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Bonomi M, Cangiano B, Cianfarani S, Garolla A, Gianfrilli D, Lanfranco F, Rastrelli G, Sbardella E, Corona G, Isidori AM, Rochira V. "Management of andrological disorders from childhood and adolescence to transition age: guidelines from the Italian Society of Andrology and Sexual Medicine (SIAMS) in collaboration with the Italian Society for Pediatric Endocrinology and Diabetology (SIEDP)-Part-1". J Endocrinol Invest 2024:10.1007/s40618-024-02435-x. [PMID: 39126560 DOI: 10.1007/s40618-024-02435-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 07/23/2024] [Indexed: 08/12/2024]
Abstract
PURPOSE Andrological pathologies in the adulthood are often the results of conditions that originate during childhood and adolescence and sometimes even during gestation and neonatal period. Unfortunately, the reports in the literature concerning pediatric andrological diseases are scares and mainly concerning single issues. Furthermore, no shared position statement are so far available. METHODS The Italian Society of Andrology and Sexual Medicine (SIAMS) commissioned an expert task force involving the Italian Society of Pediatric Endocrinology and Diabetology (SIEDP) to provide an updated guideline on the diagnosis and management of andrological disorders from childhood and adolescence to transition age. Derived recommendations were based on the grading of recommendations, assessment, development, and evaluation (GRADE) system. RESULTS A literature search of articles in English for the term "varicoceles", "gynecomastia", "fertility preservation", "macroorchidism", "precocious puberty" and "pubertal delay" has been performed. Three major aspects for each considered disorder were assessed including diagnosis, clinical management, and treatment. Recommendations and suggestions have been provided for each of the mentioned andrological disorders. CONCLUSIONS These are the first guidelines based on a multidisciplinary approach that involves important societies related to the field of andrological medicine from pediatric to transition and adult ages. This fruitful discussion allowed for a general agreement on several recommendations and suggestions to be reached, which can support all stakeholders in improving andrological and general health of the transitional age.
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Affiliation(s)
- M Bonomi
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy.
- Department of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Piazzale Brescia 20, 20149, Milan, Italy.
| | - B Cangiano
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
- Department of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Piazzale Brescia 20, 20149, Milan, Italy
| | - S Cianfarani
- Endocrinology and Diabetes Unit, Bambino Gesù Children's Hospital, Rome, Italy
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - A Garolla
- Unit of Andrology and Reproductive Medicine, Department of Medicine, University of Padova, Padua, Italy
| | - D Gianfrilli
- Section of Medical Pathophysiology and Endocrinology, Department of Experimental Medicine, "Sapienza" University of Rome, Rome, Italy
- Centre for Rare Diseases (Endo-ERN Accredited), Policlinico Umberto I, Rome, Italy
| | - F Lanfranco
- Division of Endocrinology, Andrology and Metabolism, Department of Medical Sciences, Humanitas Gradenigo, University of Turin, Turin, Italy
| | - G Rastrelli
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", Careggi Hospital, University of Florence, Florence, Italy
| | - E Sbardella
- Section of Medical Pathophysiology and Endocrinology, Department of Experimental Medicine, "Sapienza" University of Rome, Rome, Italy
- Centre for Rare Diseases (Endo-ERN Accredited), Policlinico Umberto I, Rome, Italy
| | - G Corona
- Endocrinology Unit, Medical Department, Maggiore-Bellaria Hospital, Azienda Usl, Bologna, Italy
| | - A M Isidori
- Section of Medical Pathophysiology and Endocrinology, Department of Experimental Medicine, "Sapienza" University of Rome, Rome, Italy
- Centre for Rare Diseases (Endo-ERN Accredited), Policlinico Umberto I, Rome, Italy
| | - V Rochira
- Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria Di Modena Policlinico Di Modena, Ospedale Civile Di Baggiovara, Via Giardini 1355, 41126, Modena, Italy.
