Abstract
Objective: The aim of this retrospective study is to evaluate if the early repair
of varicocele in children and adolescents can prevent testicular growth arrest
and male infertility later on.
Methods: During
a three year period (2004- 2006), 70 children and adolescents with varicocele who
were operated on at Prince
Rashid Hospital
were reviewed (mean age 15 years, 9-19 years). All patients had been evaluated
by a urologist or a pediatric surgeon. High ligation of the internal spermatic
vein was carried out either by open retroperitoneal approach or transperitoneal
laparoscopic approach.
Results: Of
the 70 patients 39 had grade II varicocele and 31 had grade III varicocele. In 33 patients (49%), the disease was
associated with ipsilateral testicular growth arrest. In seven patients (10%), the
disease was associated with impaired seminal fluid analysis parameters, four patients
had recurrence of varicocele, and three patients developed hydrocele. Of 33
patients with testicular growth arrest, 32 ( 97% ) regained normal testicular
volume post operatively, while six of the seven patients with impaired seminal
fluid analysis achieved normal parameters after surgery.
Conclusion: Varicocele can affect
ipsilateral testicular growth and seminal fluid analysis parameters, which may
adversely affect fertility. We recommend early recognition and treatment.
Key words: Adolescent, Childhood, Varicocele
JRMS
August 2009; 16(2): 35-38
Introduction
A varicocele can be defined as an abnormal dilatation and tortuosity of
pampiniform plexus.(1) Its prevalence in boys aged 10-19
years is reportedly 7.2% to 16% and in approximately 40% of men presenting with
infertility.(2-4) In most affected adolescents the varicocele
is grade I (60%), while in 40% it is grade II or III.(4)
Varicocele is most common on the left side in 90% of boys and bilateral
in 10%. A unilateral, primary right sided varicocele is exceedingly rare(2)
and, should prompt investigation for a retroperitoneal mass compromising venous
return from the right testicle.(5)
Table
I. The
results of our observations
|
|
No. of patients
|
|
Grade
Grade II
Grade III
|
39
31
|
|
Presenting
symptoms
Incidental
Pain
|
58
12
|
|
Associated
abnormality
Testicular growth arrest
Abnormal SFA parameters
|
33 (32 Improved after repair)
7 (6 Improved after repair)
|
A varicocele first develops in early adolescence and it may negatively
affect testicular growth, histology and function.(6-8) These
gonadotoxic effects may be progressive and irreversible, and several
investigators have proposed early varicocelectomy to prevent severe testicular
damage and infertility in adulthood.(9,10) This knowledge has
raised the question of how best to manage adolescents with varicocele. In the
present study we described our experience in the management of adolescents with
varicocele in the north part of Jordan
at Prince Rashid Bin Al-Hassan Military
Hospital.
Method
Based on the belief that varicocele may affect male fertility in the
future, we operated on all children and adolescents with varicocele. In the three
year period between 2004 and 2006, 70 children and adolescent patients with
varicoceles were operated on. Mean age was 15 years (range 9-19). Abnormal
seminal fluid analysis data in young men (low motility, low count), testicular
atrophy, scrotal pain (heaviness) and grade II-III varicocele were considered
as indications for surgery. Patients over 19 were excluded from our study.
Varicocele was diagnosed by history and physical examination. All
patients were examined in a warm room by a urologist or pediatric surgeon both while
supine and standing with and without coughing.
The clinical findings were confirmed
by color Doppler ultrasound. All
patients had reflux and a venous diameter > 2mm, testicular volume was also evaluated
by ultrasound (three dimensions). Seven young men of the total number treated
for sub fertility had at least two seminal fluid analyses before
varicocelectomy which showed at least one abnormality, either motility < 50%
or count < 20 million (Table I).
Laparoscopic high clipping of internal spermatic vein was performed in
those with bilateral varicocele (six patients) as described by Schwentner et
al.(11) Open
surgery was done for those with unilateral disease (64 patients) via left Lanz
incision through retroperitoneal approach. All operations were performed under general
anesthesia as day surgery procedure. All
patients were followed up at one week (wound observation) and ≥ 3 months post
operatively for clinical examination and Doppler ultrasound. Seminal fluid
analysis for sub-fertile young men was done after 80 days.
Results
Of the 70 varicoceles, 39 were classified as grade II and 31 as grade
III, 58 patients (81%) detected incidentally either during physical examination
or noticed by the patient himself. In 12 patients (19%) pain was the presenting
symptoms.
In 33 patients (49%), the varicocele was associated with impaired growth
of left testicle. In seven patients (10%) out of 70 the disease was associated
with abnormal seminal fluid analysis.
