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.     

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.     

The prevalence of varicocele and varicocele-related testicular atrophy in Turkish children and adolescents

OBJECTIVE: To determine the prevalence and site of varicocele and varicocele-related testicular atrophy in children and adolescents. PATIENTS AND METHODS: The study included 4052 boys aged of 2-19 years, divided into four age groups; the findings of a physical examination, any testicular atrophy and testicular volume were recorded. RESULTS: Varicocele was detected in 293 (7.2%) of the 4052 boys; the prevalence was 0.79% in those aged 2-6 years, 0.96% at 7-10 years, 7.8% at 11-14 years and 14.1% at 15-19 years. The prevalence was 0.92% in 1232 children aged 2-10 years and 11.0% in 2531 adolescents aged 11-19 years (P < 0.001). The prevalence increased significantly at age 13 years (P < 0.005). The varicocele was unilateral in 263 of the 293 (89.7%) boys with varicocele; of these, one (0.38%) was on the right and the others on the left side. Varicoceles were bilateral in 30 of 279 boys (10.8%) aged 11-19 years but none were detected in those aged < 11 years. Varicocele-related testicular atrophy was not present in those aged < 11 years, but seven boys (7.3%) aged 11-14 years and 17 (9.3%) aged 15-19 years had testicular atrophy. The difference in prevalence between the last two age groups with atrophy was not significant. CONCLUSION: These findings support the view that varicocele is a progressive disease and that the prevalence of varicocele and testicular atrophy increases with the puberty.     

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.     

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.     

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.     

THE ADOLESCENT VARICOCELE I: LEFT TESTICULAR HYPERTROPHY FOLLOWING VARICOCELECTOMY

PURPOSE: Ipsilateral testicular catch-up growth has been reported to occur in approximately 80% of adolescents with varicoceles following unilateral varicocelectomy. We have been observing not only catch-up growth, but hypertrophy (left at least 10% larger than right testicular volume) in some adolescents postoperatively. To our knowledge this phenomenon has not been previously described. We assess the incidence of left testicular hypertrophy following ipsilateral varicocele ligation and whether it is related to age at operation and/or procedure performed. MATERIALS AND METHODS: We reviewed the records of 42 patients who underwent unilateral left varicocelectomy for asymptomatic varicoceles. Testicular volume was determined before and after surgery, and all patients were followed for a minimum of 6 months. Indication for surgery was ipsilateral left testicular hypotrophy in 23 cases, grade 2 to 3 varicocele with palpably softer ipsilateral left testicle in 5, grade 3+ varicoceles in 12, an exaggerated response to gonadotropin-releasing hormone stimulation test in 1 and persistent pain in 1. Average patient age at operation was 14.7 years (range 9 to 22) and average followup was 22 months (range 6 to 84). Patients were stratified according to Palomo versus modified Ivanissevich technique and age at operation. Testes were measured using the Takihara ring orchidometer with relative volume of the left testis expressed as a percentage of the right testis. Results were compared in different age groups as well as by procedure performed to correct the varicocele using chi-square analysis. RESULTS: Left testicular hypertrophy developed in 13 of 32 patients (43.8%) who underwent a Palomo repair and in 3 of the 10 (30%) who underwent a modified Ivanissevich repair. When compared by age at operation, 8 of 20 patients (40%) 14.7 years old or younger had left testicular hypertrophy compared to 8 of 22 (36.4%) older than 14.7 years. Differences between these groups were not statistically significant. CONCLUSIONS: Ipsilateral testicular hypertrophy occurs in a substantial number of adolescents following varicocele ligation. This phenomenon does not seem to be dependent on age at surgery or type of varicocele repair.     

