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Greenberg DR, Hudnall MT, Goyette BN, Fantus RJ, Dubin JM, Brannigan RE, Halpern JA. Predictors of Semen Parameters Decline Following the Microsurgical Varicocelectomy. Cureus 2023; 15:e45061. [PMID: 37829944 PMCID: PMC10567203 DOI: 10.7759/cureus.45061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2023] [Indexed: 10/14/2023] Open
Abstract
Objective Varicocele is considered the most common reversible cause of male infertility. However, some men do not clinically improve after surgical repair. We aimed to identify preoperative factors associated with decreased semen parameters and clinical "downgrading" of total motile sperm count (TMSC) following varicocelectomy. Methods We examined men with preoperative laboratory testing and pre- and postoperative semen analyses (SA) who underwent varicocelectomy between 2010 and 2020. Ejaculate volume, sperm motility, sperm concentration, TMSC, and clinical grade of TMSC (in vitro fertilization: <5M sperm, intrauterine insemination: 5-9M sperm, natural pregnancy: >9M sperm) were used to determine postoperative outcomes. Demographic and clinical factors were compared between cohorts. Results Among 101 men who underwent varicocelectomy, 35 (34.7%) had decreased postoperative TMSC with a median follow-up of 6.6 months (interquartile range 3.9-13.6 months). Eleven (10.9%) men experienced TMSC clinical "downgrading" following surgery. Clinical grade III varicocele was significantly associated with decreased sperm motility on postoperative SA (OR 4.1, 95% CI 1.7-10.0, p=0.002), and larger left testicle volume (OR 1.4, 95% CI 1.1-1.8, p=0.02) was associated with clinical "downgrading" after varicocelectomy. Conclusion A small but significant proportion of men experienced a "downgrading" of semen parameters after varicocelectomy. Larger left testis size was associated with clinical downgrading, whereas clinical grade III varicoceles were associated with lower post-treatment sperm motility. These data are critical for preoperative patient counseling.
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Affiliation(s)
- Daniel R Greenberg
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Matthew T Hudnall
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | | | | | - Justin M Dubin
- Department of Urology, Memorial Healthcare, Aventura, USA
| | - Robert E Brannigan
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Joshua A Halpern
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, USA
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2
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Porto JG, Raymo A, Suarez Arbelaez MC, Gurayah AA, Ramasamy R. Patient Satisfaction and Long-Term Clinical Outcomes in Adolescent Sub-inguinal Microscopic Varicocelectomy. Cureus 2023; 15:e44349. [PMID: 37654902 PMCID: PMC10465803 DOI: 10.7759/cureus.44349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 09/02/2023] Open
Abstract
INTRODUCTION AND OBJECTIVE The long-term outcomes of varicocelectomy in adolescents is debated. The aim of this study was to evaluate symptom improvement, hypogonadism, and paternity in those who underwent adolescent sub-inguinal microscopic varicocelectomy. MATERIAL AND METHODS A retrospective chart review was done of adolescents (median=19, interquartile range (IQR)=16-19.75 years) who underwent microscopic varicocelectomy between 2011 and 2021. Demographics, surgical indications, and outcomes were collected, as well as pre- and postoperative hormone levels and semen parameters. A questionnaire was prospectively collected to evaluate orchialgia, paternity, and symptoms of hypogonadism. Descriptive statistics and t-tests were performed, with significance assessed at p-value < 0.05. RESULTS A total of 46 adolescents were included. Age at the time of diagnosis and surgery was 19 (IQR=16-20) and 19 (IQR= 18-21) years, respectively. Follicle-stimulating hormone (FSH), luteinizing hormone (LH), and total testosterone were not affected after surgery. Similarly, semen parameters were preserved after varicocelectomy, with median concentration increasing from 12x106/ml to 16x106/ml but not reaching significance (p=0.272). A total of 26 men completed the questionnaire. The age of responders was 22 (IQR=21-24) years, and the time after having had the varicocelectomy was 36.5 (IQR= 18.25-62.25) months. Orchialgia persisted in five men, and three reported having a recurrence. Two men, who had a preoperative abnormal semen analysis, were actively trying to have children and reported successfully having achieved natural pregnancies. None of the patients reported having hypogonadism, and none were receiving testosterone therapy. CONCLUSION Our study suggests that microscopic varicocelectomy in adolescents appears to be a safe and feasible procedure with a low rate of syndrome recurrence and no association with symptoms or biochemical evidence of hypogonadism.
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Affiliation(s)
- Joao G Porto
- Desai Sethi Urology Institute, University of Miami, Miami, USA
| | - Adele Raymo
- Department of Pediatric Urology, Nicklaus Children's Hospital, Miami, USA
| | | | - Aaron A Gurayah
- Desai Sethi Urology Institute, University of Miami, Miami, USA
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Reinhardt S, Thorup J, Joergensen PH, Fode M. Robot-assisted laparoscopic varicocelectomy in a pediatric population. Pediatr Surg Int 2023; 39:202. [PMID: 37209246 PMCID: PMC10199840 DOI: 10.1007/s00383-023-05488-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/12/2023] [Indexed: 05/22/2023]
Abstract
PURPOSE To present our experience with robot-assisted laparoscopic varicocelectomy in a pediatric population. METHODS We reviewed 49 consecutive cases performed by the same experienced surgeon. One-to-four veins were ligated at the internal ring of the inguinal canal, while the testicular artery and lymphatics were spared. Information on patient characteristics, surgical time, complications, and recurrences were collected. RESULTS Median patient age was 14 (range 10-17) years. Forty-eight had left-sided varicoceles and one had a bilateral varicocele. Forty-five were grade 3. All patients were referred due to discomfort/pain and 20 also had reduced testicular size. The median operating time from skin incision was 48 min (31-89 min) and the median console time was 18 min (7-55 min). Forty-seven patients were discharged the same day. Two patients experienced pain and problems urinating, respectively. These issues had resolved by the first post-operative day. There were no other complications, but at 6 months, eight recurrences were noted (16%). Scrotal complaints had subsided in all patients. Catch-up growth of the affected testicles was seen in 19/20 cases. CONCLUSION Robot-assisted laparoscopic varicocelectomy is feasible and safe in a pediatric population but with a relatively high recurrence rate.
