Varicocele in pediatric patients: comparative assessment of different therapeutic approaches

Long-term impact of commonly performed operations in pediatric urology on reproductive and sexual health

Introduction

Sexual dysfunction is highly prevalent among men of reproductive age. Clinical practice guidelines have been established to assist providers in identification and education of patients who are at increased risk for infertility and sexual dysfunction with certain congenital and acquired urogenital disorders. The authors sought to review the reproductive and sexual health implications of treating common childhood urological conditions with commonly performed surgical procedures.

Methods

To ensure the inclusion of influential and highly regarded research, we prioritized citations from the most-frequently cited articles on our respective review topics. Our inclusion criteria considered studies with substantial sample sizes and rigorously designed methodologies. Several topics were reviewed, including penile chordee, hypospadias, posterior urethral valves, varicoceles, undescended testicles, and testicular torsion.

Results

For chordee, surgical plication or corporal grafting may be employed. Erectile function remains unaltered post-surgery, while penile length may decrease after repair, which may be avoided using dermal grafts. Hypospadias repair hinges on severity and availability of the urethral plate. Those who underwent hypospadias repair report decreased penile length, but sexual satisfaction, libido, and semen quality are comparable to controls. Posterior urethral valves are usually treated with valve ablation. While valve ablation and bladder neck incision have not been found to affect ejaculatory function, high degree of concurrent renal dysfunction related to nephrogenic and bladder dysfunction may impact semen parameters and erectile function. Regarding varicocele, earlier management has been associated with better long-term fertility outcomes, and surgical intervention is advisable if there is observable testicular atrophy. Earlier repair of undescended testicle with orchiopexy has been found to improve fertility rates as well as decrease malignancy rates. Unilateral orchiectomy for testicular torsion without the ability for salvage has been shown to have decreased semen parameters but unaffected fertility rates.

Conclusion

Infertility and sexual dysfunction are multivariable entities, with etiologies both congenital and acquired. At the same time, many common pediatric urology surgeries are performed to correct anatomic pathology that may lead to reproductive dysfunction in adulthood. This review highlights the need for diagnosis and management of pediatric urologic conditions as these conditions may impact long-term sexual function post-operatively.

Outcome following the surgical management of varicocele in children and adolescents: a systematic review and meta-analysis

Background

The ideal surgical approach for the management of varicocele in children and adolescents remains controversial. Several techniques are available including artery- or lymphatic-sparing with optical magnification (via open inguinal or sub-inguinal approach), laparoscopic, antegrade and retrograde embolization/sclerotherapy.

Objectives

We aimed to appraise the clinical outcomes of these techniques in children and adolescents.

Data Sources and Methods

A systematic review was conducted (1997-2023). Meta-analysis or proportional meta-analysis for non-comparative studies (Freeman-Tukey transformation) using the random effects model was conducted. Results are expressed as overall proportion % and 95% confidence interval (CI).

Results

We identified 1910 studies; 632 duplicates were removed, 1278 were screened, 203 were reviewed and 56 were included, with 12 reporting on 2 different techniques (total of 68 data sets). Optical magnification via inguinal approach (498 cases): recurrence 2.5% (0.6-5.6), hydrocele 1.6% (0.47-3.4), testicular atrophy 1% (0.3-2.0), complications 1.1% (0.2-2.6); optical magnification via sub-inguinal approach (592 cases): recurrence 2.1% (0.7-4.4), hydrocele 1.26% (0.5-2.3), testicular atrophy 0.5% (0.1-1.3), complications 4% (1.0-8.8). Laparoscopic with mass-ligation/division (1943 cases): recurrence 2.9% (1.5-4.6), hydrocele 11.4% (8.3-14.9); complications 1.5% (0.6-2.9); laparoscopic with lymphatic-sparing (974 cases): recurrence 2.4% (1.5-3.5), hydrocele 1.2% (0.45-3.36), complications 1.2% (0.05-3.9); laparoscopic with artery-sparing (228 cases): recurrence 6.6% (2.3-12.9), hydrocele 6.5% (2.6-12.0). Antegrade embolization/sclerotherapy (403 cases): recurrence 7.6% (5.2-10.4), hydrocele 0.8% (0.17-1.9), technical failure 0.6% (0.1-1.6), complications 4.0% (2.3-6.1); retrograde embolization/sclerotherapy (509 cases): recurrence 6.9% (4.6-9.5), hydrocele 0.8% (0.05-2.5), technical failure 10.2% (4.6-17.6), and complications 4.8% (1.0-11.2).

Conclusion

The recurrence rate varies between 2.1% and 7.6% and is higher with the embolization/sclerotherapy techniques. Post-operative hydrocele rate varies between 0.8% and 11.4% and is higher with the laparoscopic mass-ligation/division technique. Testicular atrophy has not been reported with the laparoscopic and embolization/sclerotherapy techniques. The retrograde embolization technique is associated with 10% technical failure (inability to complete the procedure). The laparoscopic lymphatic-sparing technique is characterized by the lowest recurrence rate, incidence of hydrocele and other complications, and no reports of testicular atrophy.

Indigo Carmine Dye–Assisted Lymphatic-Sparing Microsurgical Subinguinal Varicocelectomy Among Children and Adolescents

The purpose of this study is to clarify the safety and efficacy of indigo carmine dye–assisted lymphatic-sparing microsurgical subinguinal varicocelectomy for children and adolescents in our institution. Medical records of boys aged ≤ 15 years who underwent varicocelectomy between November 2008 and December 2019 at our institution were retrospectively reviewed. Microsurgical subinguinal varicocelectomy was performed using indigo carmine injection under the tunica vaginalis to preserve lymphatics. A total of 29 patients underwent varicocelectomy, among whom six underwent retroperitoneal high ligation (modified Palomo technique), nine underwent laparoscopic varicocelectomy, and 14 underwent microsurgical subinguinal varicocelectomy. The median operative time for retroperitoneal high ligation, laparoscopic varicocelectomy, and microsurgical subinguinal varicocelectomy was 71 (IQR: 59–82.5) min, 131 (95–151) min, and 125.5 (112–134.25) min, respectively. Among the patients who underwent laparoscopic varicocelectomy, one and two experienced hydrocele and varicocele recurrence as postoperative complications, respectively. None of the patients who underwent microsurgical subinguinal varicocelectomy developed hydrocele and varicocele recurrence during 15.5-month median follow-up period (IQR: 11.25–25.75 month). Indigo carmine dye–assisted lymphatic-sparing microsurgical subinguinal varicocelectomy can be a safe and efficient treatment modality among children and adolescents.

