Adolescent varicocele

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

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

Practice Pattern of Redo Varicocelectomy for Recurrent Varicocele according to Type of Initial Treatment: Retrospective Analysis of a United States-Based Insurance Claims Database

PURPOSE

The objective of this study was to investigate the type of redo varicocelectomy according to the initial surgery type using a large population of USA insurance data.

MATERIALS AND METHODS

This is a retrospective observational cohort study. Administrative claims data were extracted from the IBM® MarketScan Research Database. We included all newly diagnosed patients with varicocele from January 2007 to December 2014 using International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) codes. The treatment methods were identified by Current Procedural Terminology (CPT) code.

RESULTS

A total of 261,785 subjects were diagnosed with varicocele. Of these, a total of 19,800 (7.6%) patients underwent varicocele surgery. Inguinal, abdominal, laparoscopic, microsurgery, and embolization surgery were performed in 66%, 19%, 10%, 3%, and 2%, respectively, as initial treatment. A total of 340 patients (1.7%) underwent redo varicocele surgery. Inguinal, microscopic, embolization, abdominal, and laparoscopic surgery were used as the redo method in 43%, 25%, 16%, 8%, and 7%, respectively. The redo inguinal approach was the preferred method in patients who first underwent inguinal, abdominal, and laparoscopic surgery, but not in patients who underwent microscopic or embolization procedures. Most patients who initially underwent microscopic varicocelectomy or embolization underwent redo varicocelectomy using the same method.

CONCLUSIONS

Compared to the type of initial varicocelectomy, there were changes in the proportion of each type of surgical approach in redo operation procedures. While inguinal varicocelectomy is the most common method in redo operations, the number of microscopic varicocelectomy or embolization procedures is significantly increased in redo surgery.

Adolescent varicocele: Efficacy of indication-to-treat protocol and proposal of a grading system for postoperative hydroceles

BACKGROUND

Varicocele is a common urologic anomaly in adolescent males; however, evidence-based treatment guidelines do not exist. Hydroceles are known to be a common complication after surgical therapy, with a wide variation in the reported incidence between 1 and 40%.

AIM

This study aimed to introduce a standardized indication-to-treat protocol and prove its efficacy by analyzing the outcome of patients. Secondly, it aimed to better define postoperative hydroceles because the wide variation of reported incidence is attributed to a lack of definition.

METHODS

Our standardized treatment protocol included an initial assessment with clinical grading of varicoceles, ultrasound evaluation of testicular volume, and calculation of the atrophy index. Indications for surgical treatment were testicular volume asymmetry >20%, discomfort and pain, or bilateral varicocele. The Palomo procedure (laparoscopically since 2005) was the standard procedure. Postoperative hydroceles were graded according to clinical findings and symptoms: Grade I, sonographic chance finding without clinical correlate; Grade II, palpable but clinically insignificant; Grade III, symptomatic. All patients treated according to the defined protocol were prospectively monitored between January 2001 and December 2015.

RESULTS

A total of 129 patients with left varicocele were referred to our institution; 70 fulfilled the indication criteria for surgical treatment. Twenty-eight of these patients were treated for volume asymmetry, 26 of these showed catch-up growth. Forty-two patients were treated for discomfort and pain; the symptoms subsided in all of them. Postoperative hydroceles were detected in 36 patients (51%). In 29 patients this was a sonographic chance finding (Grade I). Three patients showed a palpable but clinically insignificant postoperative hydrocele (Grade II) and four patients (5.7%) showed symptomatic hydrocele (Grade III) where treatment was recommended.

DISCUSSION

The treatment protocol allowed judicious indication for surgery and postoperative outcomes similar to previous reports. The high rate of catch-up growth in operated cases represents a proxy for successful treatment in cases where more precise parameters, like semen quality or paternity rate, were not yet detectable. The introduced grading system for postoperative hydroceles provs to be a valid and appropriate instrument, and promises to be a standardized method for comparing outcomes in future studies.

CONCLUSION

The indication-to-treat protocol proved to be easily applicable, highly efficient, and have outcomes comparable to international literature. The necessity for a standardized grading of postoperative hydroceles was underscored in the data.

Evaluation of testicular catch-up growth in adolescent microsurgical varicocelectomy

OBJECTIVE

The incidence of varicocele is approximately 15% in adolecent men. Early treatment with varicocele is aimed to resolve testicular hypotrophy and ensure catch-up growth. The aim of this study was to evaluate ipsilateral catch-up growth rates relative to contralateral testicular growth in adolescents with varicocele undergoing microsurgical subinguinal varicocelectomy.

