical Sciences. Authors’ contributions: SM; the concept, design, data analysis, and manuscript preparation, manuscript review and final revision and submission. LM; the concept, design, data analysis, and manuscript preparation, manuscript review and final revision and submission. FSh; writing proposal and data collection. AM; writing proposal and data collection. All authors read and signed the final paper. Acknowledgments: ‎ ‏ The authors are grateful to the respected vice president of the technical and research department of Yasuj University of Medical Sciences, for the provision of facilities for this project. Additionally, we thank all staff of operating room of the Shahid Beheshti Hospital of Yasuj who assisted us in performing this procedure. References Watanabe M, Nagai A, Kusumi N, Tsuboi H, Nasu Y, Kumon H. Minimal invasiveness and effectivity of subinguinal microscopic varicocelectomy: a comparative study with retroperitoneal high and laparoscopic approaches. International journal of urology 2005; 12(10):892–8. Jungwirth A, Gögüs C, Hauser G, Gomahr A, Schmeller N, Aulitzky W, Frick J. Clinical outcome of microsurgical subinguinal varicocelectomy in infertile men. Andrologia 2001; 33(2):71–4. Mohammadali Beigi F, Mehrabi S, Javaherforooshzadeh A. Varicocele in brothers of patients with varicocele. Urol J 2007; 4(1):33–5. Gat Y, Gornish M, Heiblum M, Joshua S. Reversal of benign prostate hyperplasia by selective occlusion of impaired venous drainage in the male reproductive system: novel mechanism, new treatment. Andrologia 2008; 40(5):273–81. Mehrabi S, Ghafarian Shirhzi HR, Rasti M. Normal serum prostate specific antigen levels in men in Yasuj province, Islamic Republic of Iran. East Mediterr Health J 2007; 13(5):1190–4. Al-Kandari AM1, Shabaan H, Ibrahim HM, Elshebiny YH, Shokeir AA. Comparison of outcomes of different varicocelectomy techniques: open inguinal, laparoscopic, and subinguinal microscopic varicocelectomy: a randomized clinical trial Urology. 2007; 69(3):417–20. Shiraishi K, Oka S, Ito H, Matsuyama H. Comparison of the results and complications of retroperitoneal, microsurgical subinguinal and high inguinal approaches in the treatment of varicocele. J Androl 2012; 33(6):1387–93. Al-Said S1, Al-Naimi A, Al-Ansari A, et al. Varicocelectomy for male infertility: a comparative study of open, laparoscopic and microsurgical approaches. J Urol 2008; 180(1):266–70. Pajovic B1, Radojevic N, Dimitrovski A, Radovic M, Rolovic R, Vukovic M. Advantages of microsurgical varicocelectomy over conventional techniques. Eur Rev Med Pharmacol Sci 2015; 19(4):532–8. Yaman O1, Soygur T, Zumrutbas AE, Resorlu B. Results of microsurgical subinguinal varicocelectomy in children and adolescents. Urology 2006; 68(2):410–2. Kumar R1, Gupta NP. Subinguinal microsurgical varicocelectomy: evaluation of the results. Urol Int 2003; 71(4):368–72. O'Brien J1, Bowles B, Kamal KM, Jarvi K, Zini A. Does the gonadotropin-releasing hormone stimulation test predict clinical outcomes after microsurgical varicocelectomy? Urology 2004; 63(6):1143–7. Baazeem A, Boman JM, Libman J, Jarvi K, Zini A. Microsurgical varicocelectomy for infertile men with oligospermia: differential effect of bilateral and unilateral varicocele on pregnancy outcomes. BJU Int 2009; 104(4):524–8. Kroese AC, de Lange NM, Collins J, Evers JL. Surgery or embolization for varicoceles in subfertile men. Cochrane Database of Systematic Reviews. 2012(10). Kohn TP, Ohlander SJ, Jacob JS, Griffin TM, Lipshultz LI, Pastuszak AW. The Effect of Subclinical Varicocele on Pregnancy Rates and Semen Parameters: a Systematic Review and Meta-Analysis. Curr Urol Rep 2018; 19(7):53. Silay MS, Hoen L, Quadackaers J, Undre S, Bogaert G, Dogan HS, Kocvara R, Nijman RJ, Radmayr C, Tekgul S, Stein R. Treatment of varicocele in children and adolescents: a systematic review and meta-analysis from the European Association of Urology/European Society for Pediatric Urology Guidelines Panel. European urology 2018 Oct 10. Magoha GA. The role of varicocelectomy in the management of infertile males with varicocele. East Afr Med J 1994; 71(12): 800–2. