The adolescent varicocele: what's new with an old problem in young patients?

Mean platelet volume might be an effective indicator of poor semen quality in varicocele patients

OBJECTIVE

To delve into the relationship between mean platelet volume (MPV) and semen quality in patients with varicocele.

MATERIALS AND METHODS

A total of 246 varicocele patients and 120 healthy adult males were enrolled. Physical examinations and the color Doppler ultrasonography were conducted on patients with varicocele to confirm the diagnosis. Venous blood samples and semen samples were collected from all participants for subsequent analysis. A series of statistical analyses were conducted to assess the relationship between their MPV levels and semen quality. A series of statistical analyses were performed to assess the relationship between MPV and semen quality.

RESULTS

No statistically significant differences were found between body mass index (BMI), sexual hormones, semen volume, platelet count, and right testicular volume in all three groups (health subjects, varicocele without symptoms, and varicocele with infertility). When conducting regression analysis on two groups with varicocele, the results indicated that a lower MPV is associated with a reduced risk of varicocele accompanied by infertility (OR = 0.557 95% CI: 0.432-0.719, P < 0.001). Further correlation analysis in varicocele patients revealed that high MPV had a statistically negative impact on the occurrence of poor semen quality, affecting sperm concentration, progressive motility, and morphology (all P < 0.001). More importantly, when predicting varicocele associated with infertility, MPV demonstrated high diagnostic sensitivity (AUC = 0.745, P < 0.001).

CONCLUSION

Our results indicate that MPV is higher in varicocele with infertility and is closely related to semen quality, which may suggest an accompanying decline in semen quality associated with varicocele. However, these conclusions require further experimental validation.

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.

Peak retrograde flow a potential objective management tool to identify young adults with varicocele 'at risk' for a high sperm DNA fragmentation

INTRODUCTION

Determining which patients are negatively affected by varicocele would enable clinicians to better select those men who would benefit most from surgery. Since conventional semen parameters, have been limited in their ability to evaluate the negative effects of varicocele on fertility, specialized laboratory tests have emerged.

OBJECTIVE

To identify clinical and ultrasound parameters (including PRF) which would negatively influence standard and functional semen variables in young adults with a varicocele.

DESIGN

Prospective, cross-sectional observational study.

SETTING

Antwerp University Hospital, Belgium.

PATIENT(S)

Young volunteers between 16 and 26 years, Tanner 5, were recruited.

INTERVENTION(S)

Every participant had a scrotal ultrasound to calculate testicular volumes. If a varicocele was present, the grade, vein diameter, peak retrograde flow (PRF) in supine position and spontaneous reflux in standing position were measured. All participants provided a semen sample. Standard semen parameters were analyzed and sperm DNA fragmentation.

MAIN OUTCOME MEASURE(S)

Of all clinical and ultrasound parameters tested, PRF was an objective tool identifying young adults with a varicocele. PRF was highlighted by the prevalence of SDF, both in the total and vital fractions of the spermatozoa, providing opportunities to manage such 'at-risk' adolescents/young adults.

RESULT(S)

Total SDF was significantly increased in grade 3 varicocele compared to grade 1 and 2 but no significant difference with vital SDF or standard descriptive semen parameters was seen. Total and vital SDF on the other hand were significantly increased when PRF was above 38.4 cm/s. Standard semen analysis showed no difference with PRF as an independent predictor. Testicular atrophy index, varicocele vein diameter and spontaneous reflux revealed no significant differences in both the descriptive and functional semen variables.

DISCUSSION

Descriptive semen parameters showed no significant difference between the non-varicocele controls and the varicocele group with low and high PRF. Increased PRF negatively influenced sperm quality via increased DNA fragmentation both in the total as in the vital fractions of the semen.

CONCLUSION(S)

Of all clinical and ultrasound parameters tested, PRF was an objective non-invasive tool to identify varicocele patients at risk for a high SDF.

Effect of varicoceles on spermatogenesis

Varicoceles are dilated veins within the spermatic cord and a relatively common occurrence in men. Fortunately, the large majority of men are asymptomatic, however, a proportion of men with varicoceles can suffer from infertility and testosterone deficiency. Sperm and testosterone are produced within the testis, and any alteration to the testicular environment can negatively affect the cells responsible for these processes. The negative impact of varicoceles on testicular function occurs mainly due to increased oxidative stress within the testicular parenchyma which is thought to be caused by scrotal hyperthermia, testicular hypoxia, and blood-testis barrier disruption. Management of varicoceles involves ligation or percutaneous embolization of the dilated veins. Repair of varicoceles can improve semen parameters and fertility, along with serum testosterone concentration. In this review, we discuss the pathophysiology of varicoceles, their impact on testicular function, and management.

