The role of testicular volume in adolescents with varicocele: the better way and time of surgical treatment

Evolution of testicular asymmetry during puberty in adolescents without and with a left varicocele

OBJECTIVES

To assess the evolution of the Testicular Atrophy Index (TAI) in adolescent boys with and without a left varicocele with special attention for the currently postulated cut-off value of 20%.

SUBJECTS AND METHODS

During 2015-2019, 364 adolescent boys aged 11-16 years were recruited. Genital examination and scrotal ultrasonography were repeatedly performed (≥4 month intervals). Testicular volume (TV) was calculated using the Lambert formula (length × width × height × 0.71). TAI was calculated using the formula: [(TVright - TVleft)/TVlargest (right, left)] × 100.

RESULTS

The final study population comprised 239 participants, 161 (67.36%) controls and 78 (32.64%) adolescent boys with left varicocele. The mean (sd) number of measurements per participant was 3.82 (1.08). A TAI of ≥20% at first measurement occurred in 9.94% and 35.90%, respectively. Of these, only 31.25% and 46.43% had a TAI of ≥20% at the last measurement, respectively. Nevertheless, the risk of ending up with a TAI of ≥20% was significantly higher if a TAI of ≥20% was recorded at first measurement (P = 0.041 and P = 0.002, respectively). The normalisation rate did not differ significantly between the groups (P = 0.182). Normalisation occurred most frequently in Tanner Stages III and IV. Normalisation was mostly (≥74%) due to catch-up growth of the left testis, in contrast to growth retardation of the right testis, in both groups. The TAI seems to be a fluctuating parameter.

CONCLUSION

A TAI of ≥20% is a phenomenon seen in boys with and without varicocele but is more common in boys with varicocele. Although normalisation of a high TAI is frequently seen, both adolescent boys with and without a left varicocele who have an initial TAI of ≥20% have a higher risk of a TAI of ≥20% in the future. As the TAI is a fluctuating parameter during pubertal development, it's use as indicator for varicocelectomy based on a single measurement during pubertal development is questioned.

Outcome following the surgical management of varicocele in children and adolescents: a systematic review and meta-analysis

Background

The ideal surgical approach for the management of varicocele in children and adolescents remains controversial. Several techniques are available including artery- or lymphatic-sparing with optical magnification (via open inguinal or sub-inguinal approach), laparoscopic, antegrade and retrograde embolization/sclerotherapy.

Objectives

We aimed to appraise the clinical outcomes of these techniques in children and adolescents.

Data Sources and Methods

A systematic review was conducted (1997-2023). Meta-analysis or proportional meta-analysis for non-comparative studies (Freeman-Tukey transformation) using the random effects model was conducted. Results are expressed as overall proportion % and 95% confidence interval (CI).

Results

We identified 1910 studies; 632 duplicates were removed, 1278 were screened, 203 were reviewed and 56 were included, with 12 reporting on 2 different techniques (total of 68 data sets). Optical magnification via inguinal approach (498 cases): recurrence 2.5% (0.6-5.6), hydrocele 1.6% (0.47-3.4), testicular atrophy 1% (0.3-2.0), complications 1.1% (0.2-2.6); optical magnification via sub-inguinal approach (592 cases): recurrence 2.1% (0.7-4.4), hydrocele 1.26% (0.5-2.3), testicular atrophy 0.5% (0.1-1.3), complications 4% (1.0-8.8). Laparoscopic with mass-ligation/division (1943 cases): recurrence 2.9% (1.5-4.6), hydrocele 11.4% (8.3-14.9); complications 1.5% (0.6-2.9); laparoscopic with lymphatic-sparing (974 cases): recurrence 2.4% (1.5-3.5), hydrocele 1.2% (0.45-3.36), complications 1.2% (0.05-3.9); laparoscopic with artery-sparing (228 cases): recurrence 6.6% (2.3-12.9), hydrocele 6.5% (2.6-12.0). Antegrade embolization/sclerotherapy (403 cases): recurrence 7.6% (5.2-10.4), hydrocele 0.8% (0.17-1.9), technical failure 0.6% (0.1-1.6), complications 4.0% (2.3-6.1); retrograde embolization/sclerotherapy (509 cases): recurrence 6.9% (4.6-9.5), hydrocele 0.8% (0.05-2.5), technical failure 10.2% (4.6-17.6), and complications 4.8% (1.0-11.2).

Conclusion

The recurrence rate varies between 2.1% and 7.6% and is higher with the embolization/sclerotherapy techniques. Post-operative hydrocele rate varies between 0.8% and 11.4% and is higher with the laparoscopic mass-ligation/division technique. Testicular atrophy has not been reported with the laparoscopic and embolization/sclerotherapy techniques. The retrograde embolization technique is associated with 10% technical failure (inability to complete the procedure). The laparoscopic lymphatic-sparing technique is characterized by the lowest recurrence rate, incidence of hydrocele and other complications, and no reports of testicular atrophy.

Semen Parameters Changes in Adolescents With Clinical Varicocele after Magnified Subinguinal Varicocelectomy: A Prospective Controlled Study

BACKGROUND

Previously, we highlighted the benefits of magnified subinguinal varicocelectomy over conservative treatment on the semen of a small group of adolescents with varicoceles. In this report, we presented changes of semen parameters of 47 adolescents who underwent magnified subinguinal varicocelectomy (MSV) and followed-up for 6 months.