Analysis of internal spermatic vein embolization through catheter versus laparoscopic high ligation in treatment of left varicocele

OBJECTIVE

Varicocele is a common disease in young and middle-aged men. This study aims to compare the efficacy of internal spermatic vein embolization of left varicocele versus laparoscopic high ligation.

METHODS

From January 2017 to September 2018, a total of 69 varicocele patients were admitted and given the opportunity to choose the treatment option. Among these, 26 patients were treated with sclerosing agent injection, while 43 patients underwent laparoscopic surgery. They were followed up for 12 months after surgery, and the technical success rate, recurrence rate, complication rate, cost, operative time, and hospitalization time with regard to these two methods were analyzed.

RESULTS

All patients completed the medical procedures. There was no recurrence in patients in the sclerotherapy group during the follow-up period; however, the complication rate was 19.2%. Furthermore, the operative time, hospitalization time, and cost of treatment were 31.1 ± 11.1 min, 1.2 ± 0.49 days, and 9613.11 ± 895.97 Yuan, respectively. In the laparoscopic group, 9 patients underwent laparoscopic bilateral high ligation, while 34 patients received treatment on the left side alone. The recurrence rate of left varicocele was 4.7% and the complication rate was 44.2%. Furthermore, the operative time, hospitalization time, and treatment cost were 50.4 ± 14.48 min, 4.0 ± 2.02 days, and 10,948.29 ± 2547.00 Yuan, respectively. Moreover, there were statistically significant differences (P < 0.05) in operative time, hospitalization time, and treatment cost. Patients in the sclerotherapy group had an advantage with respect to the overall complication rate when compared with patients from the laparoscopic group (X² = 4.448, P < 0.05), and there was a statistically significant difference in hydrocele (X² = 4.555, P < 0.05). However, there was no significant difference in the recurrence rate between these two groups (X² = 1.245, P > 0.05).

CONCLUSION

Patients who underwent sclerotherapy showed a higher technical success rate, a lower recurrence rate, fewer complications, and shorter hospitalization time compared to those treated with laparoscopic ligation. Transcatheter sclerosing agent injection may be a preferable treatment option for patients with unilateral varicocele.

[Initial experience in microsurgical treatment of varicocele: Comparative analysis with conventional macrosurgical varicocelectomy]

INTRODUCTION

Varicocele is the most common cause of male infertility and the standard treatment is varicocelectomy. Having recently started performing microsurgical varicocelectomy (MV) in our centre, the objective of this study is to determine the differences in clinical outcomes and laboratory findings between MV and the conventional varicocelectomy (CV).

MATERIAL AND METHODS

This is a comparative study between MV and CV in our centre between 01/2013 and 12/2016. We included patients with clinical varicocele and altered seminal parameters. We analyzed the following variables: age, laterality, grade of varicocele, testicular volume, surgical technique used, seminogram parameters prior to and after surgery and recurrence.

RESULTS

Between 01/2013 and 12/2016 46 varicocelectomies were performed in our centre, excluding from the study 12 patients due to lack of follow-up. Of the remaining 34, 19 (55.9%) underwent CV and 15 (44.1%) MV. There were no significant differences between the baseline characteristics of both groups. The preoperative sperm count was 30.1±35.6 10⁶/mL for MV vs. 25.6±19.9 10⁶/mL for CV (P=.64) and progressive sperm motility (a+b) was 17.7±13.6% vs. 16.5±10.1% respectively (P=.77). Postoperative sperm count was 29.16±33 10⁶/mL for MV vs. 45.6±55.5 10⁶/mL for CV (P=.32) and progressive motility (a+b) was 26.4±20.1% vs. 27.7±20.4% respectively (P=.85). We observed a tendency towards recurrence in the CV group (26.3%, vs. 6.7% for MV), although not statistically significant (P=.15).

CONCLUSIONS

Despite the learning curve with MV, we obtained improvements in seminal analysis similar to those with CV. Even though not statistically significant, there was a tendency to less recurrence in the MV group, consistent with what is already described in medical literature.

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.

Modified Inguinal Microscope-Assisted Varicocelectomy under Local Anesthesia: A Non-randomised Controlled Study of 3565 Cases

Varicocele is a common abnormality, but the conventional microsurgical subinguinal varicocelectomy (CMSV) has some disadvantages. We invented Modified Inguinal Microscope-Assisted Varicocelectomy (MIMV) under local anesthesia. This study aims to evaluate MIMV by comparing it to CMSV in operating duration, time to return to normal activity, postoperative complications, achievement of natural pregnancy and improvement of semen quality for patients with infertility, pain score for those with scrotal pain, and so on. We enrolled 3089 patients who underwent MIMV and 476 who underwent CMSV in our hospital. Both the operating duration and the time to return to normal activity of MIMV was shorter than that of CMSV (P < 0.001). The recurrence rate (P < 0.001) and injury rate of vas deferens (P = 0.011) after MIMV were lower than that after CMSV. Moreover, patients with MIMV showed higher degree of satisfaction with the surgery experience and outcome than those with CMSV (P < 0.001). However, no statistical difference was found between the two groups in scores of pain due to surgery, postoperative varicose veins diameters, reflux duration, and the postoperative complications of wound infection, hydrocele, atrophy of testis, epididymitis, and scrotal hematoma. In summary, MIMV is a promising varicocelectomy and could be applied more in clinical practice.

Varicoceles in the pediatric population: Diagnosis, treatment, and outcomes

Varicocele is commonly encountered in adolescents. There are still many controversies regarding pathophysiology, health effects, clinical significance, and optimum treatment of this condition. This article reviews the current evidence pertaining to children and adolescents with varicocele. This group present a unique and somehow challenging situation, since they are still going through pubertal changes that may confound the effects of the disease and its treatment on the developing testes.