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Affiliation(s)
- Susanne Reinhardt
- Department of Pediatric Surgery, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Jorgen Thorup
- Department of Pediatric Surgery, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | | | - Mikkel Fode
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark.
- Department of Urology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark.
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Bebi C, Bilato M, Minoli DG, De Marco EA, Gnech M, Paraboschi I, Boeri L, Fulgheri I, Brambilla R, Campoleoni M, Albo G, Montanari E, Manzoni G, Berrettini A. Radiation Exposure and Surgical Outcomes after Antegrade Sclerotherapy for the Treatment of Varicocele in the Paediatric Population: A Single Centre Experience. J Clin Med 2023; 12:jcm12030755. [PMID: 36769404 PMCID: PMC9917517 DOI: 10.3390/jcm12030755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/04/2023] [Accepted: 01/07/2023] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Antegrade sclerotherapy (Tauber) effectively treats varicocele. However, fluoroscopy exposes young males to ionizing radiation. We aimed to evaluate radiation exposure and surgical outcomes after the Tauber procedure. MATERIALS AND METHODS We retrospectively analysed data from 251 patients. Dose area product (DAP) and fluoroscopy time were recorded. The effective dose was calculated with the PCXMC software. Descriptive statistics and linear regression tested the association between clinical predictors and radiation exposure. RESULTS Median (IQR) age and body mass index (BMI) were 14 (13-16) years and 20.1 (17.9-21.6) kg/m². Five (2.1%) patients developed clinical recurrence and two (0.81%) developed complications. Median fluoroscopy time and DAP were 38.5 (27.7-54.0) s and 89.6 (62.5-143.9) cGy*cm2. The effective dose was 0.19 (0.14-0.31) mSv. Fluoroscopy time was higher in patients with collateral veins (41 (26-49) s vs. 36 (31-61) s, p = 0.02). The median amount of sclerosing agent (SA) used was 3 (3-4) ml. DAP was higher when SA > 3 mL was used (101.4 (65-183) cGy*cm2 vs. 80.5 (59-119) cGy*cm2; p < 0.01). At univariable linear regression, age, BMI, operative time and SA > 3 mL were associated with higher DAP (all p < 0.01). At multivariable linear regression, only BMI (beta 12.9, p < 0.001) and operative time (beta 1.9, p < 0.01) emerged as predictors of higher DAP, after accounting for age and SA > 3 mL. CONCLUSIONS The Tauber procedure is safe and associated with low effective doses. Operative time and the patient's BMI independently predict a higher radiation dose.
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Affiliation(s)
- Carolina Bebi
- Department of Paediatric Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Correspondence: ; Tel.: +39-02-55038690; Fax: +39-02-5032545
| | - Marco Bilato
- Department of Paediatric Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Dario Guido Minoli
- Department of Paediatric Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Erika Adalgisa De Marco
- Department of Paediatric Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Michele Gnech
- Department of Paediatric Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Irene Paraboschi
- Department of Paediatric Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Luca Boeri
- Department of Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Irene Fulgheri
- Department of Vascular Surgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Roberto Brambilla
- Medical Physics Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Mauro Campoleoni
- Medical Physics Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Giancarlo Albo
- Department of Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Emanuele Montanari
- Department of Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Gianantonio Manzoni
- Department of Paediatric Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Alfredo Berrettini
- Department of Paediatric Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
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5
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Abstract
Varicocele is defined as an abnormal dilation and tortuosity of the internal spermatic veins found within the pampiniform plexus. It is a common finding in adolescents and adult men alike, however its diagnosis in the adolescent population poses different dilemmas in regard to indications for treatment than in adults. Failed Paternity is a clear-cut indication for repair in adult men attempting to father children. In adolescents, the physicians, family and patients must consider potential for future fertility problems which may or may not actually become of concern. Assessing the degree of negative effect of the varicocele on an adolescent's testicular health can also be difficult as teenagers typically are not asked to provide semen for analysis and thus surrogate markers for testicular health such as testicular size differentials must be used. Treatment options for the adolescent varicocele are similar to options in adult populations. While risks and benefits of various techniques can be considered, the gold standard for varicocele repair in adolescents has not been clearly defined. We aim to discuss diagnosis of varicocele, considerations for initiating treatment of varicocele in the adolescent, and techniques for management.