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Lay R, Logvinenko T, Kurtz MP, Masoom S, Venna A, Diamond DA. Successful Adolescent Varicocelectomy Improves Total Motile Sperm Count. J Pediatr Surg 2023; 58:2449-2452. [PMID: 37716841 DOI: 10.1016/j.jpedsurg.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 08/09/2023] [Accepted: 08/13/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Management of the adolescent varicocele focuses on optimizing fertility potential, but to date there is limited data on the success of varicocelectomy on optimizing semen parameters for individual adolescent patients. We reviewed our database of over 1600 adolescent varicocele patients to find those with pre- and postoperative semen analyses to determine the impact of varicocele correction. METHODS 15 Tanner stage V patients with unilateral clinically apparent left-sided with pre- and postoperative semen analyses were identified. Mixed models were used to compare semen parameters pre- and post-varicocelectomy in patients with successful management. RESULTS Complete elimination of the varicocele was achieved in 12/15 (80%) patients. Three patients had persistent varicocele (with down-grading in two) and declined further intervention. Median time between pre- and postoperative semen analyses was 24.2 months. For those with successful varicocele correction, total motile sperm count (TMSC) improved in all but one (Figure 1), with an average increase of 44.0 million (95% CI: 18.7-69.3) in post-varicocelectomy analyses compared to pre-varicocelectomy (p = 0.0016). Mean percent improvement was 649.2%. It went from abnormal to normal (≥20 million/cc) in 55.6% (5/9). For the three patients with persistent varicocele, one had improved TMSC from abnormal to normal range, one had worsening within normal range, and one had effectively no change. CONCLUSION Successful correction of adolescent varicocele may improve TMSC. In over half of our institution's cases, an abnormal value normalized. Surgical intervention may be considered for adolescent varicoceles associated with abnormal semen parameters. LEVELS OF EVIDENCE Level III. TYPE OF STUDY Treatment study.
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Affiliation(s)
- Raymond Lay
- University of Rochester School of Medicine & Dentistry, 601 Elmwood Ave, Rochester, NY 14642, USA.
| | - Tanya Logvinenko
- Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Michael P Kurtz
- Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Saafia Masoom
- Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Alyssia Venna
- Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - David A Diamond
- Department of Urology, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY 14642, USA
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Shebl SE, Sabry K. Semen Parameters Changes in Adolescents With Clinical Varicocele after Magnified Subinguinal Varicocelectomy: A Prospective Controlled Study. Am J Mens Health 2022; 16:15579883221141808. [PMID: 36536998 PMCID: PMC9772951 DOI: 10.1177/15579883221141808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Salah E. Shebl
- Urology Department, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt,Salah E. Shebl, Urology Department, Faculty of Medicine for Girls, Al-Azhar University, AlZahraa University Hospital, Abbassia, Cairo 1117, Egypt.
| | - Khaled Sabry
- Urology Department, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
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De Win G, De Neubourg D, De Wachter S, Vaganée D, Punjabi U. Peak retrograde flow a potential objective management tool to identify young adults with varicocele 'at risk' for a high sperm DNA fragmentation. J Pediatr Urol 2021; 17:760.e1-760.e9. [PMID: 34627700 DOI: 10.1016/j.jpurol.2021.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 07/30/2021] [Accepted: 09/19/2021] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Determining which patients are negatively affected by varicocele would enable clinicians to better select those men who would benefit most from surgery. Since conventional semen parameters, have been limited in their ability to evaluate the negative effects of varicocele on fertility, specialized laboratory tests have emerged. OBJECTIVE To identify clinical and ultrasound parameters (including PRF) which would negatively influence standard and functional semen variables in young adults with a varicocele. DESIGN Prospective, cross-sectional observational study. SETTING Antwerp University Hospital, Belgium. PATIENT(S) Young volunteers between 16 and 26 years, Tanner 5, were recruited. INTERVENTION(S) Every participant had a scrotal ultrasound to calculate testicular volumes. If a varicocele was present, the grade, vein diameter, peak retrograde flow (PRF) in supine position and spontaneous reflux in standing position were measured. All participants provided a semen sample. Standard semen parameters were analyzed and sperm DNA fragmentation. MAIN OUTCOME MEASURE(S) Of all clinical and ultrasound parameters tested, PRF was an objective tool identifying young adults with a varicocele. PRF was highlighted by the prevalence of SDF, both in the total and vital fractions of the spermatozoa, providing opportunities to manage such 'at-risk' adolescents/young adults. RESULT(S) Total SDF was significantly increased in grade 3 varicocele compared to grade 1 and 2 but no significant difference with vital SDF or standard descriptive semen parameters was seen. Total and vital SDF on the other hand were significantly increased when PRF was above 38.4 cm/s. Standard semen analysis showed no difference with PRF as an independent predictor. Testicular atrophy index, varicocele vein diameter and spontaneous reflux revealed no significant differences in both the descriptive and functional semen variables. DISCUSSION Descriptive semen parameters showed no significant difference between the non-varicocele controls and the varicocele group with low and high PRF. Increased PRF negatively influenced sperm quality via increased DNA fragmentation both in the total as in the vital fractions of the semen. CONCLUSION(S) Of all clinical and ultrasound parameters tested, PRF was an objective non-invasive tool to identify varicocele patients at risk for a high SDF.
