Diagnosis and surgical correction of the pediatric varicocele

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

CONTEXT

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

OBJECTIVE

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

PATIENT SUMMARY

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

Relationship between varicocele grade, vein reflux and testicular growth arrest

The development of testicular hypotrophy (or testicular growth arrest) in pediatric patients with varicocele is the first indication for surgery. The aim of this study is to identify the correlation between grade of varicocele, grade of vein reflux and testicular growth arrest. Between 2000 and 2001, we recruited 226 patients affected by varicocele without testicular hypotrophy and with grades 2-3 spermatic vein reflux observed during Doppler velocimetry. Medical examinations carried out every 6 months allowed the assessment of varicocele grade, testicular volume, and grade of vein reflux. Other parameters considered in the study were: mean time of grade deterioration, mean time to onset of testicular growth arrest and the relationship between varicocele grade and testicular growth arrest. Deterioration of the condition was experienced in 92 patients (40%) in which 60 patients showed higher varicocele grades without testicular growth arrest, while 32 patients developed testicular growth arrest. There was a statistically significant relationship between testicular growth arrest and varicocele grades (grade 2 and 3) and between grade of reflux and testicular growth arrest. Although it is not possible to determine which patients will develop testicular growth arrest, the assessment of vein reflux allows the identification of those subjects who may potentially develop such a condition.

Improvement of sexual activity, pregnancy rate, and low plasma testosterone after bilateral varicocelectomy in impotence and male infertility patients

To evaluate the effects of bilateral varicocelectomy on sexual activity, testicular volumes, semen quality, and serum hormone levels in impotence and male infertility patients, 48 patients were studied from an outpatient clinic from May 1998 to March 2001. The mean age was 37+/-5.9; 16 patients were complaining of erectile dysfunction and 32 patients were complaining of male infertility. The mean duration of impotence was 3.3+/-2.4 years and for male infertility was 3.8+/-3.2 years. Sexual and reproductive history was taken for erectile dysfunction and male infertility patients. General, local examination, and laboratory investigations were done for all patients. Preoperative and postoperative testicular volumes; semen parameters, including semen volume, sperm count, and motility; and morphology and hormonal parameters, including LH and FSH, and testosterone levels were measured. All patients were followed up for 3-36 months after varicocele repair. Left and right testicular volume was improved in impotence and male infertility patients and fertility groups, but this improvement was not statistically significant (p>.25). The semen volume was significantly increased in male infertility patients and fertility group (p<.05), but there was no statistical significant difference in impotent patients (p>.25). The sperm count was improved in male infertility patients and fertility group, but this improvement was not statistically significant (p>.25), and in impotent patients there was no significant difference (p>.40). The sperm motility was very significantly increased in male infertility patients and the fertility group (p<.0005), and highly significantly increased in impotent patients (p<.005). The abnormal forms were not statistically significant in impotence and male infertility patients (p>.40), but significantly decreased in the fertility group (p<.05). Serum testosterone was very significantly increased in impotence and male infertility patients (p<.0005) and was highly significantly increased in fertility groups (p<.005). Serum FSH was improved in impotence and male infertility patients, but this improvement was not statistically significant (p>.10), and in fertility groups of male infertility patients, the results showed a statistically significant increase (p<.05). Serum LH was not statistically significant in impotence and male infertility patients (p>.10), and was significantly increased in fertility groups (p<.05). The improvement of sexual activity was 50-75%, the pregnancy rate for their partners was 37% and increased plasma testosterone levels over a period of 3 years of follow-up after varicocele repair.

Varicocele in schoolboys

This study was conducted to examine the effect of height and weight on the incidence of varicocele in schoolboys aged 5-16 years and the impact of varicocele on testicular size. Genital stage, height, weight, varicocele grade, and testicular size were recorded for 3047 school boys who were clinically examined while standing by a specialist in urology. Left varicocele was detected in 98 of the boys who were all aged 9-16 years. The mean weight of boys with and without varicocele was 42 kg (95% confidence interval [CI] 40-44 kg) and 47 (95% CI 47-47 kg), respectively (p =.00). There was no difference in mean height between the two groups nor in left and right testicular volume. Although 6 boys with varicocele had a left testicular volume > or =2 mL less than right, there were also 7 boys of comparable age who had a left testicular volume > or =2 mL larger than right. The incidence of varicocele in Greek adolescents is low. Boys with varicocele weighed significantly less but there were no significant differences in height or left versus right testicular volumes. In the light of these observations, the use of left testicular hypotrophy (> or =2 mL compared with the right testicle) should be reconsidered as an indicator for varicocele-induced damage of the testicle in this age group.