METHODS

The present prospective controlled study was conducted on 47 adolescents with varicocele who underwent MSV and were followed up for 6 months. In addition, age and sex-matched patients were added as control group. The primary outcome of this study was to assess the postoperative change in semen analysis parameters.

RESULTS

A significant increase in sperm volume from 2.5 (1.9-3) to 3.2 (2.6-4) mL at the end of the sixth month of follow-up. Likewise, the sperm count increased from 10.8 (3.51-21.6) to 20.3 (9.6-35) million. Notably, the percentage of rapid and slow sperms increased significantly from a median of 5% (0%-10%) and 15% (10 -20%) to a median of 10% (5%-15%) and 17.5% (15%-25%), respectively. The percentage of sperm with progressive movement increased from 35% (30%-40%) to 59% (45%-69%). The vitality of the sperms increased significantly as well. While the percentage of sperms with abnormal morphology decreased significantly at the end of follow-up.

CONCLUSION

Our findings support the safety and efficacy of MSV in patients with clinically detectable varicocele. MSV has improved the semen parameters of the included patients, including sperm motility, volume, count, and total progressive motility, which may positively impact their fertility potential.

Liquid and Solid Embolic Agents in Gonadal Veins

Male varicocele and pelvic congestion syndrome (PCS) are common pathologies with high predominance in young patients, having a high impact on the quality of life and infertility. Lately, the use of different endovascular embolization techniques, with various embolizing agents, shows good technical results and clinical outcomes. With the aim of presenting the “state of the art” of endovascular techniques for the treatment of male varicocele and PCS, and to discuss the performance of the different embolic agents proposed, we conducted an extensive analysis of the relevant literature and we reported and discussed the results of original studies and previous meta-analyses, providing an updated guide on this topic to clinicians and interventional radiologists. We have also underlined the technical aspects for the benefit of those who approach this type of interventional treatment. Our review suggests promising results in both the endovascular embolic treatment of male varicocele and PCS; for varicocele, a success rate of between 70% and 100% and a recurrence rate of up to 16% is reported, while for PCS it has been found that technical success is achieved in almost all cases of endovascular treatment, with a highly variable recurrence rate based on reports. Complications are overall rather rare and are represented by periprocedural pain, migration of embolic media and vascular perforations: severe adverse events have been reported very rarely.

Analysis of internal spermatic vein embolization through catheter versus laparoscopic high ligation in treatment of left varicocele

OBJECTIVE

Varicocele is a common disease in young and middle-aged men. This study aims to compare the efficacy of internal spermatic vein embolization of left varicocele versus laparoscopic high ligation.

METHODS

From January 2017 to September 2018, a total of 69 varicocele patients were admitted and given the opportunity to choose the treatment option. Among these, 26 patients were treated with sclerosing agent injection, while 43 patients underwent laparoscopic surgery. They were followed up for 12 months after surgery, and the technical success rate, recurrence rate, complication rate, cost, operative time, and hospitalization time with regard to these two methods were analyzed.

RESULTS

All patients completed the medical procedures. There was no recurrence in patients in the sclerotherapy group during the follow-up period; however, the complication rate was 19.2%. Furthermore, the operative time, hospitalization time, and cost of treatment were 31.1 ± 11.1 min, 1.2 ± 0.49 days, and 9613.11 ± 895.97 Yuan, respectively. In the laparoscopic group, 9 patients underwent laparoscopic bilateral high ligation, while 34 patients received treatment on the left side alone. The recurrence rate of left varicocele was 4.7% and the complication rate was 44.2%. Furthermore, the operative time, hospitalization time, and treatment cost were 50.4 ± 14.48 min, 4.0 ± 2.02 days, and 10,948.29 ± 2547.00 Yuan, respectively. Moreover, there were statistically significant differences (P < 0.05) in operative time, hospitalization time, and treatment cost. Patients in the sclerotherapy group had an advantage with respect to the overall complication rate when compared with patients from the laparoscopic group (X² = 4.448, P < 0.05), and there was a statistically significant difference in hydrocele (X² = 4.555, P < 0.05). However, there was no significant difference in the recurrence rate between these two groups (X² = 1.245, P > 0.05).

CONCLUSION

Patients who underwent sclerotherapy showed a higher technical success rate, a lower recurrence rate, fewer complications, and shorter hospitalization time compared to those treated with laparoscopic ligation. Transcatheter sclerosing agent injection may be a preferable treatment option for patients with unilateral varicocele.

Zeta and hyaluronic acid assessments, novel sperm selection procedures, in animal model for male infertility

Considering varicocele (VCL)-induced severe, progressive DNA damage, histone-protamine anomalies and low sperm production, in the current study, the experimental VCL was induced and the efficiency of hyaluronic acid (HA)-binding method (HABM) and zeta preparation procedure (ZPP) in selection of appropriate spermatozoa was compared with those spermatozoa from intact animals. Following 2 and 4 months, the histological alterations in testicular tissue, sperm count and viability were assessed to prove the VCL condition. The spermatozoa were undergone simple wash, HABM and ZPP. The chromatin condensation, active caspase-3 expression, DNA fragmentation and apoptosis index were analysed after applying selection techniques and compared with the spermatozoa from intact and VCL-induced animals, which were undergone a simple wash. Observations showed that both HABM and ZPP effectively prepared the spermatozoa with higher chromatin condensation and lower DNA damage. Meanwhile, the ZPP exerted a more preferable effect by preparing the spermatozoa with higher chromatin condensation, and lower caspase-3 expression, and DNA disintegrity versus the HABM, especially after 4 months. In conclusion, ZPP seems to exert much more reliable efficiency in selecting appropriate spermatozoa for ICSI processes, while more studies are needed to find out which one is more useful in the clinical assisted reproductive technique (ART) process.

