TESTICULAR HYPOTROPHY DOES NOT CORRELATE WITH GRADE OF ADOLESCENT VARICOCELE

The prevalence and severity of varicocele in adult population over the age of forty years old: a cross-sectional study

Objectives: To investigate the prevalence and severity of varicocele in adult population over the age of 40. We also measured testicular size, consistency, and total testosterone levels with an aim to observe the effect of varicocele on testis as men age. Methods: Two hundred twenty-four patients with varicocele, 241 patients without varicocele who admitted to our clinic were enrolled in the study. We stratified participants by four age groups (40-49, 50-59, 60-69, >70 yr). Patients were grouped according to varicocele grade and laterality. The morning testosterone level was drawn. The subgroups were compared with each other. Results: Overall, varicocele prevalence was 48%. Of the patients, 104 had unilateral, 120 had bilateral varicocele. Of the patients with varicocele, 62 (13.30%) were found as grade 3, 99 (21.10%) were grade 2, and 63 (13.60%) were grade 1. The percentages of smaller testes in grade 1, grade 2, and grade 3 varicocele group were 20.60, 79.80, and 88.70 and a significant association was detected. Age stratification of the data revealed the smaller and soft testis prevalence as well as higher grade varicocele prevalance increased in older age groups. Conclusions: Varicocele presence is associated with lower testicular size, softer testicular consistency, and lower testosterone levels, especially in older patients with bilateral and high-grade varicocele.

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.

Transitional Urology for Male Adolescents: What Adult Urologists Should Know

In recent years, there has been increasing interest in transitional urology, or how to best prepare patients with major congenital urologic diseases, such as bladder exstrophy and neuropathic bladder, to manage their own health care with adult urologists. However, common pediatric urologic conditions may be encountered by the adult urologist with more regularity. This review focuses on three relatively common conditions which may be identified in childhood, the consequences from which a patient may seek help from an adult urologist: cryptorchidism, varicocele, and Klinefelter syndrome.

Prognostic Predictors of Fertility in Young Adult Patients With Varicocele: Peak Retrograde Flow Velocity and Reflux Grade

OBJECTIVES

The purpose of this study was to determine prognostic factors affecting semen parameters in patients with varicocele during the postadolescent period.

METHODS

This study was approved by the Institutional Review Board. Between May 2013 and May 2015, we prospectively obtained demographic and sonographic data from postadolescent patients with varicocele. Potential risk factors affecting semen parameters, including age at diagnosis, height, weight, body mass index, varicocele laterality, varicocele grade, left testicular volume, right testicular volume, total testicular volume, testicular atrophy index, testicular volume differential, right and left maximum vein diameters, peak retrograde flow velocity, reflux flow volume, and reflux grade in both supine and standing positions, were recorded.

RESULTS

The left peak retrograde flow velocity, reflux flow volume, and reflux grade in the supine and standing positions, left testicular volume, right testicular volume, total testicular volume, and follicle-stimulating hormone level were found to be associated with abnormal semen parameters (P < .05). By multivariate analysis, the follicle-stimulating hormone level was associated with the sperm concentration and morphologic characteristics, and the left peak retrograde flow velocity in the standing position was associated with deterioration of sperm motility and morphologic characteristics. Additionally, the left reflux grade in the standing position was associated with the sperm concentration, and the left testis volume was associated with motility.

CONCLUSIONS

The left peak retrograde flow velocity and reflux grade in the standing position were significantly associated with all semen analysis parameters. This finding supports the use of testicular duplex Doppler sonography as a noninvasive tool for evaluation of testicular function in patients with varicocele and helps clinicians determine patients' fertility status.

Adolescent varicocele: A large multicenter analysis of complications and recurrence in academic programs

OBJECTIVE

After varicocelectomy a wide range of recurrence rates have been reported from 0 to 18%, and rates of post-operative hydrocele formation between 0 and 29%. Controversy exists as to the appropriate approach for varicocele treatment, whether open, laparoscopic, or percutaneous embolization (PE) is best for young men. The literature on treatment of adolescent varicocele is limited to high-volume single surgeon, single institution, or small multi-institution series. Our goal was to evaluate the retreatment and complication rates from numerous institutions to determine more generalizable results.

STUDY DESIGN

The Faculty Practice Solutions Center database was queried to identify males under age 19 years with a diagnosis and/or treatment of varicocele between January 2009 and December 2012. Patients were followed until December 2013 (1-5 years follow-up) to determine if they had occurrence of outcome variables: retreatment, diagnosis, or treatment of hydrocele. Associations of the variables age, race, insurance type, geographical region, surgeon-volume, and surgical approach, with outcome variables were analyzed using a mixed-effects Cox proportional hazard model.

