Color Doppler ultrasonography as a routine clinical examination in male infertility

AIM: We assessed the value of scrotal color Doppler ultrasonography as a routine examination in infertile men. METHODS: Color Doppler ultrasonography was performed in 545 infertile men with a mean age of 35.8 years to detect intrascrotal abnormalities. Findings were compared with those of physical examination. RESULTS: Intrascrotal abnormalities were detected by ultrasonography in 65.3% of patients. Of 374 abnormalities, 58.3% were undetected by physical examination. Left varicocele was found in 313 patients (57.4%); testicular microlithiasis in 30 (5.5%); epididymal cyst in 21 (3.9%); right varicocele in 4 (0.8%); and testicular cysts in 3 (0.6%). One occurrence each (0.2%) was found for testicular tumor, intrascrotal hemangioma, and hydrocele of the spermatic cord. Compared to ultrasonography, sensitivity in detecting left varicocele by physical examination was 58.4%; specificity, 79.3%; accuracy, 67.3%; and positive predictive value, 79.3%. Venous diameters in the pampiniform plexus were 3 mm or more in 61.5% of 130 subclinical left varicoceles. Of 30 patients with testicular microlithiasis, 14 had varicocele, 2 had epididymal cyst,s 3 had a history of mumps orchitis, 1 had retractile testis, and 1 had a history of orchiectomy for contralateral testicular tumor. CONCLUSIONS: The routine Color Doppler ultrasonography is valuable for diagnosing scrotal abnormalities in infertile men, frequently detecting non-palpable lesions.     

Multiparametric evaluation of testicular atrophy due to varicocele

63 men with palpable left varicoceles were evaluated by semen analysis, scrotal ultrasonography, Doppler sonography, scrotal contact thermography, and radionuclide scanning. 11 (17.4%) patients had bilateral varicoceles detected by scrotal ultrasonography as compared with an incidence of 3.1% by scrotal palpation. Testicular atrophy was found in 29 (46%) patients by scrotal ultrasonography. This was found to be 39.6% by scrotal palpation alone. In this study using advanced diagnostic procedures, the incidences of bilateral varicocele and testicular atrophy due to varicocele were found to be much higher than when scrotal palpation alone was performed.     

The effect of varicocele repair on testicular volume in children and adolescents with varicocele

PURPOSE: We investigated the effect of varicocele repair on testicular volume according to age in children and adolescents and review the long-term results of varicocele surgery. MATERIALS AND METHODS: The study included 39 boys 11 to 19 years old with clinical palpable varicocele who underwent varicocele surgery with at least 1 year of postoperative followup. Preoperative and postoperative testicular volumes were monitored and measured with an ellipsoid Prader orchidometer. Physical examination findings (testicular volumes and testicular consistency) in all boys, and serum hormone values and semen parameters in 16 adolescents were recorded and compared before and after surgery. RESULTS: Left unilateral varicocelectomy was done in 29 boys (74%) and bilateral varicocelectomy in 10 (26%). While no postoperative hematoma, infection or testicular atrophy was observed, 1 boy (2.5%) had varicocele recurrence and 2 boys (5.1%) had minimal hydroceles that required no intervention. Significant increases were observed in postoperative sperm concentration (p = 0.01), total motile sperm count (p = 0.009), testis volume (p = 0.000) and serum testosterone level (p = 0.014). All 15 boys with preoperative soft testis had normal testicular consistency postoperatively. Of the 19 boys with preoperative testicular atrophy 10 (53%) did regain normal testicular growth, while 9 (47%) retained testicular volume loss after surgery. When comparing preoperative to postoperative increase in testicular volume according to age in all boys, the mean was statistically significantly higher in boys younger than 14 years (left testis p = 0.037, right testis p = 0.000). CONCLUSIONS: Testicular consistency achieved normal firmness after varicocelectomy in all boys with preoperative soft testis. While there was catch-up growth in comparison to the contralateral testis, testicular consistency improved but testicular volumes may not increase significantly after varicocele repair at ages older than 14 years. However, in these adolescents postoperative semen parameters and serum hormone values may significantly improve regardless of testicular volume. Therefore, boys with varicocele and their families should be fully informed in light of these findings.     

