Effects of grade 1 varicocele detected in the pediatric age-group on testicular development

Purpose

A number of reports have indicated the effectiveness of varicocelectomy on large varicoceles in adolescents. We carried out a 5-year follow-up study to examine the effect of grade 1 varicocele on testicular development.

Methods

Of 31 boys with left grade 1 varicocele (mean age, 12.6 years), 10 underwent microsurgical varicocelectomy and 21 were conservatively observed and evaluated for testicular volume and varicocele grade. The control group consisted of 20 healthy age-matched boys without a varicocele. The mean relative left testicular volume was compared with the right testis and the absolute bilateral testicular volumes among the boys in all groups.

Results

Of 21 boys who were observed, 13 (62%) continued to have grade 1 varicocele, 4 (19%) developed grade 2 varicocele, and the other 4 boys (19%) showed spontaneous resolution. Twelve testes (57%) developed in parallel with the right testis, and 1 boy (5%) who experienced spontaneous resolution of the varicocele had catch-up testicular growth, whereas 8 boys (38%) had left testicular growth delay with or without an increasing grade of varicocele. Varicocelectomy, but not observation, improved the previously noted testicular growth delay. Furthermore, right testicular growth delay was also noted during observation.

Conclusions

More than half of the total number of boys with grade 1 varicocele showed normal development, whereas many boys presented with growth delay in both testes. Thus, we still need to define reliable predictors that will permit selection of the best candidates for varicocelectomy.     

Managing varicoceles in children: results with microsurgical varicocelectomy

Authors from New York present their experience of elective varicocelectomy, using microsurgical techniques, in a large series of children. They found the procedure to be safe and effective, and gave a much lower complication rate than the published rate in open varicocelectomy. The results of urethroplasty in post-traumatic paediatric urethral strictures are presented by authors from Mansoura. They found the overall success of one-stage perineal anastomotic repair of such strictures to be excellent, with very little morbidity. OBJECTIVE: To report our experience of microsurgical subinguinal varicocelectomy in boys aged < or = 18 years. PATIENTS AND METHODS: Boys aged < or = 18 years treated with microsurgical varicocelectomy between 1996 and 2000 at one institution were retrospectively reviewed. Indications for surgery included ipsilateral testicular atrophy, large varicocele or pain. Microsurgery was assisted by an operating microscope (x10-25) allowing preservation of the lymphatics, and the testicular and cremasteric arteries. Patient age, varicocele grade, complications and follow-up interval were recorded. RESULTS: In all there were 97 microsurgical subinguinal varicocelectomies (23 bilateral) in 74 boys (mean age 14.7 years). Left-sided varicoceles were significantly larger (mean grade 2.9) than right-sided (mean grade 1.4) varicoceles. The mean follow-up was 9.6 months. There were four complications: two hydroceles, of which one resolved spontaneously after 4 months; one patient had persistent orchialgia that resolved after 8 months; and one developed hypertrophic scarring at the inguinal incision site. There were no infections, haematomas or intraoperative injuries to the vas deferens or testicular arteries. All boys were discharged home on the day of surgery. CONCLUSIONS: Microsurgical subinguinal varicocelectomy in boys is a safe, minimally invasive and effective means of treating varicoceles. Compared with published results of the retroperitoneal mass ligation technique, which has a 15% overall complication rate and a 7-9% hydrocele occurrence rate, the microsurgical subinguinal approach appears to offer less morbidity, with a 1% hydrocele rate. We consider that microsurgical subinguinal varicocelectomy offers the best results with lower morbidity than other techniques.     

Lymphatic sparing laparoscopic Palomo varicocelectomy for varicoceles in children: intermediate results

Objectives

Varicocele is a relatively rare disorder in children that can lead to testicular atrophy and infertility. The ideal surgical treatment for varicoceles is still a matter of controversy because of the frequency of postoperative complications. Here, we report our series of children who underwent lymphatic sparing laparoscopic Palomo varicocelectomy.

Patients and Methods

A total of 46 boys, 9 to 14 years old, underwent laparoscopic repair for varicoceles between January 2002 and December 2007. All of them had a left-sided varicocele. The varicocele was diagnosed by physical examination and Doppler ultrasonography. The laparoscopic procedure included obligatory dissection and preservation of the lymphatic vessels, followed by double ligation of the spermatic vessels. Follow-up for these children included physical examination and Doppler ultrasonography.

