Authors: Jianjia Wang, He Jiang, Jianhua Lan
Categories: Research, Varicocele, Microsurgical varicocelectomy, Laparoscopic surgery, Varicocele embolization
Source: BMC Urology
Authors: Jianjia Wang, He Jiang, Jianhua Lan
Varicocele is one of the most common causes of male infertility. Although multiple surgical and interventional methods are available, their cost-effectiveness remains insufficiently studied. This study aimed to compare short-term clinical outcomes and cost-effectiveness of microsurgical and laparoscopic varicocelectomy, reporting embolization outcomes as exploratory data owing to the limited number of cases.
A retrospective analysis was conducted on 113 patients with varicocele who were admitted to our hospital between June 2022 and May 2025. Based on the surgical approach, patients were categorized into three microsurgical (n = 42), embolization (n = 8), and laparoscopic (n = 63). Owing to the small size of the embolization cohort, primary comparative and cost-effectiveness analyses were performed for the microsurgical and laparoscopic groups, while embolization outcomes were reported descriptively. Preoperative and postoperative measures, including sperm concentration, percentage of forward-moving spermatozoa (PR%), maximum diameter of the spermatic vein, surgical cost, and postoperative complications, were compared and analyzed. All procedures were performed by senior urologists experienced in varicocele repair, and postoperative complications were recorded. A cost-effectiveness analysis was performed by calculating the cost-effectiveness ratio (CER) and incremental CER based on hospitalization costs and improvements in semen parameters.
All 113 patients successfully completed surgical treatment. Intra-group comparisons showed that all three surgical approaches led to significant postoperative improvements compared with the preoperative period (P < 0.05). Inter-group comparisons indicated that the improvement in PR% was significantly greater in the microsurgical group than in the laparoscopy group (P < 0.05). Cost-effectiveness analysis revealed that microsurgery yielded the lowest CERs for sperm concentration improvement (CER: 410.13) and PR% improvement (CER: 220.78), with incremental analysis demonstrating that microsurgery was superior to laparoscopic surgery.
In this single-center retrospective cohort, microsurgical varicocelectomy was associated with superior short-term improvement in PR% and more favorable cost-effectiveness compared with laparoscopic varicocelectomy. Embolization outcomes were exploratory because of the limited sample size and should be interpreted with caution. Further multicenter studies with larger embolization cohorts and longer follow-up are warranted.
In the primary analysis, microsurgical and laparoscopic varicocelectomy significantly improved semen quality and reduced spermatic vein diameter at 3 months.Microsurgery demonstrated greater improvement in PR% and a more favorable cost-effectiveness profile than laparoscopy in our cohort.Embolization outcomes were reported descriptively as exploratory findings because only eight patients underwent this procedure.
Varicocele refers to the abnormal dilation, elongation, and tortuosity of the pampiniform venous plexus within the spermatic cord. Epidemiological studies reported a prevalence of approximately 15% in the general male population, rising to 25–35% among men with primary infertility and 50–80% among those with persistent infertility [1]. The primary pathological mechanisms through which varicocele contributes to testicular tissue dysfunction include elevated oxidative stress levels, metabolite reflux, testicular hypoxia, and increased testicular temperature due to impaired venous return [2]. Clinical manifestations often include scrotal heaviness and discomfort, accompanied by abnormal semen analysis parameters.
Among the available treatment approaches, surgical intervention remains a crucial therapeutic option, particularly for patients with impaired semen quality. The core objective of surgery is to block abnormal reflux and restore the normal physiological environment of the testes [3]. Rapid advancements in surgical techniques and interventional radiology have introduced multiple minimally invasive treatment strategies for varicocele management. Among these, laparoscopic high ligation, microsurgical varicocele ligation, and percutaneous varicocele embolization have emerged as mainstream clinical approaches [4]. Laparoscopic surgery, with its clear magnified visualization, represents a minimally invasive technique that facilitates effective identification of the testicular artery while reducing the number of veins requiring ligation. It is particularly suitable for patients with bilateral varicoceles [5]. Microsurgical techniques, through precise anatomical identification, preserve the testicular artery, lymphatics, and small veins, thereby significantly reducing postoperative complications and improving sperm quality [6]. Percutaneous varicocele embolization, a minimally invasive alternative that does not require general anesthesia, involves catheter-guided injection of solid or liquid embolization agents to occlude dilated varicocele veins. This method provides an alternative surgical option for men seeking to avoid surgical incisions or for those with recurrent varicocele following failed prior varicocele surgery [7].
