Varicocelectomy is considered when conservative treatment fails to resolve varicocele-associated testicular pain [14]. All our patients had undergone conservative treatment for 3 months without any improvement before surgery. Currently, microscopic subinguinal varicocelectomy is the most common approach for the treatment of patients with varicocele [9]. Hence, we used this technique in the present study. Overall, 132 patients underwent microscopic subinguinal varicocelectomy for testicular pain. To the best of our knowledge, this is the second largest single-institution series that investigated the success rate and assessed the predictive factors of varicocelectomy for testicular pain [7]. The results of this study extend our knowledge of the true success rate of varicocelectomy for testicular pain, with a more specific definition of success than that reported in previous studies. Unilateral testicular pain (63.6%) was more common than bilateral pain (36.4%). Most patients (83.3%) reported complete resolution of pain. Only 16.7% experienced persistent pain, and none of them had recurrent varicocele, as examined using Doppler ultrasonography during follow-up, indicating that the primary cause of testicular pain was not varicocele and could be related to chronic orchialgia [6]. Microsurgical spermatic cord denervation has been described to treat chronic orchialgia; however, this procedure was not performed in the current study [15]. The success rate of varicocelectomy for testicular pain has varied among studies [10]. Our results corroborate those of the previous studies [5, 6, 8, 16,17,18], which reported postoperative symptomatic improvement and repair of painful varicocele in over 80% of patients. However, lower success rates of varicocelectomy for testicular pain were reported by Park et al. (52.8%) [10] and by Biggers and Soderdahl (48%) [19]. A lower rate was reported in another study, where 47.8% of the patients experienced complete resolution and 25.4% experienced partial resolution [14]. These variations in success rates could be a result of differences in the definition of success, surgical approach and techniques, or follow-up duration after surgery.
Only 1.5% of patients in our study reported postoperative complications, consisting of one wound infection and one hematoma. Reported predictors for postoperative pain resolution have included the varicocele grade and the quality and severity of preoperative pain [5, 8, 9, 20]. Kim et al. [20] stated that a significant number of patients who presented with dragging, dull, and aching pain experienced pain resolution after varicocelectomy. All our patient complaints matched these pain criteria but without significant correlation with pain relief, similar to those in other studies [6, 16]. In accordance with the finding of Karademir et al. [17], preoperative pain intensity and pain resolution were not correlated. However, Chen et al. [9] suggested that a preoperative pain score of > 6 could be predictive of symptomatic relief. Abd Ellatif et al. [6] reported no association between varicocele grade and pain relief after surgery. However, another study demonstrated that the preoperative grade of varicocele affected pain relief, where persistent pain was more common in patients with high-grade varicocele [8]. The duration of preoperative pain was another reported predictor of postoperative pain resolution [6, 10, 14, 16]. Abd Ellatif et al., Park et al., and Altunoluk et al. identified long pain duration before surgery (> 6, > ≥ 3, and > 3 months, respectively) as the only factor associated with pain resolution [6, 14, 16]. In contrast, in one study [10], a short preoperative pain duration of < 6 months predicted postoperative pain resolution. Our study showed an insignificant relation between pain relief and the duration of preoperative pain. Possible explanations for these variations in the duration of pain as a predictive factor are differences in pain duration criteria and the definition of success. Hence, further prospective randomized studies are required. Moreover, some studies have reported subinguinal ligation and microsurgical varicocelectomy as more effective in relieving varicocele-associated pain than other surgical techniques [20, 21]. However, in our study, we adopted only the gold standard microscopic subinguinal approach [13]. In another study, greater number of ligated veins (> 7) was a significant prognostic factor for pain relief after varicocelectomy [9]. No predictors for pain resolution were found, apart from the association of varicocelectomy for unilateral testicular pain with pain relief.
The limitations of this study include a relatively short median follow-up of just over 1 year and its retrospective design. Prospective randomized studies are needed to validate our findings. Given that patients with bilateral varicoceles have two different varicocele grades, there was an uneven distribution of patients for the varicocele grade, creating a potential for bias. In addition, not including other predictive factors such as various surgical techniques, varicocele location, and number of ligated veins could have potentially affected the pain resolution and success rate after varicocelectomy [9, 10, 21].