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Affiliation(s)
- G De Win
- Department of Urology, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium; Department of Urology, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, Wilrijk, Belgium.
| | - D De Neubourg
- Centre for Reproductive Medicine, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium; Department of Reproductive Medicine, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, Wilrijk, Belgium
| | - S De Wachter
- Department of Urology, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium; Department of Urology, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, Wilrijk, Belgium
| | - D Vaganée
- Department of Urology, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium
| | - U Punjabi
- Centre for Reproductive Medicine, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium; Department of Reproductive Medicine, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, Wilrijk, Belgium
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Cannarella R, Calogero AE, Condorelli RA, Giacone F, Aversa A, La Vignera S. Management and Treatment of Varicocele in Children and Adolescents: An Endocrinologic Perspective. J Clin Med 2019; 8:E1410. [PMID: 31500355 PMCID: PMC6780349 DOI: 10.3390/jcm8091410] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/25/2019] [Accepted: 09/03/2019] [Indexed: 11/16/2022] Open
Abstract
Pediatric varicocele has an overall prevalence of 15%, being more frequent as puberty begins. It can damage testicular function, interfering with Sertoli cell proliferation and hormone secretion, testicular growth and spermatogenesis. Proper management has a pivotal role for future fertility preservation. The aim of this review was to discuss the diagnosis, management and treatment of childhood and adolescent varicocele from an endocrinologic perspective, illustrating the current evidence of the European Society of Pediatric Urology (ESPU), the European Association of Urology (EAU), the American Urological Association (AUA) and the American Society for Reproductive Medicine (ASRM) scientific societies. According to the ASRM/ESPU/AUA practice committee, the treatment of adolescent varicocele is indicated in the case of decreased testicular volume or sperm abnormalities, while it is contraindicated in subclinical varicocele. The recent EAS/ESPU meta-analysis reports that moderate evidence exists on the benefits of varicocele treatment in children and adolescents in terms of testicular volume and sperm concentration increase. No specific phenotype in terms of testicular volume cut-off or peak retrograde flow (PRF) is indicated. Based on current evidence, we suggest that conservative management may be suggested in patients with PRF < 30 cm/s, testicular asymmetry < 10% and no evidence of sperm and hormonal abnormalities. In patients with 10-20% testicular volume asymmetry or 30 < PRF ≤ 38 cm/s or sperm abnormalities, careful follow-up may ensue. In the case of absent catch-up growth or sperm recovery, varicocele repair should be suggested. Finally, treatment can be proposed at the initial consultation in painful varicocele, testicular volume asymmetry ≥ 20%, PRF > 38 cm/s, infertility and failure of testicular development.
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Affiliation(s)
- Rossella Cannarella
- Department of Clinical and Experimental Medicine, University of Catania, 95125 Catania, Italy
| | - Aldo E Calogero
- Department of Clinical and Experimental Medicine, University of Catania, 95125 Catania, Italy
| | - Rosita A Condorelli
- Department of Clinical and Experimental Medicine, University of Catania, 95125 Catania, Italy
| | - Filippo Giacone
- Department of Clinical and Experimental Medicine, University of Catania, 95125 Catania, Italy
| | - Antonio Aversa
- Department of Experimental and Clinical Medicine, University Magna Graecia of Catanzaro, 88100 Catanzaro, Italy
| | - Sandro La Vignera
- Department of Clinical and Experimental Medicine, University of Catania, 95125 Catania, Italy.