Comparison of the clinical characteristics of patients with varicocele according to the presence or absence of scrotal pain

We investigated the clinical characteristics of patients with varicocele according to the presence or absence of scrotal pain. We retrospectively reviewed the records of patients who underwent varicocelectomy. The age, body mass index, grade, laterality of varicocele, testicular volume difference, time to hospital visit, serum testosterone level and semen parameters were evaluated. A total of 954 patients were included. The painful group had lower mean age, lower BMI, higher grade of varicocele, smaller testicular volume difference and shorter time to hospital visit than the painless group. In addition, the median serum total testosterone level and total sperm count, concentration and motility were higher in the painful group than in the painless group. In multivariate analysis, there were significant differences between the two groups in age, grade of varicocele, testis volume difference, time to hospital visit, total sperm count and concentration. Patients with painful varicocele visited hospital earlier because of the pain and tended to start treatment sooner. They were also younger, had smaller testis atrophy and had higher sperm concentration, even though they had a higher grade of varicocele than patients without pain. Although scrotal pain in varicocele patients is difficult to treat, it leads to early diagnosis and treatment.

Treatment of Varicocele in Children and Adolescents: A Systematic Review and Meta-analysis from the European Association of Urology/European Society for Paediatric Urology Guidelines Panel

CONTEXT

The benefits and harms of intervention (surgical or radiological) versus observation in children and adolescents with varicocele are controversial.

OBJECTIVE

To systematically evaluate the evidence regarding the short- and long-term outcomes of varicocele treatment in children and adolescents.

EVIDENCE ACQUISITION

A systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. A priori protocol was registered to PROSPERO (CRD42018084871), and a literature search was performed for all relevant publications published from January 1980 until June 2017. Randomized controlled trials (RCTs), nonrandomized comparative studies (NRSs), and single-arm case series including a minimum of 50 participants were eligible for inclusion.

EVIDENCE SYNTHESIS

Of 1550 articles identified, 98 articles including 16 130 patients (7-21 yr old) were eligible for inclusion (12 RCTs, 47 NRSs, and 39 case series). Varicocele treatment improved testicular volume (mean difference 1.52ml, 95% confidence interval [CI] 0.73-2.31) and increased total sperm concentration (mean difference 25.54, 95% CI 12.84-38.25) when compared with observation. Open surgery and laparoscopy may have similar treatment success. A significant decrease in hydrocele formation was observed in lymphatic sparing versus non-lymphatic sparing surgery (p=0.02). Our findings are limited by the heterogeneity of the published data, and a lack of long-term outcomes demonstrating sperm parameters and paternity rates.

CONCLUSIONS

Moderate evidence exists on the benefits of varicocele treatment in children and adolescents in terms of testicular volume and sperm concentration. Current evidence does not demonstrate superiority of any of the surgical/interventional techniques regarding treatment success. Long-term outcomes including paternity and fertility still remain unknown.

PATIENT SUMMARY

In this paper, we review benefits and harms of varicocele treatment in children and adolescents. We found moderate evidence that varicocele treatment results in improvement of testicular volume and sperm concentration. Lymphatic sparing surgery decreases hydrocele formation. Paternity and fertility outcomes are not clear.

Therapeutic efficacy and safety of laparoscopic surgery versus microsurgery for varicocele of adult males: A meta-analysis

OBJECTIVES

This study aimed to systemically evaluate the efficacy and safety of laparoscopy versus microsurgery in the surgical therapy of varicocele in male adults.

METHODS

Relevant literature, published between January 1995 and October 2012, were searched in Pubmed/Medline database, OVID, EMBASE, Chinese Biology Medicine disc (CBMdisc), CNKI, CEBM\CCD, and Cochrane database. The newly published papers were also manually searched. Randomized controlled trials (RCT) related to the surgical interventions of varicocele were included, and full texts were obtained. Each study was evaluated with the Cochrane Risk of Bias tool. Two investigators collected data independently to produce the meta-analysis.

RESULTS

Five RCTs met the inclusion criteria and included 554 patients. Data were merged by the RevMan5.1 software. The sperm concentration increased significantly after surgery (WMD = 4.28; 95% CI = 4.16, 6.99; P < .00001, Z = 7.72). There was no significant difference in the postoperative hospital stay between laparoscopy and microsurgery (WMD = 0.24, 95% CI = 0.44, 0.93; P = .49, Z = 0.69). The operation time of laparoscopy was significantly shorter than that of microsurgery (WMD = 40.31, 95% CI = 37.77, 42.86; P < .00001, Z = 31.03). The incidence of hydrocele reduced significantly after microsurgery as compared to laparoscopy (WMD = 0.05, 95% CI = 0.01, 0.27; P = .0005, Z = 3.49). The postoperative recurrence rate after microsurgery was significantly lower than that after laparoscopy (WMD = 0.10, 95% CI = 0.04, 0.25; P < .00001, Z = 5.01).

CONCLUSION

No significant differences were found between microsurgery and laparoscopy for the increase of sperm concentration and operation time. Compared to the laparoscopy group, the microsurgery group had lower postoperative incidence of hydrocele and recurrence rate, but longer in the operation time.

