madman
Super Moderator
ABSTRACT
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 the potential for future fertility problems which may or may not actually become of concern. Assessing the degree of the 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 the diagnosis of varicocele, considerations for initiating treatment of varicocele in the adolescent, and techniques for management.
With an incidence of approximately 15%, left-sided varicoceles are a common urologic anomaly in adolescent males.1 The enlargement of the pampiniform venous plexus in the scrotum is believed to be due to suboptimal drainage of blood on the left side. Three factors are discussed to play a role. 1 Cadaver studies have shown that valves are missing in approximately 1/3 of testicular veins.2 Secondly, the left testicular vein drains into the left renal vein with what is believed to be an unfavorable angle. 3 The third reason is believed to be the impingement of the left renal vein between the aorta and the superior mesenteric artery also known as nutcracker syndrome.4 Rarely, varicoceles can be caused by an intraabdominal or retroperitoneal tumor that compresses the testicular vessels. This entity should be ruled out in right-sided varicoceles. Routine abdominal ultrasound to rule out associated malignancy in left-sided varicoceles is not mandatory as the risk is very low.5
Varicoceles are typically identified by the adolescent or found on routine examinations. They are graded as published by Dubin and Amelar into 4 Grades (Table 1).6
Ultrasound is often used as a diagnostic tool to assess venous diameter, peak flow, and testicular volume (Fig. 1.). Ultrasound was found to be more accurate in estimating testicular size differentials than the examination with the Prader orchidometer.7 There is however great inter-institutional and inter-radiologist variability.8 Volume differences should therefore be evaluated both clinically and radiologically and findings need to be interpreted carefully when making surgical decisions. Repair of varicoceles with a higher preoperative spermatic venous diameter has been associated with more improvement in postoperative semen parameters. Schiff et al. correlated preoperative ultrasound findings with postoperative semen parameters in 68 infertile men. The greatest improvement was seen when the preoperative spermatic venous diameter exceeded 3 mm and reversal of spermatic venous flow on valsalva was demonstrated.9 The value of the peak retrograde flow as a prognostic factor and guide for surgical decision-making has yet to be identified, but there are data suggesting that a high peak flow (>38 cm/sec) has predictive value for persistent or worsening testicular asymmetry.10
*Indications for the repair of varicocele
*Pain
*Fertility
*Androgen deficiency and hypogonadism
Another consideration to repair varicoceles in adolescents is the potential for the preservation of testicular health. Varicoceles can have an effect on sperm, as well as Sertoli and Leydig cells within the testicle. Clinically, Sertoli cell dysfunction can be observed by a decreased responsiveness to follicle-stimulating hormone (FSH), and by alterations in androgen binding protein (ABP), transferrin, and inhibin. In the setting of varicocele, some men present with elevated FSH and decreased testosterone production, and 48%–76% have improvement in one or both of these parameters the following varicocelectomy.18,19 Inhibin B levels also often improve after varicocelectomy, suggesting a reversible Sertoli cell defect.20
*Testicular size asymmetry
*Treatment options
*High (retroperitoneal) ligation of the vasa spermatic: Palomo technique
*Modified Palomo technique
-Artery sparing = supra-inguinal (Ivanissevich)
-Lymphatic sparing classic Palomo procedure
*Percutaneous embolization by interventional radiology
Summary
Indications for varicocele repair in teenagers include pain and poor testicular growth, as well as poor semen analysis parameters when this data is available. Recent data in adult populations suggest varicocele repair improves not only fertility but also the hormonal milieu. The implications of varicocele on the hormonal status of adolescents are poorly understood. Further studies about the long-term implications of varicocele on fertility and hormone status may help pediatric practitioners to make decisions about the timing of varicocele repair in adolescence.
The evidence suggests that the laparoscopic lymphatic-sparing Palomo procedure and the microsurgical subinguinal approach are associated with the lowest recurrence rates and lowest hydrocele formation rates. There is not enough evidence to decide which technique is superior. Comparable data for catch-up growth, semen quality, and pregnancy rates are also lacking.