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Welliver C, Cardona-Grau D, Elebyjian L, Feustel PJ, Kogan BA. Surprising interobserver and intra-observer variability in pediatric testicular ultrasound volumes. J Pediatr Urol 2019; 15:386.e1-386.e6. [PMID: 31104998 DOI: 10.1016/j.jpurol.2019.04.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 04/13/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Testicular volume (TV) can be obtained by either scrotal ultrasound (SU) or orchidometer. Scrotal ultrasound allows for a more objective measurement; however, the interobserver and intra-observer variability of TV measurements has not been rigorously studied. OBJECTIVE The authors measured intra-observer and interobserver variability of SU TV measurements in pediatric patients to assess the reliability and reproducibility of SU. Special attention was paid to how often a 20% discrepancy in TV was noted as this has previously been utilized as an indication for varicocelectomy. DESIGN Patients with an indication for SU or undergoing an ultrasound for another reason were prospectively recruited. Two different urologic specific ultrasound technicians (A and B) performed SU to assess interobserver variability. A second measurement was taken by technician A within 90 days to assess intra-observer variability (A vs A1). The technicians were blinded to other ultrasound results. RESULTS Fourteen patients (28 testes, 56 volume measurements) were included in the intra-observer group and 17 patients (34 testes, 68 volume measurements) in the interobserver group. The mean time to repeat intra-observer ultrasound measurements (range) was 46 days (23-84). Mean age (range) in the intra-observer group was 14.3 years (11-19) and 14.1 years (11-19) in the interobserver group. Indication for ultrasound was varicocele (n = 6), scrotal pain (4), hydronephrosis (3), hydrocele (2), epididymal cyst (2), posterior urethral valves (1), and testis asymmetry (1). Utilizing Bland-Altman analysis and plots, variability was seen in both intra-observer and interobserver measurements. The mean values for testicular sizes for technician A and technician B were 13.0 ± 9.7 cm3 vs 13.8 ± 9.9 cm3, respectively. The mean values for TV measurement for technician A's first and second measurements (A, A1) were 14.3 ± 9.7 cm3 and 14.8 ± 8.9 cm3, respectively. An errant 20% difference in TV measurements for the same testis was seen in 25% (7 of 28) of intra-observer measurements and 35% (12 of 34) of interobserver measurements. These 20% differences were more common with a lower body mass index (odds ratio, OR = 0.74, p = 0.01) in the interobserver group, and lower TV was a predictor in the intra-observer group (OR: 0.82, p = 0.009). CONCLUSIONS Variability exists in both interobserver and intra-observer measurements of TV by dedicated urologic ultrasonographers, and greater than 20% of differences in measured TV in same testicles occurred in over 25% of cases. Caution should be exercised in basing operative decisions and scientific studies on limited measurements of TV.
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Affiliation(s)
- C Welliver
- Albany Medical College, Division of Urology, Department of Surgery, Albany, NY, 12208, USA; Albany Stratton Veterans Affairs Medical Center, Albany, NY, 12208, USA.