Results

Lymphatic sparing laparoscopic Palomo varicocelectomy was feasible in all 46 (100%) of the children. Mean operative time was 34.2 minutes (range, 25-42 minutes). There were no intraoperative complications. One patient recurred because of incomplete ligation of spermatic vein. Mean follow-up was 20 months (range, 7-32 months). Hydrocele formation, testicular atrophy, and testicular hypertrophy were not observed postoperatively. However, 2 preoperative hypotrophic testes were noted with 10.4% and 12.5% decreases in size.

Conclusions

Our study reveals that lymphatic sparing laparoscopic Palomo varicocelectomy in children is safe, effective, and the reliable treatment of pediatric varicocele. However, long-term follow-up is required to best characterize ultimate outcome.     

Diagnosis of pediatric varicoceles by physical examination and ultrasonography and measurement of the testicular volume: using the prader orchidometer versus ultrasonography

INTRODUCTION: The differentiation of unilateral versus bilateral varicoceles and testicular volume measurements are important in determining the need for adolescent varicocele surgery and also in following patients after varicocelectomy. The aim of this study was to prospectively compare the findings of physical examination and color Doppler ultrasonography in the diagnosis of pediatric varicoceles and to compare the findings using the Prader orchidometer and scrotal ultrasonography in the measurement of testicular volumes. PATIENTS AND METHODS: This study included 68 boys with varicoceles, ranging in age from 8 to 19 years. Varicoceles were diagnosed using both physical examination and scrotal color Doppler ultrasonography. The testicular volumes of 136 testicles were measured using the Prader orchidometer and scrotal ultrasonography. A difference of more than 10% or 2 ml in each testicular volume was considered significant. RESULTS: The mean age of the boys was 13.5 +/- 2.3 years. On physical examination, a left unilateral varicocele was diagnosed in 46 boys (67.6%). The other 22 boys (32.4%) had bilateral varicoceles. Color Doppler ultrasonography detected bilateral varicoceles in 4 of the 46 boys (8.7%) who were diagnosed by physical examination as having only left unilateral varicoceles (grade 3 in 3 patients and grade 2 in 1 patient). A different of more than 10% or 2 ml in testicular volume using the Prader orchidometer versus scrotal ultrasonography was detected in 3 out of 136 testicles (2.2%). The correlation between ultrasonography and Prader orchidometer results in the measurement of testicular volumes was statistically highly significantly consistent using the intraclass correlation test (r = 0.997 and p < 0.001 for the left testis; r = 0.998 and p < 0.001 for the right testis). CONCLUSIONS: Although the management of subclinical varicoceles remains controversial, these data show that color Doppler ultrasonography may be necessary in the diagnosis of bilateral varicoceles, especially in boys with high-grade left varicoceles. In contrast, scrotal ultrasonography, if considered the gold standard, did not show superiority over the Prader orchidometer in measuring testicular volumes.     

Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique.

Conventional techniques of varicocele repair are associated with substantial risks of hydrocele formation, ligation of the testicular artery, and varicocele recurrence. We describe a microsurgical technique of varicocelectomy that significantly lowers the incidence of these complications. The testicle is delivered through a 2 to 3 cm. inguinal incision, and all external spermatic and gubernacular veins are ligated. The testis is returned to the scrotum and the spermatic cord is dissected under the operating microscope. The testicular artery and lymphatics are identified and preserved. All internal spermatic veins are doubly ligated with small hemoclips or 4-zero silk and divided. The vas deferens and its vessels are preserved. Initially, we performed 33 conventional inguinal varicocelectomies in 24 men without delivery of the testis or use of a microscope. Postoperatively, 3 unilateral hydroceles (9%) and 3 unilateral recurrences (9%) were detected. For the next 12 cases 2.5x loupes were used resulting in no hydroceles but another recurrence (8%). We then performed 640 varicocelectomies in 429 men using the microsurgical technique with delivery of the testis. Among 382 men available for followup examination from 6 months to 7 years postoperatively no hydroceles and no cases of testicular atrophy were found. A total of 4 unilateral recurrent varicoceles (0.6%) was identified. The differences between the techniques in the incidence of hydrocele formation and varicocele recurrence are highly significant (p < 0.001). No wound infections occurred in any men. Four scrotal hematomas (0.6%), 1 of which required surgical drainage, occurred in the group with microsurgical ligation and delivery of the testis compared to none with the conventional technique. Preoperative and postoperative semen analyses (mean 3.57 analyses per patient) were obtained on 271 men. The changes in sperm count x 10(6) cc (36.9 to 46.8, p < 0.001), per cent motility (39.6 to 45.7%, p < 0.001) and per cent normal forms (48.4 to 52.10%, p < 0.001) were highly significant. The pregnancy rate was 152 of 357 couples (43%) followed for a minimum of 6 months postoperatively. Delivery of the testis through a small inguinal incision provides direct visual access to all possible avenues of testicular venous drainage. The operating microscope allows identification of the testicular artery, lymphatics and small venous channels. This minimally invasive, outpatient technique results in a significant decrease in the incidence of hydrocele formation, testicular artery injury and varicocele recurrence.     

