Evaluation and Management of the Persistent/Recurrent Varicocele

Elastography and contrast-enhanced ultrasound to assess the effect of varicocelectomy: A case-controlled study

To evaluate the changes in testicular stiffness and microcirculation caused by spermatic vein ligation in patients with varicocele, we conducted a case-controlled study. A total of 27 grade III left varicocele cases were enrolled. Testicular stiffness and perfusion were evaluated by shear wave elastography and contrast-enhanced ultrasound during subinguinal microscopic varicocelectomy. The external and the internal parenchyma of bilateral testes were selected to compare the shear wave velocity of bilateral testes during the spermatic vein ligation. We mapped and compared the intensity-time curves following bolus contrast injection three times in the same region of interest. Initially, the shear wave velocity of the left internal parenchyma was higher than the right side (1.10 ± 0.06 m/s vs. 1.00 ± 0.03 m/s). It decreased (1.09 ± 0.06 m/s) (p < 0.05) after ligation. Meanwhile, the left epididymis had the higher agent peak intensity (0.90 × 10E-5 AU), the largest area under the curve (80.20 × 10E-5 AU s), and the longest washout area (54.35 × 10E-5 AU s). In addition, the left internal parenchyma presented a sharper slope (0.18 × 10E-5 AU/s) (p < 0.05). In conclusion, the spermatic vein ligation improved the perfusion of the internal testicular parenchyma, but it could temporally deteriorate the stasis of the epididymis. These changes caused softer testicular parenchyma.

An Analysis of Major Causes of Surgical Failure Using Bähren System in Intraoperative Venography During Varicocelectomy

PURPOSE

In young patients with varicocele, preservation of the internal spermatic artery may be advantageous for catch-up growth, but it may also increase the likelihood of treatment failure. Intraoperative venography reduces the likelihood that unsealed veins will remain after varicocelectomy. We analyzed the characteristics of remnant veins visualized through intraoperative venography to investigate the cause of surgical failure in artery-sparing varicocelectomy (ASV).

MATERIALS AND METHODS

We retrospectively analyzed clinical characteristics and outcomes of patients aged 18 years or younger who underwent varicocelectomy with intraoperative venography from January 2005 to December 2017. During varicocelectomy, intraoperative venography was performed to distinguish veins from other structures. Any unsealed veins that were discovered were ligated and classified using the Bahren system.

RESULTS

One hundred and sixty-two patients underwent intraoperative venography: 153 cases (94.4%) were for primary varicocelectomy, and 9 cases (5.6%) were for repeat varicocelectomy. Open varicocelectomy was performed in 105 cases (64.8%), and laparoscopic varicocelectomy was performed in 57 cases (35.2%). Venography revealed remnant veins after the first ligation in 51 cases (31.2%), 46 (90.2%) and 5 (9.8%) of which were Bähren types 3 and 4, respectively. Five patients (3.1%) experienced varicocele recurrence, classified as persistence in 1 patient (0.6%) and relapse in 4 patients (2.5%).

CONCLUSION

Remnant collateral veins of the internal spermatic vein (ISV) (Bahren type 3) are the most common cause of failure in ASV. In a few patients, an external spermatic vein merges with the ISV at a higher level (Bahren type 4) and is unidentifiable without venography.

Ultrasound evaluation of varicoceles: systematic literature review and rationale of the ESUR-SPIWG Guidelines and Recommendations

Although often asymptomatic and detected incidentally, varicocele is a relatively common problem in patients who seek medical attention for infertility problems. Ultrasound (US) is the imaging modality of choice for evaluation, but there is no consensus on the diagnostic criteria, classification, and examination technique. In view of this uncertainty, the Scrotal and Penile Imaging Working Group of the European Society of Urogenital Radiology (ESUR-SPIWG) undertook a systematic review of the available literature on this topic, to use as the basis for evidence-based guidelines and recommendations. This paper provides the results of the systematic review on which guidelines were constructed.