MATERIAL AND METHODS

Fifty adolescents with unilateral grade 2-3 varicoceles were included in the study. All patients underwent microsurgical subinguinal left varicocelectomies performed by the same experienced surgeon. All patients were evaluated clinically and using orchidometric measurements to define the grade of varicocele and testicular volume at presentation and follow-up. The number of internal and external spermatic veins, testicular arteries and lymphatic vessels preserved during the subinguinal microsurgical varicocelectomy were recorded. The mean follow-up period was 26 months (range 6-48 months).

RESULTS

At presentation, mean patient age was 12.9±2.1 years. Mean testicular preoperative volumes were 7.1±4.3 mL for the right and 5.4±3.4 mL for the left testis. There were significant differences between mean volumes of the right and left testis (p=0.002). At the final postoperative follow-up visit, mean testicular volumes were 10.8±5.1 mL (range 3-25) for the right and 9.9±4.3 mL (range 2-20) for the left, and the difference between the right and left testicular volumes was insignificant (p=0.47). In our series, catch-up growth was observed in 70% (35/50) of our patients.

CONCLUSION

Adolescent varicocelectomy is associated with a higher percentage of patients showing testicular catch-up growth. In our study, similarly to the available literature the catch-up growth rate was found as 70% and observed to have positive effects of adolescent varicocelectomy on testicular growth.

The effect of the degree of left renal vein constriction on the development of adolescent varicocele in Sprague-Dawley rats

Experimental models have allowed inquiry into the pathophysiology of varicocele (VC) beyond that possible with human patients. A randomized controlled study in rats was designed to clarify the influence of the degree of left renal vein constriction on the development of adolescent VC. Fifty adolescent male Sprague–Dawley rats (Rattus norvegicus) were randomly assigned to five groups of 10: the experimental groups (I–IV) underwent partial ligation of left renal veins with 0.5-, 0.6-, 0.7-, and 0.8-mm diameter needles, respectively. The control group (V) underwent a sham operation. The diameter of the left spermatic vein (LSV) was measured at baseline and 30 days postoperatively. In addition, the lesion of the left kidney was examined with the naked eye and assessed by Masson's trichrome staining. VC was successfully induced in 2 (20%), 4 (40%), 7 (70%), and 10 (100%) rats in groups I–IV, respectively. The other rats failed to develop VCs primarily due to left renal atrophy. No VC was observed in group V. The postsurgical LSV diameters in VC rats in groups III and IV were 1.54 ± 0.16 and 1.49 ± 0.13 mm, respectively (P > 0.05), and their increments were 1.36 ± 0.10 and 1.31 ± 0.10 mm, respectively (P > 0.05). These results suggest that suitable constriction of the left renal vein is critical for adolescent VC development. In addition, the 0.8-mm diameter needle may be more suitable for inducing left renal vein constriction in adolescent rat models.

Surgical approaches for varicocele in pediatric patient

BACKGROUND

Varicocele represents one of the most common surgically correctible urologic anomalies in adolescent males. The best procedure for the treatment of adolescent varicocele has not been established, but with recent advances in minimal access surgery, there have been many reports praising the safety and efficacy of laparoscopy and retroperitoneoscopy for the surgical correction of varicocele in adolescent. The aim of this review is to compare the results of Palomo's technique, with retroperitoneoscopic and transperitoneoscopic approaches in adolescent, analyzing recurrence, testicular growth and complications.

METHODS

A literature search on PubMed and Cochrane Database was conducted with regard to management of varicocele in adolescent population. Twenty two English language studies that compared outcome of different minimally invasive treatments or outcome of minimally invasive and traditional surgical treatments for adolescent diagnosed with varicocele were included.

RESULTS

Intraoperative complications of minimally invasive approaches occur in early cases, but in pediatric urology these procedures would become more efficient with experience and these approaches continue to increase in number. Postoperative hydrocele is the most postoperative compliance of Palom technique, and reports have shown a wide range of variability for his incidence, depending on the technique used for surgical treatment. Literature showed an increase of testicular volume for real growth of testis after surgery, and an intratesticular improvement in sperm quality after minimally invasive approach. In laparoscopic approach reports have showed very low recurrence because allows better vision of collateral veins, and a lymphatic sparing technique permit to identify lymphatic vessels in 100% of cases.