The Effect of Microsurgical Varicocelectomy on Semen Parameters in Men with Non-Obstructive Azoospermia

Introduction

The aim of this study was to evaluate the effect of microsurgical subinguinal varicocelectomy on semen parameters in azoospermic men with clinical varicocele and to determine the predictive parameters of postoperative improvement.

Methods

Twenty-three men with non-obstructive complete azoospermia and varicocele underwent subinguinal open microsurgical varicocele repair. The outcome was assessed in terms of improvement in semen parameters after surgical repair for varicocelectomy.

Results

Bilateral varicocelectomy was performed on 15 patients and unilateral (left) varicocelectomy was performed on 8 patients. In the post-operative period, of the 23 patients, 7 (30.4%) had motile sperm in the ejaculate. The mean sperm concentration of these patients was 1.34 ± 2.6 × 10⁶/ml and the mean total sperm motility was 37.5 ± 15.5%.

Conclusion

Infertile men with non-obstructive azospermia can have improvement in semen analysis after subinguinal microsurgical repair of varicoceles. Motile sperm in ejaculate were detected after microsurgical varicocele repair.Key Words: Azoospermia, Microsurgery, Motile sperm, Varicocele     

Ipsilateral Testicular Hypotrophy is Associated With Decreased Sperm Counts in Infertile Men With Varicoceles

Purpose

The presence of ipsilateral testicular growth retardation (hypotrophy) is the most common indication for prophylactic varicocele repair in adolescents in an effort to prevent future infertility. We examined the relationship between semen parameters and ipsilateral versus contralateral testicular size in men with unilateral varicoceles to determine whether testicular size is an appropriate parameter for predicting future fertility.

Materials and Methods

We studied the records of consecutive patients with palpable unilateral left varicoceles for whom a history, physical examination and semen analysis were available. Total motile sperm counts of men with and without ipsilateral testicular hypotrophy were compared.

Results

We identified 611 patients with unilateral clinical left varicoceles, including 305 (50%) with ipsilateral testicular hypotrophy. Mean total motile sperm counts plus or minus standard error of mean were significantly less in the patients with than without testicular hypotrophy (80 +/− 5.2 versus 126 +/− 7.8 × 10⁶ sperm, p = 0.0018). Hypotrophy was more common in patients with large varicoceles (73%) than in those with medium (53%) or small (43%) varicoceles.

Conclusions

Infertile patients with testicular hypotrophy associated with unilateral varicoceles have worse semen parameters than those without hypotrophy. These data support the practice of varicocele repair in adolescents with varicocele associated testicular growth retardation.     