| | - D Cardona-Grau
- Arnold Palmer Hospital for Children, Orlando, FL, 32806, USA
| | - L Elebyjian
- Albany Medical College, Division of Urology, Department of Surgery, Albany, NY, 12208, USA
| | - P J Feustel
- Department of Anesthesiology, Albany Medical College, Albany, NY, USA
| | - B A Kogan
- Albany Medical College, Division of Urology, Department of Surgery, Albany, NY, 12208, USA
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Mancini M, Carrafiello G, Melchiorre F, Pelliccione F, Andreassi A, Mantellassi G, Ahmed Said Z, Pecori Giraldi F, Banderali G, Folli F. Early varicocelectomy by percutaneous scleroembolization improves seminiferous tubules spermatozoa release in the adolescent phase of testicular growth. Andrologia 2019; 51:e13286. [DOI: 10.1111/and.13286] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 02/27/2019] [Accepted: 03/05/2019] [Indexed: 11/30/2022] Open
Affiliation(s)
- Mario Mancini
- Pediatric and Adolescent Andrological Unit, Department of Pediatrics San Paolo Hospital, ASST Santi Paolo e Carlo, Università degli Studi di Milano Milan Italy
| | - Gianpaolo Carrafiello
- Department of Diagnostic and Interventional Radiology San Paolo Hospital, ASST Santi Paolo e Carlo Milan Italy
- Department of Health Science Università degli Studi di Milano Milan Italy
| | - Fabio Melchiorre
- Department of Diagnostic and Interventional Radiology San Paolo Hospital, ASST Santi Paolo e Carlo Milan Italy
- Department of Health Science Università degli Studi di Milano Milan Italy
| | - Fiore Pelliccione
- Pediatric and Adolescent Andrological Unit, Department of Pediatrics San Paolo Hospital, ASST Santi Paolo e Carlo, Università degli Studi di Milano Milan Italy
| | - Alice Andreassi
- Pediatric and Adolescent Andrological Unit, Department of Pediatrics San Paolo Hospital, ASST Santi Paolo e Carlo, Università degli Studi di Milano Milan Italy
| | - Gianna Mantellassi
- Pediatric and Adolescent Andrological Unit, Department of Pediatrics San Paolo Hospital, ASST Santi Paolo e Carlo, Università degli Studi di Milano Milan Italy
| | - Zakaria Ahmed Said
- Department of Health Science Università degli Studi di Milano Milan Italy
- Departmental Unit of Diabetes and Metabolic Diseases San Paolo Hospital, ASST Santi Paolo e Carlo Milan Italy
| | - Francesca Pecori Giraldi
- Neuroendocrinology Research Laboratory Istituto Auxologico Italiano IRCCS Milan Italy
- Department of Clinical Sciences and Community Health Università degli Studi di Milano Milan Italy
| | - Giuseppe Banderali
- Department of Pediatrics San Paolo Hospital, ASST Santi Paolo e Carlo, Università degli Studi di Milano Milan Italy
| | - Franco Folli
- Department of Health Science Università degli Studi di Milano Milan Italy
- Departmental Unit of Diabetes and Metabolic Diseases San Paolo Hospital, ASST Santi Paolo e Carlo Milan Italy
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Zavattaro M, Ceruti C, Motta G, Allasia S, Marinelli L, Di Bisceglie C, Tagliabue MP, Sibona M, Rolle L, Lanfranco F. Treating varicocele in 2018: current knowledge and treatment options. J Endocrinol Invest 2018; 41:1365-1375. [PMID: 30284221 DOI: 10.1007/s40618-018-0952-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 09/11/2018] [Indexed: 01/20/2023]
Abstract
PURPOSE Varicocele is defined as a state of varicosity and tortuosity of the pampiniform plexus around the testis caused by retrograde blood flow through the internal spermatic vein. The prevalence of clinically relevant varicocele ranges from 5 to 20% in the male population and is often associated with infertility and reduction of sperm quality. In this review, the pathophysiology and clinical aspects of varicocele are reviewed along with therapeutic options and treatment effects on sperm parameters and fertility both in adult and in pediatric/adolescent subjects. METHODS We conducted a Medline and a PubMed search from 1965 to 2018 to identify publications related to varicocele clinical aspects, treatment procedures and treatment outcomes. Keywords used for the search were: "varicocele", "varicocelectomy", "sclerotherapy", "male infertility", "subfertility", and "semen abnormalities". RESULTS Data from a large number of studies in adolescent and adult males indicate that varicocele correction improves semen parameters in the majority of patients, reducing oxidative stress and improving sperm nuclear DNA integrity either with surgical or percutaneous approach. CONCLUSIONS Varicocele repair seems to represent a cost-effective therapeutic option for all males (both adolescent and adults) with a clinical varicocele in the presence of testicular hypotrophy, worsening sperm alterations or infertility. On the other hand, some investigators questioned the role of varicocelectomy in the era of assisted reproduction. Thus, a better understanding of the pathophysiology of varicocele-associated male subfertility is of paramount importance to elucidating the deleterious effects of varicocele on spermatogenesis and possibly formulating new treatment strategies.