Scrotal ultrasound in the infertile man: detection of subclinical unilateral and bilateral varicoceles

Clinical and laboratory studies have provided convincing evidence that varicoceles are detrimental to spermatogenesis and that this effect is unrelated to their size. Thus, physicians have used diagnostic techniques other than physical examination to find these small but clinically significant varicoceles. Because scrotal sonography has proved to be invaluable to detect many intrascrotal abnormalities, and has the unique ability to visualize the testicle and surrounding structures, we used it to evaluate 50 infertile men. Of our 50 patients 22 had a clinically palpable left varicocele and 3 additional patients had bilateral varicoceles. All clinical varicoceles were confirmed by sonography. However, sonography also demonstrated a left varicocele in an additional 12 patients (34 of 50 or 68 per cent) and a right varicocele in 21 (a total of 24 or 48 per cent). Reflux on the right side always occurred in conjunction with that on the left side. Thus, among our 50 infertile men 24 of 34 (70 per cent) had bilateral varicoceles as detected by sonography, and 12 of 50 (24 per cent) had a subclinical varicocele on the left side. The high percentage of bilateral varicoceles detected by sonography may explain the pathophysiological mechanism by which what formerly was considered a unilateral anatomical abnormality may produce bilateral testicular dysfunction. It also may challenge us to change our present unilateral surgical approach to the patient with a clinically evident left varicocele.     

Correlation of testicular color Doppler ultrasonography, physical examination and venography in the detection of left varicoceles in men with infertility

High resolution color Doppler ultrasound is a noninvasive means of simultaneously imaging and evaluating the blood flow to the testes. To define the ability of color Doppler ultrasound to detect clinically evident as well as subclinical varicoceles men referred to our urology division with oligospermia and infertility underwent spermatic vein venography of the left testis if there was physical examination and/or color Doppler ultrasound evidence of a varicocele. The detection of valvular incompetence on venography was considered diagnostic for a varicocele. Of 17 study patients physical examination detected 10 of 14 venographically evident varicoceles (71%), whereas color Doppler ultrasound detected 13 of 14 (93%). Of 5 patients with a normal physical examination but with color Doppler ultrasound evidence of a varicocele 4 had a confirmatory venogram, and 1 of 2 patients with a varicocele on physical examination and a normal Doppler ultrasound had a positive venogram. These data suggest that color Doppler ultrasound of the testis may more appropriately direct further invasive testing and therapy of infertile men than physical examination alone.     

Improvement of sperm count and motility after ligation of varicoceles detected with colour Doppler ultrasonography

The debate regarding the efficacy of varicocele ligation for improvement of semen parameters and pregnancy rates is ongoing. In addition, no consensus exists as to the benefit of treatment of subclinical varicoceles. The aim of this study was to investigate, retrospectively, the effect of high ligation of both subclinical and clinical varicoceles on sperm count and motility. The value of several factors from history-taking and physical examination for the prediction of successful varicocelectomy was analysed. A total of 139 patients, operated on for a unilateral varicocele on the left side, were studied. Varicoceles were subclinical in 73 patients, based on colour Doppler ultrasonography, and 66 varicoceles were clinical, based on palpation in addition to ultrasonography. Comparison of semen parameters before and after surgery revealed a significant improvement. The median sperm count increased from 10.0 to 14.7, and from 18.2 to 28.6 million/ejaculate, in patients with subclinical and clinical varicoceles, respectively ( p  < 0.001). The percentage improvement in median sperm count in subclinical varicoceles was not statistically different from the improvement in clinical varicoceles. Mean progressive motility improved significantly after ligation ( p  < 0.001). The improvement in motility in subclinical varicoceles, from 16 to 23%, was significantly larger than the 24 to 27% improvement in clinical varicoceles. The increase in sperm count was related positively to testicular volume before surgery ( p  < 0.05). The increase in sperm motility was significantly lower in patients with a history of cryptorchidism ( n  = 22, p  < 0.05). The present data show that ligation of varicoceles detected using Doppler ultrasonography, whether palpable or not, results in an increase in sperm concentration and motility.     