Surgical or radiological treatment for varicoceles in subfertile men

BACKGROUND

Varicoceles are associated with male subfertility; however, the mechanisms by which varicoceles affect fertility have yet to be satisfactorily explained. Several treatment options exist, including surgical or radiological treatment, however the safest and most efficient treatment remains unclear.  OBJECTIVES: To evaluate the effectiveness and safety of surgical and radiological treatment of varicoceles on live birth rate, adverse events, pregnancy rate, varicocele recurrence, and quality of life amongst couples where the adult male has a varicocele, and the female partner of childbearing age has no fertility problems.

SEARCH METHODS

We searched the following databases on 4 April 2020: the Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL. We also searched the trial registries and reference lists of articles.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) if they were relevant to the clinical question posed and compared different forms of surgical ligation, different forms of radiological treatments, surgical treatment compared to radiological treatment, or one of these aforementioned treatment forms compared to non-surgical methods, delayed treatment, or no treatment. We extracted data if the studies reported on live birth, adverse events, pregnancy, varicocele recurrence, and quality of life.

DATA COLLECTION AND ANALYSIS

Screening of abstracts and full-text publications, alongside data extraction and 'Risk of bias' assessment, were done dually using the Covidence software. When we had sufficient data, we calculated random-effects (Mantel-Haenszel) meta-analyses; otherwise, we reported results narratively. We used the I² statistic to analyse statistical heterogeneity. We planned to use funnel plots to assess publication bias in meta-analyses with at least 10 included studies. We dually rated the risk of bias of studies using the Cochrane 'Risk of bias' tool, and the certainty of evidence for each outcome using the GRADE approach.

MAIN RESULTS

We identified 1897 citations after de-duplicating the search results. We excluded 1773 during title and abstract screening. From the 113 new full texts assessed in addition to the 10 studies (11 references) included in the previous version of this review, we included 38 new studies, resulting in a total of 48 studies (59 references) in the review providing data for 5384 participants. Two studies (three references) are ongoing studies and two studies are awaiting classification. Treatment versus non-surgical, non-radiological, delayed, or no treatment Two studies comparing surgical or radiological treatment versus no treatment reported on live birth with differing directions of effect. As a result, we are uncertain whether surgical or radiological treatment improves live birth rates when compared to no treatment (risk ratio (RR) 2.27, 95% confidence interval (CI) 0.19 to 26.93; 2 RCTs, N = 204; I² = 74%, very low-certainty evidence). Treatment may improve pregnancy rates compared to delayed or no treatment (RR 1.55, 95% CI 1.06 to 2.26; 13 RCTs, N = 1193; I² = 65%, low-certainty evidence). This suggests that couples with no or delayed treatment have a 21% chance of pregnancy, whilst the pregnancy rate after surgical or radiological treatment is between 22% and 48%. We identified no evidence on adverse events, varicocele recurrence, or quality of life for this comparison. Surgical versus radiological treatment We are uncertain about the effect of surgical versus radiological treatment on live birth and on the following adverse events: hydrocele formation, pain, epididymitis, haematoma, and suture granuloma. We are uncertain about the effect of surgical versus radiological treatment on pregnancy rate (RR 1.13, 95% CI 0.75 to 1.70; 5 RCTs, N = 456, low-certainty evidence) and varicocele recurrence (RR 1.31, 95% CI 0.82 to 2.08; 3 RCTs, N = 380, low-certainty evidence). We identified no evidence on quality of life for this comparison. Surgery versus other surgical treatment We identified 19 studies comparing microscopic subinguinal surgical treatment to any other surgical treatment. Microscopic subinguinal surgical treatment probably improves pregnancy rates slightly compared to other surgical treatments (RR 1.18, 95% CI 1.02 to 1.36; 12 RCTs, N = 1473, moderate-certainty evidence). This suggests that couples with microscopic subinguinal surgical treatment have a 10% to 14% chance of pregnancy after treatment, whilst the pregnancy rate in couples after other surgical treatments is 10%. This procedure also probably reduces the risk of varicocele recurrence (RR 0.48, 95% CI 0.29, 0.79; 14 RCTs, N = 1565, moderate-certainty evidence). This suggests that 0.4% to 1.1% of men undergoing microscopic subinguinal surgical treatment experience recurrent varicocele, whilst 1.4% of men undergoing other surgical treatments do. Results for the following adverse events were inconclusive: hydrocele formation, haematoma, abdominal distension, testicular atrophy, wound infection, scrotal pain, and oedema. We identified no evidence on live birth or quality of life for this comparison. Nine studies compared open inguinal surgical treatment to retroperitoneal surgical treatment. Due to small sample sizes and methodological limitations, we identified neither treatment type as superior or inferior to the other regarding adverse events, pregnancy rates, or varicocele recurrence. We identified no evidence on live birth or quality of life for this comparison. Radiological versus other radiological treatment One study compared two types of radiological treatment (sclerotherapy versus embolisation) and reported 13% varicocele recurrence in both groups. Due to the broad confidence interval, no valid conclusion could be drawn (RR 1.00, 95% CI 0.16 to 6.20; 1 RCT, N = 30, very low-certainty evidence). We identified no evidence on live birth, adverse events, pregnancy, or quality of life for this comparison.