Perspectives in Pediatric Pathology, Chapter 20. Adolescent Varicocele

Varicocele is characterized by elongation, dilatation, and tortuosity of the veins draining the testis and its covers, causing circulatory reflux along the inner spermatic vein [ 1 ]. Varicocele results in progressive testicular lesions and, if untreated, can lead to testicular atrophy [ 2 ]. Varicocele is considered the most frequently identified cause of male infertility [ 3 ]. The mechanisms involved in varicocele formation are not well known and probably are multiple, differing from one patient to another.

The Dilemma of Adolescent Varicoceles: Do They Really Have to Be Repaired?

The primary indication for varicocele repair in adults, that of failed paternity, must be substituted in the adolescent population with surrogate parameters of testicular size differential and semen analysis. Making recommendations based on these two parameters is incredibly difficult because studies often have contradictory findings, different patient populations, and lack of long-term follow up of the key endpoint, paternity. Therefore, it is not a surprise that recommendations for adolescent varicocele repair are general (with some exceptions) and necessarily so because of limitations in quality of evidence. Apart from pain, all indications for varicocele repair in adolescence remain controversial. This highlights the most important task for future studies: to prevent pediatric urologists from allowing a potentially damaging process to go untreated, while at the same time avoiding unnecessary intervention on a highly prevalent condition.

Laparoendoscopic single-site varicocelectomy compared with conventional laparoscopic surgery: a systematic review and meta-analysis

Purpose

To present a systematic review and meta-analysis comparing laparoendoscopics single-site varicocelectomy (LESS-V) versus conventional laparoscopic surgery (CTL-V).

Methods

A literature search was performed using The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded and Google Scholar. Literature reviewed included meta-analyses, and randomized and nonrandomized prospective studies. We utilized weight mean difference (WMD) to measure hospital stay, time to return normal activity, postoperative pain and improvement of semen parameters and odds ratio (OR) to postoperative complications and cosmetic satisfaction. We used the Cochrane Collaboration’s Review Manager 5.1 software for statistical analysis.

Results

We identified six publications which strictly met our eligibility criteria. Meta-analysis of extractable data showed that LESS-V was better than CTL-V in postoperative pain (WMD: −0.46; 95 % CI −0.75 to −0.17; p = 0.002), time to convalescence (WMD: −1.4 days; 95 % CI −2.55 to −0.25; p = 0.02) and cosmetic satisfaction (OR 6.86; 95 % CI 2.89–16.28; p < 0.00001). However, CTL-V was better than LESS-V in operative time (WMD 1.96 min, 95 % CI 0.96–2.96; p = 0.0001). There were no differences between LESS-V and CTL-V in hospital stay (WMD: −0.02 days, 95 % CI −0.39 to 0.35; p = 0.92) and postoperative complications (OR 1.13, 95 % CI 0.57–2.21; p = 0.73).

Conclusions

This meta-analysis comparing the efficacy of LESS-V and CTL-V showed that LESS-V was safe, with significantly reduced postoperative pain, shorter recovery time, and better cosmetic outcome.

Transitional Urology for Male Adolescents: What Adult Urologists Should Know

In recent years, there has been increasing interest in transitional urology, or how to best prepare patients with major congenital urologic diseases, such as bladder exstrophy and neuropathic bladder, to manage their own health care with adult urologists. However, common pediatric urologic conditions may be encountered by the adult urologist with more regularity. This review focuses on three relatively common conditions which may be identified in childhood, the consequences from which a patient may seek help from an adult urologist: cryptorchidism, varicocele, and Klinefelter syndrome.

Prognostic Predictors of Fertility in Young Adult Patients With Varicocele: Peak Retrograde Flow Velocity and Reflux Grade

OBJECTIVES

The purpose of this study was to determine prognostic factors affecting semen parameters in patients with varicocele during the postadolescent period.

METHODS

This study was approved by the Institutional Review Board. Between May 2013 and May 2015, we prospectively obtained demographic and sonographic data from postadolescent patients with varicocele. Potential risk factors affecting semen parameters, including age at diagnosis, height, weight, body mass index, varicocele laterality, varicocele grade, left testicular volume, right testicular volume, total testicular volume, testicular atrophy index, testicular volume differential, right and left maximum vein diameters, peak retrograde flow velocity, reflux flow volume, and reflux grade in both supine and standing positions, were recorded.

RESULTS

The left peak retrograde flow velocity, reflux flow volume, and reflux grade in the supine and standing positions, left testicular volume, right testicular volume, total testicular volume, and follicle-stimulating hormone level were found to be associated with abnormal semen parameters (P < .05). By multivariate analysis, the follicle-stimulating hormone level was associated with the sperm concentration and morphologic characteristics, and the left peak retrograde flow velocity in the standing position was associated with deterioration of sperm motility and morphologic characteristics. Additionally, the left reflux grade in the standing position was associated with the sperm concentration, and the left testis volume was associated with motility.

CONCLUSIONS

The left peak retrograde flow velocity and reflux grade in the standing position were significantly associated with all semen analysis parameters. This finding supports the use of testicular duplex Doppler sonography as a noninvasive tool for evaluation of testicular function in patients with varicocele and helps clinicians determine patients' fertility status.

Natural history of testicular size in boys with varicoceles

INTRODUCTION

Testicular size is commonly used as a proxy for future fertility in adolescent boys diagnosed with varicoceles. Surgery is often performed based on a 15-20% reduction in volume of the ipsilateral testicle when compared to the unaffected side. Recent European Association of Urology guidelines, however, have highlighted the risk of overtreatment. Data on the natural progression of testicular size discrepancy are limited in this population. To evaluate the role of a non-surgical approach, the present study reports on testicular size progression in 35 boys with left-sided varicoceles managed with observation alone.