Varicocele percutaneous embolization outcomes in a pediatric group: 7-year retrospective study

PURPOSE

Percutaneous embolization and surgical repair are the current treatment options for varicocele, but determining method superiority remains controversial. In this retrospective study, we evaluate the technical success, complication and recurrence rates following percutaneous embolization in a pediatric group, which were compared to reported outcomes for surgical repairs.

METHODS

Thirty children treated for percutaneous varicocele embolization were recruited. The side and grade of varicocele, symptoms, testicular asymmetry, mean recurrence time, total radiation dose and complications were evaluated. Recurrence and follow-up complications due to embolization were also reviewed.

RESULTS

The venography showed retrograde filling of the internal spermatic vein with the identification of aberrantly fed vessels in 23 % of patients. None of the patients suffered from procedure complications except one who had venous injury which was treated with a sclerosing agent. The technical success rate was 93 % (28 patients) with a recurrence rate of 13 % (4 patients). Interestingly, the mean radiation dose used was 862.5 µGy m(2), 3 times lower than abdominal CT.

CONCLUSION

Considering the intravascular nature of embolization, which aims to avoid testicular artery and spermatic cord damage (difficult to avoid with the surgical method), and consequently a lower complication rate, along with the same success rate and recurrence rate, our study supports that embolization is a superior method to surgical interventions.

Laparoscopic varicocelectomy in the management of chronic scrotal pain

Background and Objectives:

To evaluate the usefulness of laparoscopic varicocelectomy in the management of chronic scrotal pain.

Methods:

Between 2009 and 2011, 48 patients in total were treated with laparoscopic varicocelectomy for dull scrotal pain that worsened with physical activity and was attributed to varicoceles. All patients were followed up at 3 and 6 months and biannually thereafter with a physical examination, visual analog scale score, and ultrasonographic scan in selected cases.

Results:

The mean age was 38.2 years (range, 23–54 years). The mean follow-up period was 19.6 months (range, 6–26 months). Bilateral varicoceles were present in 7 patients (14.6%), and a unilateral varicocele was present in 41 (85.4%). The varicocele was grade 3 in 27 patients (56.3%), grade 2 in 20 (41.6%), and grade 1 in 1 (2.1%). The mean preoperative visual analog scale score was 4.8 on a scale from 0 to 10. The mean postoperative visual analog scale score at 3 months was 0.8. After the procedure, 42 patients (87.5%) had a significant improvement in the visual analog scale score (P < .001); 5 (10.4%) had symptom improvement, although it was not statistically significant; and 1 (2.1%) remained unchanged. During follow-up, we observed 5 recurrences (10.4%) whereas de novo hydrocele formation was identified in 4 individuals (8.3%).

Conclusion:

Laparoscopic varicocelectomy is efficient in the treatment of symptomatic varicoceles with a low complication rate. However, careful patient selection is necessary because it appears that individuals presenting with sharp, radiating testicular pain and/or a low-grade varicocele are less likely to benefit from this procedure.

Adolescent varicocele: limited indications for treatment during puberty and adolescence

A varicocele is defined as an abnormal dilatation of the pampiniform plexus of veins of the testis. The vast majority of children and adolescents with varicoceles have no subjective symptoms. The complete work-up of patient diagnosed with a varicocele involves a physical exam in supine and prone position with and without Valsalva, and the use of ultrasound to measure testicular volume and blood flow. Because of growth issues occurring during puberty and adolescence, serial follow-ups may be done to determine any detrimental change in testicular size and symptomatology. The main difference of an adolescent varicocele is the fact that semen parameters are unavailable and do not count for treatment strategy. In this review, the focus is made on a recent study that has evaluated the ultimate endpoint: paternity. It appears that screening and treatment of a varicocele in the adolescent period does not influence the ultimate chance of paternity.

Intravenous methylene blue venography during laparoscopic paediatric varicocelectomy

INTRODUCTION

One of the challenges of varicocele surgery is to prevent hydrocele formation while still ensuring success. Methylene blue has been used to identify and preserve lymphatic vessels, and venography has been a standard component of sclerotherapy and percutaneous retrograde techniques. The authors have combined both approaches during laparoscopic varicocelectomy and report their experience.

METHODS

A prospective study was performed of adolescents with idiopathic varicocele and spontaneous venous reflux on Doppler ultrasound. A pampiniform plexus vein was cannulated via scrotal incision before creating the pneumoperitoneum. A mixture of methylene blue and Omnipaque™ was injected into the pampiniform plexus with fluoroscopic screening. Laparoscopic selective vein ligation was then performed using 5mm endoscopic clips or a bipolar vessel sealing device such as Plasmakinetic™ or Ligasure™. Venography was repeated to confirm complete ligation of the internal testicular veins. Patients were followed-up at 3, 6, and 9 months post-surgery with clinical examination and Doppler ultrasound. Data are presented as median (interquartile range).

RESULTS

Twenty-four patients underwent laparoscopic selective vein ligation with venography and methylene blue injection. The median age was 14.7 (14.6-15.7) years. The recurrence rate was 12%. No patients developed a hydrocele. The length of surgery was 120 (100-126) minutes.

CONCLUSION

Intra-operative intra-venous methylene blue injection and venography helps to identify venous duplications of the internal testicular veins and enhances the success rate of laparoscopic selective vein ligation. This approach prevents hydrocele formation but has a 12% recurrence rate, which appears to be higher than some techniques described in the literature.

Surgical management of adolescent varicocele: Systematic review of the world literature

Historically, idiopathic varicocele is the most commonly diagnosed pre-pubertal andrological condition. The clinical presentation of varicocele may vary from dull and dragging unilateral or bilateral testicular pain to visible varicose veins lying over the hemiscrotum. Over the last decade, significant strides were made in managing symptomatic varicoceles, particularly minimal invasive procedures and surgeries. We sought to review the published literature in a systematic manner to gain an overview and streamline the presentations and main treatment modalities.

Varicocele in adolescence: where are we now?

The exact pathophysiology of varicocele and the subsequent alteration of spermatogenesis has been the subject of much debate. Despite an enormous amount of literature on the subject, the appropriate management of varicocele in the adolescent patient population has not yet been clearly elucidated. While not every male with varicocele will be subfertile, the possibility potentially lends credence to early diagnosis for those in whom treatment will have an impact.