AUTHORS' CONCLUSIONS

Based on the limited evidence, it remains uncertain whether any treatment (surgical or radiological) compared to no treatment in subfertile men may be of benefit on live birth rates; however, treatment may improve the chances for pregnancy. The evidence was also insufficient to determine whether surgical treatment was superior to radiological treatment. However, microscopic subinguinal surgical treatment probably improves pregnancy rates and reduces the risk of varicocele recurrence compared to other surgical treatments. High-quality, head-to-head comparative RCTs focusing on live birth rate and also assessing adverse events and quality of life are warranted.

Varicocoele and oxidative stress: New perspectives from animal and human studies

BACKGROUND

Varicocoele (VCL), one of the main causes of male subfertility, negatively affects testicular function. Due to limited access to human testicular tissue, animal model studies have been used to evaluate molecular and, recently, epigenetic changes attributed to pathophysiology induced by VCL.

OBJECTIVES

This review aims to provide an update on the latest findings regarding the link between VCL-induced biochemical stress and molecular changes in germ cells and spermatozoa. Endocrine and antioxidant status, testicular chaperone-specific hemostasis failure, altered testicular ion balance, metabolic disorders, and altered carbon cycling during spermatogenesis are among the many features that will be presented.

DISCUSSION

Literature review coupled with our own findings suggests that ionic imbalance, hypoxia, hyperthermia, and altered blood flow could lead to severe chronic oxidative and nitrosative stress in patients with VCL leading to defective spermatogenesis and impairment of the integrity of all sperm cell components and compartments down to the epigenetic information they carry.

CONCLUSION

Since oxidative stress is an important feature of the reproductive pathology of VCL, therapeutic strategies such as the administration of appropriate antioxidants could be undertaken as a complementary non-invasive treatment line.

The relationship between epicardial fat thickness and high-grade varicocele

BACKGROUND

Varicocele is abnormal dilation of testis veins. The precise mechanism of varicocele is not fully understood despite some hypothesis were suggested in the literature. Disequilibrium between constrictor and dilatator mechanism of the veins have been shown to cause varicocele. High-grade varicoceles have been also linked to endothelial dysfunction and increased vasoconstriction.

OBJECTIVES

We hypothesized that epicardial fat thickness (EFT), flow-mediated dilatation (FMD) and aortic stiffness (AS) could be associated with varicocele. In the present study, we aimed to compare vascular parameters such as FMD, EFT and AS in healthy subjects and high-grade varicocele patients.

METHODS

The study population consisted of 35 men with high-grade varicocele and 32 age- and sex-matched control subjects younger than 45 years old. This is a cross-sectional study conducted at Bolu Abant Izzet Baysal University Hospital between May to October 2018.

RESULTS

EFT, aortic diastolic diameters (AoDD) and EFT/BMI ratio were significantly higher in control group than in patients with high-grade (p=0.012, p=0.044, p=0.026, respectively). EFT and EFT /BMI ratio were significantly and inversely correlated with presence of varicocele (r=-0.422, p=0.009; r=-0.38, p=0.026, respectively).