METHODS

In the present study, 103 consecutive boys who were seen for varicocele were retrospectively evaluated; the 35 who were seen for at least three sequential visits by the same pediatric urologist for a unilateral left varicocele were selected. In the present practice, surgical management of varicoceles in teens is offered, but not recommended unless surgery is being performed for another reason (3/103). The Prader orchidometric testicular volumes that were documented for all visits were recorded and the volume of the left testicle as a percentage of the right was calculated. This analysis was performed for the entire population, and subgroup analysis was conducted for boys with a Grade 3 varicocele, with >10% asymmetry at diagnosis, and by dividing the population into prepubertal and pubertal age groups. Boys with bilateral varicoceles, concurrent testicular masses, or volumes recorded by a nurse practitioner were excluded from the study.

RESULTS

The mean left testicular volume in the population was found to measure 96%, 95% and 96% of the right at the first, second and third visit (median interval was 2.0 years), respectively. Among the 26 boys seen for a fourth visit (median 3.3 years) and the 15 seen for a fifth visit (median 4.3 years), the mean left testicular volumes were 98% and 97% of the right at diagnosis and 97% at both the fourth and fifth visits (Figure). Likewise, no differences were seen after dividing the population into prepubertal (9-11 years, n = 9) and pubertal (12-14 years, n = 26) groups. Among the 13 (37%) boys with a Grade 3 varicocele at presentation, the left testicular volume was 95% (SD 11.4) of the right and remained unchanged by the third visit (96%, P = 0.69). In addition, among the 11 boys (31%) with greater than 10% size difference at the first visit, the left testicle measured 82% of the right (SD 5.3) at diagnosis and increased to 92% (SD 6.3) by the third visit (P < 0.001).

DISCUSSION

In the 35 boys observed over a median of 2.0 years or three consecutive visits, there was no worsening of testicular asymmetry. This finding is consistent with some previous observational data on pediatric varicoceles, but carries the advantages of a narrower age range and longitudinal follow-up in all patients. At the same time, these results differ from other studies that show no improvement or worsening of asymmetry during follow-up. This difference is attributed to the inherent characteristics of the present study population and the choice of orchidometer for measurement. The present data have the advantage of excluding selection bias. Recognizing that this study is a retrospective, single-operator study with a small sample size, prospective, randomized trials are recommended to weigh surgery vs observation in adolescent varicocele patients.

CONCLUSIONS

No progression in atrophy/hypotrophy of the left testis was found in a series of 35 consecutive patients who were followed non-surgically for left-sided varicocele. Our data thus support observation as management for childhood varicocele in younger teens.

Surgical retroperitoneoscopic and transperitoneoscopic access in varicocelectomy: duplex scan results in pediatric population

OBJECTIVE

This is a retrospective study to compare duplex scan results of laparoscopic Palomo's technique through retroperitoneal and transperitoneal approach for varicocelectomy in children. We statistically analyzed recurrence, testicular volume growth and complications.

PATIENTS AND METHODS

Surgical intervention was performed utilizing transperitoneoscopic (group A) or retroperitoneoscopic access (group B). Duplex scan control was performed after 12 months (T1), after 2 years (T2) and the last one at 18 years old in most patients. Statistical analysis was performed using the t-test for parametric data. Differences in proportions were evaluated using χ2 or Fisher's exact test.

RESULTS

We treated 120 children (age range 10-17 years) who presented an asymptomatic IV grade of reflux, Coolsaet 1, associated with a left testicular hypotrophy in 36.6% of the cases (44 patients). No post-operative complications were verified. Duplex scan exam showed an increase of left testicular growth in both groups, with complete hypotrophy disappear in patients in both groups after 24 months. Hydrocele, diagnosed clinically and confirmed with duplex scan, was the most frequent post-operative complication (22/120 cases; 18.3%).

CONCLUSIONS

This study showed the importance of duplex scan at all steps of this vascular pathology in children, and that there is no significantly difference in results between the two surgical techniques except for hydrocele in transperitoneoscopic access.

Effects on normalized testicular atrophy index (TAIn) in cryptorchid infants treated with GnRHa pre and post-operative vs surgery alone: a prospective randomized trial and long-term follow-up on 62 cases

PURPOSE

The aim of this study was to investigate the effects of gonadotropin releasing hormone analog (GnRHa) therapy on normalized testicular atrophy index (TAIn) using gonadorelin before and after orchiopexy.

METHODS

62 infants with 87 undescended testes (UDT) were prospectively assigned to two homogeneous groups according to age, position of UDT and TAIn. The patients were randomized to receive either orchiopexy alone or orchiopexy combined with GnRHa as nasal spray at 1.2 mg daily for 4 weeks before surgery and 4 weeks after surgery. Surgical approaches were relative to the position of the UDT: Shoemakers technique in proximal-UDT and Bianchi technique in distal-UDT. All the patients were evaluated clinically and sonographically 1 month before surgery, at the time of surgery, 1 month, 6 months and 5 years after surgery.

RESULTS

Ultrasound data in our study have shown a statistically significant decrease of TAIn in children given additional HT only after 5 years of follow-up, in unilateral cases and in the entirety of treated patients; in bilateral cases this difference was not statistically significant.

