A cost outcome study of varicocoele embolisation and future pregnancy in an Australian public hospital setting

INTRODUCTION

Varicocoele is commonly encountered in males with infertility. Studies have shown that varicocoele repair (surgery or embolisation) can improve the rate of subsequent pregnancy. In Australia, there have been no studies assessing the cost of varicocoele embolisation and current practice is based on international data. This study aimed to assess the cost of varicocoele embolisation and estimate the treatment cost per pregnancy.

METHODS

Retrospective cost-outcome study of patients treated by embolisation between January 2018 and 2023. A bottom-up approach was used to calculate procedure costs whereas a top-down approach was used to calculate costs for all other patient services, including direct and indirect costs. To calculate cost per pregnancy, costs were adjusted according to existing published data on the rate of pregnancy after embolisation.

RESULTS

Costing data from 18 patients were included, of median age 33.5 years (range 26-60) and median varicocoele grade 2.5 (range 1-3). All patients had unilateral treatment, most commonly via right internal jugular (16 patients, 89%) and using a 0.035″ system (17 patients, 94%). The median cost for the entire treatment including procedural, non-procedural, ward and peri-procedural costs was AUD$2208.10 (USD$1405 or EUR€1314), range AUD$1691-7051. The projected cost to the healthcare system per pregnancy was AUD$5387 (USD$3429 or EUR€3207).

CONCLUSION

Total varicocoele embolisation cost and the cost per-pregnancy were lower than for both embolisation and surgical repair in existing international studies. Patients undergoing varicocoele treatment should have the option to access an interventional radiologist to realise the benefits of this low-cost pinhole procedure.

[The application of acupuncture in varicocele infertility based on " Visceral Collateral " theory]

The occurrence of varicocele infertility can be attributed to the small and flexural spermatic plexus which constitutes the main structure of spermatic cord.Obstruction of blood circulation, stagnation of qi and blood, ultimately leading to infertility. The spermatic plexus ' physiological and pathological symptoms are consistent with the theory of visceral collateral. Based on the theory of visceral collaterals, the varicocele infertility caused by stagnation of liver collateral and deficiency of kidney collateral. And the acupuncture is used to directly act on the relevant points on the meridians, so as to dredge the meridians, strengthen the healthy and expel the evil, and harmonize the yin and yang of visceral, which is more in line with the therapeutic principle of " unblocking the meridians " for collateral diseases. For varicocele infertility caused by liver meridian stasis, it can regulate the liver meridian Chong Ren, eliminate blood stasis and promote stagnation, and be combined with LR3, LI4, GB34, SP6, CV3. For varicocele infertility caused by kidney deficiency and meridian syndrome, it can tonify the kidney meridian Du Yang, warm and disperse the essence, and mainly focus on GV4, CV4, KI3, BL23 and BL43.

Testicular catch-up growth in the non-operative management of the adolescent varicocele

INTRODUCTION

Adolescent varicocele is a common urologic condition with a spectrum of outcomes, leading to variations in management. Testicular hypotrophy is a common indication for surgery Routine monitoring may be an appropriate form of management for many adolescents with testicular hypotrophy, as studies have shown that a large proportion of these patients may experience catch-up growth of the ipsilateral testis. Furthermore, there are few longitudinal studies which have correlated patient specific factors to catch-up growth. We aimed to determine the frequency of testicular catch up-growth in adolescents with varicocele while also examining if patient specific factors such as BMI, BMI percentile, or height correlated with testicular catch-up growth.

METHODS

A retrospective chart review found adolescent patients who presented to our institution with varicocele from 1997 to 2019. Patients between the ages of 9 and 20 years with left-sided varicocele, a clinically significant testicular size discrepancy, and at least two scrotal ultrasounds at least one year apart were included in analysis. Testicular size discrepancy of greater than 15% on scrotal ultrasound was considered clinically significant. Testicular size was estimated in volume (mL) via the Lambert formula. Statistical relationships between testicular volume differential and height, body mass index (BMI), and age were described with Spearman correlation coefficients (ρ).

RESULTS

40 patients had a testicular volume differential of greater than 15% at some point during their clinical course and were managed non-operatively with observation and serial testicular ultrasounds. On follow-up ultrasound, 32/40 (80%) had a testicular volume differential of less than 15%, with a mean age of catch up growth at 15 years (SD 1.6, range 11-18 years). There were no significant correlations between baseline testicular volume differential and baseline BMI (ρ = 0.00, 95% CI [-0.32, 0.32]), baseline BMI percentile (ρ = 0.03, 95% CI [-0.30, 0.34]), or change in height over time (ρ = 0.05, 95% CI [-0.36, 0.44]).

DISCUSSION

The majority of adolescents with varicocele and testicular hypotrophy exhibited catch-up growth with observation, suggesting that surveillance is an appropriate form of management in many adolescents. These findings are consistent with previous studies and further indicate the importance of observation for the adolescent varicocele. Further research is warranted to determine patient specific factors that correlate with testicular volume differential and catch up growth in the adolescent varicocele.

Safety and efficacy of acupuncture for varicocele-induced male infertility: a systematic review protocol

INTRODUCTION

Varicocele (VC) is a common clinical disease in andrology. Among a number of ways for VC treatment, surgery is the most common one, but the measurable benefit of surgical repair was slight. A growing exploration of complementary therapies has been conducted in clinical research on acupuncture for VC, but there is no relevant systematic review and meta-analysis to assess the efficacy and safety of acupuncture for VC.

