Controversies in the evolution of paediatric-adolescent varicocele: clinical, biochemical and histological studies

Abstract

Objective: To study hormonal and histological parameters of paediatric±adolescent varicocele in order to know certain aspects of its natural history, in an attempt to find prognostic markers of testicular damage. Design and methods: In a prospective cross-sectional study, we evaluated 93 children and adolescents with left unilateral varicocele and 29 healthy males as control group. All of them were classified according to Tanner stage. Scrotal Doppler in both testes and GnRH and human chorionic gonadotrophin (hCG) tests were performed in all subjects. Surgery was performed in 28 patients and homolateral testicular biopsy in 18. Results: Hormonal measurements of patients with varicocele were compared with a control group for each Tanner stage. Testicular biopsy specimens were analysed by light and electron microscopy. We only observed statistical differences in Tanner III patients in basal FSH (median and range) controls 1X70 (1.10±3.70) IU/l vs varicocele 4X20 (1.00±7.50) IU/l, P , 0X05 and in Tanner IV patients in LH post-GnRH: controls 11X0 (7.50±15.0) IU/l vs varicocele 18X0 (5.10±29.0) IU/l, P , 0X05 and in testosterone post-hCG: controls 9X50 (7.7±10.0) ng/ml vs varicocele 12X0 (6.2±23.0) ng/ml, P , 0X01X No correlation was found between the various clinical grades of varicocele and hormonal measurements for each Tanner stage. No statistically significant differences were found between pre-and post-operative hormonal findings, either in basal levels or in maximal responses. On the other hand, no morphological abnormalities were observed by electron microscopy in germ cells, tubular wall and interstice.Conclusions: There appears to be no reliable biochemical marker in children and adolescents that may predict impaired testicular function. A significant size discrepancy between both testes, testicular pain and a hyperresponse to GnRH stimulation should continue to be, for the time being, the indications for surgery.

Adolescent varicocoele management controversies

“…Such semen abnormalities, caused by any injury to the testes, were first described by Macleod & Gold (1951), which are now commonly referred to as a 'stress pattern'. Leydig cell dysfunction/hyperplasia, germinal epithelial sloughing, tubular thickening, interstitial fibrosis, decreased spermatogenesis and maturation arrest are also increased with varicocoele (CastroMagana et al, 1990;Fideleff et al, 2000). There is convincing evidence which supports pathological changes not only during the long term but also during adolescence (Castro-Magana et al, 1990;Paduch & Niedzielski, 1996;Fideleff et al, 2000).…”

“…Leydig cell dysfunction/hyperplasia, germinal epithelial sloughing, tubular thickening, interstitial fibrosis, decreased spermatogenesis and maturation arrest are also increased with varicocoele (CastroMagana et al, 1990;Fideleff et al, 2000). There is convincing evidence which supports pathological changes not only during the long term but also during adolescence (Castro-Magana et al, 1990;Paduch & Niedzielski, 1996;Fideleff et al, 2000). The clear objective in treating the adolescent varicocoele is to prevent testicular damage.…”

Varicocele

“…Fideleff et al performed a prospective study of 93 adolescents (mean age 12.8 years) with a left varicocele and found no correlation between the presence of a varicocele and hormonal findings when controlling for Tanner stage. 15 In those patients that underwent varicocelectomy, there were no statistically significant differences in pre vs. postoperative hormonal parameters. 15 Given these results, more research is needed before recommendations regarding hormonal testing or discussion of the benefits of adolescent varicocele treatment in preventing hypogonadism can be provided.…”

“…15 In those patients that underwent varicocelectomy, there were no statistically significant differences in pre vs. postoperative hormonal parameters. 15 Given these results, more research is needed before recommendations regarding hormonal testing or discussion of the benefits of adolescent varicocele treatment in preventing hypogonadism can be provided.…”

The hemodynamic approach to evaluating adolescent varicocele

“…15 In addition, fertility testing is not routine in adolescents and no generally accepted standards exist to define normal semen parameters for patients in this age group. 51 Although several indirect markers of testicular damage have been investigated-including inhibin B, 52 hyperresponse to gonadotropinreleasing hormone stimulation, 53,54 cytokines, 55 Fas and Fasligand proteins, 56 and reactive oxygen species anti oxidants 57 -none reliably predict impaired testicular function in adolescents. 53 …”