RESULTS

Of 6,729 patients with a diagnosis of varicocele, 1,036 underwent open (405), laparoscopic (530), or percutaneous embolization (PE) (101) treatment by 213 physicians. Retreatment rates after open, laparoscopic, and PE treatments were 1.5%, 3.4% and 9.9%, respectively. Race, region, insurance type, and age were not independently associated with outcomes. The incidence of hydrocele after open, laparoscopic, and PE treatments was 4.9%, 8.1%, and 5%, respectively. No approach was independently associated with diagnosis or treatment of hydrocele. Young age was associated with a significantly higher rate of hydrocele formation. For each year of age, there was a 14% decreased rate of hydrocele formation.

DISCUSSION

Although this series contains the largest cohort of patients, physicians, and institutions, we were limited by the inability to determine actual recurrence rates. Only patients receiving retreatment at the same institution within the 1-5 year follow-up period were captured. As such, the true rate of varicocele recurrence may be higher. The retreatment rate is influenced by the physician's threshold to retreat and the patient's desire to undergo another procedure. Despite its limitations, this is the first study to compare open, laparoscopic, and percutaneous approaches to varicocele treatment.

CONCLUSIONS

Percutaneous embolization has a significantly higher retreatment rate compared with either open or laparoscopic varicocelectomy. Retreatment and hydrocele formation after open and laparoscopic approaches were not significantly different. This supports a surgeon and family choosing an approach based on patient characteristics and surgeon preference.

Evaluation and Management of the Adolescent Varicocele

PURPOSE

Varicocele is one of the most common genital conditions referred to pediatric urologists. Most adolescents with varicocele are asymptomatic and their fertility future (and surgery benefit) is largely unknown. This review assesses varicocele evaluation, management and indications for repair, as well as types and success of varicocelectomy.

MATERIALS AND METHODS

A systematic literature review was performed on Embase™, PubMed® and Google Scholar™ for adolescent varicocele. Original research articles and relevant reviews were examined, and a synopsis of these data was generated for a comprehensive review of clinical adolescent varicocele management.

RESULTS

The prevalence of adolescent varicocele is similar to the adult population. While ultrasound is the most sensitive method for determining testicular volumes, orchidometer measurement may be adequate to gauge significant discordance. Significant hypotrophy of the affected testis with poor total testicular volume may indicate a testis at risk and warrant surgical repair. Similar findings have been noted with an associated high peak retrograde venous flow. Testicular hypotrophy often resolves following surgery but may also improve spontaneously if followed through adolescence. Continued scrotal pain despite adequate support or serial abnormal semen analysis in Tanner stage V boys is an indication for varicocelectomy. Artery and lymphatic sparing techniques (microscopic subinguinal or laparoscopic) are associated with the lowest risk of recurrence and complications.

CONCLUSIONS

Overtreatment and under treatment are medically and financially costly. Abnormal serial semen analysis with or without testicular hypotrophy is an indication for varicocele repair. If observation remains the treatment, followup with an adult urologist should be encouraged until paternity is achieved.

Children and adults varicocele: diagnostic issues and therapeutical strategies

Varicocele is defined as abnormally dilated scrotal veins. It is present in 15 % of normal males and in 40 % of males with infertility. This disorder is a challenge for the physicians involved in the diagnosis and treatment, as the pathophysiology of varicocele is not yet completely understood. For this reason, accurate diagnostic criteria and clear indications for treatment in asymptomatic adolescents or adults with clinical or subclinical varicocele are still not defined. Ultrasonography (US) is considered the best method for calculating the volume of the testicles, measuring vein diameter and monitoring the growth of the testis in adolescent patients. Color-Doppler US is the method of choice for detecting spermatic vein reflux and for classifying the grade of varicocele. Various classification systems have been published with recommendations on how to perform US imaging of the scrotum. Currently, color-Doppler US and spectral analysis are the most effective, non-invasive diagnostic procedures as they allow detection of subclinical varicocele associated with infertility. Various techniques are used in the treatment of varicocele including open surgery, laparoscopic procedures and interventional radiology. However, there is no consensus among physicians on which technique is the most effective in terms of outcome and complication rates. This review shows that color-Doppler US is currently the most widely employed diagnostic method for detection and classification of varicocele caused by venous reflux, as it is reliable and easily performed. The review also highlights the role of varicocelectomy in the management of adult male infertility.

