Varicocele: standard and alternative indications for repair

The varicocele: diagnostic dilemmas, therapeutic challenges and future perspectives

A varicocele is defined as the abnormal dilation of the internal testicular vein and pampiniform venus plexus within the spermatic cord. If a semen analysis is not obtained from the adolescent male, in the absence of other symptoms, the main clinical indication used by many urologists to recommend repair is testicular atrophy. The varicocele may result in testicular damage in some males causing testicular atrophy with impaired sperm production and decreased Leydig cell function, while in other males the varicocele may seemingly cause no ill effects. In adult men, varicoceles are frequently present and surgically correctable, yet the measurable benefits of surgical repair are slight according to a Cochrane review. While occurring more commonly in infertile men than fertile men, only 20% of men with a documented varicocele will suffer from fertility problems. Most varicoceles found in adolescents are detected during a routine medical examination, and it is difficult to predict which adolescent presenting with a varicocele will ultimately show diminished testicular function in adolescence or adulthood. As in adults, the mainstay of treatment for varicocele in adolescents is surgical correction. However, unlike an adult varicocelectomy (the microsurgical approach is the most common), treatment for an adolescent varicocele is more often laparoscopic. Nevertheless, the goals of treatment are the same in the adolescent and adult patients. Controversy remains as to which patients to treat, when to initiate the treatment, and what type of treatment is the best. This review will present the current understanding of the etiology, diagnosis and treatment of the adolescent varicocele.

Effect of varicocelectomy on testis volume and semen parameters in adolescents: a meta-analysis

Varicocele repair in adolescent remains controversial. Our aim is to identify and combine clinical trials results published thus far to ascertain the efficacy of varicocelectomy in improving testis volume and semen parameters compared with nontreatment control. A literature search was performed using Medline, Embase and Web of Science, which included results obtained from meta-analysis, randomized and nonrandomized controlled studies. The study population was adolescents with clinically palpable varicocele with or without the testicular asymmetry or abnormal semen parameters. Cases were allocated to treatment and observation groups, and testis volume or semen parameters were adopted as outcome measures. As a result, seven randomized controlled trials (RCTs) and nonrandomized controlled trials studying bilateral testis volume or semen parameters in both treatment and observation groups were identified. Using a random effect model, mean difference of testis volume between the treatment group and the observation group was 2.9 ml (95% confidence interval [CI]: 0.6, 5.2; P< 0.05) for the varicocele side and 1.5 ml (95% CI: 0.3, 2.7; P< 0.05) for the healthy side. The random effect model analysis demonstrated that the mean difference of semen concentration, total semen motility, and normal morphology between the two groups was 13.7 × 10 6 ml-1 (95% CI: -1.4, 28.8; P = 0.075), 2.5% (95% CI: -3.6, 8.6; P= 0.424), and 2.9% (95% CI: -3.0, 8.7; P= 0.336) respectively. In conclusion, although varicocelectomy significantly improved bilateral testis volume in adolescents with varicocele compared with observation cases, semen parameters did not have any statistically significant difference between two groups. Well-planned, properly conducted RCTs are needed in order to confirm the above-mentioned conclusion further and to explore whether varicocele repair in adolescents could improve subsequently spontaneous pregnancy rates.

Varicocele and testicular function

Testicular varicocele, a dilation of the veins of the pampiniform plexus thought to increase testicular temperature via venous congestion, is commonly associated with male infertility. Significant study has clarified the negative impact of varicocele on semen parameters and more recent work has shed light on its detrimental effects on the molecular and ultrastructural features of sperm and the testicular microenvironment, as well as more clearly defined the positive impacts of treatment on couples’ fertility. The relationship between varicocele and testicular endocrine function, while known for some time based on histologic evaluation, has become more apparent in the clinical setting with a growing link between varicocele and hypogonadism. Finally, in the pediatric setting, while future study will clarify the impact of varicocele on fertility and testicular function, recent work supports a parallel effect of varicocele in adolescents and adults, suggesting a re-evaluation of current treatment approaches in light of the progressive nature of the condition and potential increased risk of future disease.

Usefulness of 2010 world health organization reference values for determining indications for varicocelectomy

OBJECTIVE

To investigate the impact of 2010 World Health Organization (WHO) reference values in patients who underwent microsurgical varicocelectomy.