Although these three surgical approaches are supported by substantial evidence, systematic evaluations focusing on cost-effectiveness remain relatively scarce. Economic assessment is increasingly recognized as an indispensable component of evidence-based surgical decision-making. As clinical guidelines increasingly emphasize clinical efficacy and cost-effectiveness, surgeons must incorporate rigorous economic evaluations into future practice [8].
This retrospective analysis of clinical data from 113 patients with varicocele treated at our hospital compared short-term clinical outcomes and hospitalization costs following microsurgical and laparoscopic varicocelectomy. Because only eight patients underwent embolization during the study period, embolization outcomes are presented descriptively and were not included in the primary comparative or cost-effectiveness analyses. The study aimed to provide an economic rationale for guiding clinicians in selecting treatment options, optimizing healthcare resource allocation, and enhancing patient satisfaction.
This retrospective study was approved by the institutional review board of our hospital and was exempt from obtaining informed consent. The trial was conducted in accordance with the principles of the Declaration of Helsinki (approval no. 2025-45). A retrospective analysis was performed on the clinical data of 113 patients admitted to our hospital between June 2022 and May 2025. Thereafter, data regarding patients’ clinical characteristics, including age, body mass index (BMI), and varicocele grading, as well as surgical duration, length of hospital stay, and hospitalization cost, were recorded.
Based on the surgical approach, patients were categorized into microsurgical (n = 42), laparoscopic (n = 63), and embolization (n = 8) groups. Patients in the microsurgical group underwent low microscopic ligation of the spermatic vein, those in the embolization group underwent percutaneous sperm vein intervention embolization, and those in the laparoscopic group underwent high laparoscopic ligation of the spermatic vein. All procedures were performed by experienced surgeons in accordance with standard clinical protocols. The choice of surgical modality for each patient was based on a comprehensive clinical assessment conducted during hospitalization. Specifically, patient age, the clinical grade of varicocele, baseline semen parameters, and individual preference were considered. In addition, expectations regarding surgical invasiveness and postoperative recovery, as well as tolerance and risk evaluation related to general anesthesia, were assessed before recommending the final surgical option. Further, in our hospital, the embolization technique for varicocele is performed by urologists rather than interventional radiologists. All participating urologists had undergone formal training in vascular interventional procedures and routinely conducted venous embolization and other minimally invasive interventions in clinical practice.
Postoperative complications were assessed in a standardized manner across all three treatment groups. In addition, information regarding complications was retrospectively collected through the institutional electronic medical record system. Symptoms such as scrotal discomfort or pain were initially reported by the patients during hospitalization and at the routine 3-month postoperative follow-up visit. Subsequently, these symptoms were evaluated and documented by the attending urologist using identical follow-up intervals and assessment criteria for all patients to ensure consistency in the collection of data on complications.
All enrolled patients underwent sperm quality testing preoperatively and at 3 months postoperatively. The percentage of progressively motile sperm (PR%) and sperm concentrations were compared across the three groups. Concurrent ultrasound examinations of the reproductive system were performed to compare the diameters of the internal spermatic veins. Embolization outcomes were summarized descriptively as exploratory data.
Post-discharge analysis included comparisons of hospitalization costs, improvements in sperm concentration, improvements in progressive motility rate, and cost-effectiveness ratios (CERs) between the microsurgical and laparoscopic groups. Embolization outcomes were summarized descriptively and were excluded from the primary economic evaluation.
All enrolled patients underwent postoperative assessment of surgical site pain and scrotal discomfort. In the primary analysis, the incidence of complications and improvement in symptoms were compared between the microsurgical and laparoscopic groups. Embolization-related events were recorded and summarized descriptively.
The CER and incremental CER (ICER) were calculated using sperm concentration and PR% improvement rates as effect indicators and hospitalization costs as cost indicators for the primary comparison of microsurgical and laparoscopic surgery. Embolization was not included in CER/ICER calculations because of the limited sample size.