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Affiliation(s)
- Sabine Zundel
- Pediatric Surgery, Children's Hospital Lucerne, 6000 Lucerne 16, Switzerland.
| | - Philipp Szavay
- Pediatric Surgery, Children's Hospital Lucerne, 6000 Lucerne 16, Switzerland
| | - Irina Stanasel
- Pediatric Urology, Children's Health UT Southwestern Medical Center, Dallas, TX, United States
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Sansone A, Fegatelli DA, Pozza C, Fattorini G, Lauretta R, Minnetti M, Romanelli F, Lucatelli P, Corona M, Bezzi M, Lombardo F, Lenzi A, Gianfrilli D. Effects of percutaneous varicocele repair on testicular volume: results from a 12-month follow-up. Asian J Androl 2020; 21:408-412. [PMID: 30604693 PMCID: PMC6628742 DOI: 10.4103/aja.aja_102_18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Varicocele is a common finding in men. Varicocele correction has been advocated for young patients with testicular hypotrophy, but there is a lack of morphofunctional follow-up data. We assessed whether percutaneous treatment of left varicocele is associated with testicular "catch-up growth" in the following 12 months by retrospectively reviewing data from an electronic database of 10 656 patients followed up in our clinic between 2006 and 2016. We selected all young adults (<35 years) with left varicocele who underwent percutaneous treatment, had a minimum of 12 months' ultrasound imaging follow-up, and had no other conditions affecting testicular volume. One hundred and fourteen men (mean±standard deviation [s.d.] of age: 22.8 ± 5.4 years) met the inclusion and exclusion criteria. Left testicular hypotrophy (LTH), defined as a ≥20% difference between left and right testicular volume at baseline, was observed in 26 (22.8%) men. Participants with LTH (mean±s.d.: 14.5 ± 2.7 ml) had lower baseline testicular volume compared to those without LTH (mean±s.d.: 15.7 ± 3.8 ml; P = 0.032). Repeated measures mixed models showed a significant interaction between LTH and time posttreatment when correcting for baseline left testicular volume (β = 0.114, 95% confidence interval [CI]: 0.018-0.210, P = 0.020), resulting in a catch-up growth of up to 1.37 ml per year (95% CI: 0.221-2.516). Age at intervention was also associated with reduced testicular volume (-0.072 ml per year, 95% CI: -0.135--0.009; P = 0.024). Percutaneous treatment of left varicocele in young adults with LTH can result in catch-up growth over 1 year of follow-up. The reproductive and psychological implications of these findings need to be confirmed in longer and larger prospective studies.
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Affiliation(s)
- Andrea Sansone
- Department of Experimental Medicine, Sapienza University of Rome, Rome 00161, Italy
| | - Danilo Alunni Fegatelli
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome 00161, Italy
| | - Carlotta Pozza
- Department of Experimental Medicine, Sapienza University of Rome, Rome 00161, Italy
| | - Giorgio Fattorini
- Department of Experimental Medicine, Sapienza University of Rome, Rome 00161, Italy
| | - Rosa Lauretta
- Unit of Endocrinology, Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Marianna Minnetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome 00161, Italy
| | - Francesco Romanelli
- Department of Experimental Medicine, Sapienza University of Rome, Rome 00161, Italy
| | - Pierleone Lucatelli
- Vascular and Interventional Radiology Unit, Department of Radiological, Oncological and Anatomo-Pathological Sciences, Sapienza - University of Rome, Rome 00161, Italy
| | - Mario Corona
- Vascular and Interventional Radiology Unit, Department of Radiological, Oncological and Anatomo-Pathological Sciences, Sapienza - University of Rome, Rome 00161, Italy
| | - Mario Bezzi
- Vascular and Interventional Radiology Unit, Department of Radiological, Oncological and Anatomo-Pathological Sciences, Sapienza - University of Rome, Rome 00161, Italy
| | - Francesco Lombardo
- Department of Experimental Medicine, Sapienza University of Rome, Rome 00161, Italy
| | - Andrea Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Rome 00161, Italy
| | - Daniele Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, Rome 00161, Italy
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7
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Baba D, Kayıkçı MA. ADOLESAN VARİKOSELE YAKLAŞIMLAR. KONURALP TIP DERGISI 2019. [DOI: 10.18521/ktd.594026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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8
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Abstract
Varicoceles exert deleterious effect on testicular function. The condition has been associated with male infertility, testicular hypotrophy and pain. These comprises the common indications for varicocele repair currently. Significant improvement in semen parameters and pregnancy outcomes had been suggested by reports decades ago. However, selection of the best candidates remains an issue since not all patients respond positively to treatment. Consensus has been reached in recent decade after the publication of a series of meta-analyses. Significant improvement in pregnancy outcomes were reported in patients with clinical varicocele and abnormal semen parameters. Varicocelectomy in adolescents with testicular hypotrophy was supported by the positive implication on catch-up growth and semen parameters. However, little is known about the treatment effect of adolescence varicocelectomy on long term fertility and paternity rate. Recent studies on outcome of varicocele repair for pain consistently demonstrated a resolution rate of approximately 90% and support varicocele-associated pain as an indication for surgery. Alternate indications for varicocele repair have been proposed in recent decade. Despite the encouraging preliminary data, most studies were uncontrolled retrospective series. Although varicocelectomy may not obviate the need for assisted reproductive techniques in patients with non-obstructive azoospermia, it potentially increases sperm retrieval rate. The significant increase in serum testosterone after varicocelectomy in patients with androgen deficiency may open an alternative treatment for hypogonadism. The adjunctive role of varicocelectomy before assisted reproduction and the significant decrease in sperm DNA fragmentation after varicocele repair deserve further well-designed controlled studies.