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-597318","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":34249049,"identity":"32ff3131-f991-4ae4-ae2b-8ae189e7f4e7","order_by":0,"name":"Sadrollah Mehrabi","email":"","orcid":"","institution":"Yasuj University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Sadrollah","middleName":"","lastName":"Mehrabi","suffix":""},{"id":34249050,"identity":"0aeb10a3-f9c7-4bd4-925d-aac4311693db","order_by":1,"name":"Fataneh shojaeizadeh","email":"","orcid":"","institution":"Yasuj University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Fataneh","middleName":"","lastName":"shojaeizadeh","suffix":""},{"id":34249051,"identity":"897b14c0-91ca-463f-93a5-e92537fc117c","order_by":2,"name":"Leila Manzouri","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBUlEQVRIiWNgGAWjYBADHgZ2BoYDDxhskEQIamEGaklgSCNeCwNIC0MCw2HCCnXbzx7+8LHtngwDM/PBAwk15xM3XDv+gOFHDYOMeQN2LWZn8hIMZ7YVAx3GlnAg4djtxA23cwwYe44x8MgcwKHlQI5BMm9bAlALj8GBBDawFgYG3gYGHgkcDjM7/8bgMEQL/4cDCf/OAbWkP2D8i0/LjRzDZqgtDAcS2w4AtSQYMOO15cYbY8YZ5xJ42JjZDA4k9iUbzwT65bDMMQk8Dssx/vChLMGen7358YcP3+xk+26nP3z4psbGHpcWOGCD0o4NQOIAAwNBDQhgT7zSUTAKRsEoGCkAAPG0V9cmJxm4AAAAAElFTkSuQmCC","orcid":"","institution":"Yasuj University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Leila","middleName":"","lastName":"Manzouri","suffix":""},{"id":34249052,"identity":"e83f5f67-4573-407b-8150-e33887397acd","order_by":3,"name":"Amir Mehrabi","email":"","orcid":"","institution":"Yasuj University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Amir","middleName":"","lastName":"Mehrabi","suffix":""}],"badges":[],"createdAt":"2021-06-06 15:29:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-597318/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-597318/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":11198010,"identity":"ec11bb07-d020-43e0-b787-7afad64a2931","added_by":"auto","created_at":"2021-07-07 11:23:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":70040,"visible":true,"origin":"","legend":"CONSORT 2010 Flow Diagram","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-597318/v1/6bb14f35dcd454aabf691be4.png"},{"id":16322319,"identity":"de61ea64-bb91-4623-bf61-b496a73fb137","added_by":"auto","created_at":"2021-12-09 17:59:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":388876,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-597318/v1/b585aa09-d2ab-4fd4-99a0-fe979bd6954c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eComparison of Success Rate and Complications of Open Inguinal and Subinguinal Varicocelectomy: A Randomized Controlled Trial\u003c/p\u003e","fulltext":[{"header":"Introduction","content":" \u003cp\u003eInfertility is one of the most important health issues of society, which is observed in 15% of young couples of reproductive age and imposes many psychosocial, emotional and economic effects on community health. \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eVaricocele is the most common surgically correctable cause of infertility in men which may be familiar and, in some studies, had some relation to prostate cancer. \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e Early diagnosis and treatment of varicocele, as the major cause of male infertility, can play an important role in improving infertility and reducing harmful effects on testes and also related costs. \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThere are several methods for the surgery of varicocelectomy, including microscopic surgery (inguinal and subinguinal), laparoscopic, open surgery and interventional radiology. \u003csup\u003e[7\u0026ndash; \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eInguinal and subinguinal methods are recently developed as surgical techniques that in both methods, during operation all veins except the vassal vein are ligated, while lymphatic and if possible testicular arteries are preserved. Consequently, it reduces recurrence and complications. \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e In this study, we compare success rate and complications of open inguinal and subinguinal varicocelectomy.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003eIt was a simple blind randomized clinical trial that was conducted from March 2017 to 2018. This study was approved by ethics committee of Yasuj University of Medical Sciences. After obtaining informed consent, 66 eligible patients that met inclusion criteria(persistent pain and/or impaired spermogram ) enrolled study and were randomly allocated (sequential) in one of two groups of inguinal and subinguinal varicocelectomy(Fig. 1).