Data were analyzed using statistical software. Quantitative data are expressed as means ± standard deviation, and normality tests were performed. In the primary analysis, the Mann-Whitney U test was used for between-group comparisons, and the Wilcoxon signed-rank test for within-group comparisons between postoperative and preoperative data. Count data are expressed as numbers (percentages), and comparisons between the two groups were performed using Fisher’s exact test. The embolization cohort was summarized descriptively and not included in hypothesis testing. Statistical significance was set at P ≤ 0.05.
This study included a total of 113 patients. The primary comparative analysis included patients treated with microsurgical (n = 42) or laparoscopic (n = 63) varicocelectomy. No significant differences were observed between the two groups in terms of length of hospital stay (P = 0.138) and BMI (P = 0.225). The baseline characteristics of enrolled patients are summarized in Table 1. Eight patients underwent embolization and are presented as an exploratory cohort.
Table 1General characteristics of patients for three different surgical approachesGroup n Age (years)BMI (kg/m^2^)VC grading (n)Surgical duration (min)Length of hospital stay (days)Hospitalization cost (CNY)Grade ⅠGrade ⅡGrade ⅢLaparoscopic group6327.8 ± 12.622.0 ± 3.425271148.6 ± 22.03.4 ± 1.06150.4 ± 1274.0Embolization group820.9 ± 4.820.7 ± 3.713483.5 ± 26.82.9 ± 0.811435.5 ± 1533.7Microscope group4222.5 ± 5.621.1 ± 2.710191399.8 ± 38.43.9 ± 1.54837.5 ± 1177.4 P -0.0390.225---<0.010.138<0.01
Semen quality parameters, including sperm concentration and PR%, were assessed preoperatively and at 3 months postoperatively. In the primary analysis, the microsurgical and laparoscopic groups demonstrated significant postoperative improvements in all parameters compared with preoperative levels (P < 0.01). Inter-group analysis revealed that the improvement in PR% was significantly greater in the microsurgical group than in the laparoscopic group (P = 0.011), as shown in Table 2.
Table 2Comparison of semen quality and ultrasound findings among the three groups of patients undergoing different surgical approachesGroupLaparoscopic groupEmbolization groupMicrosurgical group n 63842Sperm concentration (×10^6^/mL) Preoperative45.5 ± 24.442.1 ± 8.550.7 ± 31.6 Postoperative56.2 ± 24.156.9 ± 7.762.5 ± 28.8 Degree of improvement10.7 ± 7.114.8 ± 6.111.8 ± 8.6PR% Preoperative24.4 ± 6.630.7 ± 16.026.6 ± 9.5 Postoperative44.2 ± 6.351.3 ± 14.748.5 ± 8.1 Degree of improvement19.8 ± 3.420.5 ± 1.921.9 ± 4.9Maximum diameter of the spermatic vein (mm) Preoperative2.5 ± 0.62.8 ± 0.82.8 ± 0.6 Postoperative2.0 ± 0.32.1 ± 0.62.2 ± 0.4 Degree of improvement0.5 ± 0.30.6 ± 0.40.6 ± 0.3PR% percentage of progressively motile sperm
Patients underwent ultrasound examinations preoperatively and at 3 months postoperatively, primarily to measure the maximum diameter of the spermatic vein. Intra-group comparisons demonstrated significant postoperative improvements compared with preoperative values in both groups (P < 0.01). Intergroup comparisons revealed no significant differences in the degree of improvement in the maximum spermatic vein diameter among the two groups (P = 0.442), as presented in Table 2.
Postoperative complications, including surgical site pain and scrotal discomfort, were evaluated in the two groups. Inter-group analysis revealed no significant difference in the degree of improvement in scrotal discomfort between the microsurgical group and the laparoscopic group. (P = 0.075), as presented in Table 3.
Table 3Comparison of postoperative complications among patients undergoing three different surgical approachesGroup n Surgical site painScrotal discomfortLaparoscopic group6345 (71.4%)28 (44.4%)Embolization group85 (62.5%)7 (87.5%)Microscopic group4224 (57.1%)12 (28.6%)
The analysis of relevant values across the two groups revealed that, for improvements in sperm concentration, the CER was approximately 410.13 in the microsurgical group and 574.58 in the laparoscopic group. For improvements in PR%, the CER was approximately 220.78 in the microsurgical group and 310.63 in the laparoscopy group, indicating a more favorable cost-effectiveness profile in our cohort. ICER calculations comparing microsurgical and laparoscopic surgery are provided in Table 4. Owing to the limited sample size, embolization therapy was excluded from the analysis. The results are presented descriptively in Table 4.
