Current management of the adolescent varicocele

Anatomical factors affecting the time required for microsurgical subinguinal varicocelectomy

Background

Microsurgical subinguinal varicocelectomy (MSV) is considered an effective and less morbid procedure, but the difficulty in preserving testicular arteries is a limitation of this procedure. We identified the microanatomy encountered during MSV and clarify its significance to the difficulty of the procedure.

Methods

Three hundred and twenty-six patients who underwent left MSV were evaluated. Detailed intraoperative microanatomy was recorded for each case. A classification system was used to assess the anatomical relationship between the internal spermatic artery and the varicose veins as follows: type I (non-adherent to the veins), type II (adherent to the veins), and type III (surrounded by veins). Type III cases were further divided into types III-a (an arterial pulse) and III-b (a blurred arterial pulse). A linear regression analysis of the factors associated with the length of the operation was used to determine the difficulty of the surgery.

Results

A mean number of 8.2 internal spermatic veins were ligated. Internal spermatic arteries were classified as type I in 14 % of patients, type II in 57 %, and type III in 29 % (III-a in 20 % and III-b in 9 %). A large number of internal spermatic veins and higher internal spermatic artery type were observed significantly more often in grade 3 varicoceles (p < 0.05). The types of internal spermatic arteries (ρ = 0.458) and numbers of internal spermatic veins (ρ = 0.431), cremasteric veins (ρ = 0.197), and gubernacular veins (ρ = 0.119) were significantly associated with the length of the operation (p < 0.05).

Conclusions

Anatomical factors were associated with the varicocele grade and surgical difficulty. These findings are helpful to perform MSV.

[Evolution of the therapeutic management of varicoceles: Analysis of French national coding database (2006-2014)]

OBJECTIVE

The varicocele is a venous abnormality frequently found in humans (1/10). Although the recommendations for management of this pathology are clear, two therapeutic options can be discussed: surgery or radiological embolisation. We wanted to study the evolution of the therapeutic management of varicocele using the French national coding database.

METHODS

Analysis of database from the "Agence technique de l'information sur l'hospitalisation" (ATIH) (number of surgical procedures and interventional radiology used in the treatment of varicocele for the period 2006-2014). The common classification of medical procedures (CCAM) was used to extract the codes for surgery and radiological embolisation. Then we recorded the corresponding "Groupes homogènes de malades" (GHM), excluding those with a different primary diagnosis of varicocele cure.

RESULTS

The number of surgical procedures and radiological embolisation performed for the treatment of varicocele increased from 3626 to 4007 procedures (+10.5%) between 2006 and 2014. While the frequency of interventional radiology (embolization pampiniform plexus) increased by 73.9%, surgery procedures (by direct approach or laparoscopy) decreased by 31.4% throughout the study (2006-2014). Thus in 2006, 60.2% of therapeutic procedures were performed surgically and 39.8% by radiological embolisation. In 2014, 37.4% of therapeutic procedures were performed surgically and 62.6% by embolization.

CONCLUSION

The analysis of French national database has confirmed a change in the therapeutic management of varicocele between 2006 and 2014. The minimally invasive treatment by radiological embolisation is currently favored in France and surgery pushed into the background. In 2014, more than one therapeutic management out of two was performed in interventional radiology.

LEVEL OF EVIDENCE

4.

The effects of varicocelectomy on the patients with premature ejaculation

BACKGROUND

Premature ejaculation is one of the most problems in clinical practice. The association between varicocele and premature ejaculation was poorly understood. The effects of varicocelectomy on premature ejaculation in varicocele patient was studied.

OBJECTIVES

The aim of this study was to determine the impacts of varicocelectomy on patients with both premature ejaculation and varicoceles.

PATIENTS AND METHODS

This was a clinical trial study, conducted on 124 patients (20-35 years old), with varicoceles and premature ejaculation (PE), since March 2011 to April 2013. Inguinal and sub inguinal varicocelectomy were performed for them. All patients had both impairment of spermiogram and PE. These patients were followed up for about 2 years and evaluated for PE, in addition to parameters of spermiogram, before and after the surgery.

RESULTS

A total number of 124 patients with varicoceles and PE were enrolled into the study. Following the surgery 46 patients (37%) were fully treated (P < 0.001), 78 patients (63%) had improvements in PE symptoms changed to early ejaculation (P < 0.05) and 89 patients (72%) had improved parameters of spermiogram (P < 0.002).

CONCLUSIONS

In a significant number of patients who had clinical varicocele and not well responded to medical treatments for PE, varicocelectomy could effectively improve PE and spermiogram parameters.

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.