\u003c/p\u003e\n\u003cdiv class=\"Section3\" id=\"Sec3\"\u003e\n \u003cp\u003eIn both groups, after taking history and physical examination, diagnosis of varicocele were confirmed by examination and ultrasonography. Then sperm analysis was performed and sperm parameters were recorded in all patients. All operations were performed by a single surgeon with two methods of inguinal and subinguinal varicocelectomy.\u003c/p\u003e\n \u003cp\u003eIn both methods after operation, patients transferred to recovery and were discharged in the absence of any complication. One week after operation patients were visited again and evaluated for pain intensity using visual analog scale, hematoma formation, scrotal swelling and infections of operation site by surgeon. One and three month later, patients were revisited and evaluated for pain intensity, varicocele recurrence, hydrocele formation and presence of numbness in the site of operation by examination and/or ultrasonography, again. After three months, Follow up spermogram was done for all patients to assess the success of operation.\u003c/p\u003e\n \u003cp\u003eA sample size of 80 patients was calculated using comparing two mean formulas counting 10% attrition rate. It was estimated to yield 80%power (type II or beta error of 0.20%) and type I error of 0.05 (\u0026micro;\u003csub\u003e1\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;48\u0026thinsp;=\u0026thinsp;Mean of sperm motility in open inguinal varicocelectomy, \u0026micro;\u003csub\u003e2\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;52\u0026thinsp;=\u0026thinsp;Mean of sperm motility in microscopic subinguinal varicocelectomy, S\u003csub\u003e1\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;4\u0026thinsp;=\u0026thinsp;S.D. of sperm motility in inguinal varicocelectomy, S\u003csub\u003e2\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;6\u0026thinsp;=\u0026thinsp;S.D. of sperm motility in microscopic subinguinal varicocelectomy).\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e\n \u003cdiv class=\"Section4\" id=\"Sec4\"\u003e\n \u003ch2 class=\"Heading\"\u003eEthical considerations\u003c/h2\u003e\n \u003cp\u003e\u003csup\u003e\u003cstrong\u003e\u0026lrm;\u0026rlm;\u003c/strong\u003e\u003c/sup\u003eThe research followed the tenets of the Declaration of Helsinki. Informed consent was obtained .The research was approved by the ethical committee of Yasuj University of Medical Sciences (Ethic code: ir.yums.REC.1395.220) and was registered in the Iranian Registry of Clinical Trial (IRCT) with code number of IRCT201710131323N12.\u003c/p\u003e\n \u003ch2\u003e\u003csup\u003e\u0026nbsp;\u003cstrong\u003e\u0026lrm;\u003c/strong\u003e\u003c/sup\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/h2\u003e\n \u003cp\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003eData were analyzed by SPSS 21 software using descriptive (frequency, mean and standard deviation) and analytical (independent sample T test, chi-square) statistics. P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered as the significant level.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eSixty six patients completed the study. Demographic characteristics of participants are summarized in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographic characteristics of participants based on surgical method\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003evariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMethod of varicocelectomy\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eCI\u003csub\u003e95%\u003c/sub\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eInguinal\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubinguinal\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLower limit\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eUpper limit\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (year)\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003e- 21\u0026ndash;29\u003c/p\u003e\n \u003cp\u003e- 30\u0026ndash;39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13(39.4%)\u003c/p\u003e\n \u003cp\u003e20(60.6% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20(60.6%)\u003c/p\u003e\n \u003cp\u003e13(39.