Minilaparoscopic varicocelectomy with preservation of testicular artery and lymphatic vessels by using intracorporeal knot-tying technique: five-year experience

BACKGROUND

In this study we present our experience using minilaparoscopic intracorporeal knot tying to ligate internal spermatic veins (ISV) while sparing the spermatic artery and lymphatics.

METHODS

Minilaparoscopic varicocelectomies were performed in 87 patients between January 2004 and January 2009. All varicoceles were detected clinically according to the World Health Organization (WHO) classification and confirmed by scrotal color Doppler ultrasonography. The surgical indications were scrotal symptoms in 71, infertility in 16, and both conditions in 2. Three 3.5 mm minilaparoscopic ports were used for the operation. The ISVs were dissected and then ligated with intracorporeal knot-tying. The testicular artery and lymphatic vessels were carefully preserved to minimize procedure-related complications.

RESULTS

Unilateral laparoscopic varicocelectomy was performed in 21 (24.2%) patients and bilateral in 66 (75.8%). Mean operative time was 71.1 ± 29.2 and 46.8 ± 12.6 min for bilateral and unilateral varicocelectomies, respectively. All patients were discharged within 24 h after surgery. Neither immediate major nor late procedure-related complications were noted. Of the 71 patients with scrotal symptoms, the symptoms completely subsided in 55 (77.5%) and partially subsided in 10 (14.1%). Only one (1.2%) recurrent varicocele was detected within a mean follow-up of 21 months (range = 3-42). Neither hydrocele formation nor testicular atrophy was found during the follow-up period.

CONCLUSION

Our 5-year experience revealed that minilaparoscopic varicocelectomy with sparing of artery and lymphatic vessels could safely and effectively ligate all spermatic veins and preserve spermatic arteries and lymphatic channels without leading to a high varicocele persistence or recurrence.

The role of varicocele sclerotherapy in men with severe oligo-astheno-teratozoospermia

The aim of this study was to verify the role of antegrade scrotal sclerotherapy for the treatment of varicoceles in infertile men with severe oligo-astheno-teratozoospermia (OAT). The 59 patients with severe OAT in this study underwent antegrade scrotal sclerotherapy for the treatment of varicoceles. The outcome was assessed in terms of improvement in semen parameters and spontaneous conception rate. Semen parameters and reproductive hormones were evaluated before antegrade sclerotherapy (AS) and 6 months after AS. After an average follow-up time of 34.8±3.2 months, significant improvement was noted in the mean sperm concentration, motility and morphology in 36 patients (61%). Spontaneous pregnancy occurred in nine couples (15%). Six months after treatment, inhibin B levels were significantly higher (P<0.04), whereas follicle-stimulating hormone (FSH) levels were significantly lower (P<0.001) than before treatment. Antegrade internal spermatic vein sclerotherapy can significantly improve seminal parameters and hormonal parameters in men with severe OAT and may even result in spontaneous pregnancy in couples who would otherwise be candidates for intracytoplasmic sperm injection (ICSI).

Management options of varicoceles

Varicocele is one of the most common causes of male infertility. Treatment options for varicoceles includes open varicocelectomy performed at various anatomical levels. Laparoscopic varicocelectomy has been established to be a safe and effective treatment for varicoceles. Robotic surgery has been introduced recently as an alternative surgical option for varicocelectomy. Microsurgical varicocelectomy has gained increasing popularity among experts in male reproductive medicine as the treatment of choice for varicocele because of its superior surgical outcomes. There is a growing volume of literature in the recent years on minimal invasive varicocele treatment with percutaneous retrograde and anterograde venous embolization/sclerotherapy. In this review, we will discuss the advantages and limitations associated with each treatment modality for varicoceles. Employment of these advanced techniques of varicocelectomy can provide a safe and effective approach aiming to eliminate varicocele, preserve testicular function and, in a substantial number of men, increase semen quality and the likelihood of pregnancy.

Laparoscopic Palomo varicocele surgery: lessons learned after 10 years' follow up of 156 consecutive pediatric patients

OBJECTIVES

To evaluate our experience using laparoscopic Palomo varicocele ligation in a population under 18years, and confirm the factors involved in postoperative hydrocele formation.

PATIENTS AND METHODS

Between 1997 and 2007, 156 boys diagnosed as having varicocele were evaluated retrospectively. Outcome variables recorded for analysis were age at presentation, symptoms, varicocele grade (Dubin-Amelar classification), testicular atrophy, length of hospital stay, perioperative complications, recurrence and hydrocele formation after surgery. Mean follow up was 5.6 years (6 months- 9 years).

RESULTS

Age at diagnosis ranged between 9 and 18 years. Mean age at operation was 14.1+/-1.8 years. There were 153 left-side varicoceles (98%) and three cases were bilateral. All patients had grade II or III varicocele (38%/62%) and testicular atrophy was noted in 43.8%; 8.1% mentioned testicular pain at diagnosis. All boys underwent Palomo laparoscopic ligation of the spermatic vessels. Mean operative time was 38 min (25-82 min). The last 51 surgeries were performed on a two-trocar basis with Ligasure vascular sealing device and operative time decreased significantly to 22 min (16-32 min) (P<0.05). Median hospital stay was 31+/-8 h. Conversion rate was 1.28%. Twenty-one patients developed hydrocele (13.5%); 11 of these underwent Winkelman-Lord's hydrocelectomy at least 1 year after Palomo (9% of total). Of the remaining 10, two resolved spontaneously and eight were stable at mean 4-year follow up.

CONCLUSIONS

Laparoscopic Palomo varicocele surgery for pediatric patients is a safe and effective procedure. Recurrence and complication rates are similar to those reported with open surgery.

Results and complications of adolescent varicocele repair with intraoperative sodium morrhuate sclerotherapy

PURPOSE

Adolescent varicocele has been shown to affect spermatogenesis and correlate with decreased ipsilateral testicular volume, prompting treatment in a select population. We report our experience with 3 varicocele ligation procedures in concordance with sclerotherapy in adolescent patients.