Association Between Left Renal Vein Entrapment and Varicocele Recurrence: A Cohort Study in 3042 Patients

The recurrence rates after varicocelectomy vary from 0.9% to 32.2%, especially for patients with the left renal vein entrapment (LRVE). This study aims to study the association between LRVE and varicocele recurrence, and to find the risk factors of LRVE. With the design of a cohort study, we included 3042 varicocele patients who would undergo modified inguinal microscope-assisted varicocelectomy (MHMV). 858 (28.21%) patients with LRVE were as the study group, and 2184 (71.79%) patients without LRVE were as the control group. Compared with the control group, BMI was lower (p < 0.001) in study group. Totally, 18 patients had recurrence after surgery, so the recurrence rate was 0.59%. Seventeen patients (1.98%) in study group and 1 patients (0.05%) in control group had recurrence, and significant statistical difference was found between the two groups (p < 0.001). The risk ratio of LRVE for varicocele recurrence is 43.27. In conclusion, the recurrence rate of our MHMV is the lowest (0.59%). There is association between LRVE and varicocele recurrence, and varicocele patients with LRVE have higher probability of recurrence rate after varicocelectomy. BMI could be a risk factor of LRVE. Thus, for varicocele patients, especially those with lower BMI, attentions should be payed to LRVE.

My indications for treatment of the adolescent varicocele (and why?)

What to do with the adolescent varicocele? With merging the information obtained from an extensive review of the literature with our own clinical research, I believe that we already have knowledge enough to say that the adolescent with a varicocele often is in the midst of a progressive disease process. Strong evidence already exists that well more than the majority of Tanner 5 boys with a varicocele and 20% asymmetry will already have abnormally low total motile sperm counts (TMCs) and likely abnormally low sperm concentration as well. There are now many studies in addition to common sense to support the value of % asymmetry as a marker of future abnormal sperm parameters. While we know that some boys at lower Tanner stages who present with asymmetry will have catch-up growth during adolescence, we also know that almost all boys with 15% asymmetry or greater in conjunction with a Doppler detected peak retrograde flow (PRF) of 38 cm/s or greater will end up with greater than 20% asymmetry on follow-up. There also are some boys of concern with less asymmetry but instead have small testes bilaterally, perhaps as a result of the left varicocele slowing the growth of the right testicle and/or an associated undetected or overlooked palpable right varicocele that is also negatively affecting the right testicle. Fortunately, we now have another marker available, i.e., total testicular volume (TTV), to assist in decision making for the adolescent falling into this scenario. Once markers are in place in an early Tanner stage boy with a varicocele that indicate that abnormal semen parameters will likely be present when a Tanner 5 stage of development is reached, there is no reason to wait until the child is older so that a semen analysis can be comfortably requested for the documentation. One argument in favor of waiting is that abnormal semen parameters in a Tanner 5 male usually are reversible. However, how do we know that once abnormal parameters are reversed they then will stay normal in a testicle that already has incurred damage. In other words, I feel it is best to operate once the indicators are in place. We do not want to be suddenly surprised when that individual when older has difficulty fathering a child at a time in life when surgery might be too late to resolve what has taken years to develop. Within this manuscript I will try to document my reasons for the aforementioned rationale.

Subsequent impaired fertility (with or without sperm worsening) in men who had fathered children after a left varicocelectomy: A novel population?

Objectives:

The objective of this paper was to assess whether the beneficial effects of a varicocelectomy on fertility are transitory or definitive after a first fathering.

Materials and Methods:

This was a retrospective study which involved seven andrological centers. The files of 2223 patients who underwent subinguinal ligation of a high grade left varicocele for (oligo)±(astheno)±(terato)-spermia and infertility between January 1^st, 2002 and January 1^st 2013 were reviewed. Inclusion criteria for the patients were the following: Sperm count improvement and fathering a child after an uneventful left varicocelectomy; 745 patients were considered. Patients who had undergone three assessments for (in-) fertility: Before surgery, before the first fathering and after the first fathering were included in the study. Each assessment included: Clinical history, physical examination, two sperm analyses, bilateral scrotal Duplex scans, blood hormonal levels [follicle stimulating hormone (FSH), luteinising hormone (LH), testosterone (T) and prolactin (PRL)].