CONCLUSION

Patients with a TAIn >20% treated with preoperative and post-operative GnRHa therapy have a significant increase in testicular volume after 5 years of follow-up, as shown by the relative reduction of TAIn values.

Impact of internal spermatic artery preservation during laparoscopic varicocelectomy on recurrence and the catch-up growth rate in adolescents

OBJECTIVE

To investigate the effectiveness of laparoscopic varicocelectomy (LV) in adolescents with varicocele and analyze the impact of internal spermatic artery (ISA) preservation on surgical outcomes.

MATERIALS AND METHODS

Data on 92 adolescents with left varicocele who underwent LV between December 1998 and January 2011 were retrospectively analyzed. The mean age of the patients was 13.2 ± 2.1 years. Age, grade of disease, number of ligation veins, recurrence rates, and catch-up growth were analyzed in patients who underwent ISA preservation and ligation. The median duration of the follow-up was 21 months.

RESULTS

ISA preservation was performed on 50 patients (54%). There were no significant inter-group differences in terms of age, varicocele grade, number of ligation veins, and catch-up growth (93% vs. 90%). The patients who received artery preservation demonstrated a higher recurrence rate (22%) than those who received artery ligation (5%; p = 0.032). Among 13 patients who had persistent or recurrent varicocele, nine were treated with embolization and one was treated with magnification-assisted subinguinal varicocelectomy. None of these 10 patients demonstrated recurrence or testicular atrophy.

CONCLUSIONS

LV with ISA ligation can reduce the recurrence rate and results in the same catch-up growth rate in comparison with LV with ISA preservation.

Children and adults varicocele: diagnostic issues and therapeutical strategies

Varicocele is defined as abnormally dilated scrotal veins. It is present in 15 % of normal males and in 40 % of males with infertility. This disorder is a challenge for the physicians involved in the diagnosis and treatment, as the pathophysiology of varicocele is not yet completely understood. For this reason, accurate diagnostic criteria and clear indications for treatment in asymptomatic adolescents or adults with clinical or subclinical varicocele are still not defined. Ultrasonography (US) is considered the best method for calculating the volume of the testicles, measuring vein diameter and monitoring the growth of the testis in adolescent patients. Color-Doppler US is the method of choice for detecting spermatic vein reflux and for classifying the grade of varicocele. Various classification systems have been published with recommendations on how to perform US imaging of the scrotum. Currently, color-Doppler US and spectral analysis are the most effective, non-invasive diagnostic procedures as they allow detection of subclinical varicocele associated with infertility. Various techniques are used in the treatment of varicocele including open surgery, laparoscopic procedures and interventional radiology. However, there is no consensus among physicians on which technique is the most effective in terms of outcome and complication rates. This review shows that color-Doppler US is currently the most widely employed diagnostic method for detection and classification of varicocele caused by venous reflux, as it is reliable and easily performed. The review also highlights the role of varicocelectomy in the management of adult male infertility.

Analysis of testicular-internal spermatic vein variation and the recreation of varicocoele in a Sprague-Dawley rat model

Many laboratories tried to recreate the varicocoele model have met with varied success. To recreate a consistent varicocoele model by exploring the anatomic variability of the testicular-spermatic venous system in Sprague-Dawley (SD) rats. Seventy-two sexually mature SD male rats were randomly divided into three groups containing 24 rats per group. Partial ligation of the left renal vein and internal spermatic vein (ISV) communicating branches to common iliac vein and ISV communicating branches ligation (RVISVCBCIV) or partial ligation of the left renal vein and ISV communicating branches ligation (RVISVCB). The results showed that the mean diameter of the left ISV was significantly increased in the RVISVCBCIV group compared with the control and RVISVCB groups (p < 0.001). Using ISV as the reference, the sensitivity of varicocoele was 71.43%, and the specificity was 80%. In addition, the positive predictive value was 83.33%, and the negative predictive value was 66.67%. Sperm count, motility, Johnsen score and the spermatogenic cell density were lower in the RVISVCBCIV group compared with the control (p < 0.01). The apoptotic index was higher in the RVISVCBCIV group compared with control groups (p < 0.01). The RVISVCBCIV provides a more effective method for establishing a varicocoele-induced model.

Sclerosis and varicocele embolization with N-butyl cyanoacrylate: experience in 41 patients

BACKGROUND

Embolization is an established treatment for varicocele. Coils are most frequently used in the procedure. Liquid embolic and sclerosing agents seem to have a number of advantages over coils.

PURPOSE

To report our experience and explain the technique of using N-2-butyl-cyanoacrylate (N2BCA) in varicocele treatment.

MATERIAL AND METHODS

From January 2010 to July 2011, 42 gonadal veins in 41 consecutive patients (age range, 11-41 years; mean, 18 years) with a diagnosis of varicocele were treated with N2BCA as an embolic agent. The clinical diagnosis was confirmed by Doppler ultrasound in all patients. Institutional review board approval was obtained, and all the patients signed informed consent for this retrospective review. In all cases, a 4-F hydrophilic catheter was used to catheterize the distal portion of the gonadal vein through which N2BCA, emulsified with lipiodol, was injected.

RESULTS

The technical success was 100%. No complications or non-targeted embolizations were reported. Seven patients reported moderate post-embolization pain that required oral analgesic treatment for 7-10 days. After 12-month follow-up, all patients exhibited varicocele resolution in the Doppler ultrasound examination as well as relief of all previous symptoms. We have no fertility-related data for patients treated for this condition.