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Affiliation(s)
- Chak-Lam Cho
- Department of Surgery, Union Hospital, Hong Kong, China
| | - Sandro C Esteves
- Andrology and Human Reproduction Clinic ANDROFERT, Referral Center for Male Reproduction, Campinas, Brazil
| | - Ashok Agarwal
- American Center for Reproductive Medicine, Department of Urology, Cleveland Clinic, Cleveland, OH, USA -
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9
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Abstract
Improved understanding of the pathogenesis and natural history of many urologic disorders, as well as advances in fertility preservation techniques, has increased the awareness of and options for management of fertility threats in pediatric patients. In children, fertility may be altered by oncologic conditions, by differences in sexual differentiation, by gonadotoxic drugs and other side effects of treatment for nonurologic disorders, and by urologic conditions, such as varicocele and cryptorchidism. Although fertility concerns are best addressed in a multidisciplinary setting, pediatric urologists should be aware of the underlying pathophysiology and management options to properly counsel and advocate for patients.
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Affiliation(s)
- Kathleen Kieran
- Division of Urology, Seattle Children's Hospital, 4800 Sand Point Way Northeast, OA.9.220, Seattle, WA 98105, USA.
| | - Margarett Shnorhavorian
- Division of Urology, Seattle Children's Hospital, 4800 Sand Point Way Northeast, OA.9.220, Seattle, WA 98105, USA
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10
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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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11
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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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12
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Esposito C, Escolino M, Castagnetti M, Cerulo M, Settimi A, Cortese G, Turrà F, Iannazzone M, Izzo S, Servillo G. Two decades of experience with laparoscopic varicocele repair in children: Standardizing the technique. J Pediatr Urol 2018; 14:10.e1-10.e7. [PMID: 28807743 DOI: 10.1016/j.jpurol.2017.06.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 06/28/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Controversy still exists about the indications and the gold standard approach for varicocele treatment in pediatric population. OBJECTIVE The authors report their 23 years of experience in laparoscopic varicocele repair in the pediatric population. STUDY DESIGN We retrospectively evaluated the data of 345 consecutive patients who underwent laparoscopic left varicocelectomy from January 1993 to December 2015. Average patient age was 12.5 years (range 8-17). Seven out of 345 patients (2%) had a recurrent varicocele, and five out of 345 patients (1.4%) had a varicocele on a single testis. In 335/345 patients (97.1%) we performed a Palomo procedure, and in 10/345 patients (2.9%) an artery-sparing Palomo procedure. After 2010, in 105/345 patients (30.4%) we performed a lymphatic sparing procedure using isosulfan blue injection preoperatively. RESULTS All procedures were completed in laparoscopy (Figure), without conversions or intraoperative complications. The average operative time was 17 min (range 14-45) for the Palomo procedure and 26 min (range 18-50) for artery-sparing Palomo. In 45/345 patients (13%) we performed additional procedures. We recorded 4/345 (1.3%) recurrences/persistences in patients undergoing Palomo, while we recorded 1/10 (10%) recurrence/persistence after artery-sparing Palomo. On 230 Palomo procedures performed in the pre-isosulfan blue era, we recorded 25 cases of hydrocele (10.8%), 13 of these were treated with transcrotal puncture and 12 required surgical operation. The last 105 patients undergoing isosulfan blue injection had no postoperative hydrocele. We also reported 10 other complications (I grade Clavien-Dindo) such as umbilical granuloma or instrumental problems. DISCUSSION Analyzing the international literature of the last 25 years, most papers focused on the minimally invasive treatment of pediatric varicocele. There are several reasons to perform laparoscopic repair of pediatric varicocele. First of all, it is technically easy to perform, the average operative time is very short, and it has excellent outcome in regard to varicocele persistence/recurrence. In addition it has a very low complication rate, and in particular adopting the intradartoic/intratesticular isosulfan blue injection before surgery we recorded no postoperative hydrocele. CONCLUSION On the basis of our 23 years of experience with varicocele repair, we clearly believe that laparoscopic Palomo lymphatic sparing varicocelectomy should be considered the standard of care for the treatment of pediatric patients with varicocele. Laparoscopic varicocelectomy is technically easy and quick to perform, painless, and scarless, with a recurrence rate of about 1%. The use of a preoperative injection of isosulfan blue completely eliminates postoperative hydrocele formation.
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Affiliation(s)
- Ciro Esposito
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy.