METHODS AND ANALYSIS

All relevant publications published from database inception through August 2022 will be searched in three English-language databases (Embase, CENTRAL, MEDLINE) and four Chinese-language databases (China National Knowledge Infrastructure, China Science and Technology Journal Database, Chinese Biomedical Literature Database and Wanfang Data). Randomised controlled trials in English and Chinese concerned with acupuncture for patients with VC will be included. The input clinical data will be processed by the Review Manager software (RevMan). The literature will be appraised with the Cochrane Collaboration risk of bias tool. The Grading of Recommendations Assessment, Development and Evaluation system (GRADE system) will be used to evaluate the quality of evidence.

ETHICS AND DISSEMINATION

This study is a secondary study based on clinical studies so it does not relate to any individual patient information or infringe the rights of participants. Hence no ethical approval is required. The results will be reported in peer-reviewed journals or disseminated at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42022316005.

[Pricking-reinforcing -reducing therapy improves semen quality and seminal plasma biochemical indexes in patients with varicocele infertility]

OBJECTIVE

To investigate the effect of pricking-reinforcing -reducing therapy (PRRT) on the semen quality and seminal plasma biochemical indexes of varicocele (VC) infertility patients.

METHODS

We randomly and equally assigned 160 patients with VC infertility into a PRRT and a control group, the former treated by PRRT and the latter with oral ShengjingCapsules. Before and after treatment, we obtained the semen parameters, sperm morphology, sperm survival rate, sperm acrosin activity, seminal plasma neutral α glucosidase and seminal plasma zinc in the patients and compared them between the two groups.

RESULTS

Before treatment, there were no statistically significant differences between the PRRT and control groups in sperm concentration (［16.81 ± 7.83］ vs ［16.80 ± 7.54］ ×106 /ml, P > 0.05), total sperm count (［42.01 ± 19.57］ vs ［41.99 ± 18.84］ ×106, P > 0.05), percentages of progressively motile sperm (PMS) (［15.37 ± 11.03］% vs ［14.68 ± 10.27］%, P > 0.05) and morphologically normal sperm ( MNS) (1.62 ± 1.51］% vs ［1.62 ± 1.13］%, P > 0.05), sperm survival rate (［28.11 ± 18.95］% vs ［28.23±18.38］%, P > 0.05) and sperm acrosin activity (［28.11 ± 14.64］ vs ［27.19 ± 14.07］ U/L, P > 0.05). After three months of treatment, all the patients showed evident increases in the above parameters (P < 0.05), even higher in the PRRT than in the control group, more significantly in sperm concentration (［38.88 ± 30.54］ vs ［25.60 ± 14.71］ ×106 /ml, P < 0.05), PMS (［32.60 ± 12.46］% vs ［27.67 ± 12.27］%, P < 0.05) and sperm acrosin activity (［65.74±31.81］ vs ［67.94±17.95］ U/L, P < 0.05), though not significantly in total sperm count (97.20 ± 76.35］ vs ［88.19 ± 39.56］ ×106, P > 0.05), MNS (［2.35 ± 1.83］% vs ［1.87 ± 1.20］%, P > 0.05) and sperm survival rate (［61.44 ± 20.02］% vs ［59.12 ± 22.48］%, P > 0.05). Compared with the baseline, after treatment, the patients in the PRRT group also exhibited elevated levels of neutral α-glucosidase (［14.42 ± 5.90］ vs ［28.43 ± 19.76］ U/L, P < 0.05) and seminal plasma zinc (［2.11 ± 1.22］ vs ［2.89 ± 1.23］ mmol/L, P < 0.05), and so did the controls (［14.44 ± 5.61］ vs ［26.66 ± 17.69］ U/L , P < 0.05) and (［2.09 ± 1.10］ vs ［2.82±1.08］ mmol/L, P < 0.05). No statistically significant difference, however, was observed between the two groups after treatment (P > 0.05).

CONCLUSION

PRRT can significantly improve semen quality in patients with VC infertility, even more effective than ShengjingCapsules in improving sperm concentration, PMS, sperm survival rate, and sperm acrosin activity, which may be related to its effect of elevating the levels of seminal plasma neutral-α glucosidase and zinc providing sufficient energy for basic sperm metabolism, maturation, energy acquisition and motility.

The efficacy and mechanism of acupuncture in the treatment of male infertility: A literature review

Fertility, a social, cultural, and medical issue, has aroused public attention because of its potential to predict future health. In recent years, the incidence of male infertility has increased significantly, and various risk factors, such as congenital factors, acquired factors, and idiopathic factors, have led to this situation. Male infertility causes substantial psychological and social distress in patients. With the implementation of the two-child policy, male infertility has brought enormous psychological and social pressure and huge economic burden to patients and the healthcare system. This has attracted the attention of not only men of childbearing age but also many male experts. The conventional therapeutic approaches for treating male infertility, including drugs, varicocele surgery, intrauterine insemination, in vitro fertilization, and intracytoplasmic sperm injection, can restore fertility to a certain extent, but their efficacy is far from satisfactory, not to mention some adverse events. Therefore, acupuncture has been chosen by many men to treat their infertility and produced significant effects. In the present paper, the efficacy and mechanism of acupuncture in the treatment of male infertility were analyzed from different perspectives such as regulating hormone secretion, reducing inflammation, and improving semen parameters. The existing literature shows that acupuncture can effectively treat male infertility.

10-year experience of Paediatric varicocele embolization in a tertiary centre with long-term follow-up

INTRODUCTION

Paediatric varicocele embolization has many benefits over surgical ligation, but lacks published long-term data. We investigated technical and clinical outcomes in this under reported patient group.

OBJECTIVE

To evaluate technical success, complications and recurrence rates following varicocele embolization in paediatric patients.

MATERIALS AND METHODS

A single-centre retrospective review of procedural data and electronic notes of consecutive patients referred for varicocele embolization over a 10-year period was performed (February 2010-March 2020). The primary outcomes were technical success and clinical efficacy (lack of symptom recurrence). Secondary outcomes included complications, testicular vein size reduction and procedural parameters including radiation exposure. Chi-square analysis was used to identify predictors of clinical success. Follow-up involved outpatient clinical assessment and telephone interview.