IS ROUTINE SCROTAL ULTRASOUND ADVANTAGEOUS IN INFERTILE MEN?

PURPOSE: We determine the value of routine scrotal ultrasonography in the evaluation of male infertility. MATERIALS AND METHODS: Scrotal color Doppler ultrasonography reports of 1,372 infertile men were reviewed to assess the prevalence of scrotal abnormalities and compared to clinical findings. RESULTS: The prevalence of scrotal abnormalities was 38%. Testicular tumor was found in 0.5%, varicocele in 29.7%, testicular cyst in 0.7%, testicular microlithiasis in 0.9%, epididymal cyst in 7.6% and hydrocele in 3.2% of the cases. Overall, 67% of sonography findings were not evident on palpation, and only 1 of 7 testicular tumors was suspected. Of the varicoceles 60% were not found on physical examination. The rate of testicular tumors (1/200) was higher than that reported for the general European population (1/20,000). CONCLUSIONS: Routine scrotal ultrasound provides valuable information in the diagnostic evaluation of infertile men and substantially more pathological conditions are detected compared to clinical palpation. The high prevalence of testicular malignancies underlines the clinical relevance of routine scrotal ultrasonography in infertile men.     

The role of Doppler ultrasonography in determining the proper surgical approach to the management of varicocele in children and adolescents

In a study from Italy, colour-Doppler ultrasonography was a reliable diagnostic tool in the preoperative assessment of patients with varicocele. The authors also found that it helped to distinguish those who could be treated laparoscopically from those who should be treated by microsurgical subinguinal ligature. OBJECTIVE: To investigate whether colour Doppler ultrasonography (CDUS) is a reliable diagnostic tool for selecting patients with varicocele to undergo either laparoscopy or open microsurgical subinguinal ligation. PATIENTS AND METHODS: In a 3-year period, 42 boys affected by left varicocele were evaluated before surgery by inguinal and scrotal CDUS. Using this method it was possible to distinguish Coolsaet type-1 varicocele (due to isolated renal-internal spermatic vein reflux) and Coolsaet type-3 varicocele (due to associated renal-internal spermatic reflux and iliac-deferential reflux). Boys with Coolsaet type-1 varicocele were treated by a laparoscopic transperitoneal Palomo procedure, whereas those with Coolsaet type-3 varicoceles were treated by lymphatic-sparing microsurgical subinguinal ligation. RESULTS: The varicocele was Coolsaet type-3 in six patients (14%), who had microsurgical open surgery, and the remaining 36 (86%) had Coolsaet type-1 and had laparoscopic surgery. At the follow-up there was no venous scrotal reflux. In two patients in the laparoscopic group a hydrocele developed after surgery, which resolved spontaneously. CONCLUSIONS: This study showed that CDUS was a reliable diagnostic tool for assessing boys with varicocele. It clearly distinguished Coolsaet-type 1 varicoceles that can be treated laparoscopically, from Coolsaet type-3 varicoceles that should be treated with microsurgical subinguinal ligature.     

Varikozele und pubertäres Hodenwachstum

BACKGROUND: We prospectively assessed male students in the 4th and 8th forms to see whether varicoceles affect testicular growth. PARTICIPANTS AND METHODS: Ultrasound measurements were done in 778 boys to define testicular size according to the different pubertal stages. Seven hundred boys had a left or bilateral varicocele; 257 children and 287 adolescents with unilateral varicoceles were assessed for testicular size discrepancies in relationship to the varicocele size and the Doppler grades of venous reflux in the upright and supine positions. RESULTS: Rapid testicular growth occurred at puberty. By comparing the frequencies and extent of ipsilateral growth failures in adolescents, we noted significant differences among the varicocele grades. A volume loss of >/=15% was associated with the higher varicocele grades and the reflux grades in the supine position. CONCLUSION: Varicoceles may impair testicular growth at puberty. The severity of volume loss depends on the varicocele size and the related alterations in circulatory flow.     