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.08\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eVaricocele side\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003e- Right\u003c/p\u003e\n \u003cp\u003e- Left\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0(0%)\u003c/p\u003e\n \u003cp\u003e33(100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(3%)\u003c/p\u003e\n \u003cp\u003e32(97%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eVaricocele grade\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003e- 1\u003c/p\u003e\n \u003cp\u003e- 2\u003c/p\u003e\n \u003cp\u003e- 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8(24.24%)\u003c/p\u003e\n \u003cp\u003e17(51.52%)\u003c/p\u003e\n \u003cp\u003e8(24.24%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(6.1%)\u003c/p\u003e\n \u003cp\u003e17(51.5%)\u003c/p\u003e\n \u003cp\u003e14(42.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.07\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003csup\u003e\u003cstrong\u003eb\u003c/strong\u003e\u003c/sup\u003e\u003cstrong\u003eSemen analysis\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003e- Volume(ml)\u003c/p\u003e\n \u003cp\u003e- Count\u003c/p\u003e\n \u003cp\u003e- Density\u003c/p\u003e\n \u003cp\u003e- Normal morphology\u003c/p\u003e\n \u003cp\u003e- Normal motility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e\n \u003cp\u003e68.6\u0026times;10\u003csup\u003e6\u003c/sup\u003e\u0026plusmn;49.21\u0026times;10\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e15.36\u0026thinsp;\u0026plusmn;\u0026thinsp;12.42\u003c/p\u003e\n \u003cp\u003e57.78\u0026thinsp;\u0026plusmn;\u0026thinsp;26.98\u003c/p\u003e\n \u003cp\u003e45.66\u0026thinsp;\u0026plusmn;\u0026thinsp;24.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.74\u0026thinsp;\u0026plusmn;\u0026thinsp;1.66\u003c/p\u003e\n \u003cp\u003e72.09\u0026times;10\u003csup\u003e6\u003c/sup\u003e\u0026plusmn;43.87\u0026times;10\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e19.73\u0026thinsp;\u0026plusmn;\u0026thinsp;12.00\u003c/p\u003e\n \u003cp\u003e48\u0026thinsp;\u0026plusmn;\u0026thinsp;23.54\u003c/p\u003e\n \u003cp\u003e45.63\u0026thinsp;\u0026plusmn;\u0026thinsp;18.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.19\u003c/p\u003e\n \u003cp\u003e-26.42\u003c/p\u003e\n \u003cp\u003e-10.37\u003c/p\u003e\n \u003cp\u003e-2.66\u003c/p\u003e\n \u003cp\u003e-10.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.51\u003c/p\u003e\n \u003cp\u003e19.43\u003c/p\u003e\n \u003cp\u003e1.63\u003c/p\u003e\n \u003cp\u003e22.24\u003c/p\u003e\n \u003cp\u003e10.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e\u003csup\u003ea Chi\u0026minus;Square test was used for analysis\u003c/sup\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e\u003csup\u003eb \u003cstrong\u003eIndependent samples T test was used for analysis\u003c/strong\u003e\u003c/sup\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e\u003csup\u003ec Fisher\u0026apos;s Exact test \u003cstrong\u003ewas used for analysis\u003c/strong\u003e\u003c/sup\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eMean time of operation in the subinguinal and inguinal methods was 17.33\u0026thinsp;\u0026plusmn;\u0026thinsp;2.18 and 22.48\u0026thinsp;\u0026plusmn;\u0026thinsp;4.45 minutes respectively (P\u0026thinsp;=\u0026thinsp;0.001,CI\u003csub\u003e95%\u003c/sub\u003e=3.41\u0026ndash;6.89).\u003c/p\u003e\n\u003cp\u003eThree months after surgery, there wasn\u0026rsquo;t any significant differences between two groups in result of semen analysis (Table\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSemen analysis three months after varicocelectomy based on method of surgery\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eSemen analysis\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMethod of varicocelectomy\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eP-value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eCI\u003csub\u003e95%\u003c/sub\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eInguinal\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubinguinal\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLower limit\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eUpper limit\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- Volume(ml)\u003c/p\u003e\n \u003cp\u003e- Count\u003c/p\u003e\n \u003cp\u003e- Density\u003c/p\u003e\n \u003cp\u003e- Normal morphology\u003c/p\u003e\n \u003cp\u003e- Normal motility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.87\u003c/p\u003e\n \u003cp\u003e69.73\u0026times;10\u003csup\u003e6\u003c/sup\u003e\u0026plusmn;47.43\u0026times;10\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e19.31\u0026thinsp;\u0026plusmn;\u0026thinsp;13.84\u003c/p\u003e\n \u003cp\u003e65.15\u0026thinsp;\u0026plusmn;\u0026thinsp;21.79\u003c/p\u003e\n \u003cp\u003e54.36\u0026thinsp;\u0026plusmn;\u0026thinsp;21.