CONCLUSION

The present study suggests that high-grade varicocele may be associated with decreased echocardiographic EFT but not with aortic stiffness and FMD.

Hypertension and Unilateral Varicoceles in a Young Male: Harbinger of a Sinister Finding

A 26-year-old young male presented with recent onset hypertension and left-sided varicocele. On physical examination, his blood pressure was elevated and varicoceles were visible. On evaluation with computed tomography of abdomen, a large left-sided para-aortic mass was seen. His 24-hour urinary metanephrines and normetanephrines levels were within normal limits. Subsequently, the mass was excised. Tumor was excised completely after carefully dissecting it from left kidney and final histopathology revealed paraganglioma and postoperatively varicoceles disappeared.

Sertoli Cell Alterations in Peripubertal Varicocelized Rats: Evidence of Primary Damage on Spermatogenesis

Idiopathic varicocele is closely associated with male infertility or subfertility. Sertoli cell is a very important regulator of spermatogenesis. We investigated the morphofunctional alterations in the Sertoli cell and its possible involvement in the establishment of testicular primary lesion in experimental left-sided varicocele, induced from peripuberty. Twenty-five male peripubertal rats (44 days postpartum [dpp]) were distributed into two groups: control (C) and varicocele (V). Experimental left varicocele was induced in rats through the partial ligature of the left renal vein. Euthanasia was performed at 100 dpp. Testicular histopathology and testosterone plasmatic level were evaluated. Transferrin and vimentin proteins were, respectively, used as immunomarkers of Sertoli cell function and structure. Significant reductions in vimentin and transferrin expressions were noticed in androgen-dependent stages (VII and VIII) of the seminiferous epithelium cycle in V rats; testosterone plasmatic level was also reduced. Bilateral testicular histopathological alterations were found in V rats, mainly massive germ cell desquamation. The histological damage and changes in protein expressions occurred bilaterally. The relevant impairment of the functional and structural characteristics of the Sertoli cell, together with the typical massive germ cell desquamation, indicates that Sertoli cell changes can primarily contribute to the significant testicular dysfunction associated with varicocele.

The association between TNP2 gene polymorphisms and Iranian infertile men with varicocele: A case-control study

Background

Numerous researches have provided great evidence that revealed the relationship between varicocele and sperm DNA damage.

Objective

Because of the crucial role of nuclear transition proteins (TPs) in sperm DNA condensation and integrity, this case-control study was designed to study TNP2 gene nucleotide variations in Iranian patients with varicocele.

Materials and Methods

PCR-SSCP and DNA sequencing were used to search for mutations in exons 1 & 2 of the TNP2 gene in 156 infertile patients with varicocele and 150 fertile men.

Results

The results of sequencing showed three variants at positions c.301C░>░T (p.R101C), c.391C░>░T (p.R131░W), and g.IVS1-26G░>░C (rs8043625) of TNP2 gene. It was found that varicocele risk in men who have the CC genotype of g.IVS1-26G░>░C SNP is higher than those who don't have these genotypes (according to Co-dominant model, Dominant model, Recessive model, and Over-dominant model). The haplotype-based analysis showed that (C/C/T) and (C/T/T) haplotypes were a risk factor of in patients with varicocele compared to controls (OR░=░3.278, p░=░0.000 and OR░=░9.304, p░=░0.038, respectively).

Conclusion

Because of the significant difference in the genotype and allele frequencies of g.IVS1-26G░>░C SNP in the intronic region of TNP2 in patients with varicocele compared with controls and also because of the high conservation of this SNP position during evolution, this SNP may be involved in some important processes associated with the expression of this gene like mRNA splicing, but the exact mechanism is not clear.