MATERIALS AND METHODS

A total of 120 males underwent varicocele surgery at our institutions during an 8-year period. Sodium morrhuate sclerotherapy was used in 91 patients and 73 adolescent males fulfilled the 6-month followup criteria. The 73 males who were 9 to 17 years old underwent a total of 75 (bilateral in 2) procedures for varicocele treatment. Of the patients 23 underwent subinguinal microscopic varicocelectomy (group 1), 9 underwent loupe assisted subinguinal varicocelectomy (group 2) and 41 underwent loupe assisted inguinal varicocelectomy (group 3). All patients received intraoperative sclerotherapy using sodium morrhuate injection. Outcome measures included recurrence, complications and catch-up growth at a minimum of 6 months of followup.

RESULTS

The varicocele recurrence rate was 2.7% in patients receiving combined surgical ligation and sclerotherapy ablation. Group 1 had 2 recurrent varicoceles and no hydrocele formation, group 2 had no varicocele recurrence and no hydrocele formation, and group 3 had no varicocele recurrence and 2 postoperative hydroceles. Catch-up growth in the ipsilateral testis was seen in 85% of patients. No atrophy or testicular loss was noted.

CONCLUSIONS

This preliminary experience with combined surgical ligation and sclerotherapy ablation in the adolescent population resulted in low varicocele recurrence with minimal morbidity. Outcomes of loupe assisted varicocelectomy appear to be improved compared to those in previous studies, alluding to an advantage in the addition of sclerotherapy.

Viable testis after retroperitoneal mass cord ligation in internal ring of inguinal canal in 15 kidney recipients: five years of experience

INTRODUCTION

Sometimes in spermatic cord handling procedures like varicocelectomy, hernioraphy, and vasectomy, there is concern about perfusion of the testis. Herein we have presented our experience with retroperitoneal mass ligation of the cord in kidney recipients. Between 2001 and 2006, we performed mass ligation of the spermatic cord, including vas deferens and all spermatic vessels, in 15 kidney recipients (older than 55 years) who gave informed consent. During retroperitoneal preparation of the Iliac fossa for allografting, we performed this maneuver next to the internal ring of the inguinal canal. After performing a J incision in the right iliac fossa, separating fascia, and pushing the peritoneum medially, we isolated the spermatic cord at the internal ring of the inguinal canal for transfixation and placing the allografted kidney in retroperitoneal position with anastomoses of the iliac vessels. Posttransplantation the scrotum of patients was followed up by color Doppler ultrasound and physical examination.

RESULT

Normal circulation was detected in the testis postoperation using color Doppler ultrasound evaluation. Six patients returned with hydrocoeles between 4 and 8 months after transplantation and 3 of them underwent hydrocoelectomy.

CONCLUSION

Mass ligation of the spermatic cord (preinternal ring of inguinal canal) did not disturb the circulation to the testis severely nor did it induce ischemic problems (atrophy). This study suggested an unknown connection between vessels of the cord and other vessels that supply blood to the testis. This study questions the safety of cryo-biopsy of a testis mass by high clamping of the cord and also suggests that vasectomy may be safe in patients with a history of a standard Palomo varicocoelectomy.

Effects of laparoscopic division of spermatic vessels on histological changes of testes: long-term observation in the model of prepubertal rat

Laparoscopic Fowler-Stephens and Palomo procedures are now commonly performed in children with high positioned intra-abdominal cryptorchidism and varicocele, respectively. During the procedures, the spermatic vessels are ligated and therefore the question of risk related to testicular atrophy is often raised. The long-term follow-up of the histology after the procedures is rare. In this study, we simulated a laparoscopic spermatic vessels clipping and division (SVCD) in a prepubertal rat model, and examined the histological alterations of the testes with regard to spermatogenic arrest between prepuberty and middle age. Thirty-day-old Wistar rats divided randomly into three groups underwent laparoscopic sham operation, unilateral SVCD and unilateral SVCD with additional contralateral orchiectomy, respectively. Histological investigations observed on semithin and paraffin sections were performed at seven different postoperative intervals between day 9 and day 540. We defined partial, most and complete spermatogenic arrest of the seminiferous tubules to correspond with mild, severe spermatogenic arrest and atrophy, respectively. Laparoscopic SVCD induced testicular spermatogenic arrest in a total of 85% of the operated testes with different severity; 27% of operated testes with mild or severe spermatogenic arrest were seen between puberty and middle age (day 45-540 postoperative), and their size was only slightly reduced. Of the operated testes, 51% showed atrophic signs with a striking decrease in size, and their contralateral testes revealed in all cases mild or severe spermatogenic arrest started as early as day 45 postoperatively. Parallel to the spermatogenic arrest, Leydig cell hyperplasia developed frequently in impaired testes, especially in those without contralateral testes, finally reaching a typical adenoma size. Laparoscopic SVCD in prepubertal rats could disturb spermatogenesis with differing severity in most cases. This impairment could persist from peripuberty to middle age, and even involve the contralateral testes, in the case of operated testes and show complete spermatogenic arrest. This study showed that laparoscopic SVCD may have high risk in compromising the operated testis.

The treatment of adolescents presenting with a varicocele

In the last 10 years there have been many reports of children and adolescents with varicocele, but virtually none from the UK. There is an increasing incidence with age, to 19% by the age of 19 years. There is some evidence that a varicocele impairs the development of the affected testis; 9.3% of boys of 19 years old have a small testis as a result. Some aspects of testicular function are compromised. Treatment of the varicocele allows compensatory growth and testicular function. The surgical technique must be meticulous to avoid complications, particularly the formation of a hydrocele. Despite much research, the effect on fertility is unknown. The incidence of varicocele is much higher than that of male factor infertility. It is not known whether varicocele in adolescence impairs fertility or whether surgery restores fertility. At present the main indications for surgery are persistent delay in growth of >20%, bilateral varicocele and impaired spermatogenesis persisting beyond 18 years old.

Comparison of outcomes of different varicocelectomy techniques: open inguinal, laparoscopic, and subinguinal microscopic varicocelectomy: a randomized clinical trial

OBJECTIVES

To compare the outcomes of the different surgical techniques used in varicocelectomy.