Evaluation of varicocele by ultrasonography through a water bag in the supine position

Recently, ultrasonography has been widely used to evaluate varicocele. However, it is difficult to obtain reproducible scrotal images with a hand probe in the standing position. We, therefore, applied the water bag technique during ultrasonographic examination of the scrotal contents in the supine position. The ultrasonographic images thus obtained were compared with physical findings and scrotal scintigraphic findings. Forty-five varicocele patients diagnosed by palpation and ultrasonography were enrolled in this study. An ultrasonographic examination through a water bag in the supine position has the following advantages 1) it is easy to perform and stable images are obtained, 2) varicoceles that are not palpable can be detected and 3) examinations can be repeated both pre- and postoperatively. Of the 45 patients, 39 and 41 had positive findings on the ultrasonographic images and physical examinations, respectively. Four patients had negative findings on physical examination but positive findings on the ultrasonographic images. Thus, ultrasonographic images through a water bag in the supine position proved to be a useful method of confirming the hemodynamics in varicoceles.     

MICROSURGICAL REPAIR OF THE ADOLESCENT VARICOCELE

Purpose

Since clinically apparent varicoceles may affect testicular volume and sperm production, early repair has been advocated. However, repair of the pediatric varicocele with conventional nonmagnified techniques may result in persistence of the varicocele after up to 16% of these procedures. Also testicular artery injury and postoperative hydrocele formation can occur after nonmagnified repair. The microsurgical technique has been successfully completed in a large series of adults with a dramatic reduction in complication and recurrence rates. We report our experience with the microsurgical technique in boys.

Materials and Methods

A total of 30 boys (average age 15.9 years) underwent 42 microsurgical varicocelectomies (12 bilateral). All patients had a large left varicocele. Indications for repair included testicular atrophy (size difference between testicles of greater than 2 ml.) in 20 boys, pain in 5 and a large varicocele without pain or testicular atrophy in 5. Six boys were referred following failure of conventional nonmicrosurgical techniques. All boys were examined no sooner than 1 month postoperatively (mean followup 12).

Results

Preoperative volume of the affected testis averaged 13.0 ml., and an average size discrepancy between testicles of 2.8 ml. was noted before unilateral varicocelectomy. No cases of persistent or recurrent varicoceles were detected, and 1 postoperative hydrocele resolved spontaneously. After unilateral varicocelectomy the treated testes grew an average of 50.1%, while the contralateral testes grew only 23%. Overall, 89% of patients with testicular atrophy demonstrated reversal of testicular growth retardation after unilateral varicocelectomy. In contrast, both testes showed similar growth rates after bilateral varicocelectomy (45% left testis, 39% right testis).

Conclusions

The meticulous dissection necessary to preserve arterial and lymphatic supply, and to ligate all spermatic veins in the pediatric patient is readily accomplished using a microsurgical approach, and results in low recurrence and complication rates. Rapid catch-up growth of the affected testis after microsurgical varicocelectomy suggests that intervention during adolescence is effective and warranted.     

不育男性患者前列腺和阴囊的超声检查

目的:评价不育男性患者行前列腺和阴囊Doppler超声检查的临床意义。方法:总结268例不育男性患者前列腺和阴囊的超声资料,并与临床体检进行对比。结果:268例中182前列腺和(或)阴囊异常(67.9%)。其中,前列腺结石14.9%,前列腺囊肿2.2%,附睾囊肿13.1%,睾丸囊肿0.4%,睾丸内微小结石3.4%,睾丸鞘膜积液3.0%,精索静脉曲张24.3%。与触诊比较,精索静脉曲张的的检出率超声是24.3%,触诊是14.5%,差异有统计学意义(P<0.05)。将患者按精液常规分成无精子症、少精子症和精子密度正常等3组,超声异常率依次为80.5%,75.4%和55.6%,各组间差异亦有统计学意义(P<0.05)。结论:超声是诊断不育男性前列腺和(或)阴囊异常的重要手段,与临床触诊相比,其结果更为客观、可信。     

Is the presence of venous reflux really significant in the diagnosis of varicocele?

