Diagnosis and Management of Pediatric and Adolescent Varicocele: A Survey of Pediatric Urologists in Korea

Semen Parameters Changes in Adolescents With Clinical Varicocele after Magnified Subinguinal Varicocelectomy: A Prospective Controlled Study

BACKGROUND

Previously, we highlighted the benefits of magnified subinguinal varicocelectomy over conservative treatment on the semen of a small group of adolescents with varicoceles. In this report, we presented changes of semen parameters of 47 adolescents who underwent magnified subinguinal varicocelectomy (MSV) and followed-up for 6 months.

METHODS

The present prospective controlled study was conducted on 47 adolescents with varicocele who underwent MSV and were followed up for 6 months. In addition, age and sex-matched patients were added as control group. The primary outcome of this study was to assess the postoperative change in semen analysis parameters.

RESULTS

A significant increase in sperm volume from 2.5 (1.9-3) to 3.2 (2.6-4) mL at the end of the sixth month of follow-up. Likewise, the sperm count increased from 10.8 (3.51-21.6) to 20.3 (9.6-35) million. Notably, the percentage of rapid and slow sperms increased significantly from a median of 5% (0%-10%) and 15% (10 -20%) to a median of 10% (5%-15%) and 17.5% (15%-25%), respectively. The percentage of sperm with progressive movement increased from 35% (30%-40%) to 59% (45%-69%). The vitality of the sperms increased significantly as well. While the percentage of sperms with abnormal morphology decreased significantly at the end of follow-up.

CONCLUSION

Our findings support the safety and efficacy of MSV in patients with clinically detectable varicocele. MSV has improved the semen parameters of the included patients, including sperm motility, volume, count, and total progressive motility, which may positively impact their fertility potential.

Management of adolescent varicocele

Varicocele is defined as an abnormal dilation and tortuosity of the internal spermatic veins found within the pampiniform plexus. It is a common finding in adolescents and adult men alike, however its diagnosis in the adolescent population poses different dilemmas in regard to indications for treatment than in adults. Failed Paternity is a clear-cut indication for repair in adult men attempting to father children. In adolescents, the physicians, family and patients must consider potential for future fertility problems which may or may not actually become of concern. Assessing the degree of negative effect of the varicocele on an adolescent's testicular health can also be difficult as teenagers typically are not asked to provide semen for analysis and thus surrogate markers for testicular health such as testicular size differentials must be used. Treatment options for the adolescent varicocele are similar to options in adult populations. While risks and benefits of various techniques can be considered, the gold standard for varicocele repair in adolescents has not been clearly defined. We aim to discuss diagnosis of varicocele, considerations for initiating treatment of varicocele in the adolescent, and techniques for management.

Surprising interobserver and intra-observer variability in pediatric testicular ultrasound volumes

INTRODUCTION

Testicular volume (TV) can be obtained by either scrotal ultrasound (SU) or orchidometer. Scrotal ultrasound allows for a more objective measurement; however, the interobserver and intra-observer variability of TV measurements has not been rigorously studied.

OBJECTIVE

The authors measured intra-observer and interobserver variability of SU TV measurements in pediatric patients to assess the reliability and reproducibility of SU. Special attention was paid to how often a 20% discrepancy in TV was noted as this has previously been utilized as an indication for varicocelectomy.

DESIGN

Patients with an indication for SU or undergoing an ultrasound for another reason were prospectively recruited. Two different urologic specific ultrasound technicians (A and B) performed SU to assess interobserver variability. A second measurement was taken by technician A within 90 days to assess intra-observer variability (A vs A1). The technicians were blinded to other ultrasound results.

RESULTS

Fourteen patients (28 testes, 56 volume measurements) were included in the intra-observer group and 17 patients (34 testes, 68 volume measurements) in the interobserver group. The mean time to repeat intra-observer ultrasound measurements (range) was 46 days (23-84). Mean age (range) in the intra-observer group was 14.3 years (11-19) and 14.1 years (11-19) in the interobserver group. Indication for ultrasound was varicocele (n = 6), scrotal pain (4), hydronephrosis (3), hydrocele (2), epididymal cyst (2), posterior urethral valves (1), and testis asymmetry (1). Utilizing Bland-Altman analysis and plots, variability was seen in both intra-observer and interobserver measurements. The mean values for testicular sizes for technician A and technician B were 13.0 ± 9.7 cm³ vs 13.8 ± 9.9 cm³, respectively. The mean values for TV measurement for technician A's first and second measurements (A, A1) were 14.3 ± 9.7 cm³ and 14.8 ± 8.9 cm³, respectively. An errant 20% difference in TV measurements for the same testis was seen in 25% (7 of 28) of intra-observer measurements and 35% (12 of 34) of interobserver measurements. These 20% differences were more common with a lower body mass index (odds ratio, OR = 0.74, p = 0.01) in the interobserver group, and lower TV was a predictor in the intra-observer group (OR: 0.82, p = 0.009).

CONCLUSIONS

Variability exists in both interobserver and intra-observer measurements of TV by dedicated urologic ultrasonographers, and greater than 20% of differences in measured TV in same testicles occurred in over 25% of cases. Caution should be exercised in basing operative decisions and scientific studies on limited measurements of TV.

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.

Current Issues in Adolescent Varicocele: Pediatric Urological Perspectives

While varicocele is the most common cause of surgically correctable infertility in adult males, with repair resulting in improved semen parameters in 60% to 80% of men and a higher likelihood of conception in up to 60% of men, the rationale for varicocele repair in the pediatric population is less clear. Additionally, prepubertal varicoceles are much less common and their management is controversial. Adolescents with a varicocele are often in the midst of a progressive disease process. Despite the high prevalence of varicocele and its association with progressive disease processes, the indications for adolescent varicocele repair and the effects thereof on paternity have been persistently challenging to study. This review will briefly present some of the current issues regarding adolescent varicocele from a pediatric urological point of view, including the evaluation of adolescent varicocele, the optimal surgical indications, the optimal choice of surgical intervention to be performed, and outcomes.