The adolescent varicocele. II: the incidence of hydrocele and delayed recurrent varicocele after varicocelectomy in a long-term follow-up

OBJECTIVE

To determine, in adolescent boys after varicocelectomy, the incidence of hydroceles, when they develop and whether the development is procedure-related.

PATIENTS AND METHODS

The records were retrospectively reviewed of 77 boys who underwent 95 varicocelectomies and had an examination at > or = 6 months after surgery. Fifty-six patients underwent a standard Palomo procedure (45 left and 11 bilateral) and 21 a modified Ivanissevich repair (14 left and seven bilateral). The mean (range) age of the patients at surgery was 14.1 (10-22) years and the mean follow-up 25.5 (6-84) months.

RESULTS

Of the 67 Palomo varicocelectomies 19 (24%) were complicated by hydroceles after surgery, compared with four of 28 (14%) Ivanissevich procedures (P = 0.034). Of the Ivanissevich repairs, none of the 14 unilateral repairs developed hydroceles. Three hydroceles (one bilateral and one left) developed in two of seven patients after bilateral varicocelectomy. Of the Palomo repairs, 12 of 45 unilateral repairs were complicated by hydroceles, and seven developed in five of 11 patients after bilateral varicocelectomy. Although more hydroceles developed after bilateral varicocelectomy, there was no significant difference from the unilateral group. However, patients who developed hydroceles after bilateral varicocelectomy were more likely to require hydrocelectomy (P = 0.013, Fisher's exact test), implying that hydroceles developing after bilateral repair tend to be larger. Of the hydroceles, two were detected in the first 6 months after surgery, nine at 6-12 months, three at 13-18 months, five at 19-24 months and four at > 2 years after surgery. Three patients had late varicocele recurrence, i.e. 15, 37 and 76 months after surgery; these patients had not had varicoceles on palpation after surgery at 3, 14 and 63 months, respectively.

CONCLUSION

Hydroceles are detected infrequently within 6 months of varicocelectomy, with most occurring after 6 months and even appearing after 3 years. They occur significantly more often after a Palomo repair. More hydroceles develop after bilateral repair regardless of the technique used, but not significantly so. Because hydroceles often develop, a lymphatic-sparing procedure should be used, especially for bilateral repair. Recurrent varicoceles may appear as late as 76 months after varicocelectomy in patients where none had been detected at a mean of 27 months after surgery.

Ultrastructural and immunohistochemical study of basal lamina of the testis in adolescent varicocele

OBJECTIVE

To evaluate a possible involvement of the extracellular matrix (ECM) in the testes of adolescents with varicocele.

DESIGN

Cross-sectional study.

SETTING

University-based medical center.

PATIENT(S)

Twenty-four adolescents aged between 13 and 18 years underwent surgical treatment for repair of left idiopathic varicocele.

INTERVENTION

A testis biopsy was performed at time of surgery.

MAIN OUTCOME MEASURE(S)

Transmission electron microscopy study of basal lamina and immunofluorescence studies of collagen type IV and laminin, two major components of basal lamina.

RESULT(S)

Transmission electron microscopy observations showed an uneven profile of the basal lamina with a variable thickness. Immunofluorescence studies showed an irregular immunofluorescent line that appeared interrupted in some observations. Collagen type IV showed some areas of strong immunostaining with other areas with reduced immunoreactivity.

CONCLUSION(S)

Our ultrastructural and immunohistochemical observations highlight focal damage at the level of peritubular basal lamina, but this damage is not as severe as that described in adult varicocele. Initial involvement of basal lamina could represent one of the mechanisms responsible for varicocele-induced histologic alterations of the testes.

Serum inhibin B levels and the response to gonadotropin stimulation test in pubertal boys with varicocele

PURPOSE

The impact of varicoceles on gonadal function in adolescents has been evaluated using several parameters, including size of testes, hormonal levels and provocative endocrine testing. Inhibin B has been demonstrated to be decreased in men with testicular damage from conditions other than varicocele. We determine whether inhibin B levels are low in adolescent boys with varicocele, and if there is a relationship between inhibin B and an exaggerated response to gonadotropin-releasing hormone (Gn-RH) stimulation testing, testicular hypertrophy and/or varicocele bilaterality.