| | - Maria Escolino
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | | | - Mariapina Cerulo
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | - Alessandro Settimi
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | - Giuseppe Cortese
- Department of Anesthesiology, Federico II University of Naples, Naples, Italy
| | - Francesco Turrà
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | - Marta Iannazzone
- Department of Anesthesiology, Federico II University of Naples, Naples, Italy
| | - Serena Izzo
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | - Giuseppe Servillo
- Department of Anesthesiology, Federico II University of Naples, Naples, Italy
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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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15
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Treatment of varicoceles: techniques and outcomes. Fertil Steril 2017; 108:378-384. [DOI: 10.1016/j.fertnstert.2017.07.020] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 07/19/2017] [Indexed: 11/23/2022]
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16
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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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18
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Keene DJB, Cervellione RM. Antegrade sclerotherapy in adolescent varicocele patients. J Pediatr Urol 2017; 13:305.e1-305.e6. [PMID: 28215837 DOI: 10.1016/j.jpurol.2016.12.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 12/29/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION In the 1970s, Tauber described the antegrade sclerotherapy technique to treat varicoceles, and reported a 10% recurrence rate. The present study aimed to evaluate paediatric success rates and the effect of modifications to the surgical technique. METHODS A prospective study was performed of all adolescent patients undergoing antegrade sclerotherapy surgery. Each patient had an idiopathic varicocele with spontaneous venous reflux on Doppler examination, and underwent cannulation of a pampiniform plexus vein via a scrotal incision under general anaesthetic. Aethoxysklerol® 3% (2 ml/kg) maximum 3 ml was injected into the pampiniform plexus vein under fluoroscopic monitoring. Success was assessed by clinical examination and Doppler ultrasound 3, 6 and 9 months after surgery. Data were presented as median (interquartile range). Patients were split into three groups: Group A - liquid sclerotherapy with Y connector; Group B - liquid sclerotherapy direct to cannula; and Group C - foam sclerotherapy direct to cannula. Fisher's exact test was used to compare the success rates in each group. RESULTS A total of 91 patients underwent antegrade sclerotherapy. The median age was 14.8 years (range 13.7-15.5). Eleven persistent varicoceles occurred and were diagnosed by Doppler ultrasound. The success rate of surgery was 58% in Group A, 90% in Group B and 96% in Group C. Success was significantly higher in Group B and Group C compared with Group A. No testicular atrophy occurred; two wound infections, two haematomas and one hydrocele were recorded (Table). CONCLUSION Introduction of antegrade sclerotherapy in the adolescent population resulted in a safe and cost-effective method for the management of adolescent varicocele. Several modifications to the technique have been introduced to achieve a high success rate (96%) with minimal complications.
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Affiliation(s)
- D J B Keene
- Department of Paediatric Urology, Royal Manchester Children's Hospital, Oxford Road, Manchester, UK
| | - R M Cervellione
- Department of Paediatric Urology, Royal Manchester Children's Hospital, Oxford Road, Manchester, UK.
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Bedir F, Keskin E, Karabakan M, Karabulut İ, Yılmazel FK, Özbey EG, Aksoy Y, Özbey İ. Evaluation of testicular catch-up growth in adolescent microsurgical varicocelectomy. Turk J Urol 2017; 43:135-140. [PMID: 28717535 DOI: 10.5152/tud.2017.51436] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 10/31/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The incidence of varicocele is approximately 15% in adolecent men. Early treatment with varicocele is aimed to resolve testicular hypotrophy and ensure catch-up growth. The aim of this study was to evaluate ipsilateral catch-up growth rates relative to contralateral testicular growth in adolescents with varicocele undergoing microsurgical subinguinal varicocelectomy. MATERIAL AND METHODS Fifty adolescents with unilateral grade 2-3 varicoceles were included in the study. All patients underwent microsurgical subinguinal left varicocelectomies performed by the same experienced surgeon. All patients were evaluated clinically and using orchidometric measurements to define the grade of varicocele and testicular volume at presentation and follow-up. The number of internal and external spermatic veins, testicular arteries and lymphatic vessels preserved during the subinguinal microsurgical varicocelectomy were recorded. The mean follow-up period was 26 months (range 6-48 months). RESULTS At presentation, mean patient age was 12.9±2.1 years. Mean testicular preoperative volumes were 7.1±4.3 mL for the right and 5.4±3.4 mL for the left testis. There were significant differences between mean volumes of the right and left testis (p=0.002). At the final postoperative follow-up visit, mean testicular volumes were 10.8±5.1 mL (range 3-25) for the right and 9.9±4.3 mL (range 2-20) for the left, and the difference between the right and left testicular volumes was insignificant (p=0.47). In our series, catch-up growth was observed in 70% (35/50) of our patients. CONCLUSION Adolescent varicocelectomy is associated with a higher percentage of patients showing testicular catch-up growth. In our study, similarly to the available literature the catch-up growth rate was found as 70% and observed to have positive effects of adolescent varicocelectomy on testicular growth.
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Affiliation(s)
- Fevzi Bedir
- Clinic of Urology, Erzurum Training and Research Hospital, Erzurum, Turkey
| | - Ercüment Keskin
- Clinic of Urology, Erzincan University Mengücek Gazi Training and Research Hospital, Erzincan, Turkey
| | | | - İbrahim Karabulut
- Clinic of Urology, Erzurum Training and Research Hospital, Erzurum, Turkey
| | | | | | - Yılmaz Aksoy
- Department of Urology, Atatürk University School of Medicine, Erzurum, Turkey
| | - İsa Özbey
- Department of Urology, Atatürk University School of Medicine, Erzurum, Turkey
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20
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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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21
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Samplaski MK, Jarvi KA. Prognostic factors for a favorable outcome after varicocele repair in adolescents and adults. Asian J Androl 2016; 18:217-21. [PMID: 26732108 PMCID: PMC4770489 DOI: 10.4103/1008-682x.169558] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The effect of varicocele repair on male fertility remains controversial. It would be helpful to determined which men would benefit most from varicocele repair, and target repair efforts at those individuals. A detailed review of the literature on prognostic factors for varicocele repair was performed using the PubMed NLM database. We found that the best predictor of postvaricocelectomy semen parameters is the preoperative semen parameters. The greatest improvements in semen parameters were found in men with larger varicoceles. While there is controversy, higher testosterone, younger age and larger testis size, in some studies predict for improvements in semen parameters postvaricocelectomy. A nomogram has been developed to predict the postvaricocelectomy semen parameters based on the preoperative semen parameters, varicocele grade and the age of the man (www.fertilitytreatmentresults.com). Limited data consistently demonstrates the greatest improvements in DNA fragmentation rates in men with higher baseline DNA fragmentation rates. With respect to reproductive outcomes, higher baseline sperm density consistently predicts for natural pregnancy or assisted reproductive technology (ART) pregnancy rates. In addition, varicocele repair does seem to reduce the need for more invasive modalities of ART. In conclusion, we can now start to use specific parameters such as baseline semen quality, varicocele grade and patient age to predict post-repair semen quality and fertility potential following varicocelectomy.