There was no significant difference in the operative time between
laparoscopic and open high ligation of the varicocele, the mean operative
duration was 20 minutes for both procedures (range 15-40 minutes), and both
groups were done as day case procedures, only one patient required admission
due to being operated at the end of the operative list.
The follow up at one week for wound inspection showed only one wound
infection and was treated by drainage.
Surgery was considered successful by complete absence of varicocele
after a minimum of three months follow up. In four patients (5.7%) there was a recurrence
of the varicocele (2 grade II and 2 grade III). Three patients (4.3%) developed
hydrocele after surgery, and there was no reduction in testicular volume
compared with the contra lateral side during the follow up period. In 32 (97%) out of 33 patients with
preoperative left testicular hypotrophy, there was clear improvement in size
after surgery. The seminal fluid analysis data turned to normal in six out of seven
patients whom their disease was associated with abnormality in the sperm count
and motility, the remaining one patient was lost follow up (Table I).
Discussion
The pathogenesis of varicocele formation is somewhat unclear. It is
thought that various factors play a role in an increase of pressure in the
pampeniform venous plexus and its venous drainage.(12) These
factors include persistent collateral veins, absent or incompetent venous valve
in the internal spermatic veins, increased pressure in the left renal vein, and
the anatomic relationships of the left internal spermatic vein at its insertion
into the renal vein is of particular relevance.
Several surgical techniques for the treatment of varicocele have been
described, but still there is no gold standard technique, and controversy still
exists on the advantages and disadvantages of each option. The most widespread
treatment of varicocele in children and adolescents has been high ligation of
the internal spermatic vein, retroperitoneo-scopic,(13,14) transperitoneoscopic
(Laparoscopic)(6,11) or open retroperitoneal approach.(15)
Recently, less invasive methods have emerged, such as, percutaneous retrograde sclerotherapy,(16)
antigrade sclerotherapy,(17,18) and percutaneous testicular
vein embolization.(19)
Scrotal ultrasonography with volume measurements has been shown to be
more accurate in determining the testicular volume than the orchoidometer.(20)
Furthermore, ultrasonography nowadays is used to diagnose the prevalence of
varicocele and the severity of associated venous reflux.(21)
It is clear that varicocele repair can result in compensatory growth of the
hypotrophic testis. A reversal of hypotrophy was reported in 53-90%(5,22,23)
and 100% by Yamamoto et al.(24) Also loss of
testicular volume has been rarely reported in association with intratesticular varicocele.(25)
In our study volume recovery after varicocele repair is reported in 32 out of
33 patients (97%), which is comparable to others.
Usually, adolescents do not present with infertility, therefore, semen
analysis data from adolescent patients with varicocele is quote sparse. There
were many observations showing that there is significant improvement of seminal
fluid analysis data after surgical repair of varicocele.(26-28)
In our study seven patients presented
with abnormal semen analysis data and sub fertility. They married early in
their life. Six regained normal seminal fluid analysis within few months of
surgery and their wives became pregnant later on, one patient was lost to follow
up after surgery.
Varicocele repair carries potential complications that occur infrequently
and are usually mild. These are wound infection, hydrocele, persistence or
recurrence of varicocele and rarely testicular atrophy. The recorded rate of complications
by others range between 0-12%,(11,13,17,19) hydrocele was reported
in 0-20%,(5,6,11,13,17,19) wound infection is not documented
well in literature and testicular atrophy is very rare. We reported persistence
rate in four patients (5.7%), hydrocele in three patients (4.3%), wound
infection in one patient and no testicular atrophy was reported.
Conclusion
-
Varicocele can affect ipsilateral testicular growth
and this growth arrest impairs fertility in the future that is why early
recognition and treatment can reverse the whole adverse effect of varicocele on
male fertility.
-
All adolescent males should be examined by schools
physician routinely and educated about testicular self examination to detect
the disease early.
-
Contra lateral testis is normal in all patients.
References
1. Darius AP,
Steven JS. Current management of adolescent varicocele. Reviews in Urology
2001; 3(3):120-133.
2. Akbay E, Cayan S, Doruk E, et
al. The prevalence of varicocele
and varicocele-related testicular atrophy in Turkish children and adolescents. BJU
International 2000; 86:490-493.
3. The practice
committee of the American society for reproductive medicine. Birmingham, Alabama.
Report on varicocele and infertility. Fertility and Sterility 2006;
86(4): 593-595.
4. Diamond DA. Adolescent varicocele:
emerging understanding. BJU International 2003; 92(1): 48-51.
