What is the best surgical option for varicocele patients? What are the advantages of microscopic spermatic vein ligation over other surgical options? The main surgical treatment options for varicocele include retroperitoneal spermatic vein ligation, laparoscopic spermatic vein ligation and microscopic spermatic vein ligation. At present, the surgical level and medical equipment of each hospital in China are different, and the surgical methods used are also different. So, what is the best surgical option for varicocele patients? Below, we explain which surgical procedure is best for patients in terms of surgical results and postoperative complications (often referred to as risks by patients). The spermatic cord contains blood vessels (including the internal spermatic artery and the internal spermatic vein) and lymphatic vessels. Varicocele surgery requires ligation of all spermatic veins while protecting the internal spermatic artery and lymphatic vessels. Due to the anatomical characteristics of the spermatic cord and the different surgical approaches and sites, the three surgical approaches currently in use have different surgical outcomes and postoperative complication rates. The main postoperative complications include recurrence, syringomyelia, and testicular atrophy due to testicular artery injury. In terms of surgical results and complications, microscopic spermatic vein ligation has unparalleled advantages over other surgical methods. (1) Low postoperative recurrence rate ① The recurrence rate after retroperitoneal high spermatic vein ligation is about 11-15%, especially in underage patients, which is about 15-45%. High retroperitoneal spermatic vein ligation emphasizes the separation and protection of the internal spermatic artery to avoid causing postoperative testicular atrophy and even necrosis. However, during the actual surgery, pulling hooks and pulling, separating instruments, or touching the spermatic vessels by hand can cause spasm of the artery and emptying of the vein, making identification difficult. In order not to mistakenly tie the artery, it is often tolerated and the vein is missed, which becomes an important reason for recurrence of varicocele after surgery. In addition, there are many tiny veins around the internal spermatic artery, and the difficulty in identifying and ligating these tiny veins under the naked eye is another important reason for the recurrence of varicocele after spermatic surgery. The laparoscopic high ligation of spermatic veins is actually the above mentioned retroperitoneal high ligation of spermatic veins, only the surgical field is enlarged, but at present most laparoscopes can only enlarge 4~6 times, so it is still difficult to identify and separate the spermatic arteries, and the recurrence rate after surgery is generally 2.9~17%. Therefore, some scholars have ligated the internal spermatic artery together to reduce the recurrence rate, which inevitably increases the risk of testicular atrophy. (iii) Microscopic spermatic vein ligation: the postoperative recurrence rate is in the range of 1~2%. The magnification of the surgical microscope is much higher than that of laparoscopy, and most surgical microscopes can magnify up to 25 times (microscopic spermatic vein ligation is usually performed at a magnification of 10 times or more). As a result, the vast majority of the internal spermatic arteries and lymphatic vessels can be protected during the procedure. In addition, microscopic spermatic vein ligation can deal with the external spermatic vein and the levator muscle vein at the same time, and can also ligate the testicular drainage vein by raising the testicle outside the incision, which largely reduces the postoperative recurrence rate, and these advantages cannot be achieved by the above two surgical methods. (2) Low incidence of postoperative syringomyelia ① Retroperitoneal spermatic vein high ligation: it is almost impossible to identify the lymphatic vessels under the naked eye, so the lymphatic flow of the testis is blocked by the cluster ligation, resulting in the leakage of lymphatic fluid in the sphincter cavity and the formation of syringomyelia. The incidence of syringomyelia is generally 7~33%. (②Laparoscopic spermatic vein high ligation: limited by the magnification, the incidence of postoperative syringomyelia is still higher, about 5-8%. Microscopic spermatic cord vein ligation: At a magnification of 10 times or more, the lymphatic vessels in the spermatic cord are clearly visible, and microscopic spermatic cord vein ligation shows incomparable advantages in protecting the lymphatic vessels and reducing the incidence of postoperative syringomyelia. The incidence of postoperative syringomyelia is almost zero. (3) Testicular artery injury causing testicular atrophy Due to the anatomical characteristics of the spermatic cord, high magnification, and superficial surgical operation site, microscopic spermatic cord ligation can better protect the testicular artery and minimize the risk of testicular atrophy than retroperitoneal high ligation and laparoscopic high ligation. (4) Less damage to human body and most minimally invasive ① Retroperitoneal high ligation of spermatic veins: due to deep surgical operation site, the surgical incision is relatively large (usually more than 5cm), and obese patients need longer incision to complete the operation. ② laparoscopic high spermatic vein ligation: generally three incisions are required, each of which is about 1~1.5 cm long. the intestinal canal, large abdominal and pelvic vessels, and internal organs may be damaged during the operation, and complications such as gas embolism and peritonitis may occur after the operation. The possibility of these complications is much higher than that of retroperitoneal spermatic vein high ligation, while microscopic spermatic vein ligation is free from these complications. (iii) Microscopic spermatic vein ligation: A surgical incision is made lateral to the pubic symphysis, usually about 2.5-3.0 cm long, which is smaller than the sum of the lengths of multiple laparoscopic incisions. Since this part is covered by pubic hair, the surgical incision is basically invisible after surgery. Therefore, microscopic spermatic vein ligation has obvious advantages both in terms of human injury and aesthetics. Thus, it is clear that of the various varicocele surgical approaches and modalities, fine surgery using a microscope is the most effective and has the lowest rate of postoperative complications.