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Affiliation(s)
- M Zavattaro
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - C Ceruti
- Division of Urology, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - G Motta
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - S Allasia
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - L Marinelli
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - C Di Bisceglie
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - M P Tagliabue
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - M Sibona
- Division of Urology, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - L Rolle
- Division of Urology, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - F Lanfranco
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy.
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Macey MR, Owen RC, Ross SS, Coward RM. Best practice in the diagnosis and treatment of varicocele in children and adolescents. Ther Adv Urol 2018; 10:273-282. [PMID: 30116303 DOI: 10.1177/1756287218783900] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 05/29/2018] [Indexed: 11/17/2022] Open
Abstract
A varicocele is an abnormal dilation of the pampiniform plexus of veins in the scrotum which begins at puberty in approximately 15% of males. Although common in the general population and often asymptomatic, varicoceles are associated with gonadal dysfunction including testicular atrophy, infertility, and hypogonadism in a subset of men diagnosed later in life. Because of the high prevalence and uncertain pathogenesis, definitive management guidelines for varicoceles diagnosed in the pediatric and adolescent population remain poorly defined. The varicocele is the most common etiology of male factor infertility, and treatment in the pediatric and adolescent population may improve semen quality and improve fecundity in adulthood. Evaluation of the pediatric and adolescent varicocele should include history, physical exam, and measurement of testicular volume with orchidometer or ultrasound. Testicular volume differentials and peak retrograde flow on Doppler ultrasonography are important factors in risk stratification of the pediatric varicocele population. Semen analysis and reproductive endocrine assessment should also be considered as part of the workup for adolescent patients. A variety of treatment approaches exist for varicocele, and while the microsurgical subinguinal approach is the gold standard for the adult population, it has yet to be confirmed as superior for the adolescent population. Referral to an andrologist for the adolescent patient with varicocele should be considered in equivocal cases. While active treatment of varicocele in the pediatric and adolescent population is controversial, it is clear that some untreated patients will suffer symptoms later in life, while overtreatment remains a concern for this large, vulnerable population. Therefore, surveillance strategies and improved accuracy in diagnosis of clinically important pediatric varicoceles prompting treatment are needed in the future.
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Affiliation(s)
- Matthew R Macey
- Department of Urology, UNC School of Medicine, Physicians Office Building, 170 Manning Drive, Campus Box #7235, Chapel Hill, NC 27599-7235, USA
| | - Ryan C Owen
- Department of Urology, UNC School of Medicine, Chapel Hill, NC, USA
| | - Sherry S Ross
- Department of Urology, UNC School of Medicine, Chapel Hill, NC, USA
| | - R Matthew Coward
- Department of Urology, UNC School of Medicine, Chapel Hill, NC, USA UNC Fertility LLC, Raleigh, NC, USA
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Verhovsky G, Neheman A, Rappaport YH, Kedem R, Hofman A, Zisman A, Haifler M. Varicocele Management Strategies and Resulting Paternity Rates in a Cohort of Young Adults. Urology 2018; 117:78-81. [PMID: 29729366 DOI: 10.1016/j.urology.2018.04.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 04/11/2018] [Accepted: 04/17/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To evaluate the paternity rate in a large cohort of asymptomatic adult varicocele patients undergoing nonsurgical management and surgery. METHODS The study population included 1845 men with varicocele and 9286 healthy controls. All data were retrospectively obtained from the Israeli Defense Forces medical database. Patients were divided according to the management strategy: 1758 (95.2%) were followed up nonsurgically, 63 (3.4%) had preventive surgery (patients without known infertility), and 24 (1.4%) had secondary surgery (patients with varicocele and primary infertility) as young adults. The primary outcome was the live birth rate. RESULTS The live birth rate was similar in the preventive surgery and control groups. Both preventive surgery and control groups had higher live birth rate than the nonsurgical group. Finally, the secondary surgery group had the lowest live birth rate of all groups. CONCLUSION Preventive surgery for asymptomatic varicocele provides similar fertility outcomes to control groups, whereas nonsurgical strategy provides inferior outcomes and may be overutilized.