RESULTS

40 patients (median age 15) were referred for left-sided symptomatic varicocele. Technical embolization success was achieved in 36/40 patients (90%), with 4 procedures abandoned (inaccessible vein). Embolization technique was platinum-based coils ± sclerosant. There were no immediate or long-term procedural complications. 32/36 patients completed short term follow-up at a median interval of 2.8 months. 30/32 (93.78%) experienced early clinical success. We found a significant reduction in peritesticular vein size following embolization (pre-3.70 vs post-2.56 mm, p = 0.00017) and a significant relationship between varicocele grade and early clinical success (χ2 = 4.2, p = 0.04), but not pre-treatment peritesticular vein size (χ2 = 0.02, p = 0.88). 33/36 patients completed long-term follow-up (median 4.2 years, range 0.36-9.9 years) producing a late clinical success rate of 93.9% (31/33). No post procedural complications including hydroceles were identified.

DISCUSSION

This study demonstrates technical success, matching rates described in adult patients which is reassuring and in support of embolization in the younger patient cohort. More importantly, the overall clinical success rate is comparable with previous embolization studies. Reassuringly, all symptom recurrences occurred early in follow-up, and there is a cogent argument for a single follow-up appointment at this juncture. Our long-term average follow-up duration, primarily gained via telephone interview, exceeds other studies. Although our study has the longest follow-up for varicocele embolization in children, it is limited by a few patients being lost to early and long-term follow-up. This is a recognised issue faced by studies attempting to follow-up benign conditions with a high clinical success rate.

CONCLUSION

Paediatric varicocele embolization is a successful alternative to surgical ligation, with no complications and good clinical outcomes over a long-term follow-up.

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.

[Recommendations of the Committee of Andrology and Sexual Medicine of the AFU concerning the management of Varicocele]

The diagnosis of varicocele is clinical, carried out in supine and standing position and in Valsalva maneuver. Only clinical varicoceles have to be treated. A scrotal ultrasound with Doppler is generally performed as part of the infertile man's evaluation or in case of examination difficulties. The main indication for varicocele treatment is the adult man with clinical varicocele and abnormalities of sperm parameters, in a context of infertility of couple, with a partner having a satisfactory ovarian reserve and no cause of female infertility or a curable infertility cause. The decision to treat varicocele must therefore be taken after evaluation of the two partners of the couple. Adults with symptomatic varicocele and those with spermogram abnormalities may also be offered a cure for their varicocele even in the absence of a paternity plan, as well as adolescents with reduced testicular growth, an ipsilateral decrease testicular volume, or a size gradient between the 2 testes. The cure of varicocele can be carried out by surgery or by percutaneous embolization. Microsurgery (inguinal or subinguinal) offers lower rates of recurrence and complications than high surgical approaches (laparoscopic or not) and surgeries without magnification. It is therefore the reference surgical technique. Percutaneous retrograde embolization is a minimally invasive alternative to microsurgery offering satisfactory outcomes with rare and often benign complications. The cure for varicocele results in an improvement in sperm parameters and recent data seem to confirm that it increases the natural pregnancy rate. These results appear after a delay of 3 to 9 months (at least 1 to 2 cycles of spermatogenesis). When the sperm involvement was severe (azoospermia, severe oligospermia), the improvement of the spermogram allow (1) to avoid surgery testicular sperm extraction or (2) perform intrauterine insemination rather than ICSI.

Treatment of varicocele with Fu's subcutaneous needling: A case report

RATIONALE

Fu's subcutaneous needling (FSN) is an innovative therapy of traditional acupuncture. FSN has been widely applied for the treatment of pain symptoms by relieving local muscle tension and promoting local blood circulation. Varicocele (VCL) is a disease that commonly occurs in male adolescents. Patients with VCL can suffer from pain in the scrotum, inguinal area, or unilateral testis, which could be an indication for FSN. In this study, we present a unique case, in which a 30-year-old male patient with VCL benefitted from FSN.

PATIENT CONCERNS

A 30-year-old male complained of dull pain and swelling in the testicular area for 4 months. No significant abnormalities were identified in his genitalia by physical examination.

DIAGNOSES

The patient was diagnosed with VCL, with his symptoms and signs of dull pain and swelling in the testicular area, and ultrasound also demonstrated the left-side VCL.

INTERVENTIONS

FSN was performed successfully twice a week on a different day without postoperative complications. The total course lasted 8 weeks.

OUTCOMES

The patient experienced obvious relief of his testicular pain and swelling after each treatment course. All his symptoms resolved and disappeared after 4 treatment courses. After the 8-week treatment course, the color ultrasound after treatment demonstrated improved anastomotic blood flow rates in his left spermatic vein. No narrow or thrombotic parts were observed post-treatment compared to the color ultrasound before treatment. The patient was followed up at 1, 3, and 6 months after treatment. During the follow-up period, his previous symptoms disappeared without recurrence.

LESSONS

FSN significantly improved the patent's symptoms of testicular pain and abnormal dilatation and tortuosity of the spermatic veins. FSN might exert its therapeutic effect by improving the relaxation of muscle oppression and increasing the local blood reperfusion to resume blood stream. Due to the limitation of a single clinical observation case, a randomized clinical trial with a sufficient follow-up time is needed.