METHODS

The study included 120 patients with 147 clinically palpable varicoceles who underwent varicocelectomy. The patients were randomly allocated to one of three equal groups according to the varicocelectomy technique, which included the open inguinal approach, a laparoscopic approach, and subinguinal microscopic varicocelectomy. The assessment included operative and postoperative parameters, together with semen analysis and pregnancy rate. The mean follow-up was 18 months (range 11 to 26).

RESULTS

The operative time in the microscopic group was significantly longer than that for the other two groups. At follow-up, none of the patients of the microscopic group had developed postoperative hydrocele; however, it was observed in 7 (13%) of 52 varicoceles in the open group and 10 (20%) of 50 in the laparoscopic group. This difference was statistically significant in favor of the microscopic group only. Only 1 patient in the microscopic group experienced recurrence of one varicocele compared with 7 and 9 patients in the open and laparoscopic groups, respectively. This difference was statistically significant in favor of the microscopic group only. Improvement in sperm motility and/or concentration was comparable and observed in 65%, 67%, and 76% of the open, laparoscopic, and microscopic groups, respectively. Also, the pregnancy rate at 1 year was not significantly different and was 28%, 30%, and 40% in three groups, respectively.

CONCLUSIONS

The findings of our study have demonstrated that, compared with open inguinal and laparoscopic varicocelectomy, subinguinal microsurgical varicocelectomy offers the best outcome.

Laparoscopic varicocele ligation in children and adolescents using isosulphan blue: a prospective randomized trial

OBJECTIVES

To evaluate, in a randomized prospective trial in children and adolescents, the feasibility of isosulphan blue-based lymphatic vessel preservation during laparoscopic varicocelectomy and its impact on the complication rate, as the operative management of varicoceles remains controversial.

PATIENTS AND METHODS

In all, 50 consecutive patients were randomly assigned to two laparoscopic varicocelectomy groups. The indications for surgery included scrotal pain and a difference in testicular size, as well as severe cosmetic impairment. All the patients had a laparoscopic varicocelectomy using three ports. Patients in group A had standard laparoscopy, while those in group B had additional isosulphan blue administered. After surgery, the patients were assessed at 3, 6 and 12 months for varicocele recurrence, hydrocele formation, atrophy, pain or other complications.

RESULTS

There were no intraoperative complications or conversions to open surgery. There were no adverse reactions, scrotal haematomas or atrophy. At 3 months after surgery, the incidence of hydrocele in group A was 20% whereas in group B no hydroceles were detected (P = 0.025); at 6 months the 20% still had hydroceles. One patient in each group had varicocele recurrence associated with persistent pain. In two patients in group B, blue pigmentation of the left hemiscrotum persisted at the 3-month follow-up but resolved by 6 months.

CONCLUSIONS

Laparoscopic repair of varicoceles using isosulphan blue helps to identify and preserve the lymphatic drainage. It prevents secondary hydrocele formation, the most common complication, with no supplementary risk to the patient. Also, testicular oedema causing impaired spermatogenesis can be avoided.

Treatment of varicocele with reference to age: a retrospective comparison of three minimally invasive procedures

BACKGROUND

This study investigated whether the therapeutic efficacy and morbidity of three minimally invasive techniques for varicocele correction--laparoscopic varicocelectomy (LV), antegrade sclerotherapy (AS), and retrograde embolization (RE)--differed between children and adults.

METHODS

During a 10-year period, 356 procedures for varicocele correction, including 122 cases of LV, 108 cases of AS, and 126 cases of RE, were performed for 314 patients at our institution. Of these patients, 223 were 19 years of age or younger (group 1), and 133 were older than 19 years (group 2). Diagnosis and postoperative results were established clinically and with the use of Doppler ultrasonography. The failure rates and complications for each procedure were retrospectively evaluated and compared between the two age groups.

RESULTS

The median follow-up period was 69 months (range, 6-122 months). For 25 patients (19.8%), RE was not feasible for technical reasons. In both groups, LV had a lower failure rate than AS or RE, but the difference between LV and AS was not significant in group 1 (7.7(% vs 11.9%; p > 0.5). Also in group 1, AS was associated with fewer complications than LV 1 (4.5% vs 15.4%; p < 0.05). In group 2, LV was significantly more effective in correcting varicoceles than the other two techniques (p < 0.01). In this group, the complication rates for all three procedures did not differ significantly (p > 0.05).

CONCLUSIONS

In our experience, LV was more effective than AS or RE in correcting varicoceles. For children and adolescents, AS may be more indicated because of the slightly lower complication rate and similar recurrence rates, as compared with LV, for this age group. The higher incidence of postoperative hydrocele formation after LV warrants more refined techniques such as the lymphatic-sparing approach.

Results of microsurgical subinguinal varicocelectomy in children and adolescents

OBJECTIVES

To report our experience with microsurgical subinguinal varicocelectomy in boys younger than 18 years old.

METHODS

A total of 92 boys with a mean age of 15.8 years (range 11 to 18) underwent microsurgical subinguinal varicocelectomy because of ipsilateral testicular hypotrophy (n = 63), pain, or parental preference. The varicoceles were grade III in 82 (89.1%) and grade II in 10 (10.9%) boys. Microsurgery was assisted by an operating microscope (10x to 25x) and Doppler probe. All boys were discharged home on the same day of surgery.

RESULTS

Of the 92 patients, 78 attended the initial postoperative visit at 1 month and 61 attended the 1-year follow-up visit. At 1 year, 40 (65.6%) of 61 testes demonstrated catch-up growth, with no evidence of testicular loss or persistent hypotrophy in the other 21. The only complication was persistent scrotal pain in 1 patient. At 1 year of follow-up, 1 patient (1.6%) had a recurrence and no patients had hydrocele formation or evidence of testicular loss or persistent hypotrophy.

CONCLUSIONS

Microsurgical subinguinal varicocelectomy is a safe, effective, and minimally invasive treatment modality in children and adolescents.

Antegrade scrotal sclerotherapy for treating primary varicocele in children

OBJECTIVE

To evaluate the effectiveness and limitations of antegrade sclerotherapy (AS) for the treatment of primary varicocele in childhood.