Objectives  We have attempted to determine the incidence of venous reflux detected by color Doppler in varicoceles of various grades evaluated during a physical examination. Patients and methods  The data of patients referred to our outpatient clinic between 1997 and 2007 with the diagnosis of varicocele due to complaints of scrotal pain, palpable swelling or infertility were retrospectively reviewed. The presence of venous reflux was compared with the grade of varicoceles during a physical examination. Results  A total of 802 male patients with a mean age of 27.1 years (range 16–52 years) were included in this study. Of these, physical examination reviewed that ten (1.2%), 72 (9.0%), 433 (54.0%) and 287 (35.8%) patients had grade 0, 1, 2 or 3 varicoceles, respectively, on the left side and that 607 (75.7%), 73 (9.1%), 108 (13.5%) and 14 (1.7%) patients had grade 0, 1, 2 or 3 varicoceles, respectively, on the right side. Color Doppler examination revealed venous reflux in three (30.0%) grade 0 testicular units, 63 (87.5%) grade 1 testicular units, 400 (92.4%) grade 2 testicular units and 273 (95.1%) grade 3 testicular units on the left side and venous reflux in 99 (16.3%) grade 0 testicular units, 54 (73.6%) grade 1 testicular units, 88 (81.5%) grade 2 testicular units and 12 (85.7%) grade 3 testicular units on the right side. Physical examination did not reveal any statistically significant correlation between the incidence of venous reflux and the grade of the clinically evident varicoceles for both sides. Conclusions  For assessing the severity of clinically evident varicoceles, the clinician should not use venous reflux as the sole predictor because of its high incidence in all grades of varicoceles. Additional measurements, such as flow volume, duration and velocity of reflux, are recommended as diagnostic tools for assessing the severity of varicocele more accurately.     

Varicocele in adolescence induces left and right testicular volume loss

OBJECTIVE: To determine the effect of a palpable left-sided varicocele (which in adolescent patients can adversely affect left testicular volume) on right testicular volume with progressive Tanner development and increasing varicocele grade. PATIENTS AND METHODS: The right and left testicular volumes were measured with a standard orchidometer in 70 control patients (mean age 14.6 years, SD 2.2) with no palpable testicular abnormality and in 434 (mean age 14.3 years, SD 2.3) with a palpable left-sided varicocele. Patients with bilateral and right-sided varicoceles were excluded from the study. RESULTS: There was no significant difference between the left and right testicular volumes in the control patients. The testicular volumes of patients with a grade I varicocele were similar to those in control patients. Patients with a grade II varicocele had a significantly smaller left testis than the controls at Tanner stages 4 and 5 (P < or = 0.05). Patients with a grade III varicocele had a significantly smaller left testis than controls at each Tanner stage (P < or = 0.05) and significantly smaller right testis than controls at Tanner stages 4 and 5 (P < or = 0.05). CONCLUSION: The presence of a grade I varicocele in adolescence appears to have no effect on normal testicular growth. Some patients with a grade II varicocele are at risk of left testicular volume loss with time and should have their testicular volume measured annually. Patients with grade III varicocele are at risk of bilateral testicular volume loss; a careful evaluation and early surgical intervention are recommended in this group of patients.     