Best practice in the diagnosis and treatment of varicocele in children and adolescents

A varicocele is an abnormal dilation of the pampiniform plexus of veins in the scrotum which begins at puberty in approximately 15% of males. Although common in the general population and often asymptomatic, varicoceles are associated with gonadal dysfunction including testicular atrophy, infertility, and hypogonadism in a subset of men diagnosed later in life. Because of the high prevalence and uncertain pathogenesis, definitive management guidelines for varicoceles diagnosed in the pediatric and adolescent population remain poorly defined. The varicocele is the most common etiology of male factor infertility, and treatment in the pediatric and adolescent population may improve semen quality and improve fecundity in adulthood. Evaluation of the pediatric and adolescent varicocele should include history, physical exam, and measurement of testicular volume with orchidometer or ultrasound. Testicular volume differentials and peak retrograde flow on Doppler ultrasonography are important factors in risk stratification of the pediatric varicocele population. Semen analysis and reproductive endocrine assessment should also be considered as part of the workup for adolescent patients. A variety of treatment approaches exist for varicocele, and while the microsurgical subinguinal approach is the gold standard for the adult population, it has yet to be confirmed as superior for the adolescent population. Referral to an andrologist for the adolescent patient with varicocele should be considered in equivocal cases. While active treatment of varicocele in the pediatric and adolescent population is controversial, it is clear that some untreated patients will suffer symptoms later in life, while overtreatment remains a concern for this large, vulnerable population. Therefore, surveillance strategies and improved accuracy in diagnosis of clinically important pediatric varicoceles prompting treatment are needed in the future.

Varicocele Management Strategies and Resulting Paternity Rates in a Cohort of Young Adults

OBJECTIVE

To evaluate the paternity rate in a large cohort of asymptomatic adult varicocele patients undergoing nonsurgical management and surgery.

METHODS

The study population included 1845 men with varicocele and 9286 healthy controls. All data were retrospectively obtained from the Israeli Defense Forces medical database. Patients were divided according to the management strategy: 1758 (95.2%) were followed up nonsurgically, 63 (3.4%) had preventive surgery (patients without known infertility), and 24 (1.4%) had secondary surgery (patients with varicocele and primary infertility) as young adults. The primary outcome was the live birth rate.

RESULTS

The live birth rate was similar in the preventive surgery and control groups. Both preventive surgery and control groups had higher live birth rate than the nonsurgical group. Finally, the secondary surgery group had the lowest live birth rate of all groups.

CONCLUSION

Preventive surgery for asymptomatic varicocele provides similar fertility outcomes to control groups, whereas nonsurgical strategy provides inferior outcomes and may be overutilized.

Perspectives in Pediatric Pathology, Chapter 20. Adolescent Varicocele

Varicocele is characterized by elongation, dilatation, and tortuosity of the veins draining the testis and its covers, causing circulatory reflux along the inner spermatic vein [ 1 ]. Varicocele results in progressive testicular lesions and, if untreated, can lead to testicular atrophy [ 2 ]. Varicocele is considered the most frequently identified cause of male infertility [ 3 ]. The mechanisms involved in varicocele formation are not well known and probably are multiple, differing from one patient to another.

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.

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.

Diagnosis of clinical and subclinical varicocele: how has it evolved?

In this review, we examine the evolution and application of various diagnostic modalities for varicoceles starting with venography, scintigraphy, and thermography and their role in the evaluation of a varicocele patient. Some of these methods have been supplanted by less invasive and more easily performed diagnostic modalities, especially ultrasound and Doppler examination of the scrotum. Advances in ultrasound and magnetic resonance imaging hold the potential to expand the role of imaging beyond that of visual confirmation and characterization of varicoceles. The ability to identify the early indicators of testicular dysfunction based on imaging findings may have implications for the management of varicoceles in the future.

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.

Spermatozoa protein alterations in infertile men with bilateral varicocele

Among infertile men, a diagnosis of unilateral varicocele is made in 90% of varicocele cases and bilateral in the remaining varicocele cases. However, there are reports of under-diagnosis of bilateral varicocele among infertile men and that its prevalence is greater than 10%. In this prospective study, we aimed to examine the differentially expressed proteins (DEP) extracted from spermatozoa cells of patients with bilateral varicocele and fertile donors. Subjects consisted of 17 men diagnosed with bilateral varicocele and 10 proven fertile men as healthy controls. Using the LTQ-orbitrap elite hybrid mass spectrometry system, proteomic analysis was done on pooled samples from 3 patients with bilateral varicocele and 5 fertile men. From these samples, 73 DEP were identified of which 58 proteins were differentially expressed, with 7 proteins unique to the bilateral varicocele group and 8 proteins to the fertile control group. Majority of the DEPs were observed to be associated with metabolic processes, stress responses, oxidoreductase activity, enzyme regulation, and immune system processes. Seven DEP were involved in sperm function such as capacitation, motility, and sperm-zona binding. Proteins TEKT3 and TCP11 were validated by Western blot analysis and may serve as potential biomarkers for bilateral varicocele. In this study, we have demonstrated for the first time the presence of DEP and identified proteins with distinct reproductive functions which are altered in infertile men with bilateral varicocele. Functional proteomic profiling provides insight into the mechanistic implications of bilateral varicocele-associated male infertility.

