(323) Microsurgical Varicocelectomy for Challenging Periarterial Veins: Transfixion of Artery-adherent Veins and En Bloc Ligation of Venous Bundles

Introduction Varicocele is a common and surgically correctable cause of male infertility, present in up to 15% of the general male population and nearly 40% of men with primary infertility. Microsurgical varicocelectomy, using an operating microscope for high magnification, has become the gold-standard technique due to its superior outcomes and reduced complication rates compared to macroscopic or laparoscopic approaches. A major intraoperative challenge, however, lies in managing periarterial veins that are either tightly adherent to the testicular artery or clustered in venous bundles adjacent to it. Conventional meticulous dissection can be time-consuming and may risk inadvertent arterial injury, which can compromise testicular perfusion. While several refinements in microsurgical technique have been described, practical solutions tailored to distinct periarterial vein morphologies remain limited. Objective This study aimed to demonstrate and evaluate two alternative microsurgical strategies for periarterial venous management during varicocelectomy: Transfixion of artery-adherent veins, preserving arterial integrity when separation is unsafe. En bloc ligation of venous bundles, simplifying surgery when multiple periarterial veins lack clear dissection planes. We sought to assess the feasibility, safety, and procedural efficiency of these approaches. Methods We conducted a descriptive surgical series at the Department of Infertility & Sexual Medicine, Third Affiliated Hospital of Sun Yat-sen University. Patients with clinically significant varicocele (grades II–III, confirmed by Doppler ultrasound) undergoing subinguinal microsurgical varicocelectomy were included. Intraoperatively, when periarterial veins were encountered: Transfixion technique was applied if a vein was inseparably adherent to the artery, using 10-0 or 9-0 nylon microsutures placed under ×15–×20 magnification. En bloc ligation was performed when multiple veins formed a tightly packed venous bundle but were distinctly separated from the artery; 2–3 veins (sometimes more, depending on anatomy) were ligated together with 6-0 or 7-0 silk. Standard microsurgical principles were followed, including artery identification with Doppler, meticulous lymphatic preservation, and confirmation of arterial pulsation after each ligation. Operative time, intraoperative difficulties, complications, and short-term postoperative outcomes were recorded. Results Both techniques were applied in a consecutive cohort of varicocelectomy patients. The transfixion method successfully controlled artery-adherent veins in all cases without compromising arterial flow, as confirmed by Doppler and postoperative testicular examination. The en bloc ligation approach facilitated efficient control of periarterial venous bundles, reducing operative time compared to tedious single-vein dissection. No cases of arterial injury, testicular atrophy, or hydrocele were observed during follow-up. Subjective surgeon feedback highlighted improved efficiency and reduced technical stress in challenging periarterial scenarios. Conclusions Periarterial venous variations present unique technical obstacles during microsurgical varicocelectomy. The two alternative techniques described-transfixion of artery-adherent veins and en bloc ligation of venous bundles-provide safe, efficient, and anatomically tailored solutions. By applying transfixion when separation from the artery is not feasible, and en bloc ligation when clustered venous bundles are encountered, surgeons can preserve arterial integrity, simplify dissection, and potentially improve procedural outcomes. These refinements represent valuable additions to the microsurgical varicocelectomy armamentarium, particularly for surgeons faced with difficult periarterial anatomy. Disclosure No