Lymphatic sparing laparoscopic varicocelectomy: a microsurgical repair

PURPOSE: The division of lymphatic vessels during pediatric varicocelectomy is complicated by hydrocele formation, testicular hypertrophy due to intratesticular edema and decline in testicular function. To prevent these complications, we introduced a microsurgical lymphatic sparing dissection into laparoscopic varicocelectomy. MATERIALS AND METHODS: We retrospectively compared outcomes in 104 boys who underwent microsurgical laparoscopic repair for grade II to III varicocele between April 1999 and December 2002 to a group of 67 boys operated on using conventional laparoscopy without lymphatic preservation between January 1997 and March 1999. Using 10x to 20x optical magnification, the lymphatic vessels were identified as colorless tubular structures that were easily separated and preserved. RESULTS: After a mean followup of 17 months there was no significant difference in varicocele recurrence between the 2 groups (6.7% vs 8.9%, p = 0.56). Hydrocele formation and testicular hypertrophy occurred significantly less frequently after microsurgical repair (1.9% and 2.9%, respectively, vs 17.9% and 20.1% in the conventional group, p = 0.0003). No major complications were encountered. CONCLUSIONS: Preservation of lymphatics in laparoscopic varicocelectomy is technically feasible, and decreases hydrocele formation and the development of testicular hypertrophy. This microsurgical modification is a safe and efficacious alternative for urologists skilled in reconstructive laparoscopy.     

Effect of microsurgical repair of the varicocele on testicular function in adolescence and adulthood

OBJECTIVE: Many reports on varicoceles suggest improved spermatic findings and increased pregnancy rates after correction of these lesions. Early repair during adolescence has been advocated, since clinically apparent varicoceles may affect testicular volume and sperm production in the future. We examined the efficacy of microsurgical varicocelectomy, and aimed to establish predictive parameters useful for ascertaining whether varicocele repair provides any benefits in adolescents and adults. METHODS: We carried out microsurgical varicocelectomy on nine boys and 19 men. In adolescents, catch-up growth of the testis, expressed by pre- and postoperative ratios of left and/or right testicular volume, grade and serum level of follicle-stimulating hormone (FSH) were evaluated. In adults, the ratio of sperm concentration improvement, grade, testicular volume, preoperative sperm concentration and serum FSH level were evaluated. All subjects were followed for 12 months. RESULTS: Catch-up growth was seen in 62.5% of boys. FSH level was significantly lower in boys with catch-up growth than in boys without catch-up growth. Improved sperm concentration was seen in 73.6% of adults. FSH level was significantly lower in adults with improved sperm concentration than in patients without improved sperm concentration. No correlations were seen between other parameters and catch-up growth in adolescents, or sperm concentration improvement in adults. CONCLUSIONS: Microsurgical varicocelectomy as a treatment for varicoceles with low FSH might be effective and the relevant predictive parameter for testicular development and function after surgery might be serum FSH level in both adults and adolescents.     

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.     

Microsurgical Varicocele Repair on Men with Grade III Lesions and Chronic Dull Scrotal Pain: A Pilot Study

Introduction

The aim of the present study was to evaluate the effectiveness of microsurgical varicocele repair in patients with grade III lesions and chronic dull scrotal pain.

Materials and Methods

The study was based on 8 patients with grade III left-sided varicocele and chronic dull scrotal pain for whom a microsurgical subinguinal varicocele repair was performed. The 1-year follow-up included pain assessment and scrotal examination.

Results

Of the 8 patients, 7 (88%) reported complete resolution of pain with no palpable varicocele on scrotal examination. No cases of testicular atrophy or hydrocele formation were reported.

Conclusion

These results indicated that microsurgical varicocele repair may benefit patients with grade III lesions and chronic dull scrotal pain.Key Words: Microsurgery, Chronic scrotal pain, Varicocele, Varicocele repair     

Optimizing the operative treatment of boys with varicocele: sequential comparison of 4 techniques

PURPOSE: We compared 4 techniques of varicocele ligation in boys and young adolescents to determine the optimal operative treatment that avoids varicocele recurrence and postoperative hydrocele formation. MATERIALS AND METHODS: In 10 years a total of 128 varicocelectomies were performed sequentially in 121 boys and young adolescents with a mean age of 12 years using the laparoscopic, inguinal testicular artery sparing, standard Palomo (high mass retroperitoneal ligation) and modified Palomo approaches. The modified Palomo approach involved suprainguinal and retroperitoneal ligation of the veins and artery, and microsurgical sparing of the blue stained lymphatic pathway of the testis. Patients were followed a mean of 52 months. RESULTS: In the 19 boys in the laparoscopy group varicocele persisted in 10% and hydrocele developed in 5%. In the 21 patients who underwent inguinal surgery with artery preservation recurrent varicoceles were identified in 14% and no hydroceles were observed. In the 32 patients who underwent the standard Palomo procedure there was no palpable varicocele persistence or recurrence, while hydroceles developed in 12%. Of the 56 patients in the modified Palomo group varicocele recurred in 1 (2%) and there were no hydroceles. No testicular atrophy developed in any patient. CONCLUSIONS: Comparison of all 4 groups revealed significant differences in varicocele recurrence (p = 0.038) and hydrocele formation (p = 0.023). Pairwise group comparison showed that the modified Palomo technique resulted in a significant decrease in the incidence of postoperative hydrocele formation compared with the standard Palomo method (p = 0.015). This procedure can be recommended as the optimal surgical technique for varicocele treatment in males of this young age.     