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Affiliation(s)
- Guy Verhovsky
- Israeli Defense Forces (IDF), Medical Corps, Israel; Department of Urology, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel; Affiliated to the Sackler School of Medicine, Tel-Aviv university, Tel-Aviv, Israel
| | - Amos Neheman
- Department of Urology, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel; Affiliated to the Sackler School of Medicine, Tel-Aviv university, Tel-Aviv, Israel
| | - Yishai Hode Rappaport
- Department of Urology, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel; Affiliated to the Sackler School of Medicine, Tel-Aviv university, Tel-Aviv, Israel
| | - Ron Kedem
- Israeli Defense Forces (IDF), Medical Corps, Israel
| | - Azik Hofman
- Israeli Defense Forces (IDF), Medical Corps, Israel
| | - Amnon Zisman
- Department of Urology, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel; Affiliated to the Sackler School of Medicine, Tel-Aviv university, Tel-Aviv, Israel
| | - Miki Haifler
- Department of Urology, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel; Affiliated to the Sackler School of Medicine, Tel-Aviv university, Tel-Aviv, Israel.
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12
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Chung JM, Lee SD. Current Issues in Adolescent Varicocele: Pediatric Urological Perspectives. World J Mens Health 2018; 36:123-131. [PMID: 29623699 PMCID: PMC5924953 DOI: 10.5534/wjmh.170053] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 12/01/2017] [Accepted: 01/03/2018] [Indexed: 01/17/2023] Open
Abstract
While varicocele is the most common cause of surgically correctable infertility in adult males, with repair resulting in improved semen parameters in 60% to 80% of men and a higher likelihood of conception in up to 60% of men, the rationale for varicocele repair in the pediatric population is less clear. Additionally, prepubertal varicoceles are much less common and their management is controversial. Adolescents with a varicocele are often in the midst of a progressive disease process. Despite the high prevalence of varicocele and its association with progressive disease processes, the indications for adolescent varicocele repair and the effects thereof on paternity have been persistently challenging to study. This review will briefly present some of the current issues regarding adolescent varicocele from a pediatric urological point of view, including the evaluation of adolescent varicocele, the optimal surgical indications, the optimal choice of surgical intervention to be performed, and outcomes.
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Affiliation(s)
- Jae Min Chung
- Department of Urology, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sang Don Lee
- Department of Urology, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.
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Locke JA, Noparast M, Afshar K. Treatment of varicocele in children and adolescents: A systematic review and meta-analysis of randomized controlled trials. J Pediatr Urol 2017; 13:437-445. [PMID: 28851509 DOI: 10.1016/j.jpurol.2017.07.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 07/16/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND The prevalence of varicoceles is as high as 15% in children and adolescents. Optimal management of varicoceles has not been consolidated. Options include observation, radiological intervention, or surgical varicocelectomy. OBJECTIVE Herein, we aim to assess the outcomes of radiological and surgical interventions for varicocele in children and adolescents evaluated by RCTs. STUDY DESIGN The study subjects were children and adolescents up to 21 years old, diagnosed with varicocele and allocated to receive either "surgical or radiological intervention" or "no treatment". MATERIALS AND METHODS We searched MEDLINE and EMBASE (Ovid platform), Web of Science, CINAHL, Cochrane Central Register of Controlled Trials, Google Scholar, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform for RCTs reporting on varicocele treatment in children and adolescents up to June 23, 2016. Only RCTs with patients aged under 21 years were included. Main outcomes of interest included changes in testicular size, semen analysis parameters, surgical adverse events and failures. RESULTS Nine eligible studies were included in the systematic review. Meta-analysis based on available outcomes data demonstrated an improvement in testicular volume (mean difference 3.18 mL, 95% CI 1.94-4.42) and in sperm count (mean difference 25.54 × 106/mL, 95% CI 12.84-38.25) in patients who underwent radiological or surgical treatment compared with conservative management. CONCLUSIONS Based on current available randomized controlled trials, there is low to moderate level of evidence that radiological or surgical treatment of adolescent varicocele is associated with improved testicular size/growth and sperm concentration. The ultimate effects on fertility and paternity rates are not known.