Relationship between testicular volume and testicular function： comparison of the Prader orchidometric and ultrasonographic measurements in patients with infertility

Aim： To evaluate the relationship between testicular function and testicular volume measured by using Prader orchidometry and ultrasonography （US） to determine the critical testicular volume indicating normal testicular function by each method. Methods： Total testicular volume （right plus left testicular volume） was measured in 794 testes in 397 men with infertility （mean age, 35.6 years） using a Prader orchidometer and also by ultrasonography. Ultrasonographic testicular volumes were calculated as length x width x height x 0.71. To evaluate volume-function relationships, patients were divided into 10 groups representing 5-mL increments of total testicular volume by each method from below 10 mL to 50 mL or more. Results： Mean total testicular volume based on Prader orchidometry and US were 36.8 mL and 26.3 mL, respectively. Semen volume, sperm density, total sperm count, total motile sperm count, and serum FSH, LH, and testosterone all correlated significantly with total testicular volume measured by either method. Mean sperm density was in the oligozoospermic range in patients with total testicular volume below 35 mL by orchidometry or below 20 mL by ultrasonography. Mean total sperm count was subnormal in patients with total testicular volume below 30 mL by orchidometry or under 20 mL by ultrasonography. Conclusion： Testicular volume measured by either ultrasonography or Prader orchidometry correlated significantly with testicular function. However, critical total testicular volume indicating normal or nearly normal testicular function was 30 mL to 35 mL using Prader orchidometer and 20 mL using ultrasonography. Prader orchidometry morphometrically and functionally overestimated the testicular volume in comparison to US. （Asian JAndro12008 Mar; 10： 319-324）     

Improvement of semen characteristics after surgical repair of bilateral testicular varicocele as compared to unilateral varicocele patients

The operative treatment for surgical repair of bilateral testicular varicoceles was evaluated in terms of the improvement achieved in the sperm density and percentage progressive motile sperm. These parameters were compared for 27 cases of bilateral varicocele diagnosed by palpation and subjected to bilateral high ligation of the internal spermatic vein and for 40 cases of left unilateral testicular varicocele. There were no significant differences in preoperative values (such as sperm density; progressive motile sperm; serum levels of luteinizing hormone, follicle-stimulating hormone, and testosterone; and Johnson's score count) between the bilateral and unilateral testicular varicocele groups. The improvement in postoperative sperm density in the cases with bilateral testicular varicocele was apparently less satisfactory than in the cases with testicular varicocele only on the left side.     

Testicular volume assessment in the adolescent with a varicocele.

Testicular growth arrest is the main criterion for performing varicocele ligation in the adolescent population. Previous assessments concerning significant size discrepancy range from 0.5 to 5 cm.3, a 10-fold difference. We prospectively assessed testicular size in 22 male adolescents (ages 9 to 19 years) with varicoceles, and compared testicular volume as measured by ultrasound and Prader orchidometer in 19 of these patients. The accuracy of ultrasound for this purpose was evaluated by blinded ultrasonic measurements of models of known volume and a standard deviation of +/- 1.6 cm.3 was found. Using a size discrepancy of greater than 2 cm.3 as the criterion for growth arrest, 4 of 17 patients (24%) with growth arrest would have been missed with the Prader orchidometer alone. Testicular volumetric assessment by ultrasound accurately measured volumetric differences of greater than 2 cm.3 and can be used to determine growth arrest in the male adolescent with a varicocele.     

Correlation of ultrasonographic and orchidometer measurements of testis volume in adults

OBJECTIVE: To determine the correlation between testicular volume measured with an orchidometer or high-resolution scrotal ultrasonography (US) with colour-flow Doppler analysis. PATIENTS AND METHODS: In all, 159 men (mean age 36.6 years) presenting for infertility evaluation underwent both a physical examination by a one experienced examiner and high-resolution US with colour-flow Doppler analysis. An orchidometer was also used to measure testicular volume after stretching the scrotal skin tightly over the testis and after warming with a heating pad. The US was interpreted by a radiologist who had no knowledge of the orchidometer estimates. The volume was calculated as 0.71 x length x width x height. RESULTS: For the right testes the mean orchidometer and US estimates were 18.4 and 18.3 mL, yielding a correlation coefficient of 0.72 (r (2) = 0.52, P < 0.01). On the left the respective values were 17.1 and 16.9 mL, with a correlation coefficient of 0.69 (r (2) = 0.48, P < 0.01). CONCLUSION: Orchidometer estimates of testicular volume correlate closely and very significantly with US estimates in adults. In the hands of an experienced examiner orchidometer measurements provide an accurate, rapid and inexpensive assessment of testicular volume.     