COMPARISON OF BILATERAL VERSUS UNILATERAL VARICOCELECTOMY IN MEN WITH PALPABLE BILATERAL VARICOCELES

PURPOSE: The left varicocele is usually larger in men with bilateral varicoceles. We hypothesized that most of the benefit of varicocelectomy would derive from repair of the larger varicocele. To test this hypothesis we prospectively compared the effect of unilateral versus bilateral microsurgical varicocelectomy in men with large (grade III) or moderate (II) left varicocele associated with small but palpable (I) right varicocele. MATERIALS AND METHODS: A total of 91 patients were prospectively followed and included in the study. Of the patients 65 underwent bilateral and 26 underwent unilateral left repair. All patients underwent preoperative and postoperative semen analysis. RESULTS: Motile sperm concentration increased from 12.1+/-1.7 to 23.7+/-31.8 (95.8% change) in the bilateral group compared with an increase from 19.5+/-21.4 to 27.8+/-34.8 (42.6% change) in the unilateral group (p<0.05). Similarly, sperm concentration increased from 23.8+/-29.5 to 48.6+/-61.3 (157.6% change) in the bilateral group compared with an increase from 41.1+/-40.9 to 59.5+/-66.7 (44.8% change) in the unilateral group (p<0.05). CONCLUSIONS: Bilateral varicocelectomy resulted in significantly greater improvement in post-operative seminal parameters than unilateral repair in patients with grades II to III left varicocele associated with grade I right varicocele. Even a small, unrepaired palpable right varicocele continues to have a detrimental effect on bilateral testis function. Men with bilateral palpable varicoceles require bilateral repair.     

Seminal Improvement Following Repair of Ultrasound Detected Subclinical Varicoceles

Purpose

We determined whether repair of subclinical varicoceles detected by scrotal duplex ultrasonography results in significant seminal improvement and identified the best ultrasonographic criteria to use in the selection of patients for subclinical varicocelectomy.

Materials and Methods

Of 256 consecutive infertile men being evaluated by physical examination and color duplex scrotal ultrasonography 76 underwent varicocele repair and were followed with serial semen analyses. All subclinical varicoceles were confirmed by venography. The outcome of varicocelectomy was determined by changes in total motile sperm count and compared among patients with different clinical grades of varicoceles and ultrasonographically measured vein sizes.

Results

A significant overlap was observed between ultrasonographically measured venous diameter and clinical grade of varicocele. There was no correlation between venous diameter and postoperative outcome when controlled for clinical grade. Significant postoperative improvement in semen parameters was noted in 67 percent of patients with clinical and only 41 percent with subclinical varicoceles (p less than 0.05). The best ultrasonographic cutoff to predict a positive outcome after subclinical varicocelectomy was venous diameter greater than 3 mm. Patients with larger clinical varicoceles had greater postoperative seminal improvement than those with small or subclinical varicoceles regardless of baseline sperm count.

Conclusions

Varicocele size has a direct impact on the probability and amount of seminal improvement after varicocelectomy. Outcome following subclinical varicocelectomy is significantly less than after repair of clinical varicoceles. Although 41 percent of patients with subclinical varicoceles had significant postoperative improvement in semen parameters, an equal number were worse postoperatively and, thus, mean sperm count was unchanged for the group. The results of our study suggest that subclinical varicocelectomy is of questionable benefit.     