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Affiliation(s)
- Jennifer A Locke
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Maryam Noparast
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Kourosh Afshar
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada.
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14
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Jacobson DL, Johnson EK. Varicoceles in the pediatric and adolescent population: threat to future fertility? Fertil Steril 2017; 108:370-377. [DOI: 10.1016/j.fertnstert.2017.07.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 06/21/2017] [Accepted: 07/13/2017] [Indexed: 11/28/2022]
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Çayan S, Bozlu M, Akbay E. Update on the novel management and future paternity situation in adolescents with varicocele. Turk J Urol 2017; 43:241-246. [PMID: 28861292 PMCID: PMC5562239 DOI: 10.5152/tud.2017.01033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 07/19/2017] [Indexed: 11/22/2022]
Abstract
Varicocele is a progressive disease, and the incidence of varicocele and varicocele related testicular hypotrophy increases with puberty. This review updates novel management and future paternity potential in adolescents with varicocele. Main goal of treatment of the adolescent varicoceles is preservation of fertility. Current recommendations for adolescent varicocele repair are testicular hypotrophy (>2 mL or >20%) on the affected side and/or impaired spermatogenesis in the post-pubertal period. The best treatment modality for adolescent varicocele should include elimination of the varicocele with lower complication rates. Microsurgical varicocelectomy techniques have been shown to result in fewer recurrences and postoperative complications than conventional varicocelectomy in adolescents. We conducted a meta-analysis, including 2 studies with the control groups, and reporting paternity situation after varicocele treatment. In this meta-analysis, varicocele repair increases paternity rate 2.42 times with a p value of 0.000. Adolescents with varicocele and their families should be counselled in the light of these findings.
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Affiliation(s)
- Selahittin Çayan
- Department of Urology, Mersin University School of Medicine, Mersin, Turkey
| | - Murat Bozlu
- Department of Urology, Mersin University School of Medicine, Mersin, Turkey
| | - Erdem Akbay
- Department of Urology, Mersin University School of Medicine, Mersin, Turkey
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17
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What Can we Learn (and What Can’t we Learn) from Observational Studies of Adolescent Varicocele Treatment? J Urol 2017; 198:6-8. [DOI: 10.1016/j.juro.2017.04.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2017] [Indexed: 11/22/2022]
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Bayne CE, Cardona-Grau D, Hsieh MH. Featuring: Asymptomatic adolescent varicoceles. J Pediatr Urol 2017. [PMID: 28645617 DOI: 10.1016/j.jpurol.2017.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Christopher E Bayne
- Division of Pediatric Urology, Children's National Health System, Washington, DC, USA.
| | - Diana Cardona-Grau
- Division of Urology, University of California at San Diego, USA; Rady Children's Hospital, San Diego, CA, USA
| | - Michael H Hsieh
- Division of Pediatric Urology, Children's National Health System, Washington, DC, USA
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Sack BS, Schäfer M, Kurtz MP. The Dilemma of Adolescent Varicoceles: Do They Really Have to Be Repaired? Curr Urol Rep 2017; 18:38. [PMID: 28315171 DOI: 10.1007/s11934-017-0686-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Bryan S Sack
- Department of Pediatric Urology, Boston Children's Hospital/Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA.
| | - Mattias Schäfer
- Department of Pediatric Urology, Boston Children's Hospital/Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA.,Department of Pediatric Surgery and Pediatric Urology, Cnopf'sche Kinderklinik, St. Johannis-Muehlgasse 19, 90419, Nuremberg, Germany
| | - Michael P Kurtz
- Department of Pediatric Urology, Boston Children's Hospital/Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
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Bayne CE, Cardona-Grau D, Hsieh MH. Robotic versus open pediatric ureteral reimplantation. J Pediatr Urol 2017; 13:128-129. [PMID: 28528821 DOI: 10.1016/j.jpurol.2017.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Christopher E Bayne
- Division of Pediatric Urology, Children's National Health System, Washington, DC, USA.
| | - Diana Cardona-Grau
- Division of Urology, University of California at San Diego, San Diego, CA, USA
| | - Michael H Hsieh
- Division of Pediatric Urology, Children's National Health System, Washington, DC, USA
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