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 the potential for future fertility problems which may or may not actually become of concern. Assessing the degree of the 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 the diagnosis of varicocele, considerations for initiating treatment of varicocele in the adolescent, and techniques for management.
With an incidence of approximately 15%, left-sided varicoceles are a common urologic anomaly in adolescent males.1 The enlargement of the pampiniform venous plexus in the scrotum is believed to be due to suboptimal drainage of blood on the left side. Three factors are discussed to play a role. 1 Cadaver studies have shown that valves are missing in approximately 1/3 of testicular veins.2 Secondly, the left testicular vein drains into the left renal vein with what is believed to be an unfavorable angle. 3 The third reason is believed to be the impingement of the left renal vein between the aorta and the superior mesenteric artery also known as nutcracker syndrome.4 Rarely, varicoceles can be caused by an intraabdominal or retroperitoneal tumor that compresses the testicular vessels. This entity should be ruled out in right-sided varicoceles. Routine abdominal ultrasound to rule out associated malignancy in left-sided varicoceles is not mandatory as the risk is very low.5
Varicoceles are typically identified by the adolescent or found on routine examinations. They are graded as published by Dubin and Amelar into 4 Grades (Table 1).6
Ultrasound is often used as a diagnostic tool to assess venous diameter, peak flow, and testicular volume (Fig. 1.). Ultrasound was found to be more accurate in estimating testicular size differentials than the examination with the Prader orchidometer.7 There is however great inter-institutional and inter-radiologist variability.8 Volume differences should therefore be evaluated both clinically and radiologically and findings need to be interpreted carefully when making surgical decisions. Repair of varicoceles with a higher preoperative spermatic venous diameter has been associated with more improvement in postoperative semen parameters. Schiff et al. correlated preoperative ultrasound findings with postoperative semen parameters in 68 infertile men. The greatest improvement was seen when the preoperative spermatic venous diameter exceeded 3 mm and reversal of spermatic venous flow on valsalva was demonstrated.9 The value of the peak retrograde flow as a prognostic factor and guide for surgical decision-making has yet to be identified, but there are data suggesting that a high peak flow (>38 cm/sec) has predictive value for persistent or worsening testicular asymmetry.10
*Indications for the repair of varicocele
*Pain
*Fertility
*Androgen deficiency and hypogonadism
Another consideration to repair varicoceles in adolescents is the potential for the preservation of testicular health. Varicoceles can have an effect on sperm, as well as Sertoli and Leydig cells within the testicle. Clinically, Sertoli cell dysfunction can be observed by a decreased responsiveness to follicle-stimulating hormone (FSH), and by alterations in androgen binding protein (ABP), transferrin, and inhibin. In the setting of varicocele, some men present with elevated FSH and decreased testosterone production, and 48%–76% have improvement in one or both of these parameters the following varicocelectomy.18,19 Inhibin B levels also often improve after varicocelectomy, suggesting a reversible Sertoli cell defect.20
*Testicular size asymmetry
*Treatment options
*High (retroperitoneal) ligation of the vasa spermatic: Palomo technique
*Modified Palomo technique
-Artery sparing = supra-inguinal (Ivanissevich)
-Lymphatic sparing classic Palomo procedure
*Percutaneous embolization by interventional radiology
Summary
Indications for varicocele repair in teenagers include pain and poor testicular growth, as well as poor semen analysis parameters when this data is available. Recent data in adult populations suggest varicocele repair improves not only fertility but also the hormonal milieu. The implications of varicocele on the hormonal status of adolescents are poorly understood. Further studies about the long-term implications of varicocele on fertility and hormone status may help pediatric practitioners to make decisions about the timing of varicocele repair in adolescence.
The evidence suggests that the laparoscopic lymphatic-sparing Palomo procedure and the microsurgical subinguinal approach are associated with the lowest recurrence rates and lowest hydrocele formation rates. There is not enough evidence to decide which technique is superior. Comparable data for catch-up growth, semen quality, and pregnancy rates are also lacking.