CONCLUSIONS

The literature has shown that laparoscopic varicocelectomy is the surgical approach most commonly reported in adolescent patients, and that its use is increasing for better training for surgeons and the ability to avoid operational hydrocele that is a main complication after technical Palomo's technique.

Practice patterns in the surgical approach for adolescent varicocelectomy

Objective

To describe practice patterns in the choice of surgical approach for adolescent varicocelectomy using the Pediatric Health Information System (PHIS) database.

Methods

Hospitals enrolled in the PHIS database that reported all outpatient surgeries by CPT code from 2003 to 2012 were included. Patients at least 10 years of age whose records contained both the ICD-9 code for varicocele (456.4) and a CPT code for varicocelectomy [55550 (laparoscopic), 55530 (open inguinal), 55535 (open abdominal)] were identified. Microsurgical approach was identified by the add-on CPT code 69990. Comparisons among surgical approaches were made using one-way ANOVA, and time trend was evaluated with linear regression.

Results

A total cohort of 2528 patients was identified from 38 hospitals. Laparoscopic approach was utilized in 53.6 % of patients. (n = 1354) Microsurgical approach was reported in only 2 % (n = 23) of open varicocelectomies. A subgroup analysis was performed including only those hospitals that reported varicocelectomies in every year of the study period. (n = 587) In this subgroup, 57 % of cases were performed laparoscopically (n = 333), and the trend in laparoscopic cases within this subgroup remained stable over the study period (r² = 0.00, p = 0.97).

Conclusions

Laparoscopic varicocelectomy was the most commonly reported surgical approach in this cohort, and the distribution of surgical approaches appeared to remain stable between 2003 and 2012. While subinguinal microsurgical repair has become the gold standard for management of varicocele in adults with infertility, this technique does not appear to be widely adopted in adolescents, though use of an operating microscope is likely underreported in the PHIS database.

Evaluation of heat-shock protein A2 (HSPA2) in male rats before and after varicocele induction

Varicocele is a major cause of infertility and may impair spermatogenesis. This study evaluated the molecular consequences of varicocele on the induction of heat-shock proteins, intracellular chaperones involved in stress responses, and of the ubiquitin-proteasome system, which is participates in the removal of defective sperm in the testis and epididymis. Wistar rats were randomly divided into three groups: surgically induced left varicocele, sham-operated, and untreated controls. Two months after surgery, we observed significantly reduced sperm parameters, DNA integrity, and protamine content in the sperm retrieved from the left epididymis compared to the right epididymis in the varicocele group, as well as compared to sperm retrieved from the left epididymis of the sham and control groups. According to Western blot analysis, we observed significantly higher HSPA2 expression in testicular tissue from the left testis compared to the right testis in the varicocele group or the left testis of the control group. Immunohistochemical analysis showed that expression of HSPA2 was higher in the round spermatid and sperm from the left varicocele compared to the control group. There was normally less HSPA2 expressed in the caput and corpus compared to the cauda of the epididymis in the control group, but this pattern was altered in the caput epididymis of the varicocele group. Levels of ubiquitination were also remarkably lower in the left testis of the varicocele group. Therefore, varicocele impacts expression of HSPA2 and ubiquitination.

Role of varicocele repair for male infertility in the era of assisted reproductive technologies

Varicocele is an abnormal condition characterized by dilatation of the pampiniform plexus veins draining the testis and is present in 15 % of men. Varicoceles have an adverse effect on spermatogenesis and are the most common cause of male infertility. Approximately 35 % of infertile men and more than 70 % of men with secondary infertility were reported to have varicoceles. Although data on methods of varicocele repair are accumulating, there remains controversy regarding the indications and techniques for varicocele repair. In addition, the role of varicocele repair in this era of assisted reproductive technologies continues to be debated. In this study, we performed a comprehensive PubMed search in order to review the current status of varicocele repair for male infertility. We reviewed English-language studies published from 1992 through 2013. After reviewing the articles, we identified a recent meta-analysis of four randomized controlled trials, which found that varicocele repair for oligozoospermic men was associated with better pregnancy rates as compared with observation. Our review of prospective studies showed that all semen parameters, including sperm concentration, motility, and progressive motility, were significantly improved after varicocele repair. We also summarize the findings of recent studies reporting beneficial effects of varicocele repair, i.e., decreased oxidative stress and sperm DNA fragmentation after varicocele repair and superior cost effectiveness versus in vitro fertilization/intracytoplasmic sperm injection alone, which may be important in the era of assisted reproductive technologies. Varicocele repair is a widespread, well-established procedure that can improve semen parameters in men with infertility. The effect of such treatment on the pregnancy rate is unclear because evidence is limited due to difficulties in recruiting patients for studies. Among the repair techniques, microsurgical repair using a subinguinal approach is potentially the best practice, although this procedure requires training in microsurgery. All these topics require further research in studies with sufficient patient enrollment and follow-up.