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.76\u0026thinsp;\u0026plusmn;\u0026thinsp;1.14\u003c/p\u003e\n \u003cp\u003e92.56\u0026times;10\u003csup\u003e6\u003c/sup\u003e\u0026plusmn;57.65\u0026times;10\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e24.07\u0026thinsp;\u0026plusmn;\u0026thinsp;11.85\u003c/p\u003e\n \u003cp\u003e55.45\u0026thinsp;\u0026plusmn;\u0026thinsp;20.87\u003c/p\u003e\n \u003cp\u003e57.48\u0026thinsp;\u0026plusmn;\u0026thinsp;13.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.69\u003c/p\u003e\n \u003cp\u003e-48.23\u003c/p\u003e\n \u003cp\u003e-11.09\u003c/p\u003e\n \u003cp\u003e-0.79\u003c/p\u003e\n \u003cp\u003e-11.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003cp\u003e3.69\u003c/p\u003e\n \u003cp\u003e1.58\u003c/p\u003e\n \u003cp\u003e20.19\u003c/p\u003e\n \u003cp\u003e5.54\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e\u003csup\u003e\u003cstrong\u003ea Independent samples T test was used for analysis\u003c/strong\u003e\u003c/sup\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eIn inguinal varicocelectomy, there was significant difference before and after surgery in sperm density(P\u0026thinsp;=\u0026thinsp;0.008), normal morphology(P\u0026thinsp;=\u0026thinsp;0.0001) and normal motility( P\u0026thinsp;=\u0026thinsp;0.0001) in semen analysis but there wasn\u0026apos;t any significant difference in semen volume(P\u0026thinsp;=\u0026thinsp;0.14) and sperm count(P\u0026thinsp;=\u0026thinsp;0.88).\u003c/p\u003e\n\u003cp\u003eIn subinguinal varicocelectomy, there was significant difference before and after surgery in sperm count (P\u0026thinsp;=\u0026thinsp;0.017), sperm density (P\u0026thinsp;=\u0026thinsp;0.0001), normal morphology (P\u0026thinsp;=\u0026thinsp;0.0001) and normal motility (P\u0026thinsp;=\u0026thinsp;0.0001) in semen analysis but there wasn\u0026apos;t any significant difference in semen volume (P\u0026thinsp;=\u0026thinsp;0.96).\u003c/p\u003e\n\u003cp\u003eThere was no significant difference in pain intensity one week (p\u0026thinsp;=\u0026thinsp;0.51), one (p\u0026thinsp;=\u0026thinsp;0.29) and three months (p\u0026thinsp;=\u0026thinsp;0.67) after surgery between two groups. There wasn\u0026apos;t any report of hematoma formation, scrotal swelling and infections one week after surgery in both groups. There wasn\u0026apos;t any report of pain, hydrocele formation and paresthesia in the site of operation, one and three months after surgery in both groups. There wasn\u0026apos;t any significant difference in varicocele recurrence three months after surgery in inguinal and subinguinal varicocelectomy, respectively (12.1% vs. 6.1%, P\u0026thinsp;=\u0026thinsp;0.67).\u003c/p\u003e"},{"header":"Discussion","content":" \u003cp\u003eVaricocele is the most common correctable cause of male infertility that may cause severe oligospermia and even azoospermia in some patients. \u003csup\u003e[\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e.Recently two systematic reviews concluded that there isn\u0026rsquo;t sufficient evidence regarding treatment of varicocele and its relation to fertility to warrant their repair. \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e However many studies reported fertility rate of 30\u0026ndash;50% after different type of operation. \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAt present inguinal, subinguinal, microsurgical and laparoscopic methods are performed with different success rate and complications. \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e This study was performed for comparison of success rate and complication of open inguinal and subinguinal varicocelectomy.\u003c/p\u003e \u003cp\u003eAccording to our results, there was no significant difference between two groups regarding patients' age, site and grade of varicocele and semen analysis parameters before operation. Mean time of operation was significantly lower in subinguinal varicocelectomy.\u003c/p\u003e \u003cp\u003eIn study by Watanabe and his colleagues, mean age of patients was 33.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9 year and grade 2 was the most common type of varicocele. Mean time of operation was 28.