Efficacy and Safety of Single-Port Robot-Assisted Artery-Sparing Varicocelectomy: A Comparative Study with Microsurgical Subinguinal Varicocelectomy

초록

Introduction: Microscopic subinguinal varicocelectomy (MV) has been considered the standard surgical treatment because of its proven efficacy and low recurrence rate, although it requires fine microsurgical dexterity within a narrow operative field, often leading to surgeon fatigue and visible scars, especially in bilateral varicocele cases.Laparoscopic or robotic approaches have been attempted to overcome these limitations, offering enhanced visualization, tremor elimination, and improved ergonomics for precise dissection, enabling efficient treatment of bilateral varicoceles through a single access. However, varicocelectomy using the da Vinci SP (single-port) robotic system has not yet been reported. Objective: Therefore, this study aimed to evaluate and compare the efficacy and safety of single-port robot-assisted artery-sparing varicocelectomy (SP-RALV) with those of conventional microscopic subinguinal varicocelectomy (MV) in patients with clinical varicocele. Methods: A retrospective analysis was performed on 48 patients who underwent varicocelectomy between January 2023 and June 2025 at a single tertiary institution, with a minimum of 4 months of follow-up. Patients were divided into the SP-RALV (n=23) and MV (n=25) groups. SP-RALV was performed via a transperitoneal single-port approach using the da Vinci SP system with artery- and lymphaticsparing dissection.MV was performed using a standard subinguinal approach under an operating microscope. Preoperative parameters included age, surgical indication (pain, infertility, or cosmetic concern), varicocele grade, venous diameter, testicular volume, pain score, and semen parameters. Except for age and surgical indication, all variables were analyzed pre- and postoperatively to assess surgical outcomes. Statistical analyses were conducted using appropriate parametric or non-parametric tests, with p<0.05 considered statistically significant. Results: There were no statistically significant differences between the two groups in age (32.7 vs 32.3 years) or surgical indications, including abnormal semen parameters (82.6% vs 44.0%) and scrotal pain (73.9% vs 68.0%). Although total operative time did not differ significantly between groups, SP-RALV tended to be shorter (unilateral: 68.3 vs 71.4 min; bilateral: 90.0 vs 101.2 min, p>0.05). Both groups showed significant postoperative improvements in pain scores and varicocele grade, with no intergroup difference. Regarding semen parameters, sperm count and morphology exhibited postoperative improvement trends without statistical significance.Sperm motility increased by +15.0% in the SP-RALV group but decreased slightly (−9.3%) in the MV group, without statistical significance (p=0.127). No postoperative hydrocele formation or recurrence was observed in either group during the minimum four-month follow-up period. In the SP-RALV group, all umbilical wounds healed uneventfully, leaving barely visible scars. Conclusions: SP-RALV demonstrated comparable safety and efficacy to conventional microscopic subinguinal varicocelectomy for clinical varicocele. The single-port robotic system provided enhanced visualization, improved instrument dexterity, and ergonomic advantages, enabling precise artery-sparing dissection and efficient bilateral repair through a single umbilical incision. Although differences in semen improvement, pain relief, and complication rates were not statistically significant, SP-RALV achieved equivalent outcomes with distinct benefits of minimal invasiveness, faster recovery, reduced surgeon fatigue, and excellent cosmetic satisfaction. These findings suggest that SP-RALV represents a feasible, non-inferior, and cosmetically superior alternative to microsurgery, warranting further prospective validation through larger, longterm multicenter studies.