Intravascular Ultrasound for Evaluation of Left Gonadal Vein Anatomic Variations During Coil Embolization

We illustrate the intravascular ultrasound (US) findings in the evaluation of left gonadal vein anatomic variations. During a 2-year period, 4 consecutive patients (mean age, 37 years; range, 28-45 years) with left-sided varicocele underwent embolization. Intravascular US examinations and retrograde venography were performed to assess varicocele anatomy. Anatomic variants were recorded and categorized. A comparison between intravascular US and fluoroscopic findings was performed. The Fisher exact test was used for statistical analysis (P < .05). Technical success was achieved in all cases. There was a statistically significant difference in the maximum gonadal vein diameter between venography and intravascular US (P = .0087). Intravascular US showed left gonadal vein anatomic variations and better ability in the evaluation of the vein diameter.

[Two decades of experience in endovascular treatment of varicocele in pediatric age]

OBJECTIVES

To present our experience of 23 years in the treatment of varicocele by embolization in pediatric age.

MATERIAL AND METHODS

Observational descriptive study of all patients with varicocele treated by embolization after phlebography, by indication of the pediatric surgery service between 1995 and 2017. We performed descriptive statistical analysis and comparison between pain and testicular asymmetry before and after treatment (SPSSv22).

RESULTS

Embolization was performed in 113 patients with left varicocele. The mean age of diagnosis was 12.4 years (5.2-15.5). The main clinical manifestations were: incidental finding (46.7%), increase in scrotal volume (28%) and testicular pain (15.9%). 61.5% were grade 3 and 38.5% grade 2. The selective embolization procedure was performed at an average age of 13.6 years (8-18). There were no serious complications of the procedure or reactive hydrocele. The overall success rate of endovascular treatment was 93.8%. In 85 patients (75.2%) a single procedure was performed and in 21, two procedures (18.6%). Only 4 patients required surgical intervention. The pain disappeared in all cases in which it presented and the testicular asymmetry decreased from 44.7% pre-treatment to 21.2% post-treatment (p<0.05).

CONCLUSIONS

Endovascular treatment through embolization allows a selective varicocele management, after venous mapping, with an adequate effectiveness, without altering the arterial flow of the testicle or producing hydrocele. It is a minimally invasive treatment that could be considered the first choice in varicoceles of children and adolescents.

Varicocele, conventional laparoscopic ligation versus occluding balloon embolization

INTRODUCTION

Varicocele is a relatively complex pathology that affects the pampiniform plexus of veins in the spermatic cord. Modern treatment involves both urological/surgical and interventional procedures. Our objective is to compare outcomes of conventional laparoscopic ligation (LL) and occluding balloon embolization (OBE) a percutaneous interventional procedure.

MATERIALS AND METHODS

We treated retrospectively a total of 98 patients, divided in two cohorts; arm A with 48 and arm B with 50 patients. Arm A patients underwent LL, while arm B ones were treated in interventional radiology suite, via OBE method. No comorbidities were reported, especially scrotal ones. Hence, all patients have been asked to respect 3 and 6 months' follow-up, clinical examination and ultrasonography were performed. Age range of the entire sample: 15-45 years old, with average of 28 years. The study involved two European centers. We performed a comparative analysis (Fisher's test) of intra-operative time, hospitalization and patient's postoperative recovery time.

RESULTS AND LIMITATIONS

Outcomes have been in line with the recent literature ones, allowing the occluding balloon embolization a small advantage for quicker operative average time, hospitalization needed and full recovery to normal activities for the patient. Main limitation was the unfeasibility of cost-effectiveness analysis due to national differences, limited sample and lack of complete semen analysis pre- and postoperative.

CONCLUSION

Both OBE and LL are safe and effective procedures in the treatment of varicocele, conceding OBE a slight advantage in terms of hospital stay and full recovery to normal activity of patients.

Effects of Varicocele Treatment on Sperm Conventional Parameters: Surgical Varicocelectomy Versus Sclerotherapy

INTRODUCTION

Varicocele is often associated with impaired sperm parameters. Different procedures have been developed for varicocele treatment. The aim of this study was to evaluate the effects of varicocele treatment on conventional sperm parameters.

MATERIALS AND METHODS

We compared two different techniques of intervention: surgical varicocelectomy and sclerotherapy. We also evaluated the number of varicocele recurrences and the pregnancy rate. We included 102 patients (mean age 29.8 ± 0.8 years) with ultrasound diagnosis of varicocele. We excluded patients whose ultrasound evaluation and/or sperm parameters were not known before and after varicocele correction. We divided the patients (excluding 8 with azoospermia) into two subgroups: surgical varicocelectomy (n = 44) and sclerotherapy (n = 50). For each patient, we compared conventional sperm parameters before and after varicocele correction.

RESULTS

After varicocele correction, we found a significant improvement in sperm concentration, total count and total motility. Considering the two subgroups, baseline sperm parameters did not differ significantly. Sperm concentration and total count increased significantly after varicocele correction by varicocelectomy. Varicocele correction by sclerotherapy resulted in a significant increase in sperm concentration, progressive and total motility. We found varicocele recurrence in 32% of patients who underwent varicocelectomy and in 19.7% of patients undergoing sclerotherapy. The pregnancy rate was higher after sclerotherapy (28%) than after surgical varicocelectomy (13%).

CONCLUSION

Varicocele treatment must be recommended when other causes of infertility have been treated. Our results suggest the use of sclerotherapy for varicocele repair.

LEVEL OF EVIDENCE

2 b.

[Therapeutic strategies for male infertility with varicocele]

The therapeutic decision for male infertility with varicocele is difficult and controversial, which requires the consideration of the patient's purpose of seeking medical help. The treatment of this condition involves not only surgery, but also medication and assisted reproductive technique (ART), and synergetic effects can be achieved by combination of the three options. In making a therapeutic decision, all related factors should be taken into full consideration.