Laparoscopic Palomo varicocelectomy in the adolescent is safe after previous ipsilateral inguinal surgery

OBJECTIVE: To evaluate the outcome of laparoscopic Palomo varicocelectomy (LPV) in young boys who had undergone previous ipsilateral inguinal surgery (in whom potentially the arterial supply to the testicles may be compromised) in an attempt to assess its safety for the collateral vascular supply in such cases. PATIENTS AND METHODS: Over a 5-year period (1995-2000) 44 patients underwent LPV, where both the spermatic artery and vein were ligated high above the internal ring. Thirteen patients had undergone previous ipsilateral inguinal surgery, which included inguinal hernia repairs in five, orchidopexy in two, communicating hydrocele repair in three and previous varicocele repair in three. All patients were followed clinically at 3 months and 1 year after surgery. RESULTS: There were no complications related to laparoscopy or varicocele ligation. No patient developed ipsilateral testicular atrophy; moreover the testis size remained stable or was associated with compensatory growth in all patients. CONCLUSION: Previous inguinal surgery involving the ipsilateral testicle does not appear to affect the collateral blood circulation to the affected testis in boys who undergo LPV mass ligation of the internal spermatic vein and artery. LPV for varicocele is safe in boys who have undergone previous inguinal surgery, suggesting that an adequate collateral blood supply is present.     

Adolescent varicocele repair: long-term results and comparison of surgical techniques according to optical magnification use in 100 cases at a single university hospital

PURPOSE: We review the long-term results of varicocele repair, and compare the complication rates of varicocelectomy techniques according to optical magnification use in adolescents with varicocele at a single university hospital. MATERIALS AND METHODS: We prospectively studied 100 males 7 to 19 years old with clinical palpable varicocele. Of the patients 52 (52%) underwent left unilateral varicocelectomy and 48 (48%) underwent bilateral varicocelectomy. Varicocelectomy was performed using a microscope in 49 patients (79 sites), loupe magnification in 25 (35 sites) and no magnification in 26 (34 sites) using either a subinguinal or inguinal approach. Postoperative complications were compared in all patients based on technique. Preoperative and postoperative serum hormone values and semen parameters were compared in 33 patients. RESULTS: Mean postoperative followup was 30.4 +/- 13.06 months (12 to 65). Total motile sperm count increased from 22.6 million +/- 5.16 million to 64.53 million +/- 12.3 million postoperatively, which was statistically significant (p = 0.002). Postoperative recurrence rates were 0% in cases managed by microsurgical varicocelectomy, 2.9% in those where loupe magnification was used and 8.8% in those where no magnification was used. Postoperative hydrocele rates in these cases were 0%, 2.9% and 5.9%, respectively. The highest rates of recurrence and hydrocele were observed in cases where no magnification was used, compared to those managed by microsurgery (p = 0.03 and p = 0.116, respectively). CONCLUSIONS: Adolescent varicocele repair improves semen parameters and is a safe method with low recurrence and low complication rates. Our study suggests that the postoperative complication rate significantly decreases with use of higher magnification, such as microscopy. Microsurgical varicocele repair is the best technique with the lowest postoperative rates of recurrence and hydrocele in the treatment of adolescent varicoceles.     

Laparoscopic Varicocelectomy in the Management of Chronic Scrotal Pain

Background and Objectives:

To evaluate the usefulness of laparoscopic varicocelectomy in the management of chronic scrotal pain.

Methods:

Between 2009 and 2011, 48 patients in total were treated with laparoscopic varicocelectomy for dull scrotal pain that worsened with physical activity and was attributed to varicoceles. All patients were followed up at 3 and 6 months and biannually thereafter with a physical examination, visual analog scale score, and ultrasonographic scan in selected cases.

Results:

The mean age was 38.2 years (range, 23–54 years). The mean follow-up period was 19.6 months (range, 6–26 months). Bilateral varicoceles were present in 7 patients (14.6%), and a unilateral varicocele was present in 41 (85.4%). The varicocele was grade 3 in 27 patients (56.3%), grade 2 in 20 (41.6%), and grade 1 in 1 (2.1%). The mean preoperative visual analog scale score was 4.8 on a scale from 0 to 10. The mean postoperative visual analog scale score at 3 months was 0.8. After the procedure, 42 patients (87.5%) had a significant improvement in the visual analog scale score (P < .001); 5 (10.4%) had symptom improvement, although it was not statistically significant; and 1 (2.1%) remained unchanged. During follow-up, we observed 5 recurrences (10.4%) whereas de novo hydrocele formation was identified in 4 individuals (8.3%).