Left renal vein compression as cause for varicocele: prevalence and associated findings on contrast-enhanced CT

PURPOSE

The purpose of this study is to determine the prevalence of left renal vein compression in patients with varicoceles.

METHODS

Abdominal and pelvis contrast-enhanced CT images from 100 male patients with varicoceles (mean age 50.6 years) and 100 matched control patients (mean age 49.8 years) were retrospectively reviewed. The diameter of the left renal vein was measured as it crosses between the aorta and superior mesenteric artery and was classified as compressed if there was greater than 50% narrowing. The diameter of the left gonadal vein was measured at the origin. Comparison of the prevalence of left renal vein compression was made via a Chi-squared test and the gonadal vein diameter via a t test.

RESULTS

The distribution of varicoceles was 68 on the left, 24 bilateral, and 8 on the right. Compression of the left renal vein was significantly more common in the left varicocele (78%, 53/68) than in the bilateral varicocele (42%, 10/24, p = 0.002), right varicocele (13%, 1/8, p < 0.001), or control group (10%, 10/100, p < 0.001). In the subgroup analysis, the gonadal vein diameter was significantly greater in the left varicocele (mean 5.6 mm) than in the bilateral varicocele (mean 4.6 mm, p = 0.018), right varicocele (mean 3.2 mm, p < 0.001), and control group (mean 3.1 mm, p < 0.001).

CONCLUSION

Left renal vein compression by the superior mesenteric artery is a major contributor to left-sided varicoceles.

Clinical Outcomes of Varicocele Repair in Infertile Men: A Review

Varicoceles are a major cause of impaired spermatogenesis and the most common correctable cause of male infertility. They are found in approximately 40% of men with primary infertility and 80% of men with secondary infertility, although they also occur in 12% of men with normal semen parameters. The presence of a varicocele does not always affect spermatogenesis, as it has been reported that only 20% of men with documented varicoceles suffer fertility problems. However, varicocele repair appears to have beneficial effects in men with impaired semen parameters and palpable varicoceles. Currently, the main procedures employed for varicocele repair are microsurgical subinguinal or inguinal varicocelectomy, laparoscopic varicocelectomy, and radiological percutaneous embolization. Microsurgical varicocelectomy appears to be the optimal treatment in most cases, whereas the other procedures are useful only in specific cases. After treatment, it typically takes 3 to 6 months for patients' semen parameters to improve; thus, other therapies, including assisted reproductive technology, should be considered if infertility persists after this interval, especially in older couples. Controversies still remain regarding how varicoceles in certain subgroups, such as adolescents or men with azoospermia, should be treated. Due to their relatively high prevalence rate among the general population, varicoceles can occur concomitantly with other conditions that cause impaired spermatogenesis. Further studies are necessary in order to identify the patients who are most likely to benefit from treatment. In this review, we sought to summarize the issues currently associated with varicocele treatment in infertile men.

Resveratrol improves reproductive parameters of adult rats varicocelized in peripuberty

The aim of this study was to investigate the protective action of resveratrol against the reproductive damage caused by left-sided experimental varicocele. There was a reduction of testicular major axis in the varicocele group when compared with the other groups; the testicular volume was reduced in varicocele group in comparison to the sham–control and resveratrol groups. The frequency of morphologically abnormal sperm was higher in varicocele and varicocele treated with resveratrol groups than in sham–control and resveratrol groups. The frequency of sperm with 100% of mitochondrial activity and normal acrosome integrity were lower in varicocele group than in varicocele treated with resveratrol, sham–control and resveratrol groups. Sperm motility was also reduced in varicocele group than in other groups. The sperm DNA fragmentation was higher in varicocele group than in other groups. Testicular levels of malondialdehyde were higher in varicocele and varicocele treated with resveratrol groups. The varicocele and varicocele treated with resveratrol groups had a significantly higher frequency of TUNEL-positive cells than sham–control and resveratrol groups; however, immunolabeling of the testes from varicocele treated with resveratrol group showed a lower number of apoptotic germ cells in comparison with the left testis of rats of the varicocele group. Reproductive alterations produced by varicocele from peripuberty were reduced by resveratrol in adulthood. Resveratrol should be better investigated as an adjuvant in the treatment of varicocele. Daily administration of resveratrol to rats with varicocele from peripuberty improves sperm quality in the adulthood.