CONCLUSION

N2BCA as an embolic agent is a therapeutic alternative for the endovascular treatment of varicocele. This technique is uncomplicated, inexpensive, efficient, and safe.

Adolescent varicocoele management controversies

Varicocoele is defined as excessive dilatation of the pampiniform venous plexus of the spermatic cord. Varicocoele frequently appears during early puberty and is recognized to be the most common surgically correctable cause of male infertility. However, the actual incidence in adolescents, pathophysiology and the association with male factor infertility all remain somewhat controversial. The most accurate diagnostic technique for identifying young men who will benefit from surgical treatment has yet to be established. Observations of testicular asymmetry and deteriorating semen quality helped establish current guidelines and recommendations for surgical treatment. Further studies, comparing observation with surgical intervention, are needed to refine the current indications for varicocoele repair in the adolescent male.

Varicocele: standard and alternative indications for repair

PURPOSE OF REVIEW

This review provides timely and relevant information to address the indications for repair of the adolescent varicocele. In this review, we summarize the most recent available evidence and provide clinical guidelines.

RECENT FINDINGS

The indications for adolescent varicocelectomy commonly include testicular hypotrophy and pain but become confusing and contradictory when discussing potential infertility as an indication for repair. The preponderance of patients with varicocele in the infertile population leads to the search for causality and reversibility. However, in the era of assisted reproduction, the question of early prevention of infertility is brought to the forefront of discussion. Recent attempts have been made to determine the patient parameters that predict future infertility. Current publications have focused on predictors for clinically significant varicoceles that would benefit from intervention, such as hormonal profile and peak retrograde flow. Contradictory evidence exists regarding the significance of testicular asymmetry in adolescence.

SUMMARY

Substantial effort has been made to tease out the clinically significant adolescent varicocele. However, definitive evidence regarding fertility outcomes and adolescent varicocele repair remains limited and controversial. Large-scale, long-term follow-up studies are necessary to determine the true benefit of adolescent varicocele repair on decreasing the risk of fertility problems in adulthood.

[Varicocele in adolescents]

Testicular varicocele is present in 15 % of adolescent boys. The very impact of this pathology and who will be at risk of developing into infertility remains unclear. Research on the pathophysiology, results of surgical or radiological interventions and potential predictors for long-term impairment of spermatogenesis and thus fertility is still ongoing. Indications for treatment are mainly based on differences in testicular volumes as semen parameters are most often not available; however, whether testicular volume is a valuable prognostic parameter for later fertility remains questionable. Approximately 50 % of adolescent patients with varicocele experience spontaneous increase of testicular volume without any intervention.

Varicocele in adolescence: where are we now?

The exact pathophysiology of varicocele and the subsequent alteration of spermatogenesis has been the subject of much debate. Despite an enormous amount of literature on the subject, the appropriate management of varicocele in the adolescent patient population has not yet been clearly elucidated. While not every male with varicocele will be subfertile, the possibility potentially lends credence to early diagnosis for those in whom treatment will have an impact.

Varicocele surgery: 10 years of experience in two pediatric surgical centers

AIM

The study was designed to compare recurrence rates and complications after laparoscopic versus open varicocele surgery in children.

SUBJECTS AND METHODS

A retrospective case-note review of all varicocele surgery over a 10-year period (April 1999-March 2009) in two pediatric surgical centers was performed. Multivariate analysis using logistic regression was performed using SPSS Statistics version 18 (SPSS Inc., Chicago, IL).

RESULTS

Thirty-seven patients had varicocele surgery during the study period. The median age at surgery was 14 years (range, 11-16 years). Most children had left-sided Grade 2 varicocele. Twenty-five (68%) primary procedures were laparoscopic (17 artery-sparing), and 12 (32%) procedures were open (9 artery-sparing). Six (16%) children had recurrence, and 6 (16%) had postoperative hydrocele. Recurrence rates after laparoscopic (16%) and open (17%) surgery were similar. Increasing age significantly decreased recurrence (odds ratio, 0.373; 95% confidence interval 0.161-0.862; P = .021). Although laparoscopy was associated with higher rates of postoperative hydrocele (odds ratio, 2.817; 95% confidence interval, 0.035-3.595; P = .380) and artery-sparing ligation was associated with higher rates of recurrence (odds ratio, 2.667; 95% confidence interval, 0.022-4.235; P = .787), these associations were not statistically significant.

CONCLUSIONS

The best results of varicocele surgery in terms of recurrence and postoperative hydrocele were achieved by open mass ligation; however, larger prospective studies are warranted.

Effect of varicocelectomy on testicular volume in children and adolescents: a meta-analysis

OBJECTIVE

To evaluate the effect of surgical intervention on catch-up growth as determined by a decreased testicular volume discrepancy in children and adolescents with varicocele.

METHODS

A systematic search was performed using MEDLINE and the PubMed database and cross-referenced as of October 28, 2011 using the terms "varicocele," "children," "adolescent," "surgery," and "testicular volume." All relevant studies were of the testicular volume discrepancy variance before and after surgical repair. The outcomes included the number of patients with initial testicular atrophy and those with catch-up growth after surgical repair. The database search, quality evaluation, and data extraction were independently performed by 2 reviewers.