Morphological and surgical overview of adolescent testis affected by varicocele

Varicocele is a common pathology of the testis frequently associated with infertility. For its management, a fine morphological study of the testis, both macroscopically and microscopically, and an accurate choice of surgical procedure are mandatory. The present review focuses its attention on the anatomic substrates of adolescent varicocele and its pathophysiologic modifications. The comprehensive assessment of all the reported alterations should be considered by the clinician before deciding the type of treatment and the timing.

[Varicocele in adolescents]

Testicular varicocele is present in 15 % of adolescent boys. The very impact of this pathology and who will be at risk of developing into infertility remains unclear. Research on the pathophysiology, results of surgical or radiological interventions and potential predictors for long-term impairment of spermatogenesis and thus fertility is still ongoing. Indications for treatment are mainly based on differences in testicular volumes as semen parameters are most often not available; however, whether testicular volume is a valuable prognostic parameter for later fertility remains questionable. Approximately 50 % of adolescent patients with varicocele experience spontaneous increase of testicular volume without any intervention.

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.

The hemodynamic approach to evaluating adolescent varicocele

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

Angiographic findings of primary versus salvage varicoceles treated with selective gonadal vein embolization: an explanation for surgical treatment failure

BACKGROUND AND PURPOSE

Gonadal vein angioembolization is a successful means of primary and salvage treatment for symptomatic varicoceles. We aim to investigate angiographic findings during embolization of primary varicoceles vs those with failed surgical ligation.

PATIENTS AND METHODS

Between 1992 and 2010, 106 cases referred to our interventional radiologists for primary or salvage varicocelectomy were reviewed. These patients underwent venography and gonadal vein embolization using a combination of embolization coils and vascular plugs. All images were reviewed by an interventional radiologist to determine the anatomic etiology of the varicocele. Primary and salvage embolization cohorts were compared using t test and chi-square analyses for continuous and categorical variables, respectively. Angiographic parameters were analyzed using univariate and multivariable regression models to determine significance in predicting primary vs salvage status.

RESULTS

Of the 106 patients, 46 patients (57 testicles) underwent primary and 60 patients (62 testicles) underwent salvage embolization. The salvage cohort of patients was younger (P<0.001) and comprised more solely left-sided pathology (P=0.002). An equivalent number of gonadal vein divisions and proportion of patent gonadal veins was found. However, there was a significantly higher proportion (27.8% vs 6.7%) of inguinal collateral vessels and combined presence of inguinal and retroperitoneal collateral veins (8.5% vs 2.1%) identified in the cohort undergoing embolization after failed surgical varicocelectomy. Presence of inguinal collaterals (P=0.008) as well as presence of both inguinal and retroperitoneal collaterals (P=0.038) on multivariable regression analysis revealed both as independent prognosticators of salvage status.

CONCLUSION

Recurrence after surgical varicocelectomy is associated with increased inguinal collaterals. The pitfall presented by this anatomic variant to surgical ligation may be successfully managed with selective gonadal vein embolization.

Current management principles for adolescent varicocele

The authors review the current approach to management of the adolescent varicocele which has evolved over the past two decades. Principles of observational, surgical and adjunctive management are discussed relative to significant clinical findings. A selective approach to surgical intervention is advocated with the goal of preserving fertility potential.

Testicular symmetry and adolescent varicocele--does it need followup?

PURPOSE

Appropriate management for adolescent varicocele with testicular symmetry is rarely discussed. We examined the natural history of varicocele in patients presenting with testicular symmetry to achieve better understanding of the clinical course.

MATERIALS AND METHODS

Our varicocele registry was queried for adolescent boys who presented with varicocele in association with less than 15% testicular asymmetry and who underwent at least 1 testicular asymmetry assessment 12 or more months later. Patients were stratified into 2 groups based on an initial testicular asymmetry measurement of less than 10% vs 10.0% to 14.9%. Logistic regression modeling was used to analyze the association of Tanner stage, varicocele grade, peak retrograde flow and maximum vein diameter at presentation with increased testicular asymmetry at followup. Kaplan-Meier methodology was applied to compare testicular asymmetry progression rates.

RESULTS

We identified 89 adolescents, of whom 52 (58.4%) and 37 (41.6%) presented with less than 10.0% and 10.0% to 14.9% testicular asymmetry, respectively. Of the patients 37 (41.6%) showed testicular asymmetry progression at a median 18-month followup. The overall 3-year testicular asymmetry progression-free rate was 48% while in patients with peak retrograde flow 30 cm per second or greater it was 23%. On multivariate analysis controlled for age, Tanner stage and varicocele grade a peak retrograde flow of 30 cm per second or greater was associated with worsening testicular asymmetry (OR 4.87, 95% CI 1.6-8.0).