MATERIALS AND METHODS

We studied 9 boys at Tanner stages III to V of pubertal development who had either left or bilateral varicoceles. Basal inhibin B, follicle-stimulating hormone, luteinizing hormone and testosterone were measured. Each patient underwent Gn-RH stimulation testing.

RESULTS

All patients had essentially normal inhibin B levels for Tanner stage. Of the 9 boys 4 had an exaggerated response to Gn-RH stimulating testing. Inhibin B levels did not vary significantly either with the presence of bilateral or unilateral varicoceles or asymmetric testis.

CONCLUSIONS

The lack of correlation between inhibin B levels and the aforementioned parameters failed to suggest that inhibin B has a significant role in the clinical assessment of testicular function in adolescents with varicocele. Further studies of larger populations may further elucidate the value of inhibin B levels and varicoceles.

Juxta-renal varicocelectomy for recurrent varicocele following retroperitoneal operation

Two patients with recurrent painful left varicocele following retroperitoneal varicocelectomy were subjected to juxta-renal varicocelectomy by a transverse supraumbilical incision. Ligature of the testicular vein was carried out just below the renal vein. Minute periarterial veins were disrupted by desheathing the testicular artery. Both patients were cured of their varicocele as judged by scrotal ultrasonography and by color duplex ultrasonography. Average follow-up period was 5 months.

Incidence and pattern of varicocele recurrence after laparoscopic ligation of the internal spermatic vein with preservation of the testicular artery

OBJECTIVES

To determine the incidence and pattern of recurrence of varicocele after laparoscopic internal spermatic vein ligation with testicular artery preservation.

METHODS

In a prospective study, 16 patients who underwent 20 laparoscopic varix ligation were evaluated postoperatively for recurrence by clinical physical examination and percutaneous spermatic venography.

RESULTS

No significant complications were encountered with the surgical or radiological procedure. Clinical recurrence was detected by physical examination in 20% of cases, while percutaneous spermatic venography detected recurrence in 45% of cases. The sensitivity and specificity of clinical physical examination for detecting varicocele recurrence was 33% and 90.9%, respectively with an accuracy rate of 65%. Recurrences were through parallel collaterals or medial transverse collaterals in 88.8% and 11.2%, respectively. Parallel collaterals joined the spermatic vein in mid or high retroperitoneum in seven patients while it joined the renal vein in one patient. There were no low retroperitoneal parallel collaterals.

CONCLUSIONS

Laparoscopic ligation of internal spermatic vein with preservation of testicular artery is a procedure that is associated with low morbidity and quick recovery. It is able to achieve its surgical objective in only 55% of cases, however. Such information should be taken into consideration during patient counselling when selecting the operative technique of choice for varicocele ligation.

Testicular fate after incarcerated hernia repair and/or orchiopexy performed in patients under 6 months of age

This study assessed testicular viability after 476 inguinal procedures performed in 338 infants under 6 months of age, between 1974 and 1993. One hundred twenty-one elective hernia repairs (contralateral explorations) were compared with 355 hernia repairs complicated by incarceration and/or orchiopexy. Clinical examination of 323 testes in the early postoperative period showed 20 atrophic testes. Since January 1994, 71 of the 338 patients have had testicular measurements obtained through ultrasonography (US). An additional 13 atrophic testes were found during US examination. Of these, nine were believed to be normal during early postoperative examination. Assuming that US examination will confirm atrophy in the 20 atrophic testes noted early in the postoperative clinical evaluation, and that all other testes not yet scanned are found to be normal, the minimal atrophy rate (MAR) would be 9.3% (33 of 355). Neither operative nor early postoperative testicular assessment correlates with ultimate testicular survival. Testicular pathology may become more evident after puberty, and the real incidence of atrophy may increase.

Antegrade scrotal sclerotherapy for the treatment of varicocele in childhood and adolescence

OBJECTIVE

To test the efficacy of antegrade scrotal sclerotherapy (ASS) for the treatment of varicocele in teenagers.

PATIENTS AND METHODS

The study included 38 patients (mean age 14.9 years, range 12-18) with left-sided varicocele. Three patients had a grade 1 varicocele, 22 were grade 2 and 13 were grade 3. ASS was performed under local anaesthesia on an out-patient basis.

RESULTS

ASS was accepted by all patients except one. There were no peri-operative problems and only one patient developed post-operative epididymitis. During 9 to 15 months of follow-up (mean 11 months), only two patients developed persistence of a lower grade of varicocele.

CONCLUSION

This study illustrates that ASS is a safe and successful out-patient procedure for the treatment of varicocele in teenagers.