Table 4Cost-effectiveness analysis for microsurgical, laparoscopic, and embolization groupsGroupLaparoscopic groupEmbolization groupMicrosurgical groupHospitalization cost(Yuan)6150.4 ± 1274.011435.5 ± 1533.74837.5 ± 1177.4Improvement in sperm concentration (×10⁶/mL)10.7 ± 7.114.8 ± 6.111.8 ± 8.6CER574.58772.47410.13Improvement in PR%19.8 ± 3.420.5 ± 1.921.9 ± 4.9CER310.63557.59220.78ICER vs. Microsurgery (sperm concentration)-Dominated by microsurgery2199.33ICER vs. Microsurgery (PR%)-Dominated by microsurgeryDominated by microsurgery
This retrospective analysis demonstrated that while microscopic surgery and laparoscopic surgery significantly improved semen parameters and reduced spermatic vein diameter in patients with varicocele, microsurgical varicocelectomy was the most cost-effective approach, yielding superior improvement in sperm motility (PR%) and the lowest incidence of postoperative complications. Varicocele is a common urological condition characterized by excessive dilation of the spermatic plexus. It typically occurs on the left side; however, approximately 50% of patients with spermatic varicocele have bilateral involvement. Isolated right-sided spermatic varicocele is extremely rare and may be associated with retroperitoneal tumors [1, 9, 10]. Varicoceles are relatively uncommon in boys aged 2–10 years (1.75%), but prevalence increases with age, reaching 7.8% among those aged 11–14 years and 14.1% among those aged 15–19 years [11]. In addition, the prevalence of varicocele varies across regions and countries. For example, Hu et al. reported a 7.66% prevalence among 211,989 Chinese male patients with an average age of 31.2 years [12], whereas a European study involving 7,035 young men reported a prevalence rate of 15.7% [13]. Varicocele causes scrotal hyperthermia, metabolic backflow, testicular hypoxia, and cadmium accumulation, all of which promote oxidative stress and impair testicular spermatogenesis [2, 14].
Currently, the most common surgical and interventional approaches for treating varicoceles include microsurgical varicocelectomy, laparoscopic varicocelectomy, and percutaneous varicocele embolization. Microsurgery, performed under a microscope that magnifies the surgical field 5–10 times, enables precise identification of critical structures, such as vessels and lymphatics, within the spermatic cord, thereby enhancing surgical precision. Microsurgical procedures typically use a subinguinal approach that avoids damaging the fascia, thereby reducing postoperative pain and accelerating recovery, offering an unmatched advantage over laparoscopy alone. Microsurgical techniques not only facilitate the preservation of the vascular and lymphatic networks of the spermatic cord but also maintain the equilibrium of lymphatic absorption and secretion. This approach reduces the incidence of hydrocele formation and testicular edema, thereby lowering the rate of postoperative complications [11, 14–17]. Our findings further confirmed that microsurgery is associated with the lowest postoperative complication rates. All patients enrolled in this study had a confirmed diagnosis of varicocele, and we compared the effects of two distinct surgical techniques on semen quality. The results demonstrated significant improvements in semen parameters and maximum varicocele diameter postoperatively across all approaches compared with preoperative levels. Notably, the microsurgical group demonstrated superior improvement in PR% to the laparoscopic group. This finding may be due to the enhanced ability of this approach to identify and preserve the spermatic artery and lymphatic vessels, ligate more venous branches below the inguinal canal, reduce venous reflux, improve testicular blood flow, and alter sperm metabolism to enhance semen quality [3, 10, 18]. Because only eight patients underwent embolization, embolization outcomes were treated as exploratory and were not included in hypothesis testing or cost-effectiveness calculations. Therefore, the comparative and economic conclusions of this study pertain primarily to microsurgical and laparoscopic surgery. This study noted that the proportion of patients with grade III varicocele was 17.5% and 31% in the laparoscopic and microsurgical groups, respectively. Although statistical analysis revealed no significant differences in the distribution between the two groups (P > 0.05), this uneven distribution of disease severity may represent a key confounding factor influencing efficacy and complications. Severe varicoceles are generally associated with more pronounced pathophysiological alterations, which may contribute to suboptimal surgical outcomes [13, 19]. Because subgroup analyses based on grading were not conducted, the independent impact of disease severity on outcomes remains unclear, limiting the strength of inter-group efficacy comparisons.