PATIENTS AND METHODS

From December 1996 to December 2004, 88 patients (mean age 13.3 years, range 9-18) with primary varicocele underwent AS (91 varicocele ablations in all). The indications for surgery were testicular pain (16 boys, 18%), a large varicocele with cosmetic implications, testicular hypotrophy (one) and in 71 (81%) the varicocele was detected incidentally during a routine physical examination; all were left-sided. According to the classification used by Tauber, 46 (52%) varicoceles were grade II and 42 (48%) grade III. The clinical and ultrasonography (US) results were evaluated over a median (range) follow-up of 11 (3-60) months, and the operative duration, X-ray exposure time, persistence rate of varicoceles and complications were compared with those using other techniques.

RESULTS

In 11 patients there was a palpable difference in size between the testicles, but in only five (6%) was testicular hypotrophy (testicular volume (<75% testicular volume vs the normal side) confirmed by US. The mean (sem) operative duration for AS was 33.2 (2.14) min. In 16 (18%) patients it was necessary to expose a second or third vein because the first vein chosen was unsuitable for sclerotherapy. The mean operative radiation exposure was 2.18 (0.21) s. One patient (1%) was treated with a high ligature of the testicular vein (Palomo procedure) after initial unsuccessful AS, and was excluded from the analysis. Eighty-four (97%) patients were eligible for follow-up: six (7%) had a persistent varicocele (four grade II, two grade III), four of whom had repeat sclerotherapy successfully (no recurrence at follow-up). Fourteen (15%) patients had enlarged testicular veins only on US (varicocele grade 0). No patient developed a hydrocele after AS, There were complications after surgery in three (3%) patients (two superficial wound infections, one scrotal haematoma together with focal testicular necrosis).

CONCLUSIONS

AS is an efficient minimally invasive surgical method for correcting varicoceles in older children, although the operative duration is sometimes longer than in adults, and surgery can be more difficult because of the smaller veins. Partial testicular necrosis, despite correct AS, is a very rare but serious complication.

Is the laparoscopic Palomo procedure for pediatric varicocele safe and effective?

BACKGROUND

Varicocele is a rare disorder in children that can lead to testicular atrophy and infertility; therefore, radical treatment is frequently required. Whatever treatment is chosen, postoperative complications are fairly common (hydrocele, recurrence, persistence, and testicular atrophy). Laparoscopic varicocelectomy (the laparoscopic Palomo procedure) is one of the surgical options that has recently gained popularity. The aim of this study is to assess the safety and effectiveness of laparoscopic Palomo varicocelectomy by describing a series of patients operated on during a 9 year period at the Royal Hospital for Sick Children in Edinburgh.

METHODS

This is a retrospective unicentric study including patients operated on between June 1995 and June 2004. All patients preoperatively underwent ultrasound scan of the testicles (color Doppler) and the abdomen. Indications for surgery included symptoms, high-grade varicocele (grade II and III), and testicular atrophy. Pneumoperitoneum was created using carbon dioxide insufflation with intraabdominal pressure up to 12 mmHg. Three 5 mm ports were inserted. The first port was inserted just below the umbilicus (telescope) under direct vision, and the others were inserted at the left flank and in the suprapubic region. All the enlarged spermatic and vas vessels were ligated or clipped. Outcomes and possible intraoperative, postoperative, or long-term complications are described.

RESULTS

Forty-one patients were included in the study. Ninety percent of symptomatic patients improved significantly postoperatively, and 62% of patients with preoperative testicular atrophy showed postoperative catch-up growth of the involved testis. Nevertheless, hydrocele represents the most frequent postoperative complication in this series of patients. Approximately 15% of the patients required some sort of further surgical intervention (12% because of postoperative hydrocele occurrence).

CONCLUSIONS

The laparoscopic Palomo procedure is a safe and effective surgical option for the treatment of pediatric varicocele, although it carries a fairly high risk of postoperative hydrocele. Postoperative hydrocele seems to be related to some sort of lymphatic obstruction, therefore lymphatic sparing procedures that can be accomplished laparoscopically should be reconsidered. Nevertheless, their feasibility and effectiveness need to be more carefully assessed.

ADOLESCENT VARICOCELE REPAIR: LONG-TERM RESULTS AND COMPARISON OF SURGICAL TECHNIQUES ACCORDING TO OPTICAL MAGNIFICATION USE IN 100 CASES AT A SINGLE UNIVERSITY HOSPITAL

PURPOSE

We review the long-term results of varicocele repair, and compare the complication rates of varicocelectomy techniques according to optical magnification use in adolescents with varicocele at a single university hospital.

MATERIALS AND METHODS

We prospectively studied 100 males 7 to 19 years old with clinical palpable varicocele. Of the patients 52 (52%) underwent left unilateral varicocelectomy and 48 (48%) underwent bilateral varicocelectomy. Varicocelectomy was performed using a microscope in 49 patients (79 sites), loupe magnification in 25 (35 sites) and no magnification in 26 (34 sites) using either a subinguinal or inguinal approach. Postoperative complications were compared in all patients based on technique. Preoperative and postoperative serum hormone values and semen parameters were compared in 33 patients.

RESULTS

Mean postoperative followup was 30.4 +/- 13.06 months (12 to 65). Total motile sperm count increased from 22.6 million +/- 5.16 million to 64.53 million +/- 12.3 million postoperatively, which was statistically significant (p = 0.002). Postoperative recurrence rates were 0% in cases managed by microsurgical varicocelectomy, 2.9% in those where loupe magnification was used and 8.8% in those where no magnification was used. Postoperative hydrocele rates in these cases were 0%, 2.9% and 5.9%, respectively. The highest rates of recurrence and hydrocele were observed in cases where no magnification was used, compared to those managed by microsurgery (p = 0.03 and p = 0.116, respectively).

CONCLUSIONS

Adolescent varicocele repair improves semen parameters and is a safe method with low recurrence and low complication rates. Our study suggests that the postoperative complication rate significantly decreases with use of higher magnification, such as microscopy. Microsurgical varicocele repair is the best technique with the lowest postoperative rates of recurrence and hydrocele in the treatment of adolescent varicoceles.

Lymphatic sparing laparoscopic varicocelectomy: a microsurgical repair

PURPOSE

The division of lymphatic vessels during pediatric varicocelectomy is complicated by hydrocele formation, testicular hypertrophy due to intratesticular edema and decline in testicular function. To prevent these complications, we introduced a microsurgical lymphatic sparing dissection into laparoscopic varicocelectomy.