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.86 minutes that was less than other studies. \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e Results of our study are similar to this study regarding mean age of patients and varicocele grades but the mean time of operation was lower in our study. In AL-kandari study the mean time of operation in subinguinal method was longer than laparoscopic and open group. \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e Also in Shiraishi study and his colleagues, the time of operation in subinguinal method was more than laparoscopic and open methods and postoperative pain in subinguinal method was less than other methods.\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e These results are in contrast to our results and mean time of operation in subinguinal group was less than inguinal method in our study. This difference may be due to type of anesthesia that in some patients was regional or inappropriate answers of patients to questionnaire. Regarding recurrence rate and complications in Shiraishi study, subinguinal method showed lower rate than other methods which is in concordance with our results. \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThree months after operation sperm analysis revealed that there was no significant difference between two groups regarding semen volume and sperm parameters such as count, density, morphology and density. On the other hand, intergroup comparison showed that in both methods sperm density, morphology and motility improved after operation and sperm count improved more in subinguinal method (p\u0026thinsp;=\u0026thinsp;0.017). These results are similar to Watanabe and Shiraishi studies, \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e but in contrast to these studies, in the present study both sperm density and motility improved with higher improvement in subinguinal varicocelectomy.\u003c/p\u003e \u003cp\u003eRegarding postoperative complications there was no case of hematoma, scrotal swelling, infection, pain and inguinal paresthesia one week to 3 month after operation in both groups. In this study, there wasn't any significant difference in varicocele recurrence, three month postoperatively between two groups. These results are similar to Watanabe et al, except that in their study there was no recurrence in subinguinal method but we have two cases of recurrence in this method that may be due to non-microscopic method.\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eRegarding postoperative pain, other studies reported different results; but in all of them, pain intensity was higher than our study, \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e which may be due to small incision in our study.\u003c/p\u003e \u003cp\u003eWith regard to importance of infertility in our society we suggest further studies with loner duration of follow up to compare fertility rate in inguinal and subinguinal varicocelectomy.\u003c/p\u003e "},{"header":"Conclusions","content":" \u003cp\u003eIn this study subinguinal varicocelectomy was superior to inguinal method due to less time of operation. However, there was no significant difference in postoperative complications and improvement of spermogram, the necessity of further studies with loner duration of follow up to compare fertility rate in inguinal and subinguinal varicocelectomy is felt.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cul\u003e\n \u003cli\u003e\n \u003ch2\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/h2\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe research was approved by the ethical committee of Yasuj University of Medical Sciences (Ethic code: IR.YUMS.REC.1395.220). Informed consent was obtained from all participants.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003ch2\u003eConsent for publication:\u0026nbsp;\u003c/h2\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003ch2\u003eAvailability of data and materials:\u0026nbsp;\u003c/h2\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003ch2\u003eCompeting interests: \u0026lrm;\u003cspan dir=\"RTL\"\u003e\u0026rlm;\u003c/span\u003e\u003c/h2\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe authors declared that they have no competing interest.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003ch2\u003eFunding:\u0026nbsp;\u003c/h2\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eDeputy of research of Yasuj University of Medical Sciences.