Previous studies have predominantly focused on the clinical assessment of treatment efficacy, with limited systematic research on the cost-effectiveness of different therapeutic approaches. For instance, Wu et al. compared the efficacy of laparoscopic surgery versus microsurgical repair and found that the latter was superior in improving semen quality; however, they did not perform cost-effectiveness comparisons [5]. Therefore, the core innovation of the present study lies in systematically incorporating an assessment of hospitalization costs alongside an efficacy analysis and introducing a critical economic perspective to clinical decision-making. Although all three interventions (microsurgery, laparoscopy, and embolization) effectively improved semen quality and reduced spermatic vein diameter, their cost structures differed significantly. The microsurgical group demonstrated cost advantages due to the use of inexpensive consumables, and the laparoscopic group incurred higher expenditures because of the use of general anesthesia and specialized endoscopic materials. The high costs in the embolization group primarily stemmed from expenses on interventional materials and imaging equipment. These cost variations resulted in substantial divergence in the CERs. Taken together, the microsurgical group demonstrated optimal cost-effectiveness, whereas the laparoscopic group showed lower cost-effectiveness than the other two groups. Nevertheless, the embolization group had a small sample size, rendering its cost-effectiveness outcomes and inferences regarding its clinical applicability insufficient. Therefore, further validation using large-scale studies is necessary.
This study has several limitations. First, the sample size was relatively small, with only 113 patients, which may have reduced statistical power. In particular, only eight patients underwent embolization. Therefore, we treated embolization outcomes as exploratory and did not include this cohort in the primary comparative or cost-effectiveness analyses. Second, the treatment modalities were performed by different physicians. Although all procedures were conducted by experienced specialists and standardized institutional protocols were applied, residual operator-related confounding cannot be entirely excluded. Third, the study was conducted at a single center, which may have introduced selection bias and limited generalizability. Additionally, varicocele recurrence was not assessed because of the relatively short follow-up period of 3 months, potentially introducing bias from insufficient follow-up time, which may have led to an overestimation of the efficacy of both surgical procedures. Furthermore, prior research indicates a higher recurrence rate with embolization, which is generally not recommended as a first-line treatment for varicoceles [7, 20]. Total testosterone was not collected in a standardized manner, in turn preventing a valid comparison of endocrine changes among surgical approaches. Future prospective studies incorporating uniform morning hormone sampling are warranted to clarify the endocrine impact of varicocele surgery. Another limitation is the lack of formal infertility assessment and the absence of complete postoperative pregnancy data. Furthermore, the length of hospital stay may be influenced by postoperative management protocols rather than solely by differences in surgical techniques. Therefore, the interpretation of postoperative semen improvement in the microsurgical groups and laparoscopic groups should be approached with caution. Although early postoperative outcomes demonstrated measurable improvements, the follow-up duration in this study was limited to 3 months. Consequently, potential early recurrence may not have been fully captured. In addition, semen parameters were used as intermediate surrogate outcomes. However, improvements in semen quality do not necessarily translate into improved fertility. This incomplete detection of recurrence could have led to an overestimation of the true and durable therapeutic effect of these two approaches. Therefore, the observed improvements in semen parameters in these groups may appear overly optimistic when considering the possibility of early relapse, underscoring the need for longer and more standardized follow-up in future research. Future studies should employ multicenter, large-sample designs, more detailed cost-effectiveness, balanced sample sizes, unified surgical teams, and subgroup analyses, such as using Markov decision models, to validate the reliability and applicability of the results of this study and provide more reliable evidence for personalized clinical treatment.
In summary, this retrospective analysis compares the short-term clinical outcomes and cost-effectiveness of microsurgical versus laparoscopic varicocelectomy in our cohort, supporting microsurgical varicocelectomy as the more favorable option with respect to improvement in PR% and cost-effectiveness. Embolization outcomes were exploratory owing to the limited sample size and warrant further validation in larger multicenter studies. Despite certain limitations, the findings provide useful evidence to guide treatment selection, support individualized varicocele management strategies, and optimize the allocation of healthcare resources.