MATERIALS AND METHODS

We retrospectively compared outcomes in 104 boys who underwent microsurgical laparoscopic repair for grade II to III varicocele between April 1999 and December 2002 to a group of 67 boys operated on using conventional laparoscopy without lymphatic preservation between January 1997 and March 1999. Using 10x to 20x optical magnification, the lymphatic vessels were identified as colorless tubular structures that were easily separated and preserved.

RESULTS

After a mean followup of 17 months there was no significant difference in varicocele recurrence between the 2 groups (6.7% vs 8.9%, p = 0.56). Hydrocele formation and testicular hypertrophy occurred significantly less frequently after microsurgical repair (1.9% and 2.9%, respectively, vs 17.9% and 20.1% in the conventional group, p = 0.0003). No major complications were encountered.

CONCLUSIONS

Preservation of lymphatics in laparoscopic varicocelectomy is technically feasible, and decreases hydrocele formation and the development of testicular hypertrophy. This microsurgical modification is a safe and efficacious alternative for urologists skilled in reconstructive laparoscopy.

Managing varicoceles in children: results with microsurgical varicocelectomy

Authors from New York present their experience of elective varicocelectomy, using microsurgical techniques, in a large series of children. They found the procedure to be safe and effective, and gave a much lower complication rate than the published rate in open varicocelectomy. The results of urethroplasty in post-traumatic paediatric urethral strictures are presented by authors from Mansoura. They found the overall success of one-stage perineal anastomotic repair of such strictures to be excellent, with very little morbidity.

OBJECTIVE

To report our experience of microsurgical subinguinal varicocelectomy in boys aged < or = 18 years.

PATIENTS AND METHODS

Boys aged < or = 18 years treated with microsurgical varicocelectomy between 1996 and 2000 at one institution were retrospectively reviewed. Indications for surgery included ipsilateral testicular atrophy, large varicocele or pain. Microsurgery was assisted by an operating microscope (x10-25) allowing preservation of the lymphatics, and the testicular and cremasteric arteries. Patient age, varicocele grade, complications and follow-up interval were recorded.

RESULTS

In all there were 97 microsurgical subinguinal varicocelectomies (23 bilateral) in 74 boys (mean age 14.7 years). Left-sided varicoceles were significantly larger (mean grade 2.9) than right-sided (mean grade 1.4) varicoceles. The mean follow-up was 9.6 months. There were four complications: two hydroceles, of which one resolved spontaneously after 4 months; one patient had persistent orchialgia that resolved after 8 months; and one developed hypertrophic scarring at the inguinal incision site. There were no infections, haematomas or intraoperative injuries to the vas deferens or testicular arteries. All boys were discharged home on the day of surgery.

CONCLUSIONS

Microsurgical subinguinal varicocelectomy in boys is a safe, minimally invasive and effective means of treating varicoceles. Compared with published results of the retroperitoneal mass ligation technique, which has a 15% overall complication rate and a 7-9% hydrocele occurrence rate, the microsurgical subinguinal approach appears to offer less morbidity, with a 1% hydrocele rate. We consider that microsurgical subinguinal varicocelectomy offers the best results with lower morbidity than other techniques.

Pediatric varicocele embolization

Varicocele is a very common condition. Although some patients may have pain, it is usually asymptomatic. Treatment of adolescent and pediatric patients is based on the desire to prevent testicular dysfunction and infertility that may be irreversible in adulthood. Venous embolization of the spermatic vein is an effective and minimally invasive method to occlude the varicocele and is known to improve testicular size and function. Embolization can be optimized by use of sclerosant, such as sodium tetradecyl sulfate (STS) foam or ethanol to permanently occlude the internal spermatic vein. About 10 to 15% of patients have recurrent varicocele after embolization. This is usually due to collateral vessels, such as from the right spermatic vein or the splanchnic veins. Embolizing as low as possible, while preventing pampiniform phlebitis by externally compressing the external inguinal ring, and empiric bilateral embolization appear to have the best outcome for preventing recanalization. Complications of varicocele embolization are uncommon. They include pampiniform phlebitis and venous thromboembolism into the renal vein or pulmonary artery.

The effect of varicocele repair on testicular volume in children and adolescents with varicocele

PURPOSE

We investigated the effect of varicocele repair on testicular volume according to age in children and adolescents and review the long-term results of varicocele surgery.

MATERIALS AND METHODS

The study included 39 boys 11 to 19 years old with clinical palpable varicocele who underwent varicocele surgery with at least 1 year of postoperative followup. Preoperative and postoperative testicular volumes were monitored and measured with an ellipsoid Prader orchidometer. Physical examination findings (testicular volumes and testicular consistency) in all boys, and serum hormone values and semen parameters in 16 adolescents were recorded and compared before and after surgery.

RESULTS

Left unilateral varicocelectomy was done in 29 boys (74%) and bilateral varicocelectomy in 10 (26%). While no postoperative hematoma, infection or testicular atrophy was observed, 1 boy (2.5%) had varicocele recurrence and 2 boys (5.1%) had minimal hydroceles that required no intervention. Significant increases were observed in postoperative sperm concentration (p = 0.01), total motile sperm count (p = 0.009), testis volume (p = 0.000) and serum testosterone level (p = 0.014). All 15 boys with preoperative soft testis had normal testicular consistency postoperatively. Of the 19 boys with preoperative testicular atrophy 10 (53%) did regain normal testicular growth, while 9 (47%) retained testicular volume loss after surgery. When comparing preoperative to postoperative increase in testicular volume according to age in all boys, the mean was statistically significantly higher in boys younger than 14 years (left testis p = 0.037, right testis p = 0.000).

CONCLUSIONS

Testicular consistency achieved normal firmness after varicocelectomy in all boys with preoperative soft testis. While there was catch-up growth in comparison to the contralateral testis, testicular consistency improved but testicular volumes may not increase significantly after varicocele repair at ages older than 14 years. However, in these adolescents postoperative semen parameters and serum hormone values may significantly improve regardless of testicular volume. Therefore, boys with varicocele and their families should be fully informed in light of these findings.