Varicocele related testicular atrophy and its predictive effect upon fertility

Varicoceles are the most common reversible cause of male factor infertility, yet approximately 80% of men with varicoceles are fertile. Therefore, it is unclear whether all adolescents should undergo prophylactic varicocelectomy to prevent future infertility or whether a subgroup of patients who are at increased risk for future infertility can be identified and treated. Testicular size discrepancy or hypotrophy of the testis associated with a unilateral varicocele has been suggested as an indication for prophylactic varicocelectomy in adolescents. We examined 946 men attending a urological clinic for complaints other than infertility to determine whether testis size discrepancy was predictive of infertility in men with left varicoceles. A left varicocele was detected on physical examination in 211 men, of whom 173 (82%) had been able to father children and 38 (18%) had never fathered children. A group of 630 men without palpable varicoceles served as controls, including 528 (84%) with a history of fertility. Testicular size was measured using an orchidometer and the average testicular volume difference was obtained by subtracting left from right testicular volume. The mean testicular volume difference for the fertile men without varicoceles (1.6 +/- 0.3 ml.) was significantly lower than the fertile men with varicoceles (3.1 +/- 0.4 ml.) (p < 0.05) and infertile men with varicoceles (2.5 +/- 0.6 ml.) (p < 0.05). There was no significant difference between fertile and infertile men with varicoceles. This study confirms prior reports that the majority of men with left varicoceles are able to father children and that varicoceles cause significant ipsilateral testicular atrophy/hypotrophy. However, we were unable to demonstrate a correlation between loss of testicular volume and fertility status in men with left varicoceles. Further study is needed to identify the clinical parameters predictive of future infertility in adolescents with varicoceles.

Ligation of the testicular artery and vein in adolescent varicocele

Proper surgical management of adolescent varicocele is controversial. Recent evidence suggests that the Palomo approach gives the best results. We report on the outcomes of 43 consecutive adolescent boys who underwent operative correction of varicocele by a single surgeon from 1979 to 1992. An inguinal approach with ligation of the vascular pedicle above the vas deferens (modified Palomo) was used in each case. From 1979 to 1983 an attempt was made to preserve the testicular artery but it was successful in only 6 of 12 cases. After 1983 no further attempt was made to preserve the artery and, therefore, 37 patients underwent total ligation of the vascular pedicle above the entry of the vas deferens into the spermatic cord. Most of the varicoceles were grade II. Significant discrepancy in testicular volume (10% difference) constituted the main indication for operation. The ipsilateral (left) testis was smaller in 30 of 37 patients (81%). Of those testes with size discrepancy 90% showed significant volume increase following surgery. Many left testes assumed the same volume as the normal right testis. The only surgical failure (recurrence) of the 43 cases occurred in 1 of the 6 in which artery preservation was successful. There were no surgical failures in the group of 37 boys. Mean followup is 3.7 years. Total ligation of the testicular vascular pedicle seems to afford catch-up growth for smaller ipsilateral testes with low risk for recurrence of the varicocele.

Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique

Conventional techniques of varicocele repair are associated with substantial risks of hydrocele formation, ligation of the testicular artery, and varicocele recurrence. We describe a microsurgical technique of varicocelectomy that significantly lowers the incidence of these complications. The testicle is delivered through a 2 to 3 cm. inguinal incision, and all external spermatic and gubernacular veins are ligated. The testis is returned to the scrotum and the spermatic cord is dissected under the operating microscope. The testicular artery and lymphatics are identified and preserved. All internal spermatic veins are doubly ligated with small hemoclips or 4-zero silk and divided. The vas deferens and its vessels are preserved. Initially, we performed 33 conventional inguinal varicocelectomies in 24 men without delivery of the testis or use of a microscope. Postoperatively, 3 unilateral hydroceles (9%) and 3 unilateral recurrences (9%) were detected. For the next 12 cases 2.5x loupes were used resulting in no hydroceles but another recurrence (8%). We then performed 640 varicocelectomies in 429 men using the microsurgical technique with delivery of the testis. Among 382 men available for followup examination from 6 months to 7 years postoperatively no hydroceles and no cases of testicular atrophy were found. A total of 4 unilateral recurrent varicoceles (0.6%) was identified. The differences between the techniques in the incidence of hydrocele formation and varicocele recurrence are highly significant (p < 0.001). No wound infections occurred in any men. Four scrotal hematomas (0.6%), 1 of which required surgical drainage, occurred in the group with microsurgical ligation and delivery of the testis compared to none with the conventional technique. Preoperative and postoperative semen analyses (mean 3.57 analyses per patient) were obtained on 271 men. The changes in sperm count x 10(6) cc (36.9 to 46.8, p < 0.001), per cent motility (39.6 to 45.7%, p < 0.001) and per cent normal forms (48.4 to 52.10%, p < 0.001) were highly significant. The pregnancy rate was 152 of 357 couples (43%) followed for a minimum of 6 months postoperatively. Delivery of the testis through a small inguinal incision provides direct visual access to all possible avenues of testicular venous drainage. The operating microscope allows identification of the testicular artery, lymphatics and small venous channels. This minimally invasive, outpatient technique results in a significant decrease in the incidence of hydrocele formation, testicular artery injury and varicocele recurrence.