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Affiliation(s)
- Mary K Samplaski
- Institute of Urology, University of Southern California, Los Angeles, CA, USA
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22
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Chiba K, Ramasamy R, Lamb DJ, Lipshultz LI. The varicocele: diagnostic dilemmas, therapeutic challenges and future perspectives. Asian J Androl 2016; 18:276-81. [PMID: 26698233 PMCID: PMC4770499 DOI: 10.4103/1008-682x.167724] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
A varicocele is defined as the abnormal dilation of the internal testicular vein and pampiniform venus plexus within the spermatic cord. If a semen analysis is not obtained from the adolescent male, in the absence of other symptoms, the main clinical indication used by many urologists to recommend repair is testicular atrophy. The varicocele may result in testicular damage in some males causing testicular atrophy with impaired sperm production and decreased Leydig cell function, while in other males the varicocele may seemingly cause no ill effects. In adult men, varicoceles are frequently present and surgically correctable, yet the measurable benefits of surgical repair are slight according to a Cochrane review. While occurring more commonly in infertile men than fertile men, only 20% of men with a documented varicocele will suffer from fertility problems. Most varicoceles found in adolescents are detected during a routine medical examination, and it is difficult to predict which adolescent presenting with a varicocele will ultimately show diminished testicular function in adolescence or adulthood. As in adults, the mainstay of treatment for varicocele in adolescents is surgical correction. However, unlike an adult varicocelectomy (the microsurgical approach is the most common), treatment for an adolescent varicocele is more often laparoscopic. Nevertheless, the goals of treatment are the same in the adolescent and adult patients. Controversy remains as to which patients to treat, when to initiate the treatment, and what type of treatment is the best. This review will present the current understanding of the etiology, diagnosis and treatment of the adolescent varicocele.
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Affiliation(s)
| | | | | | - Larry I Lipshultz
- Center for Reproductive Medicine; Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
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23
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Damsgaard J, Joensen UN, Carlsen E, Erenpreiss J, Jensen MB, Matulevicius V, Zilaitiene B, Olesen IA, Perheentupa A, Punab M, Salzbrunn A, Toppari J, Virtanen HE, Juul A, Skakkebæk NE, Jørgensen N. Reply to Eugenio Ventimiglia, Francesco Montorsi, and Andrea Salonia's Letter to the Editor re: Jakob Damsgaard, Ulla N. Joensen, Elisabeth Carlsen, et al. Varicocele Is Associated with Impaired Semen Quality and Reproductive Hormone Levels: A Study of 7035 Healthy Young Men from Six European Countries. Eur Urol 2016;70:1019-29. Eur Urol 2016; 71:e71-e72. [PMID: 27638092 DOI: 10.1016/j.eururo.2016.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 09/01/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Jakob Damsgaard
- University Department of Growth and Reproduction, Rigshospitalet, and International Research and Research Training Centre in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark
| | - Ulla N Joensen
- University Department of Growth and Reproduction, Rigshospitalet, and International Research and Research Training Centre in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark
| | | | | | - Martin Blomberg Jensen
- University Department of Growth and Reproduction, Rigshospitalet, and International Research and Research Training Centre in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark; Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston, MA, USA
| | - Valentinas Matulevicius
- Institute of Endocrinology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Birute Zilaitiene
- Institute of Endocrinology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Inge A Olesen
- University Department of Growth and Reproduction, Rigshospitalet, and International Research and Research Training Centre in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark
| | - Antti Perheentupa
- Institute of Biomedicine, Department of Physiology, University of Turku, and Department of Obstetrics and Gynaecology, Turku University Hospital, Turku, Finland
| | - Margus Punab
- Andrology Unit, Tartu University Hospital, Tartu, Estonia
| | - Andrea Salzbrunn
- Department of Andrology, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Jorma Toppari
- Institute of Biomedicine, Department of Physiology, University of Turku, and Department of Paediatrics, Turku University Hospital, Turku, Finland
| | - Helena E Virtanen
- Institute of Biomedicine, Department of Physiology, University of Turku
| | - Anders Juul
- University Department of Growth and Reproduction, Rigshospitalet, and International Research and Research Training Centre in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark
| | - Niels E Skakkebæk
- University Department of Growth and Reproduction, Rigshospitalet, and International Research and Research Training Centre in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark
| | - Niels Jørgensen
- University Department of Growth and Reproduction, Rigshospitalet, and International Research and Research Training Centre in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark.