Treatment of varicocele in children and adolescents: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The prevalence of varicoceles is as high as 15% in children and adolescents. Optimal management of varicoceles has not been consolidated. Options include observation, radiological intervention, or surgical varicocelectomy.

OBJECTIVE

Herein, we aim to assess the outcomes of radiological and surgical interventions for varicocele in children and adolescents evaluated by RCTs.

STUDY DESIGN

The study subjects were children and adolescents up to 21 years old, diagnosed with varicocele and allocated to receive either "surgical or radiological intervention" or "no treatment".

MATERIALS AND METHODS

We searched MEDLINE and EMBASE (Ovid platform), Web of Science, CINAHL, Cochrane Central Register of Controlled Trials, Google Scholar, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform for RCTs reporting on varicocele treatment in children and adolescents up to June 23, 2016. Only RCTs with patients aged under 21 years were included. Main outcomes of interest included changes in testicular size, semen analysis parameters, surgical adverse events and failures.

RESULTS

Nine eligible studies were included in the systematic review. Meta-analysis based on available outcomes data demonstrated an improvement in testicular volume (mean difference 3.18 mL, 95% CI 1.94-4.42) and in sperm count (mean difference 25.54 × 10⁶/mL, 95% CI 12.84-38.25) in patients who underwent radiological or surgical treatment compared with conservative management.

CONCLUSIONS

Based on current available randomized controlled trials, there is low to moderate level of evidence that radiological or surgical treatment of adolescent varicocele is associated with improved testicular size/growth and sperm concentration. The ultimate effects on fertility and paternity rates are not known.

Determination of spermatic vein reflux after varicocele repair helps to define the efficacy of treatment in improving sperm parameters of subfertile men

PURPOSE

A continuous spermatic venous reflux (SVR) at colour Doppler ultrasound (CDU) is an evidence for varicocele, a frequent correlate for male subfertility. We explored whether SVR after left varicocele repair is predictive for changes in semen quality in subfertile men.

METHODS

Blood hormones (FSH, LH, and total testosterone) and scrotal CDU were obtained in subfertile patients with left grade II or grade III varicocele on physical evaluation and a poor sperm quality. Semen analysis and CDU were re-evaluated 6 months after a retrograde internal spermatic vein scleroembolisation.

RESULTS

The retrospective study included 100 men with a baseline SVR >3 cm/s; 60 men showed a disappearance (group 1) and 40 men (group 2) showed a reduced SVR after varicocele repair. Total motile sperm count (TMC) was markedly increased after treatment (p < 0.0001; F = 35.79) and the increase was more relevant in group 1 compared to group 2 (p = 0.04; F = 4.20). TMC and left SVR values after varicocele repair were negatively correlated (R = -0.218; p = 0.035). Multivariate analysis showed that adjusted SVR after repair negatively predicted TMC change (TMC after repair minus baseline TMC) (ß = -2.56; p = 0.022). Disappearance of a continuous left SVR at CDU after varicocele repair was associated to a better improvement of semen parameters in subfertile men.

CONCLUSION

Recording of a continuous left spermatic vein reflux is an objective method to assess a successful varicocele repair aimed to improve sperm parameters in subfertile men.

Varicoceles affect semen quality of infertile men in Southern China: A cross-sectional study of 5447 cases

The association of varicoceles with infertility is well established, but the exact effect of varicoceles on semen quality among patients with infertility is still poorly known. The study aimed to examine the prevalence of varicoceles among Chinese men with infertility and to examine the factors associated with semen quality.This was a cross-sectional study of 5447 male patients treated for infertility at the Affiliated Hospital of Guangdong Medical University from October 2012 to December 2015. The patients were divided on the basis of the presence of varicoceles. Examinations of the amount of semen and sperm morphology were performed according to seminal parameter detection methods recommended by the World Health Organization.Patients with varicoceles (n = 1429/5447, 26.2%) were slightly younger (P = .046), and had smaller testis (P = .019), higher frequency of abnormal epididymis (P < .001), slightly shorter infertility duration (P = .046), and lower frequency of smokers (P = .012). There was no difference in the distribution of occupations (P = .777). Using multiple linear regression analysis, varicoceles were shown to be independently associated with semen volume [B = -0.153, 95% confidence interval (95% CI): -0.245 to -0.062, P = .001], sperm concentration (B = 9.633, 95% CI: 7.152-12.114, P < .001), proportion of sperms with normal morphology (B = 0.951, 95% CI: 0.623-1.278, P < .001), motility (B = 3.835, 95% CI: 2.675, 4.995, P < .001), total sperm count (B = 22.481, 95% CI: 13.333-31.629, P < .001), and forward movement sperm count (B = 15.553, 95% CI: 9.777-21.329, P < .001). Varicoceles were present in 26% of Chinese male patients with infertility.Varicoceles were independently associated with sperm volume, sperm concentration, proportion of sperms with normal morphology, motility, total sperm count, and forward movement sperm count.

[Evaluation of testicular growth after varicocele treatment in early childhood and adolescence based on the technique used (Palomo, Ivanissevich and embolization)]

OBJECTIVES

To analyze, depending on the technique employed, recurrence, symptomatic improvement and testicular growth following treatment of testicular varicocele.

MATERIAL AND METHODS

Descriptive retrospective study of 69 pediatric and adolescent males diagnosed with varicocele treated in our center by open technique according Ivanissevich technique (IT), Palomo (PT) and percutaneous embolization (PE) between 2000-2014. Variables analyzed were age, symptoms, differential testicular volume (RV), employed technique, recurrence, symptomatic improvement and RV after treatment. Association between qualitative variables was evaluated (chi-square test or Fisher's exact test).