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003ch2\u003e\u0026nbsp;Authors\u0026rsquo; contributions:\u0026nbsp;\u003c/h2\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eSM; the concept, design, data analysis, and manuscript preparation, manuscript review and final revision and submission. \u0026nbsp;LM; the concept, design, data analysis, and manuscript preparation, manuscript review and final revision and submission. FSh; writing proposal and data collection. AM; writing proposal and data collection.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors read and signed the final paper.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003ch2\u003eAcknowledgments:\u0026nbsp;\u0026lrm;\u003cspan dir=\"RTL\"\u003e\u0026rlm;\u0026nbsp;\u003c/span\u003e\u003c/h2\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe authors are grateful to the respected vice president of the technical and research department of Yasuj University of Medical Sciences, for the provision of facilities for this project. Additionally, we thank all staff of operating room of the Shahid Beheshti Hospital of Yasuj who assisted us in performing this procedure.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eWatanabe M, Nagai A, Kusumi N, Tsuboi H, Nasu Y, Kumon H. Minimal invasiveness and effectivity of subinguinal microscopic varicocelectomy: a comparative study with retroperitoneal high and laparoscopic approaches. International journal of urology 2005; 12(10):892\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eJungwirth A, G\u0026ouml;g\u0026uuml;s C, Hauser G, Gomahr A, Schmeller N, Aulitzky W, Frick J. Clinical outcome of microsurgical subinguinal varicocelectomy in infertile men. Andrologia 2001; 33(2):71\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMohammadali Beigi F, Mehrabi S, Javaherforooshzadeh A. Varicocele in brothers of patients with varicocele. Urol J 2007; 4(1):33\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGat Y, Gornish M, Heiblum M, Joshua S. Reversal of benign prostate hyperplasia by selective occlusion of impaired venous drainage in the male reproductive system: novel mechanism, new treatment. Andrologia 2008; 40(5):273\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMehrabi S, Ghafarian Shirhzi HR, Rasti M. Normal serum prostate specific antigen levels in men in Yasuj province, Islamic Republic of Iran. East Mediterr Health J 2007; 13(5):1190\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAl-Kandari AM1, Shabaan H, Ibrahim HM, Elshebiny YH, Shokeir AA. Comparison of outcomes of different varicocelectomy techniques: open inguinal, laparoscopic, and subinguinal microscopic varicocelectomy: a randomized clinical trial Urology. 2007; 69(3):417\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eShiraishi K, Oka S, Ito H, Matsuyama H. Comparison of the results and complications of retroperitoneal, microsurgical subinguinal and high inguinal approaches in the treatment of varicocele. J Androl 2012; 33(6):1387\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAl-Said S1, Al-Naimi A, Al-Ansari A, et al. Varicocelectomy for male infertility: a comparative study of open, laparoscopic and microsurgical approaches. J Urol 2008; 180(1):266\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePajovic B1, Radojevic N, Dimitrovski A, Radovic M, Rolovic R, Vukovic M. Advantages of microsurgical varicocelectomy over conventional techniques. Eur Rev Med Pharmacol Sci 2015; 19(4):532\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eYaman O1, Soygur T, Zumrutbas AE, Resorlu B. Results of microsurgical subinguinal varicocelectomy in children and adolescents. Urology 2006; 68(2):410\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKumar R1, Gupta NP. Subinguinal microsurgical varicocelectomy: evaluation of the results. Urol Int 2003; 71(4):368\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eO\u0026apos;Brien J1, Bowles B, Kamal KM, Jarvi K, Zini A. Does the gonadotropin-releasing hormone stimulation test predict clinical outcomes after microsurgical varicocelectomy? Urology 2004; 63(6):1143\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBaazeem A, Boman JM, Libman J, Jarvi K, Zini A. Microsurgical varicocelectomy for infertile men with oligospermia: differential effect of bilateral and unilateral varicocele on pregnancy outcomes. BJU Int 2009; 104(4):524\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKroese AC, de Lange NM, Collins J, Evers JL. Surgery or embolization for varicoceles in subfertile men. Cochrane Database of Systematic Reviews. 