CONCLUSIONS

Adolescents with varicocele and less than 15% testicular asymmetry are at risk for asymmetry during followup. Those with peak retrograde flow 30 cm per second or greater are at increased risk for early asymmetry while those with peak retrograde flow less than 30 cm per second may still show asymmetry but tend to do so after longer followup.

Is the comparison of a left varicocele testis to its contralateral normal testis sufficient in determining its well-being?

OBJECTIVE

To determine whether a size difference between a left testis involved with a varicocele and the contralateral normal testis is sufficient in its size assessment.

METHODS

We reviewed all pediatric scrotal ultrasounds at Helen DeVos Children's Hospital between 2001 and 2008. Sonographic testicular measurements were recorded for patients with clinically diagnosed left varicocele (n = 81 for "varicocele" group) and for patients with no specific pathologic findings (n = 184 for "normal" group). We first compared the sizes between left and right testes for all patients, then between the "varicocele" group and the "normal" group separately for left and right.

RESULTS

There were no significant size differences between left and right testes for the "normal" group, whereas the left was significantly smaller than the contralateral right for the "varicocele" group (P = .0048 for length; P = .012 for volume) for all ages. For boys 16 years or older, both the left and contralateral right testes of "varicocele" boys were smaller than those of "normal" boys, adjusting for age (P for left = .026 for length and .059 for volume; for right P = .033 for length and .031 for volume).

CONCLUSION

Our study confirms that the left testis in boys with varicocele is most often smaller than the contralateral right testis no matter the age. Compared with normal boys in late adolescence, the contralateral right testis is smaller in boys with varicocele.

Testicular contrast harmonic imaging to evaluate intratesticular perfusion alterations in patients with varicocele

PURPOSE

To determine whether changes in intratesticular microcirculation perfusion affect spermatogenesis in patients with left varicocele we performed testicular contrast harmonic imaging.

MATERIALS AND METHODS

A total of 90 patients with left varicocele (oligospermia in 50 and normozoospermia in 40) and 36 controls without varicocele (oligospermia in 16 and normozoospermia in 20) were enrolled in the study. Before contrast harmonic imaging all participants were evaluated by clinical examination, hormonal analysis, semen sample and scrotal ultrasound. We calculated contrast material arrival time in the arteriolar circulation (wash-in), time to peak in arterial circulation, arrival time in the venular circulation (washout) and mean transit time in each testis on contrast harmonic imaging.

RESULTS

We found no difference in the distribution rate of varicocele grade in patients with vs without oligospermia. All contrast harmonic imaging parameters were significantly higher in patients with varicocele plus normozoospermia or oligospermia and controls. We found no significant differences in contrast harmonic imaging parameters in patients with lower varicocele grading with respect to the higher grades. In patients with varicocele we found a negative linear correlation between total sperm count and left mean transit time (r = -0.29). In a multivariate model left mean transit time was the only independent predicting parameter of oligospermia (p <0.05). Mean transit time greater than 36 seconds predicted oligospermia in patients with left varicocele with 78% sensitivity and 58% specificity.

CONCLUSIONS

To our knowledge we report for the first time that testicular contrast harmonic imaging may be a new diagnostic tool able to improve our knowledge about the influence of varicocele on intratesticular microcirculation.

Effects of grade 1 varicocele detected in the pediatric age-group on testicular development

PURPOSE

A number of reports have indicated the effectiveness of varicocelectomy on large varicoceles in adolescents. We carried out a 5-year follow-up study to examine the effect of grade 1 varicocele on testicular development.

METHODS

Of 31 boys with left grade 1 varicocele (mean age, 12.6 years), 10 underwent microsurgical varicocelectomy and 21 were conservatively observed and evaluated for testicular volume and varicocele grade. The control group consisted of 20 healthy age-matched boys without a varicocele. The mean relative left testicular volume was compared with the right testis and the absolute bilateral testicular volumes among the boys in all groups.

RESULTS

Of 21 boys who were observed, 13 (62%) continued to have grade 1 varicocele, 4 (19%) developed grade 2 varicocele, and the other 4 boys (19%) showed spontaneous resolution. Twelve testes (57%) developed in parallel with the right testis, and 1 boy (5%) who experienced spontaneous resolution of the varicocele had catch-up testicular growth, whereas 8 boys (38%) had left testicular growth delay with or without an increasing grade of varicocele. Varicocelectomy, but not observation, improved the previously noted testicular growth delay. Furthermore, right testicular growth delay was also noted during observation.