Adolescent and young adult male health: a review

Adolescent and young adult male health receives little attention, despite the potential for positive effects on adult quality and length of life and reduction of health disparities and social inequalities. Pediatric providers, as the medical home for adolescents, are well positioned to address young men's health needs. This review has 2 primary objectives. The first is to review the literature on young men's health, focusing on morbidity and mortality in key areas of health and well-being. The second is to provide a clinically relevant review of the best practices in young men's health. This review covers male health issues related to health care access and the Centers for Disease Control and Prevention's Healthy 2020 objectives for adolescents and young adults, focusing on the objectives for chronic illness, mortality, unintentional injury and violence, mental health and substance use, and reproductive and sexual health. We focus, in particular, on gender-specific issues, particularly in reproductive and sexual health. The review provides recommendations for the overall care of adolescent and young adult males.

Inguinal and genital anomalies

Problems of the groin and genitalia are a common presenting complaint in both pediatrician's offices and emergency departments. The authors endeavor to provide a comprehensive review of the most common inguinal and genital anomalies encountered by the pediatrician, with a special focus on examination and management.

Varicocele surgery: 10 years of experience in two pediatric surgical centers

AIM

The study was designed to compare recurrence rates and complications after laparoscopic versus open varicocele surgery in children.

SUBJECTS AND METHODS

A retrospective case-note review of all varicocele surgery over a 10-year period (April 1999-March 2009) in two pediatric surgical centers was performed. Multivariate analysis using logistic regression was performed using SPSS Statistics version 18 (SPSS Inc., Chicago, IL).

RESULTS

Thirty-seven patients had varicocele surgery during the study period. The median age at surgery was 14 years (range, 11-16 years). Most children had left-sided Grade 2 varicocele. Twenty-five (68%) primary procedures were laparoscopic (17 artery-sparing), and 12 (32%) procedures were open (9 artery-sparing). Six (16%) children had recurrence, and 6 (16%) had postoperative hydrocele. Recurrence rates after laparoscopic (16%) and open (17%) surgery were similar. Increasing age significantly decreased recurrence (odds ratio, 0.373; 95% confidence interval 0.161-0.862; P = .021). Although laparoscopy was associated with higher rates of postoperative hydrocele (odds ratio, 2.817; 95% confidence interval, 0.035-3.595; P = .380) and artery-sparing ligation was associated with higher rates of recurrence (odds ratio, 2.667; 95% confidence interval, 0.022-4.235; P = .787), these associations were not statistically significant.

CONCLUSIONS

The best results of varicocele surgery in terms of recurrence and postoperative hydrocele were achieved by open mass ligation; however, larger prospective studies are warranted.

Pediatric robot-assisted laparoscopic varicocelectomy

PURPOSE

We determined the feasibility and safety of robot-assisted laparoscopic varicocelectomy (RALV) in the pediatric population compared with laparoscopic varicocelectomy (LV).

PATIENTS AND METHODS

We identified all patients who underwent RALV since April of 2006. For each case, we selected two age-matched controls who underwent LV and compared the groups in terms of operative times, postoperative complications, and hospital charges. Statistics were determined using the Student t test and the Fisher exact test.

RESULTS

Four patients underwent RALV with a mean age of 15.3 years (standard deviation 1.3). All varicoceles were left-sided. Two patients had testicular size discrepancy at presentation (mean 24%). Mean operative times were 112 minutes for RALV vs 73 minutes for LV (P = 0.02). No intraoperative or postoperative complications were experienced in the RALV group. The mean total hospital charge-including facility, equipment, anesthesiology, and recovery room fees, but excluding surgeon's professional fees-was significantly higher for the robot-assisted group ($15,800 vs $8,600, P = 0.0005).

CONCLUSION

We report the first RALV in a pediatric patient population. We demonstrate that it is technically feasible with no intraoperative complications. It remains to be seen whether RALV is cost effective over LV.