RESULTS

69 patients with a median age of 14 years (7-19) were studied. PE was performed in 37 patients (53,6%), PT in 23 (33,3%) and IT in 9 (13%). Recurrence occurred in 16 patients (23,2%), 80% of them had been treated with PE. Eleven patients had pain (15.9%), there was improvement in 100% of patients treated with PE, but none of those treated by PT or IT improved. At diagnosis, 37 patients (53.6%) had decreased testicular volume (left testicular hypotrophy), in 28 cases the RV was >20%. After treatment, the RV was normalized in 11 cases (39,2%).

CONCLUSIONS

The choice of therapeutic technique in pediatric varicocele should be based on patient characteristics, symptoms, experience center for embolization and previous recurrence. Regardless of the chosen technique, 39,2% of testicular hypotrophy with VD >20% present at diagnosis normalized after treatment.

Varicocele Embolization Following Failure Of Varicocelectomy: A Case Series And Review Of Literature

Varicocelectomy remains the same mainstay of treatment for varicoceles. However, with growing focus on minimally invasive techniques, recent literature has investigated the use of venous embolization for the treatment of varicoceles in patients with recurrence after surgical treatment. Embolization has many advantages, including use of local anaesthesia, lower operating time, decreased risk of hydrocele and faster recovery times. In addition to this direct visualization of the vasculature during embolization allows for identification of any anatomic variants or collateral vessel accounting for the recurrence. This permits more definitive treatment in case of prior surgical failure. We present a case series where venous embolization is successfully done following failure of varicocelectomy. For patients who experience recurrence after a varicocelectomy, we recommend consideration for varicocele embolization.

A systematic review of clinical practice guidelines and best practice statements for the diagnosis and management of varicocele in children and adolescents

A systematic review was conducted to identify and qualitatively analyze the methods as well as recommendations of Clinical Practice Guidelines (CPG) and Best Practice Statements (BPS) concerning varicocele in the pediatric and adolescent population. An electronic search was performed with the MEDLINE, EMBASE, Science Direct, and Scielo databases, as well as guidelines' Web sites until September 2015. Four guidelines were included in the qualitative synthesis. In general, the recommendations provided by the CPG/BPS were consistent despite the existence of some gaps across the studies. The guidelines issued by the American Urological Association (AUA) and American Society for Reproductive Medicine (ASRM) did not provide evidence-based levels for the recommendations given. Most of the recommendations given by the European Association of Urology (EAU) and European Society of Pediatric Urology (ESPU) were derived from nonrandomized clinical trials, retrospective studies, and expert opinion. Among all CPG/BPS, only one was specifically designed for the pediatric population. The studied guidelines did not undertake independent cost-effectiveness and risk-benefit analysis. The main objectives of these guidelines were to translate the best evidence into practice and provide a framework of standardized care while maintaining clinical autonomy and physician judgment. However, the limitations identified in the CPG/BPS for the diagnosis and management of varicocele in children and adolescents indicate ample opportunities for research and future incorporation of higher quality standards in patient care.

Varicocele

INTRODUCTION

Varicocele is estimated to affect about 15% of the general male population. It usually occurs only on the left side, and is often asymptomatic. There is little evidence that varicocele reduces male fertility, although it is found in 12% of male partners of couples presenting with infertility and in 25% of men with abnormal semen analysis.

METHODS AND OUTCOMES

We conducted a systematic overview, aiming to answer the following clinical question: What are the effects of treatments in adult males with varicocele? We searched: Medline, Embase, The Cochrane Library, and other important databases up to November 2013 (Clinical Evidence overviews are updated periodically; please check our website for the most up-to-date version of this overview).

RESULTS

Searching of electronic databases retrieved 203 studies. After deduplication and removal of conference abstracts, 91 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 53 studies and the further review of 38 full publications. Of the 38 full articles evaluated, one existing systematic review was updated and two systematic reviews and five RCTs were added at this update. We performed a GRADE evaluation of nine PICO combinations.

CONCLUSIONS

In this systematic overview we categorised the efficacy for four interventions, based on information relating to the effectiveness of embolisation, expectant management, sclerotherapy, and surgical ligation.

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.

Treatment of varicocele with transfemoral retrograde sclero-embolization in pediatric patients under local anesthesia

AIM

Varicocele treatment in pediatric age is still under discussion. The aim of this study was to present our experience with transfemoral retrograde sclero-embolization in pediatric patients and varicocele under local anesthesia

METHODS

Between December 2008 and December 2011, 184 patients aged between 10 to 14 years with left varicocele were treated. Study inclusion criteria were: grade II or III left varicocele; previous inguinal surgeries and contraindications to general anesthesia. Sclero-embolization included the following procedures: right femoral access under local sedation (carbocaine). Mean time of intervention, recurrence and persistence rates as well as early and late complications were also considered.

RESULTS

During the study period 184 cases were treated with the radiological technique, 172 of which proved to be successful. In 10 cases a continent valve was found and it was therefore impossible to use this technique (5.4%); two cases had rupture of the vein with consequent spillage of the contrast agent. Twelve cases (6.5%) showed recurrence after 3 months. No patient reported postoperative pain.

CONCLUSION

This technique proved to be efficient and reliable. It can be performed under local sedation and it involves fewer complications than traditional techniques. The use of such technique allows preservation of the spermatic artery and is free from complications like testicular atrophy and hydrocele.