CONCLUSIONS

More than half of the total number of boys with grade 1 varicocele showed normal development, whereas many boys presented with growth delay in both testes. Thus, we still need to define reliable predictors that will permit selection of the best candidates for varicocelectomy.

Peak retrograde flow: a novel predictor of persistent, progressive and new onset asymmetry in adolescent varicocele

PURPOSE

The major indication for adolescent left varicocelectomy is testicular asymmetry. However, a period of observation is often recommended preoperatively to determine if the asymmetry resolves, persists or progresses. We investigated whether varicocele grade or the duplex Doppler ultrasound measurements of peak retrograde flow and mean vein diameter could be used as predictors of persistent, progressive or new onset asymmetry.

MATERIALS AND METHODS

Only patients with left varicoceles who had undergone at least 2 duplex Doppler ultrasounds without intervening surgery were included in the study. Grade of varicocele, peak retrograde flow and mean vein diameter were analyzed as possible determinants of catch-up growth, or persistent or new onset asymmetry.

RESULTS

A total of 77 patients (mean age 14.3 years, range 9 to 20) were identified with a mean observation period of 13.2 months. Of the patients 50 (65%) had 10% or greater asymmetry at the first measurement. Of patients with initial 20% or greater asymmetry 71% had persistent or worsening asymmetry on followup evaluation. All 14 patients with the combination of an initial peak retrograde flow 38 cm per second or greater and 20% or greater asymmetry had progressive asymmetry on followup examination. Peak retrograde flow was the only significant parameter of predictive value for persistent or worsening asymmetry (p = 0.032).

CONCLUSIONS

Peak retrograde flow can serve as a valuable tool in predicting persistent, progressive and new onset asymmetry. Varicoceles associated with a peak retrograde flow of 38 cm per second or greater and 20% or greater asymmetry should be considered for varicocelectomy at initial presentation. Patients with peak retrograde flow greater than 30 cm per second need to be monitored carefully. Those with peak retrograde flow less than 30 cm per second are less likely to require surgery.

Conservative management of adolescent varicoceles: a retrospective review

OBJECTIVES

To determine whether adolescents with varicoceles experience physiologic testicular "catch-up" growth during development, thereby providing a role for conservative management of adolescent varicoceles.

METHODS

An internal review board-approved retrospective chart review of the Children's Hospital of Eastern Ontario patient database was conducted. Patients presenting with a varicocele between January 1999 and January 2005 were selected. Varicocele grade, ultrasound-determined testicular volume differential over time, and need for surgery were recorded. The difference between left and right testicular volume at diagnosis and at study completion was compared and statistically analyzed.

RESULTS

A total of 33 boys with a median age of 13.4 years (range, 8.8 to 16.1 years) was selected. Patients presented with clinical varicocele grades 3 (63.6%), 2 (33.3%), and 1 (3.0%). Of 33 patients, 3 (9.1%) required surgery for pain (1) and increasing testicular size discrepancy (2). A significant decrease was observed in the percentage difference between left and right testicular volumes over time (P = 0.017). This remained significant even after adjustment for age, length of observation, and need for surgery (P = 0.026). Of 14 patients with an initially significant difference in testicular volume (greater than 20%) who were managed conservatively, 7 experienced testicular catch-up growth (volume differential less than 20%) (P = 0.016).

CONCLUSIONS

Some adolescent boys with a varicocele and considerable testicular size discrepancy manifest significant testicular "catch-up" growth during continued physiologic development. However, those patients who show a testicular size discrepancy that is steadily increasing should be considered for surgical intervention.

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.

Adolescent varicocele

PURPOSE OF REVIEW

Adolescent varicocele is a common lesion which remains poorly understood. Recent research in pathophysiology and surgical management has shed new light on this increasingly diagnosed clinical entity.

RECENT FINDINGS

Recent research demonstrates the potential importance of heat and oxidative stress patterns on testicular dysfunction with varicocele. The importance of testicular volume differentials as a surgical indication have been demonstrated. Surgical innovations have included artery sparing, often with microscopic magnification, and enhanced identification of lymphatics to reduce hydrocele with a laparoscopic approach.

SUMMARY

Optimal management of adolescent varicocele is being clarified. A conservative, selective approach based on testicular volume differentials and semen analysis findings seems appropriate. Techniques affording artery and lymphatic sparing should be employed.