Results:

Forty patients were finally studied; they all had an improved sperm count and had fathered once after surgery. Fifteen had fathered twice and still had their sperm count increased after the second fathering. Twenty-five patients could not father twice; 13 patients had their sperm count decreased after the first fathering and 12 did not. A decrease in testicular volume and an increase in FSH paralleled the worsening of sperm concentration, motility and morphology after fathering. No other differences could be observed between the groups.

Conclusions:

Our data indicated that the beneficial effects of a varicocelectomy might be transitory in some cases.

Endovascular transcatheter embolization of recurrent postsurgical varicocele: anatomic reasons for surgical failure

BACKGROUND

Formation or pre-existence of collateral gonadal veins in varicocele patients has been reported as the main cause of surgical treatment failure.

PURPOSE

To describe venographic findings in patients with postsurgical recurrent varicoceles and to assess the efficacy of the following minimally invasive endovascular treatment.

MATERIAL AND METHODS

Thirty-three men with failed surgical treatment of left-sided varicocele were examined between 2006 and 2013, using retrograde venography to assess the anatomy of varicocele draining veins before the attempted transcatheter embolization. Anatomic variants of gonadal veins were categorized according to the classification modified for the purpose of the present study. 3% polidocanol was used as an embolic agent together with pushable fibered coils.

RESULTS

In 31 (93%) out of 33 patients venography demonstrated incompetence of the gonadal vein or veins draining varicoceles after failed surgical treatment. The most frequent venographic finding was gonadal vein duplication - 66% of cases (39% in its mid-portion). Technical success of embolization was achieved in all 31 patients. No major complications were observed.

CONCLUSION

Retrograde varicocele embolization may be superior to surgery because of its ability to detect gonadal vein variants. In our study group, transcatheter embolization with 3% polidocanol and fibered coils allowed successful, minimally invasive treatment of postsurgical varicoceles.

Tolerance of glue embolization under local anesthesia in varicoceles: a comparative study of two different cyanoacrylates

PURPOSE

To find out whether in varicocele embolization the copolymer cyanoacrylate glue (NBCA-MS) has a better patient tolerance compared to the monomer n-butyl-2-cyanoacrylate (NBCA).

MATERIALS AND METHODS

N=112 insufficient spermatic veins (left sided N=84, right sided N=28) diagnosed in N=83 adult males were prospectively randomized for blinded embolization with either NBCA N=54 (Histoacryl) or with NBCA-MS N=58 (Glubran2). Before, during and up to one week after embolization, patient discomfort was assessed by a standardized pain scale. Type, location and side of discomfort were noted. Statistical analysis was performed with the Mann-Whitney U-test, the McNemar test and the Fisher's exact test.

RESULTS

Embolization caused discomfort in N=48/112 (43%) spermatic veins, comprising N=26/54 (48%) in the NBCA group and N=22/58 (38%) in the NBCA-MS group. During the week after embolization, the overall number of discomfort reports rose to N=62/106 (59%), with an increase to N=30/53 (57%) in the NBCA group and to N=32/53 (60%) in the NBCA-MS group. The number of immediate grade 2 to 4 pain reactions was N=22/112 (20%), and rose to N=37/106 (35%) after one week. No difference in discomfort during embolization and at 1 week after treatment was noted. Characteristics, severity grading, and location of discomfort were similar in both NBCA groups, regardless the time point of observation.

CONCLUSION

Discomfort after glue embolization of varicocele is a common side effect, which might evolve to pain. The assumed lower inflammatory reaction on NBCA-MS was not translated in an improved tolerance.