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Lomboy JR, Coward RM. The Varicocele: Clinical Presentation, Evaluation, and Surgical Management. Semin Intervent Radiol 2016; 33:163-9. [PMID: 27582602 DOI: 10.1055/s-0036-1586143] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
A varicocele is an abnormal dilatation and tortuosity of the veins of the spermatic cord. Although varicoceles are common in the general population and are frequently found on routine physical examinations, they represent the most common correctable cause of male factor infertility. Varicoceles are also often incidental findings on imaging studies, particularly scrotal ultrasound. Importantly, not all varicoceles should be treated equally (or at all), and basic guidelines on the evaluation and indications for treatment of adult varicoceles should be reviewed before counseling and treatment. A semen analysis should be obtained for any male patient of reproductive age considering intervention. The adolescent varicocele is managed much differently than the adult varicocele and remains a source of controversy. This review describes the clinical presentation and the evaluation of adult and pediatric varicoceles, and provides guidance on their diagnosis and workup. It also describes options for surgical repair and the success and complication rates associated with each surgical approach, ultimately supporting microsurgical subinguinal varicocele repair as the current surgical standard.
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Affiliation(s)
- Jason R Lomboy
- Department of Urology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Robert M Coward
- Department of Urology, University of North Carolina School of Medicine, Chapel Hill, North Carolina; UNC Fertility, Raleigh, North Carolina
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25
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Abstract
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.
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Affiliation(s)
- Kristina D Suson
- Children's Hospital of Michigan, 3901 Beaubien, Detroit, MI, 48201, USA.
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26
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Zhou T, Zhang W, Chen Q, Li L, Cao H, Xu CL, Chen GH, Sun YH. Effect of varicocelectomy on testis volume and semen parameters in adolescents: a meta-analysis. Asian J Androl 2016; 17:1012-6. [PMID: 25677136 PMCID: PMC4814973 DOI: 10.4103/1008-682x.148075] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Varicocele repair in adolescent remains controversial. Our aim is to identify and combine clinical trials results published thus far to ascertain the efficacy of varicocelectomy in improving testis volume and semen parameters compared with nontreatment control. A literature search was performed using Medline, Embase and Web of Science, which included results obtained from meta-analysis, randomized and nonrandomized controlled studies. The study population was adolescents with clinically palpable varicocele with or without the testicular asymmetry or abnormal semen parameters. Cases were allocated to treatment and observation groups, and testis volume or semen parameters were adopted as outcome measures. As a result, seven randomized controlled trials (RCTs) and nonrandomized controlled trials studying bilateral testis volume or semen parameters in both treatment and observation groups were identified. Using a random effect model, mean difference of testis volume between the treatment group and the observation group was 2.9 ml (95% confidence interval [CI]: 0.6, 5.2; P< 0.05) for the varicocele side and 1.5 ml (95% CI: 0.3, 2.7; P< 0.05) for the healthy side. The random effect model analysis demonstrated that the mean difference of semen concentration, total semen motility, and normal morphology between the two groups was 13.7 × 10 6 ml-1 (95% CI: -1.4, 28.8; P = 0.075), 2.5% (95% CI: -3.6, 8.6; P= 0.424), and 2.9% (95% CI: -3.0, 8.7; P= 0.336) respectively. In conclusion, although varicocelectomy significantly improved bilateral testis volume in adolescents with varicocele compared with observation cases, semen parameters did not have any statistically significant difference between two groups. Well-planned, properly conducted RCTs are needed in order to confirm the above-mentioned conclusion further and to explore whether varicocele repair in adolescents could improve subsequently spontaneous pregnancy rates.
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Affiliation(s)
| | | | | | | | | | | | - Guang-Hua Chen
- Department of Urology, Changhai Hospital, The Second Military Medical University, Shanghai 200433, China
| | - Ying-Hao Sun
- Department of Urology, Changhai Hospital, The Second Military Medical University, Shanghai 200433, China
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Abstract
Testicular varicocele, a dilation of the veins of the pampiniform plexus thought to increase testicular temperature via venous congestion, is commonly associated with male infertility. Significant study has clarified the negative impact of varicocele on semen parameters and more recent work has shed light on its detrimental effects on the molecular and ultrastructural features of sperm and the testicular microenvironment, as well as more clearly defined the positive impacts of treatment on couples’ fertility. The relationship between varicocele and testicular endocrine function, while known for some time based on histologic evaluation, has become more apparent in the clinical setting with a growing link between varicocele and hypogonadism. Finally, in the pediatric setting, while future study will clarify the impact of varicocele on fertility and testicular function, recent work supports a parallel effect of varicocele in adolescents and adults, suggesting a re-evaluation of current treatment approaches in light of the progressive nature of the condition and potential increased risk of future disease.