5. Salzhaue WE, Sokol A, Glassberg KI.
Paternity after adolescent varicocele repair. Pediatrics 2004; 114(6):
1631-1633.
6. Belloli G,
Musi L, D’Agostino S. Laparoscopic surgery for adolescent varicocele:
preliminary report on 80 patients. J Pediatr Surg 1996; 31(11):
1488-1490.
7. Belloli G, D’Agostino S, Zen F, et al. Fertility rates after
successful correction of varicocele in adolescence and adulthood. Eur J
Pediatr Surg 1990; 5:216-218.
8. Belloli G, D’Agostino S, Pesce C, et al. Adolescent varicocele and
other testicular anomalies: an epidemiologic study. Med Surg Ped 1993; 15:
159-162.
9. Kass EJ,
Marcol B. Results of varicocele surgery in adolescents: a comparison of
techniques. J Urol 1992; 148: 694-696.
10. Belloli G,
D’Agostino S, Musi L, et al. Adolescent varicocele: operative
anatomy and tricks for successful correction. Eur J Pediatr Surg 1995;
5: 219-221.
11. Schwentner C,
Radmayr C, Lunacek A, et al. Laparoscopic varicocele ligation in children
and adolescents using isosulphan blue: a prospective randomized trial. BJU International
2006; 98: 861-865.
12. Nielsen ME,
Zderic S, Freedland SJ, et al. Insight on pathogenesis of varicoceles:
relationship of varicocele and body mass index. Urology 2006; 68(2):
392-396.
13. Cobellis G, Mastroianni L, Cruccetti A, et al. Retroperitoneoscopic varicocelectomy
in children and adolescents. J Pediatr Surg 2005; 40: 846-849.
14. Geng-Long
Hsu, Pei-Ying Ling, Cheng-hsing Hsieh, et al. Outpatient varicocelectomy
performed under local anesthesia. Asian J Androl 2005; 7(4): 439-444.
15. Abdulmaboud
MR, Shokeir AA, Farage Y, et al. Treatment of varicocele: a
comparative study of conventional open surgery, percutaneous retrograde
sclerotherapy and laparoscopy. Urology 1998; 52: 294-300.
16. Colpi G M, Carmignani L, Nerva F, et al. Surgical treatment of
varicocele by a subinguinal approach with antigrade intraoperative
sclerotherapy of venous vessels. BJU International 2006; 97: 142-145.
17. Zaupa P, Mayr
J, Höllwarth ME. Antegrade scrotal sclerotherapy for treating
primary varicocele in children. BJU International 2006; 97: 809-812.
18. Clarke S A,
Agrawal M, Reidy J. Percutaneous transfemoral teaticular vein embolization in the treatment
of childhood varicocele. Pediatr Radiol 2001; 31: 515-517.
19. Fette A, Mayr
J.
Treatment of varicocele in childhood and adolescence with tuber's antegrade
scrotal sclerotherapy. J Pediatr Surg 1997; 35(8): 1222-1225.
20. Diamond DA, Paltiel HJ, DiCanzio J, et al. Comparative assessment of
pediatric testicular volume: orchoidometer versus ultrasound. J Urol
2000; 164: 1111-1114.
21. Pfeiffer D, Berger J, Schoop C, et al. A Doppler- based study on the
prevalence of varicocele in German children and adolescents. Blackwell
Publishing Ltd Andrologia 2006; 38: 13-19.
22. Parrott TS,
Hewatt L. Ligation of the testicular artery and vein in adolescent varicocele. J
Urol 1994; 152: 791-793
23. Belman AB. The adolescent varicocele. Pediatrics
2004; 114(6): 1669-1670.
24. Yamamoto M, Hibi H, Katsuno S, et al. Effect of
varicocelectomy on testes volume and semen parameters in adolescents: a
randomized prospective study. Nagoya
J Med Sci 1995; 58: 127-132
25. Kuo-Jong Ho,
Mcateer E, Young M. Loss of testicular volume associated
with intratesticular varicocele. Int J Urol 2005; 12: 422-423.
26. Paduch DA,
Niedzielski J. Semen analysis in young men with varicocele: a preliminary study. J
Urol 1996; 156:788-790
27. Lenzi A, Gandini L, Bagolan P, et al. Sperm parameters after early
left varicocele treatment. Fertil Steril 1998; 69: 347-349.
28. Sayfan J, Siplovich L, Koltun L, et al. Varicocele treatment in
pubertal boys prevents testicular growth arrest. J Urol 1997; 157:
1456-1457.