Evolving management of adolescent varicocele

Abstract

Objective: To review the evolution in indications for treatment and treatment modalities for adolescent varicocele at our centre, and evaluate the impact of varicocelectomy on final outcome. Patients and methods: Between 1995 and 2006, we treated 242 left varicoceles. Preoperative assessment included clinical evaluation, measurement of testicular volumes, and colourDoppler ultrasound (CDUS). A subinguinal varicocelectomy was performed in 124 patients (group A), and a laparoscopic non-artery-sparing Palomo procedure in the remaining 118 (group B). In group B patients, CDUS was also used to investigate the functional anatomy of varicocele, and all the veins found to be refluxing were divided during surgery. The two groups were compared with regard to indications for surgery and outcome. Results: Over time the proportion of patients operated on because of testicular growth retardation increased. Persistence/recurrence rate was comparable between the two groups. In 13% of group B patients, the deferential vein was found to be refluxing on preoperative CDUS and was divided at surgery. Hydrocele rate was higher in group A, unless the vaginalis was excised and everted during varicocelectomy. About 75% of patients with preoperative left testicular growth failure experienced postoperative catch-up growth, irrespective of treatment. Conclusion: Indications for treatment are still evolving. Varicocele can successfully be treated in the majority of cases by either a laparoscopic or subinguinal approach. Both techniques require care, and CDUS can aid in the decision making. Most patients with preoperative testicular growth failure experience postoperative catch-up growth.

Shunt-type and stop-type varicocele in adolescents: prognostic value of these two different hemodynamic patterns

“…Diamond et al reported abnormal sperm count in 11% and 59% of patients with testicular volume discrepancy of 10%-20% and >20%, respectively (5). Surgical repair of varicocele improves semen parameters in infertile men (12) and the prevalence of testicular catch-up growth has been reported to be as high as 80% after varicocelectomy (13)(14)(15). Patients with varicocele and no evidence of testicular hypotrophy may be eligible for a conservative nonsurgical approach.…”

Avoidance of hydrocele after non microsurgical varicocelectomy by pre-emptive eversion of tunica vaginalis in infertile men with varicocele

“…This result came in accordance to Castagnetti et al who compared 96 cases of subinguinal varicocelectomy plus pre-emptive hydrocelectomy with 46 patients who underwent subinguinal varicocelectomy alone. [19][20][21] The rate of postoperative hydrocele was statistically lower in those who received a pre-emptive hydrocelectomy (4.2% versus 13%; P = 0.04). Pre-emptive surgery can consist of vaginalis excision only or excision and eversion.…”

The hemodynamic approach to evaluating adolescent varicocele

“…9 Subsequently, a modified laparoscopic technique was developed that was also able to address reflux in the def erential vein shown by CDUS (Figure 9). [6][7][8] Using this approach, surgeons have managed to progressively lower persistence rates.…”

“…It enables assessment of the functional anatomy subtending the varicocele [6][7][8] and provides a comprehensive evaluation of the three major venous networks draining the pampiniform plexus-the ISV, the cremasteric veins, and the defer ential veins-distinguishing refluxing collateral and differentiating refluxing veins from veins dilated due to overflow. 9 In a recent study of 148 adolescent and pedi atric patients, CDUS identified reflux in the ISV alone in 126 patients (85.1%), reflux in both the ISV and the deferential vein in 21 patients (14.1%), and an isolated deferential reflux in one patient (0.6%).…”