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.

Retroperitoneal paraganglioma presenting as right-sided varicocele: case report

Varicocele, the most important identifiable pathological cause of male infertility, is rarely observed on the right side. In isolated cases of right-sided varicocele, the presence of retroperitoneal masses compressing the inferior vena cava should be considered by further investigation. The retroperitoneal masses that are detected tend to grow rapidly due to their location and may be very large at the time of diagnosis. Soft tissue sarcomas are the most common cause of retroperitoneal masses, while paragangliomas are rare causes. Retroperitoneal paragangliomas should be diagnosed via detection of symptoms caused by hormonal activity, observation of the compression effect of the mass, or incidentally during imaging studies.

SIMILAR CASES PUBLISHED

This study presents the first case of retroperitoneal paraganglioma in a 41-year old man as isolated right-sided varicocele that has been described in the published reports.

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.

The dilemma of adolescent varicocele

Adolescent varicocele is associated with ipsilateral testicular hypotrophy and the concern for future infertility. A testicular size discrepancy greater than 15-20 % between left and right testicle is an indication for treatment to allow catch-up growth in the hope of preventing a future decline in fertility. Some authors advocate for a period of watchful waiting, as normal testicular growth may occur asymmetrically. We review the current literature to highlight some controversies and challenges in management.

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.

Impact of varicocele on biological markers of gonadal function

PURPOSE

The aim of this study is to evaluate the potential effect of varicocele in the hormonal and clinical profile of adolescents.

METHODS

Twenty adolescents at Tanner stage 4-5 with left varicocele were studied and compared with a control group of 20 healthy adolescents. All patients underwent ultrasonographic testicular volumetry as well as hormonal evaluation of inhibin B, testosterone, baseline and gonadotropin-releasing hormone stimulated, follicle-stimulating hormone as well as luteinizing hormone. Statistical analysis was performed using the student's t test with p value <0.05 taken as statistical significant.

RESULTS

Patients with varicocele showed reduced levels of inhibin B compared to controls and a significant reduction in the testicular volume on the affected side. The response of luteinizing hormone to gonadotropin-releasing hormone stimulation was significantly higher in the varicocele group compared to the control group. Furthermore a significant inverse relationship of inhibin B compared to follicle-stimulating hormone was noted.

CONCLUSION

Serum inhibin B levels could represent a useful marker of Sertoli cell damage caused by varicocele.

Molecular mechanisms involved in varicocele-associated infertility

Varicocele is a pathologic enlargement of the pampiniform venous plexus within the spermatic cord, a condition that is a common cause of impaired sperm production and decreased quality of sperm. While varicocele is the most common surgically correctable risk factor for male infertility, not all males with varicocele experience infertility. In fact, most men with varicocele have normal spermatogenesis. Despite its prevalence, the molecular mechanisms of varicocele and its effect on testicular function are yet to be completely understood. We postulate that men with varicocele-associated infertility could have preexisting genetic lesions or defects in molecular mechanisms that make them more susceptible to varicocele-mediated testicular injury affecting spermatogenesis.

Intratesticular varicoceles: are they significant?

OBJECTIVE

Varicoceles occur in 15% of adult and adolescent males and are generally considered to be an extratesticular phenomenon. However, an intratesticular component has been reported in up to 2% of adult and 2% of adolescent varicoceles. We sought to determine the incidence of intratesticular varicoceles (ITV) in adolescents in our practice, its significance, associated findings and response to treatment.

MATERIALS AND METHODS

We retrospectively reviewed 684 adolescent males who were diagnosed with varicoceles and had at least one Doppler ultrasound (DUS) prior to any surgery to identify those with an intratesticular component. Testicular volumes, maximum vein diameter (MVD) and peak retrograde flow (PRF) were determined by DUS and recorded.