RESULTS

Of 75 studies, 14 were included for analysis and involved 1475 patients. The combined analysis showed that the testicular volume discrepancy was significantly reduced after surgery in the ≥10% group (P < .00001) and ≥20% group (P < .00001), respectively. No difference was found between the 2 groups (P = .70). Taken together, the number of patient with testicular volume disproportion in all pediatric and adolescent varicocele patients significantly decreased after surgery (P < .00001). The average proportion of catch-up growth was 76.4% (range 52.6%-93.8%).

CONCLUSION

The meta-analysis suggested clear advantages of surgical intervention on reducing testicular hypotrophy when the discrepancy is ≥10% in children and adolescents with varicocele. Additional prospective and controlled studies are warranted to elucidate the treatment of children and adolescents with varicocele.

Current management principles for adolescent varicocele

The authors review the current approach to management of the adolescent varicocele which has evolved over the past two decades. Principles of observational, surgical and adjunctive management are discussed relative to significant clinical findings. A selective approach to surgical intervention is advocated with the goal of preserving fertility potential.

Surgical techniques for the management of male infertility

Evaluation and surgical treatment of male infertility has evolved and expanded, now leading to more precise diagnoses and tailored treatments with diminished morbidity and greater success. Surgeries for male infertility are divided into four major categories: (i) diagnostic surgery; (ii) surgery to improve sperm production; (iii) surgery to improve sperm delivery; and (iv) surgery to retrieve sperm for use with in vitro fertilization and intracytoplasmic sperm injection (IVF-ICSI). While today we are more successful than ever in treating male infertility, pregnancy is still not always achieved likely due to factors that remain poorly understood. Clinicians treating infertility should advocate for couple-based therapy, and require that both partners have a thorough evaluation and an informed discussion before undergoing specific surgical therapies.

Risk factors for progressive deterioration of semen quality in patients with varicocele

OBJECTIVE

To assess the risk factors for progressive deterioration of semen quality (PDSQ) in adult patients with varicocele.

METHODS

A total of 32 men with left varicocele and impaired semen quality (group 1) and 30 age-matched patients with left varicocele and normal semen quality (group 2) were recruited for the present study. All the subjects received conservative treatment, and the parameters for evaluation every 12 months included semen quality, peak retrograde flow (PRF) and spontaneous venous reflux by color Doppler ultrasonography, body mass index, serum concentration of follicle-stimulating hormone, luteinizing hormone, prolactin, testosterone, testicular volume and discrepancy, grade of varicocele, and scrotal temperature.

RESULTS

The mean follow-up time was 63.2 months (range 60-66). The patients in group 1 had a significantly greater PRF, lower testicular volume, greater testicular volume discrepancy, lower testosterone level, higher scrotal temperature, and greater follicle-stimulating hormone level than those in group 2 at first. The semen quality deteriorated in 28 subjects (87.5%) in group 1, but in only 6 patients (20%) in group 2 during follow-up. Furthermore, the 6 subjects with PDSQ in group 2 had greater PRF and scrotal temperature than those without.

CONCLUSION

The rate of PDSQ was significantly greater in the varicocele patients with an initially abnormal semen quality than in those with initially normal semen quality (87.5% vs 20%). Furthermore, the varicocele patients with initially normal semen quality who had greater PRF and scrotal temperature might have a greater risk of PDSQ.

Laparoendoscopic single-site varicocele repair in adolescents-initial experience at a single institution

BACKGROUND AND PURPOSE

Laparoendoscopic single-site (LESS) varicocele repair is a modification of standard laparoscopic varicocele repair that uses a single port. We describe our initial experience with LESS varicocele repair.

PATIENTS AND METHODS

During a 1-year period, all patients who presented for varicocele repair underwent LESS repair. We evaluated our initial experience by determining operative time, operative and postoperative complications, and overall cost of the procedure.

RESULTS

A total of 11 adolescents underwent LESS varicocele repair. There were no intraoperative complications, and there were no conversions to open surgery or traditional laparoscopy. Estimated blood loss was minimal, and mean operative time was 66.9 minutes (range 48-91 min). The varicocele was corrected in all cases. During the 4 to 14 month follow-up, there was no recurrence, testis atrophy, or hernia in any patient. One subclinical hydrocele developed postoperatively that has not been repaired.

CONCLUSION

Our experience with LESS varicocele repair in adolescents suggests it to be a safe and effective method for varicocele repair in adolescents.

Is the comparison of a left varicocele testis to its contralateral normal testis sufficient in determining its well-being?

OBJECTIVE

To determine whether a size difference between a left testis involved with a varicocele and the contralateral normal testis is sufficient in its size assessment.

METHODS

We reviewed all pediatric scrotal ultrasounds at Helen DeVos Children's Hospital between 2001 and 2008. Sonographic testicular measurements were recorded for patients with clinically diagnosed left varicocele (n = 81 for "varicocele" group) and for patients with no specific pathologic findings (n = 184 for "normal" group). We first compared the sizes between left and right testes for all patients, then between the "varicocele" group and the "normal" group separately for left and right.

RESULTS

There were no significant size differences between left and right testes for the "normal" group, whereas the left was significantly smaller than the contralateral right for the "varicocele" group (P = .0048 for length; P = .012 for volume) for all ages. For boys 16 years or older, both the left and contralateral right testes of "varicocele" boys were smaller than those of "normal" boys, adjusting for age (P for left = .026 for length and .059 for volume; for right P = .033 for length and .031 for volume).

CONCLUSION

Our study confirms that the left testis in boys with varicocele is most often smaller than the contralateral right testis no matter the age. Compared with normal boys in late adolescence, the contralateral right testis is smaller in boys with varicocele.