METHODS

This retrospective cohort study included 206 men who underwent microsurgical varicocelectomy for a clinical varicocele with at least 1 abnormal semen parameter according to the 1999 WHO criteria. The preoperative semen analysis findings were reclassified according to the 2010 WHO criteria, and an improved seminal result after varicocelectomy was defined as a ≥20% increase in sperm count or motility.

RESULTS

Semen results of 114 men (55.3%) were reclassified as being above the reference values according to the 2010 WHO criteria. Among those with below reference values, 79.3% and 34.8% showed improved sperm counts and motility, respectively. However, in patients whose semen results converted to normal, 47.4% and 20.2% showed improved sperm counts and motility, respectively. Among those whose semen results were normal on the 2010 criteria, 58.8% showed improved sperm count or motility after microsurgical varicocelectomy.

CONCLUSION

More than half of the patients whose semen results converted to normal on the 2010 WHO criteria showed improved seminal results after microsurgical varicocelectomy. It is necessary to reconsider the 2010 WHO criteria when determining the surgical indication for microsurgical varicocelectomy.

Experimental varicocoele in rats affects mechanisms that control expression and function of the androgen receptor

Varicocoele is an important cause of male infertility. Normal male reproductive function and fertility depends on a delicate balance between androgen receptor (AR) and the classic oestrogen receptors ESR1 (ERα) and ESR2 (ERβ). Using a model of surgically induced varicocoele in rats, this study aimed to investigate the effects of varicocoele on the expression of AR, ESR1, ESR2 and G-protein coupled oestrogen receptor (GPER). Varicocoele did not affect the mRNA and protein expression of ESR1 and ESR2 in both testes. Varicocoele did not affect the mRNA and protein expression of GPER in the right testis, but slightly reduced the mRNA and increased the protein levels in the left testis. Varicocoele did not affect the mRNA for AR, but reduced the protein levels in both testes. A proteomic approach was used in an attempt to find differentially expressed targets with possible correlation with AR downregulation. Varicocoele caused the differential expression of 29 proteins. Six proteins were upregulated, including the receptor for activated C kinase 1 (RACK1), and 23 were downregulated, including dihydrolipoamide dehydrogenase, alpha-enolase and pyrophosphatase 1. Western blot analysis confirmed that varicocoele upregulated the expression of RACK1, a protein involved with tyrosine phosphorylation and regulation of AR transcriptional activity, AR metabolism and dynamics of the blood-testis barrier. In conclusion, this study suggests that varicocoele affects mechanisms that control AR expression and function. This regulation of AR may play an important role in the varicocoele-induced testicular dysfunction. Furthermore, varicocoele downregulates several other proteins in the testis that may be useful markers of spermatozoa function and male infertility.

The use of titanium ligation clips in microsurgical subinguinal varicocelectomy

OBJECTIVE

The aim of this study is to evaluate the use of titanium ligation clips for dilated spermatic veins in microsurgical subinguinal varicocelectomy.

MATERIAL AND METHODS

In this retrospective study, eighty-four men with clinical varicocele underwent microsurgical varicocele repair. The patients were divided into two groups according to the ligation materials used for the varicocelectomy (silk sutures vs. titanium clips). Group 1 included 43 patients; these patients underwent microsurgical subinguinal varicocelectomy with the titanium clips. The 41 patients included in Group 2 underwent microsurgical subinguinal varicocelectomy with silk sutures. Microsurgical subinguinal varicocelectomy was performed in all patients. The two study groups were compared in terms of intra-operative and postoperative parameters.

RESULTS

The mean age of the patients was 28.6±4.6 years, and the mean follow-up was 12.3±2.7 months. The two groups exhibited comparable improvements in sperm motility and/or concentration: 79.1% and 82.9% in Group 1 and Group 2, respectively (p>0.05). The operation time in Group 1 (titanium clip) was significantly shorter than in Group 2 (silk sutures). None of the patients experienced any intra-operative complications. There were no significant differences between Group 1 and Group 2 with regard to postoperative recurrences, ligated veins, postoperative complications and hydrocele formation, hospitalization time, the requirement for postoperative analgesia or the time until the patient could return to work.

CONCLUSION

Titanium ligation clips can be used for the ligation of dilated vessels during microsurgical subinguinal varicocelectomy, and the operation time is significantly reduced with the use of titanium ligation clips.