Predictive factors of successful redo varicocelectomy in infertile patients with recurrent varicocele

To examine the predictive factors of successful redo varicocelectomy in infertile patients with recurrent varicocele, we made a retrospective study. Twenty-one patients who had improved quality of spermatozoon 6 months after RV were designated as group 1, those with no improvement as group 2 (17 subjects) and those who received close surveillance as group 3 (10 patients) were recruited. The predictive factors included were time to recurrent varicocele; semen quality; testicular volume; number of ligated veins; body mass index; serum levels of follicle-stimulating hormone (FSH), luteinising hormone and testosterone; scrotal temperature; and peak retrograde flow (PRF) and maximal vein diameter (MVD) by colour Doppler ultrasound. The quality of spermatozoon improved significantly 6 months after RV in group 1 patients (21, 55.3%), and no improvement in group 2 and 3 patients. Patients in group 1 also had significantly lower FSH and PRF, longer time to recurrent varicocele, higher number of ligated veins and larger testicular volume than the group 2 (17, 44.7%) and group 3 patients. The significant predictive factors of successful RV were lower FSH and PRF; longer time to recurrent varicocele; and larger testicular volume preoperatively and a higher number of ligated veins during redo varicocelectomy.

Incidence, significance and natural history of persistent retrograde venous flow after varicocelectomy in children and adolescents: correlation with catch-up growth

PURPOSE

Varying incidences and levels of persistent retrograde venous flow have been reported following adult and adolescent varicocelectomy but the significance remains unclear. We sought to determine the incidence and natural history of persistent flow and whether it had any effect on postoperative testicular catch-up growth.

MATERIALS AND METHODS

We retrospectively analyzed pre-varicocelectomy and post-varicocelectomy Doppler duplex ultrasound findings. Peak retrograde venous flow, maximum vein diameter, flow quality and varicocele grade were recorded at each visit. Catch-up growth was defined as less than 15% testicular asymmetry at final visit.

RESULTS

Of 330 patients (median age 15.4 years) undergoing varicocelectomy (laparoscopic in 247, open in 83) 145 had residual retrograde venous flow after Valsalva maneuver with a mean peak of 13.3 cm per second. Of 290 patients with repeat Doppler duplex ultrasound (median followup 2.6 years) 124 had initial peak retrograde venous flow less than 20 cm per second (43%) and only 17 (6%) had flow 20 cm per second or greater. Incidence of post-varicocelectomy retrograde venous flow at last visit (48%) was similar to that at initial postoperative visit (49%). Of 330 boys 20 had recurrence of palpable varicocele (grade 2 or 3), of whom 18 (90%) had initial retrograde venous flow. Catch-up growth was more likely in patients with no retrograde venous flow, and rates of catch-up growth decreased as peak retrograde venous flow increased. All 5 patients with initial testicular asymmetry and persistent retrograde venous flow at levels greater than 30 cm per second had continued testicular asymmetry (ie none had catch-up growth).

CONCLUSIONS

Retrograde venous flow is frequently present after varicocelectomy and is almost always associated with peak retrograde venous flow rates significantly lower than those seen in patients who are recommended for initial varicocelectomy. Retrograde venous flow tends to persist during followup at stable peak retrograde venous flow rates. Palpable recurrence and persistent testicular asymmetry are most often associated with postoperative peak retrograde venous flow rates 20 cm per second or greater.

[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.

The hemodynamic approach to evaluating adolescent varicocele

During adolescence, the risk of developing a varicocele increases. Prevalence is less than 1% in boys aged younger than 10 years, but approaches that of the general adult population (about 15%) during puberty. For adolescent males with varicoceles, surgical risk factors have not yet been clearly delineated and clinical severity correlates poorly with prognosis. Fortunately, the widespread use of Doppler ultrasonography is transforming the diagnostic work-up for this demographic. A continuous reflux detected by color Doppler ultrasound (CDUS) is thought to have a negative prognostic value and evidence suggests that a peak retrograde flow above 38 cm per second is a powerful predictor of lack of spontaneous improvement in adolescent patients with ≥ 20% asymmetry between testes. CDUS also enables the detection of varicocele resulting from reflux in the deferential vein adjunctive to a refluxing internal spermatic vein; a causality that accounts for approximately 15% of cases. In addition to a diagnostic role, hemodynamic parameters can be used to predict the risk of persistence or worsening asymmetry. Although further studies are necessary to validate single parameters, it seems that the more severe the reflux, the greater the likelihood that the patient will develop testicular asymmetry.

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.