Intraoperative spermatic venography during varicocele surgery in adolescents

Intraoperative internal spermatic venography performed immediately following varicocele ligation in the adolescent has been touted as reducing varicocele persistence rates. Previously published data corroborate this statement with low persistence rates. Other series in which venography was not performed report a failure rate of 9 to 30%. During a 5-year period a total of 64 varicocele ligations was performed in 62 male adolescents at our institution. Followup postoperatively revealed an overall varicocele persistence rate of 9%. All patients had intraoperative internal spermatic venography on the affected side. Of 64 venograms 16% had shown collateral drainage that, if not ligated, may have resulted in varicocele persistence. These cases accounted for only 1 of the persistent varicoceles. Additionally, venograms had demonstrated filling of the ipsilateral external iliac vein in 8% of the cases. Despite the fact that no attempt was made to ligate these collaterals, none of these patients had a persistent varicocele. After varicocele ligation 30 of 62 patients were followed long enough to evaluate for testicular catch up growth. Of these 30 patients 24 demonstrated an average relative increase in left testicular volume of 17%. These data support routine intraoperative internal spermatic venography while performing varicocele ligation in the adolescent.

Effects of varicocele treatment in adolescents: a randomized study

OBJECTIVE

To study the effects of varicocele treatment on testicular function in adolescents.

DESIGN

A prospective controlled study in 88 randomly selected adolescents.

SETTING

All participants were referred to the fertility outpatient clinic of our university hospital.

PARTICIPANTS

All participants with a varicocele were randomly assigned into two groups. Group 1 (n = 33) was not treated, whereas group 2 (n = 34) was treated. A similar group of healthy volunteers without a varicocele served as a control group (group 3, n = 21).

INTERVENTIONS

Testes volumes were measured at intake and during follow-up using an orchiometer. Semen analysis was performed according to standard procedures both at intake and after 1 year of follow-up. Serum hormone levels were determined at intake using a radioimmunoassay. Treatment was performed by means of transcatheter embolization of the left testicular vein.

MAIN OUTCOME MEASURES

Testes volumes and semen quality at intake and after 1 year of follow-up were compared within and between the three groups. Hormonal parameters were determined at intake only.

RESULTS

Before treatment, the mean left testis volume in groups 1 (n = 26) and 2 (n = 27) (20.0 mL; 95% confidence interval [CI]: 18.2 to 21.8 and 21.6 mL; 95% CI: 19.4 to 23.8, respectively) were significantly smaller than those in the control group (n = 19) (24.5 mL; 95% CI: 22.7 to 26.4). During follow-up, left testis volumes of the treated group were comparable with those in the control group (24.2 mL; 95% CI: 22.2 to 26.1 and 24.8 mL; 95% CI: 23.0 to 26.7 respectively) and significantly (P < 0.001) different from the untreated group (20.3 mL; 95% CI: 18.8 to 21.8). A significant increase in left (P < 0.01) as well as right (P < 0.05) testis volume was observed after treatment. Semen parameters before treatment were not significantly different between the three groups. Sperm concentration increased significantly (P < 0.01) from 47.4 x 10(6)/mL (95% CI: 42.5 to 53.3) to 68.9 x 10(6)/mL (95% CI: 50.6 to 87.2) in the treated group, whereas semen quality in the untreated and control groups did not change. Although both testes volumes and sperm concentration improved in the treated group, these phenomena were not consistently correlated to each other.

CONCLUSIONS

Although not apparent in all adolescents, varicocele correction resulted in an increase in left testis volume and sperm concentration. At this moment, it is not clear if early preventive treatment of varicocele in adolescents, in time, will have a positive effect on testicular function.