2012(10).\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKohn TP, Ohlander SJ, Jacob JS, Griffin TM, Lipshultz LI, Pastuszak AW. The Effect of Subclinical Varicocele on Pregnancy Rates and Semen Parameters: a Systematic Review and Meta-Analysis. Curr Urol Rep 2018; 19(7):53.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSilay MS, Hoen L, Quadackaers J, Undre S, Bogaert G, Dogan HS, Kocvara R, Nijman RJ, Radmayr C, Tekgul S, Stein R. Treatment of varicocele in children and adolescents: a systematic review and meta-analysis from the European Association of Urology/European Society for Pediatric Urology Guidelines Panel. European urology 2018 Oct 10.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMagoha GA. The role of varicocelectomy in the management of infertile males with varicocele. East Afr Med J 1994; 71(12): 800\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"complication, semen analysis, varicocele, varicocelectomy","lastPublishedDoi":"10.21203/rs.3.rs-597318/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-597318/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eVaricocele is the most common surgically correctable cause of infertility in men. The aim of this study was comparing the success rate and complications of open inguinal and subinguinal varicocelectomy.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/sup\u003eThis randomized clinical trial was conducted from March 2017 to 2018. Sixty six patients that met inclusion criteria for varicocelectomy (persistent pain or impaired spermogram) were sequentially randomly allocated to inguinal and subinguinal varicocelectomy. Sperm analysis was performed in all patients before surgery. One\u0026nbsp;week, one and three\u0026nbsp;months\u0026nbsp;after\u0026nbsp;the\u0026nbsp;operation\u0026nbsp;patients were visited\u0026nbsp;and evaluated for\u0026nbsp;pain\u0026nbsp;intensity (using\u0026nbsp;visual\u0026nbsp;analog\u0026nbsp;scale) and complications( recurrence, hematoma, scrotal swelling, infection, hydrocele formation and numbness). Follow- up spermogram was done three months after varicocelectomy to evaluate the success of operation. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/sup\u003eMean time of operation was17.33±2.18 and 22.48± 4.45 minutes in the subinguinal and inguinal varicocelectomy method, respectively (p=0.001, CI\u003csub\u003e95%\u003c/sub\u003e=3.41-6.89). Semen analysis three months after surgery showed that there was no significant differences between semen volume (p=0.85), sperm count (p=0.09), sperm density (p=0.13), normal morphology (p=0.07) and motility (p=0.47) in both groups. There was no significant difference in pain density one week (p=0.51), one (p=0.29) and three months (p=0.67) after surgery between two groups. There wasn't any significant difference between two groups regarding recurrence of varicocele (p=0.67). \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/sup\u003eIn this study subinguinal varicocelectomy was superior to inguinal method due to less time of operation. However, there was no significant difference in postoperative complications and improvement of spermogram. Further studies with longer period of follow-up are recommended to compare fertility rate in inguinal and subinguinal varicocelectomy.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eTrial registration: \u003c/strong\u003eIRCT, IRCT201710131323N12, Registered 20 October 2017, Retrospectively registered\u003cstrong\u003e, https://www.irct.ir/trial/581\u003c/strong\u003e\u003c/p\u003e","manuscriptTitle":"Comparison of Success Rate and Complications of Open Inguinal and Subinguinal Varicocelectomy: A Randomized Controlled Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-07-07 11:23:17","doi":"10.21203/rs.3.rs-597318/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"742b77af-f347-43ec-ae14-9e919b62c1b3","owner":[],"postedDate":"July 7th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":5526316,"name":"Urology \u0026 Nephrology"}],"tags":[],"updatedAt":"2021-12-09T17:59:09+00:00","versionOfRecord":[],"versionCreatedAt":"2021-07-07 11:23:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-597318","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-597318","identity":"rs-597318","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}