Pathophysiology, diagnosis and treatment of varicoceles: a review

In this article we reviewed the pathophysiology, diagnosis and treatment of varicoceles. The etiology and pathogenesis of varicoceles cannot be explained by one theory. Valve dysfunction, ontogenetic collateral formation and the nutcracker phenomenon seem to act synergistically. Hyperthermia, elevated hydrostatic pressure and antisperm agents are suggested as possible causes for the pathophysiology how varicoceles induce infertility. However the combination of patient's lifestyle, genetic factors and the consequences of reflux into the pampiniform plexus are believed to contribute to the infertility. Although venography stays the gold standard, the combination of physical examination, color Doppler ultrasound and thermography has the highest sensitivity and specificity to diagnose a varicocele. Regarding infertility, we are still searching for strict criteria or grading, to decide which patients with a varicocele may or may not have benefit from treatment. Treatment of varicoceles can be performed by different open surgical or percutaneous techniques. Treatment of varicoceles for infertility or to prevent infertility remains controversial, because the majority of men with varicoceles are still fertile. At the moment, inguinal or subinguinal microscopic surgery gave the highest pregnancy rates, the lowest recurrence and lowest complication rates. But retrograde superselective glue embolization or sclerosing of the ISV are the best percutaneous alternative and can be performed on an outpatient basis under local anesthesia and with faster return to normal activities than surgery.

Practice Committee of the American Society for Reproductive Medicine; Society for Male Reproduction and Urology. Report on varicocele and infertility: a committee opinion. Fertil Steril. 2014;102:1556-1560. [PMID: 25458620 DOI: 10.1016/j.fertnstert.2014.10.007]

This document discusses the evaluation and management of varicoceles in the male partners of infertile couples, and presents the controversies and recommendations regarding this condition. This document replaces the ASRM Practice Committee document titled "Report on Varicocele and Infertility," last published in 2008, and was developed in conjunction with the Society for Male Reproduction and Urology (Fertil Steril 2008;90:S247-9).

Contemporary Approach To Diagnosis, Management, And Treatment of Varicocele In the Adolescent

Varicocele is the most common inguinoscrotal pathology among adolescents. It is of concern due to the potential effect on fertility. A review of the literature focusing on current guidelines regarding diagnosis, evaluation, and management of adolescent varicocele was conducted. An algorithm is provided as one method for approaching the adolescent varicocele.

[Effectiveness analysis of a therapeutic strategy for pediatric varicocele. Have we got what we expected?]

OBJECTIVE

Optimal treatment ot vancocele in adolescents remains a topic of discussion. Strides in interventional radiology and laparoscopy have allowed us to implement a multidisciplinary therapeutic protocol that aims to get best of both. We evaluate our results.

METHODS

. Retrospective study of pediatric patients treated for varicocele in our hospital under protocol between 2008 and 2013. Once the therapeutic indication is confirmed, through clinical and Doppler ultrasound examination, patients undergo percutaneous retrograde embolization (PRE). We perform laparoscopic varicocelectomy (LV) when the PRE fails, together with lymphatic preservation using blue patent lymphography prior to surgery.

RESULTS

. Fifty-five patients with varicocele were treated at a mean age of 13 years old (range 11-16). PRE was performed in 50 patients (90.9%), with a proportion of remission of 80% by ultrasound study 6 months after PRE. Sixteen patients (29.1%) underwent LV five of whom without prior PRE. Lymphography with patent blue was performed in 13 (23.6%), and single-port surgery in 6 patients. The presence of coils of PRE did not hinder subsequent LV. The remission rate after LV was 100% at 6 months follow up. Two postoperative lymphoceles were recorded, none after patent blue lymphography.

CONCLUSIONS

. We found in this therapeutic sequence a safe and efficient alternative, allowing a minimal surgical invasion and reducing the rate of postoperative lymphoceles.

[Positional changes of the magistral blood flow of the left kidney in men with varicocele and infertility]

This paper proves the correlation between characteristics of blood flow rate in the renal veins and resistance indices of the renal arteries. As a result of polypositional assessment of venous blood flow, it was found that the violations of magistral venous blood flow in the left kidney can affect the formation and progression of varicocele, and the severity of disorders of spermatogenesis. The necessity of assessment of testicular veins and the pressure in left renal vein not only in clin- and orthostasis or Valsalva maneuver, but in the six static positions is discussed; this can allow to register the violations of magistral renal blood flow at the early stages important for fertility disorders, improve the efficiency of diagnosis and treatment of patients with varicocele.

[Varicocele and infertility: where do we stand in 2013?]

While the incidence of clinical varicocele is common in infertile men (about 40%), the reasons why varicocele may affect sperm parameters is still unclear. In addition, the improvement of fertility after treatment of varicocele is also a subject of debate. The purpose of this review is to get new insight into the physiopathology of varicocele, its impact on sperm parameters and the effectiveness of varicocele treatment on fertility. Treatment is likely to be effective in infertile men with clinical varicocele and impaired spermatogenesis. Even if it does not systematically lead to an improvement in sperm parameters, it may prevent further sperm degradation. In case of non-obstructive azoospermia, few studies reported a slight improvement in the process of spermatogenesis. The critical role of an adequate methodology in order to establish clinical guidelines needs to be stressed. Indeed, the huge intra-individual variability in sperm production makes the usual analysis of sperm parameters inadequate to measure treatment effectiveness. Regarding the assessment of conception, it requires not only well designed and properly sized studies but also a multivariate analysis for weighing predictive factors of success. Thus, an active scientific research is needed to better identify pathogenic agents and appropriately assess the impact of varicocele treatment.

[The medical technology for the application of ultrasound therapy at the out-of-patient, in-patient, and spa-and-resort stages of medical rehabilitation of the patients presenting with pathospermia. The manual for physicians and researchers]

The present manual is intended for the graduate medical specialists who completed a training course in urology, and urology, and physiotherapy based at the state-funded educational institutions and have the relevant certificates. Also, the manual is designed for the specialists engaged in scientific research on urology, restorative medicine, medical rehabilitation, and physiotherapy. The manual expounds indications and contraindications for ultrasound therapy of the patients presenting with pathospermia. Such treatment of genital glands was shown to be effective in 96.8% of the patients with pathospermia. Moreover, its advantages over alternative therapeutic modalities were demonstrated. The criteria for its choice (for differential application and prognosis of effectiveness) include the excretory form of grade I, II, and III pathospermia, the secretory form of grade I, II, and III pathospermia, the combined form of pathospermia, the presence or absence of moderate anatomical and functional changes in the testicles, the presence or absence of partial obstruction of the vas deferens.