Results of varicocele surgery in adolescents: a comparison of techniques

We report our experience using 3 different operative techniques for varicocele ligation in adolescents. Between August 1985 and April 1991 we performed 102 varicocelectomies on 91 adolescents. Varicocele persistence rate was 16% with a modified Ivanissevich inguinal approach and 11% using a selective high retroperitoneal technique with preservation of the internal spermatic artery. Intraoperative post-ligation spermatic venography did not significantly improve the results with the artery sparing techniques. Palomo mass high retroperitoneal ligation of the internal spermatic vessels produced significantly better results compared to the artery sparing techniques. Testicular atrophy did not occur in any patient regardless of the surgical technique used. These data suggest that the Palomo technique results in a significant decrease in the operative failure rate compared to the artery sparing procedures and it should be the preferred technique for varicocele ligation in the adolescent.

Varicocelectomy: incidence of external spermatic vein involvement in the clinical varicocele

The vascular anatomy of the clinical varicocele, and the incidence of involvement of the external spermatic vein were studied. Dilation of the external spermatic vein (4 mm) was found in 49.5 percent of 93 varicoceles in 67 patients. The location of this vein, its potential involvement in a varicocele, and its management were reviewed.

Testicular volume assessment in the adolescent with a varicocele

Testicular growth arrest is the main criterion for performing varicocele ligation in the adolescent population. Previous assessments concerning significant size discrepancy range from 0.5 to 5 cm.3, a 10-fold difference. We prospectively assessed testicular size in 22 male adolescents (ages 9 to 19 years) with varicoceles, and compared testicular volume as measured by ultrasound and Prader orchidometer in 19 of these patients. The accuracy of ultrasound for this purpose was evaluated by blinded ultrasonic measurements of models of known volume and a standard deviation of +/- 1.6 cm.3 was found. Using a size discrepancy of greater than 2 cm.3 as the criterion for growth arrest, 4 of 17 patients (24%) with growth arrest would have been missed with the Prader orchidometer alone. Testicular volumetric assessment by ultrasound accurately measured volumetric differences of greater than 2 cm.3 and can be used to determine growth arrest in the male adolescent with a varicocele.

The effect of post-pubertal varicocele on testicular volume

Paediatric varicocele is a well known entity but its effect on adult infertility has not been adequately clarified. Since measurement of testicular volume is currently the best method of estimating the male reproductive potential, 945 boys aged between 13 and 18 years were examined with regard to testicular volume and the incidence of varicocele. The average volumes for right and left testes were 15.087 +/- 0.237 and 14.514 +/- 0.347 ml respectively, and the incidence of varicocele was 16.7%. The incidence increased from 14.5 to 21.7% as the ages increased from 14 to 18. The differences in volume of the 2 testes in boys with varicocele were statistically significant when compared with the normal group, but this significance failed to become more pronounced when the slight varicocele group (grade I) was included with the normal group and compared with the severe varicocele group (grades II and III). There may be no significant differences between the volumes of the 2 testes in boys with varicocele when careful measurement and strict statistical analyses are applied. However, some boys in the varicocele group were found to have testicular volumes below the confidence interval (mean - SE) or under 1 SD, and the 2 testicular volumes differed in certain age groups. This group requires further follow-up. The results of this study have added further contradictory findings to the issue of paediatric varicocele in terms of testicular atrophy, estimation of potential fertility and the indications for immediate surgery. There is a need for further prospective controlled trials.

The effect of experimental varicocele on the testis of adolescent rats

Experimental varicocele was created by partial ligation of the left renal vein in rats 4, 7 and 12 weeks old to compare the effects of varicocele on the testis at different times of onset: prepuberty, adolescence and adulthood. We examined the testes at 4 and 8 weeks after creation of the varicocele. The experimental groups of rats 4 and 12 weeks old showed slight testicular changes compared to control groups at 4 and 8 weeks postoperatively. In the 7-week group left testicular weight was significantly decreased (1.03 +/- 0.31 gm.) compared to that of the control group (1.51 +/- 0.12 gm.) at 4 weeks. The seminiferous tubular diameter in the left testis also was significantly reduced (219 +/- 37 microns) compared to that of the control group (270 +/- 14 microns). Histological changes, such as degeneration of germinal epithelium, tubular atrophy, Sertoli cell hyperplasia and interstitial edema, were observed more frequently in the 7-week group. At 8 weeks these changes were less significant. Our results suggest that varicocele during adolescence has the most damaging effects on the testis in rats.