Conclusion:

Laparoscopic varicocelectomy is efficient in the treatment of symptomatic varicoceles with a low complication rate. However, careful patient selection is necessary because it appears that individuals presenting with sharp, radiating testicular pain and/or a low-grade varicocele are less likely to benefit from this procedure.     

显微外科精索静脉曲张切除术治疗男性不育

精索静脉曲张(VAC)是导致男性不育的常见原因。手术是治疗VAC的主要方法。传统手术方法包括Palo-mo手术、经腹股沟精索内静脉高位结扎术及腹腔镜手术术后睾丸鞘膜积液、睾丸动脉损伤等并发症的发生率及VAC复发率较高。近年来国际上兴起的显微外科精索静脉曲张切除术(MV)可有效的保护精索淋巴管及睾丸动脉,彻底结扎除输精管静脉外的所有精索静脉,使并发症及复发率大为降低。MV可显著改善VAC不育患者的精液质量,提高妊娠率;对严重少弱精子症或非梗阻性无精子症的患者的精液质量也有改善作用,目前已成为治疗VAC的"金标准"。     

Open non‐microsurgical,laparoscopic or open microsurgical varicocelectomy for male infertility: a meta‐analysis of randomized controlled trials

Study Type – Therapy (systematic review) Level of Evidence 1a What's known on the subject? and What does the study add? There are several surgical techniques for the treatment of varicocele in infertile men, including open non‐microsurgical, laparoscopic and microsurgical varicocelectomy. It is currently unclear, however, which is the most beneficial method for patients. The present meta‐analysis found that microsurgical varicocelectomy is the most effective and least morbid method among the three varicocelectomy techniques for treating varicocele in infertile men.

OBJECTIVE

• ? To compare various techniques of open non‐microsurgical, laparoscopic or microsurgical varicocelectomy procedures to describe the best method for treating varicocele in infertile men.

PATIENTS AND METHODS

• ? We searched PubMed, Embase, the Cochrane Library, the Institute for Scientific Information (ISI) – Science Citation Index and the Chinese Biomedicine Literature Database up to June 2011. Only randomized controlled trials (RCTs) were included in the present study.
• ? The outcome measures assessed were pregnancy rate (primary), the incidence of recurrent varicocele, time to return to work, the incidence of postoperative hydrocele and operation duration (secondary).
• ? Two authors independently assessed the study quality and extracted data. All data were analysed using Review Manager (version 5.0).

RESULTS

• ? The present study included four randomized controlled trials comprising 1,015 patients in total.
• ? At the follow‐up endpoints, patients who had undergone microsurgery showed a significant advantage over those who had undergone open varicocelectomy in terms of pregnancy rate (odds ratio [OR]= 1.63, 95% confidence interval [CI]: 1.19–2.23].
• ? There was no significant difference between laparoscopic and open varicocelectomy (OR = 1.11, 95% CI: 0.65–1.88) or between microsurgery and laparoscopic varicocelectomy (OR = 1.37, 95% CI: 0.84–2.24).
• ? The incidences of recurrent varicocele and postoperative hydrocele were significantly lower after microsurgery than after laparoscopic or open varicocelectomy.
• ? The time to return to work after microsurgery and laparoscopic varicocelectomy was significantly shorter than that after open varicocelectomy.
• ? The operation duration of microsurgical varicocelectomy was longer than that of laparoscopic or open varicocelectomy.

CONCLUSIONS

• ? Current evidence indicates that microsurgical varicocelectomy is the most effective and least morbid method among the three varicocelectomy techniques for treating varicocele in infertile men.
• ? More high‐quality, multicentre, long‐term RCTs are required to verify the findings.

     

外环小切口睾丸提出显微精索静脉结扎术

目的 :探讨外环小切口显微精索静脉结扎术的疗效。　方法 :4 8例精索静脉曲张病人 ,采用外环小切口睾丸提出显微精索静脉结扎术。　结果 :6个月后 ,精液检查各项指标改善者 30例 ,6例不育者配偶已受孕。全部病例无复发 ,无睾丸萎缩及鞘膜积液。　结论 :该术式有并发症少、复发率低及近期效果显著等优点