Nationwide survey to evaluate the prevalence of varicoceles in South Korean middle school boys: A population based study

Objective: We carried out a nationwide epidemiological study to evaluate the prevalence and effect of varicoceles on testicular volume in South Korean adolescents. We also investigated the correlation between varicoceles and body mass index (BMI). Methods: In this prospective study, physical examinations were carried out to assess the presence and severity of varicoceles in middle school boys from six regions of South Korea. Testicular volume, height and weight of all boys were measured. The prevalence of varicoceles was assessed. The associations between age, testicular volume, BMI, and the presence and severity of varicoceles were examined. Results: A total of 1938 boys with a mean age of 14.1 years (range 13–16 years) were screened. A varicocele was found on the left side in 295 (15.2%) boys and on the right side in 8 (0.4%) boys. Bilateral varicoceles were found in 17 (0.9%) individuals. Of the subjects with a left varicocele, 151 (51.2%), 80 (27.1%) and 64 (25.1%) boys had a grade 1, 2 or 3 varicocele, respectively. The prevalence of varicoceles did not increase with age. The proportion of boys with testicular size discrepancies increased with the severity of the varicocele. After adjusting for age, BMI had a negative correlation with the presence of varicoceles. Conclusions: The prevalence of varicoceles in South Korean middle school boys is 16.5%. The presence of varicoceles seems to have a negative effect on testicular growth. BMI has a significant inverse relationship with the occurrence of varicoceles.     

Antegrade scrotal sclerotherapy for treating primary varicocele in children

OBJECTIVE: To evaluate the effectiveness and limitations of antegrade sclerotherapy (AS) for the treatment of primary varicocele in childhood. PATIENTS AND METHODS: From December 1996 to December 2004, 88 patients (mean age 13.3 years, range 9-18) with primary varicocele underwent AS (91 varicocele ablations in all). The indications for surgery were testicular pain (16 boys, 18%), a large varicocele with cosmetic implications, testicular hypotrophy (one) and in 71 (81%) the varicocele was detected incidentally during a routine physical examination; all were left-sided. According to the classification used by Tauber, 46 (52%) varicoceles were grade II and 42 (48%) grade III. The clinical and ultrasonography (US) results were evaluated over a median (range) follow-up of 11 (3-60) months, and the operative duration, X-ray exposure time, persistence rate of varicoceles and complications were compared with those using other techniques. RESULTS: In 11 patients there was a palpable difference in size between the testicles, but in only five (6%) was testicular hypotrophy (testicular volume (<75% testicular volume vs the normal side) confirmed by US. The mean (sem) operative duration for AS was 33.2 (2.14) min. In 16 (18%) patients it was necessary to expose a second or third vein because the first vein chosen was unsuitable for sclerotherapy. The mean operative radiation exposure was 2.18 (0.21) s. One patient (1%) was treated with a high ligature of the testicular vein (Palomo procedure) after initial unsuccessful AS, and was excluded from the analysis. Eighty-four (97%) patients were eligible for follow-up: six (7%) had a persistent varicocele (four grade II, two grade III), four of whom had repeat sclerotherapy successfully (no recurrence at follow-up). Fourteen (15%) patients had enlarged testicular veins only on US (varicocele grade 0). No patient developed a hydrocele after AS, There were complications after surgery in three (3%) patients (two superficial wound infections, one scrotal haematoma together with focal testicular necrosis). CONCLUSIONS: AS is an efficient minimally invasive surgical method for correcting varicoceles in older children, although the operative duration is sometimes longer than in adults, and surgery can be more difficult because of the smaller veins. Partial testicular necrosis, despite correct AS, is a very rare but serious complication.