RESULTS

A total of 6 (0.9%) patients were found to have an intratesticular component with a mean PRF of 43.7 cm/s, mean MVD of 3.3 mm and mean asymmetry of 20%. Mean PRF, MVD, and asymmetry of those without an intratesticular component who underwent surgery was 44.8 cm/s, 2.9 mm, and 21.8%, respectively (PNS for all parameters). Four of the 6 patients had 2 or more DUS, and all 4 had worsening testicular asymmetry and PRF over time. Five patients underwent laparoscopic varicocelectomy and all five had catch-up testicular growth. One patient refused surgical repair and has had subsequent worsening testicular asymmetry and softening of the testicle.

CONCLUSIONS

Our findings suggest that adolescents who present with an intratesticular varicocele in association with testicular asymmetry will develop worse asymmetry over time. Therefore, adolescents with intratesticular varicoceles and initial asymmetry should be scheduled for surgery rather than followed.

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.

Adolescent varicocoele management controversies

Varicocoele is defined as excessive dilatation of the pampiniform venous plexus of the spermatic cord. Varicocoele frequently appears during early puberty and is recognized to be the most common surgically correctable cause of male infertility. However, the actual incidence in adolescents, pathophysiology and the association with male factor infertility all remain somewhat controversial. The most accurate diagnostic technique for identifying young men who will benefit from surgical treatment has yet to be established. Observations of testicular asymmetry and deteriorating semen quality helped establish current guidelines and recommendations for surgical treatment. Further studies, comparing observation with surgical intervention, are needed to refine the current indications for varicocoele repair in the adolescent male.

Testicular volume and fertility potential in men operated due to varicocele and testicular hypotrophy in adolescence

INTRODUCTION

Failure to perform surgical repair of varicocele before puberty is among the common causes of male infertility. The purpose of this study was to evaluate the testicular volume and fertility potential in men after laparoscopic varicocelectomy conducted in adolescence due to varicocele and concomitant testicular hypotrophy.

MATERIAL AND METHODS

From 1996 through 2011, eighty-two adolescents were operated on for unilateral primary varicocele with testicular hypotrophy. Sixty-eight patients were subject to the current analysis. The age of the patients was 13 to 17 years (mean 15.3 years). Clinical diagnosis was established on the basis of andrologic examination and ultrasonography with an assessment of testicular size and varicocele severity. Laparoscopic surgical repair was performed by a transperitoneal approach with division of testicular vein only.

RESULTS

An increase in left testicular volume when compared with the contralateral testis was found in 25 (78.1%) young men with clinical grade 2 varicocele (p = 0.02) and in 32 (88.8%) subjects with grade 3 abnormality (p = 0.04). An increase in left testicular volume was found in 46 (85.1%) of 54 patients with unilateral varicocele and in 12 (85.7%) of 14 subjects operated on for bilateral disease. A left testicular volume increase was comparable independent of the use of uni- or bilateral repair. Fifty-eight (85.2%) of our 68 patients had normozoospermia.

CONCLUSIONS

Laparoscopic varicocele repair resulted in a significant increase of hypotrophic testicular volume in 83.8% of our subjects.

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.

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 volume discrepancy is associated with decreased semen quality in infertile Japanese males with varicoceles

Purpose

We retrospectively reviewed infertile Japanese males for testicular volume discrepancies (D) and semen parameters to evaluate whether left grade II-III varicoceles (V) cause testicular damage.

Methods

Seventy-seven patients who had idiopathic male infertility and 88 who had V without other causes of infertility were examined. We excluded cases of azoospermia. Testicular volume was measured using a punched-out orchidometer. D was defined as a size difference of at least 3 ml. The frequency of D was compared between the patients with and without V. The semen parameters were reviewed in association with D and V.

Results

The mean left and right testicular volumes were 19.4 and 20.1 ml, respectively (p < 0.001). D with a smaller left testis was more common in V+ cases than in V- cases (26.1 vs. 13.0%, p = 0.0351). The sperm count and motility were also significantly lower (p = 0.0213 and p = 0.0217, respectively) in the D+ patients with a smaller left testicular volume.

Conclusions

In the patients with V, D was more common than in those without V. The semen parameters were worse if D was present in the patients with V. These results indicated that V could induce testicular atrophy and negatively affect semen quality. Therefore, the ipsilateral reduced testicular volume is considered to be a sign of persisting testicular damage by V.