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Affiliation(s)
- Alexander W Pastuszak
- Center for Reproductive Medicine; Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
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Internal Spermatic Vein Insufficiency in Varicoceles: A Different Entity in Adults and Adolescents? AJR Am J Roentgenol 2015; 205:667-75. [DOI: 10.2214/ajr.14.14085] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Adolescent varicocele: A large multicenter analysis of complications and recurrence in academic programs. J Pediatr Urol 2015; 11:186.e1-6. [PMID: 26071075 PMCID: PMC4997804 DOI: 10.1016/j.jpurol.2015.05.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 05/12/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE After varicocelectomy a wide range of recurrence rates have been reported from 0 to 18%, and rates of post-operative hydrocele formation between 0 and 29%. Controversy exists as to the appropriate approach for varicocele treatment, whether open, laparoscopic, or percutaneous embolization (PE) is best for young men. The literature on treatment of adolescent varicocele is limited to high-volume single surgeon, single institution, or small multi-institution series. Our goal was to evaluate the retreatment and complication rates from numerous institutions to determine more generalizable results. STUDY DESIGN The Faculty Practice Solutions Center database was queried to identify males under age 19 years with a diagnosis and/or treatment of varicocele between January 2009 and December 2012. Patients were followed until December 2013 (1-5 years follow-up) to determine if they had occurrence of outcome variables: retreatment, diagnosis, or treatment of hydrocele. Associations of the variables age, race, insurance type, geographical region, surgeon-volume, and surgical approach, with outcome variables were analyzed using a mixed-effects Cox proportional hazard model. RESULTS Of 6,729 patients with a diagnosis of varicocele, 1,036 underwent open (405), laparoscopic (530), or percutaneous embolization (PE) (101) treatment by 213 physicians. Retreatment rates after open, laparoscopic, and PE treatments were 1.5%, 3.4% and 9.9%, respectively. Race, region, insurance type, and age were not independently associated with outcomes. The incidence of hydrocele after open, laparoscopic, and PE treatments was 4.9%, 8.1%, and 5%, respectively. No approach was independently associated with diagnosis or treatment of hydrocele. Young age was associated with a significantly higher rate of hydrocele formation. For each year of age, there was a 14% decreased rate of hydrocele formation. DISCUSSION Although this series contains the largest cohort of patients, physicians, and institutions, we were limited by the inability to determine actual recurrence rates. Only patients receiving retreatment at the same institution within the 1-5 year follow-up period were captured. As such, the true rate of varicocele recurrence may be higher. The retreatment rate is influenced by the physician's threshold to retreat and the patient's desire to undergo another procedure. Despite its limitations, this is the first study to compare open, laparoscopic, and percutaneous approaches to varicocele treatment. CONCLUSIONS Percutaneous embolization has a significantly higher retreatment rate compared with either open or laparoscopic varicocelectomy. Retreatment and hydrocele formation after open and laparoscopic approaches were not significantly different. This supports a surgeon and family choosing an approach based on patient characteristics and surgeon preference.
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Ener K, Üçgül YE, Okulu E, Aldemir M, Işik E, Kayigil Ö, Özcan MF. Comparison of arterial blood supply to the testicles in the preoperative and early postoperative period in patients undergoing subinguinal varicocelectomy. Scand J Urol 2014; 49:169-73. [DOI: 10.3109/21681805.2014.956331] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Nork JJ, Berger JH, Crain DS, Christman MS. Youth varicocele and varicocele treatment: a meta-analysis of semen outcomes. Fertil Steril 2014; 102:381-387.e6. [DOI: 10.1016/j.fertnstert.2014.04.049] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 04/15/2014] [Accepted: 04/29/2014] [Indexed: 10/25/2022]
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Kim KS, Lee C, Song SH, Cho SJ, Park S, Moon KH, Ryu DS, Park S. Impact of internal spermatic artery preservation during laparoscopic varicocelectomy on recurrence and the catch-up growth rate in adolescents. J Pediatr Urol 2014; 10:435-40. [PMID: 24314819 DOI: 10.1016/j.jpurol.2013.11.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 11/04/2013] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- K S Kim
- Department of Urology, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Pungnap2-dong, Songpa-gu, 138-736 Seoul, South Korea
| | - C Lee
- Department of Urology, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Pungnap2-dong, Songpa-gu, 138-736 Seoul, South Korea
| | - S H Song
- Department of Urology, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Pungnap2-dong, Songpa-gu, 138-736 Seoul, South Korea
| | - S J Cho
- Department of Anesthesiology and Pain Medicine, Cheju National University College of Medicine, Cheju National University Hospital, 690-716, #154, 3-Do 2-Dong, Jeju City, South Korea
| | - S Park
- School of Mechanical Engineering, Pusan National University, 30 Jangjeon-dong, Gumjeong-gu, 609-735 Busan, South Korea
| | - K H Moon
- Department of Urology, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Pungnap2-dong, Songpa-gu, 138-736 Seoul, South Korea
| | - D S Ryu
- Department of Urology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, 50, Hapsung-dong, Masan hoewon-gu, 630-723 Changwon, South Korea
| | - S Park
- Department of Urology, University of Ulsan College of Medicine, Ulsan University Hospital, 290-3 Jeonha-dong Dong-gu, 682-714 Ulsan, South Korea.
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Bogaert G, Orye C, De Win G. Pubertal Screening and Treatment for Varicocele do not Improve Chance of Paternity as Adult. J Urol 2013; 189:2298-303. [DOI: 10.1016/j.juro.2012.12.030] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 12/12/2012] [Indexed: 10/27/2022]
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Abstract
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.
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Abstract
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.
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Affiliation(s)
- K Czeloth
- Abteilung für Klinische Andrologie, Centrum für Reproduktionsmedizin und Andrologie
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Abstract
Varicocelectomy is the most commonly performed surgical procedure for the treatment of male infertility. Although several different techniques for varicocele repair have been described in the literature, microsurgical varicocelectomy performed through a subinguinal or inguinal incision is recognized as the gold-standard approach for varicocelectomy, due to high success rates with minimal complications. Standard indications for varicocelectomy include palpable varicocele(s), with one or more abnormal semen parameters, and, for the couple trying to conceive, in the setting of normal or correctable female infertility. However, varicocele repair is often recommended and undertaken for reasons other than infertility, including low serum testosterone, testicular pain, testicular hypotrophy and poor sperm DNA quality. This article reviews the technical aspects of microsurgical varicocelectomy, and its indications in adults and adolescents.
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