[Obstructive scleroobliteration as atreatment of varicocele]

Authors developed and used the method of obstructive scleroobliteration with use of occlusive balloon catheter as a treatment for 32 patients. Advantages of this method: 1. Possibility of scleroobliteration in isolated area of the left internal testicular vein and its branches. 2 Improvement of sclerosant influence on venous wall by means of aspiration of blood and contrast agent of blocked vein. 3. Decrease of contrast agent by means of it aspiration after performed phlebography. 4. Prophylaxis of negative effect (allergy, thrombotic complications) of sclerosant by means of it partial aspiration and extravasal compression of proximal part of vein. 5. No late relapse. This method allow to perform an effective scleroobliteration with exclusion of testicular vein and venous collateral without special technical skills and cost increase. Aspiration of sclerosant in a lumen of vein allows to decrease the amount of surgical complications.

[Treatment of varicocele infertility men patients of different Chinese medical syndrome types by integrative medicine treatment selection: a primary research]

OBJECTIVE

To explore the optimal treatment selection for treating varicocele (VC) male infertility patients accompanied with oligozoospermia or azoospermia of different Chinese medical syndrome types by comparing the efficacies of integrative medicine.

METHODS

One hundred and twenty male infertility patients with VC accompanied with oligozoospermia or azoospermia were assigned to Chinese medical treatment group (A) and the surgical group (B), each consisting of three Chinese medical syndrome types, i.e., damp-heat stagnation syndrome (DHSS), Shen-deficiency blood stasis syndrome (SDBSS), and blood stasis stagnation syndrome (BSSS), 20 in each group. Corresponding Chinese medical treatment was administered to those in Group A, C, and E, while microscopic ligation of internal vena spermatic was administered to those in Group B, D, and F. The routine analysis of semen, biochemical analysis of seminal plasma, and serum sex hormones (prolactin, testosterone, follicle stimulating hormone, luteinizing hormone, and estradiol) were performed before treatment and by the end of the 24th week after treatment.

RESULTS

Totally 18 patients' spouses were pregnant. Of them, 1 in Group A of DHSS (abbreviated as Group A), 3 in Group B of DHSS (abbreviated as Group B), 4 in Group A of SDB-SS (abbreviated as Group C), 5 in Group A of SDBSS (abbreviated as Group D), 1 in Group A of BSSS (abbreviated as Group E), and 4 in Group B of BSSS (abbreviated as Group F). After 24-week treatment, the sperm concentration, class a sperm percentage, class a + b sperm percentage, the motility rate, the seminal plasma of fructose density, and the seminal plasma neutral alpha-glucosidase were more significantly improved in Group B, C, D and F, when compared with the same group before treatment (P <0. 01, P <0. 05). There was no statistical difference in the aforesaid indices between before and after treatment in Group A and Group E (P >0.05). As for the improvement percentage of seminal routine indices, the difference of the seminal plasma of fructose density, and the difference of seminal plasma neutral alpha-glucosidase between before and after treatment in the same Chinese medical syndrome types, better effects were obtained in Group B than in Group A (P <0.01), and better effects were obtained in Group F than in Group E (P <0.01). There was no statistical difference between Group C and D (P >0.05). There was no statistical difference in the 5 items of sex hormones in each group between before and after treatment (P >0.05).

CONCLUSIONS

Surgical treatment could effectively improve the semen quality for male infertility VC patients accompanied with oligozoospermia or azoospermia. Of them, Chinese medical treatment could be recommended to those of SDBSS who would not receive surgical treatment.

[Varicocele in adolescents]

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

[Open surgery, laparoscopic Palomo varicocelectomy and embolization in children with varicocele]

OBJECTIVES

Our aim was to prove the outcomes in varicocele treatment during last 10 years in our institution regarding to the recurrence rate and reactive hydrocele in children and adolescents treated with open technique, laparoscopic approach or embolization.

PATIENTS AND METHODS

Medical charts of patients with varicocele younger than 17 years old were reviewed. Age, weight, surgery indications, treatment (open surgery, laparoscopic Palomo varicocelectomy or embolization), location, varicocele grade, hospital stays, recurrence, postoperative hydrocele, genitofemoral nerve damage, infection, bleeding, postoperative incisional hernia and re-do varicocelectomy were collected.

RESULTS

From 2000 to 2010, 98 boys with varicocele diagnosis were treated in our institution. Mean age of patients was 12 years. The varicocele location in all cases was on the left side. Grade III varicocele was found in 94 boys and grade II in 4 patients. Indications for surgery were high grade in 81, chronic pain in 16 and testicular hypotrophy in 1. Treatment approach was as follows: 12 patients underwent open surgery (Palomo or Ivanissevich technique), 32 underwent embolization and laparoscopic Palomo varicocelectomy was performed in 54. We found a global recurrence rate of 14.3% and an overall postoperative hydrocele of 24.5% Recurrence rate was higher in the embolization group than the open surgery and laparoscopic group. Three patients presented intraoperative bleeding in the laparoscopic group and there was one conversion to open surgery.

CONCLUSIONS

Our retrospective review proves that laparoscopic Palomo varicocelectomy is a safe and efficient approach to treat varicocele in pediatric population, because of its low recurrence rate without any major adverse outcome. Due to our high secondary hydrocele formation, lymphatic sparing laparoscopic procedure should be taken into account in order to decrease this complication.