Adolescent varicocele: association with somatometric parameters

INTRODUCTION: The developmental changes that occur as a result of puberty have been hypothesized to be important causes of varicocele. Various somatometric parameters were known to affect the occurrence of varicocele during the growth period. We conducted this study in order to examine these relationships and to determine the incidence of varicocele in adolescent males. PATIENTS AND METHODS: We evaluated 1,200 healthy males aged 0-19 years for varicocele and correlated it with the following somatometric parameters: age, height, body mass index (BMI), pubic hair distribution, penile length and testicular volume. RESULTS: Adolescent varicocele was found in 5.6% of the participants. The 13- to 19-year age-group had the highest incidence of varicocele (10.5%). Logistic regression analysis showed that the incidence was positively correlated with age, height and penile length (odds ratio 1.61, 1.04 and 1.37, respectively) and negatively correlated with left testicular volume, BMI and pubic hair distribution (odds ratio 0.87, 0.87 and 0.47, respectively). CONCLUSION: Varicocele was more prevalent in tall boys with a lower BMI, who had quickly progressed through puberty. Our observations suggest that varicocele is associated with various somatometric parameters.     

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.     

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.     

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.     

The physical characteristics of young males with varicocele

OBJECTIVE: To determine if there is an association with habitus in young males with varicocele, as adolescent boys with varicoceles appear to be mostly taller and leaner than age-matched controls. PATIENTS AND METHODS: Retrospectively reviewing our records we obtained the height and weight of 43 consecutive males (mean age 14.3 years, range 11-19) under long-term follow-up for varicocele. The body mass index (BMI), heights and weights were compared with values from the respective growth charts for boys aged 2-20 years (Center for Disease Control and Prevention), and the statistical significance of differences determined using the chi-square test. RESULTS: The height and weight distributions of patients with varicocele indicated a significant deviation from normal in the 25-95th percentiles for stature and in the 25-75th for weight (P < 0.05). Deviations in BMI were insignificantly different from normal at each percentile. CONCLUSION: These results indicate that patients with varicocele are significantly taller and heavier than age-matched controls. Future studies to address the key areas identified in this study will help to further assess the distribution of the incidence of varicocele in closely defined subsets of adolescent growth and development, which may provide some insight into the cause of varicoceles.     

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.     

Varicocele in schoolboys

This study was conducted to examine the effect of height and weight on the incidence of varicocele in schoolboys aged 5-16 years and the impact of varicocele on testicular size. Genital stage, height, weight, varicocele grade, and testicular size were recorded for 3047 school boys who were clinically examined while standing by a specialist in urology. Left varicocele was detected in 98 of the boys who were all aged 9-16 years. The mean weight of boys with and without varicocele was 42 kg (95% confidence interval [CI] 40-44 kg) and 47 (95% CI 47-47 kg), respectively (p =.00). There was no difference in mean height between the two groups nor in left and right testicular volume. Although 6 boys with varicocele had a left testicular volume > or =2 mL less than right, there were also 7 boys of comparable age who had a left testicular volume > or =2 mL larger than right. The incidence of varicocele in Greek adolescents is low. Boys with varicocele weighed significantly less but there were no significant differences in height or left versus right testicular volumes. In the light of these observations, the use of left testicular hypotrophy (> or =2 mL compared with the right testicle) should be reconsidered as an indicator for varicocele-induced damage of the testicle in this age group.     

Laparoscopic varicocelectomy with preservation of the testicular artery in adolescents

PURPOSE: The aim of this study was to determine if laparoscopic varicocelectomy (LV) with preservation of the testicular artery (TA) is a satisfactory alternative to standard open surgical techniques in adolescents. METHODS: Between June 1993 and June 1999 left LV was performed on 40 boys, median age, 12 years (range, 9 to 16 years). Selection for surgical correction included size of the varicocele, symptoms, and clinical or ultrasound assessment for testicular hypotrophy. Eight patients had undergone previous left-sided inguinal surgery, 5 of these for varicocele. Three laparoscopic ports were used. The TA was identified and preserved with the aid of a Doppler flow transducer ("Smart Needle"). All the testicular veins were ligated and divided. The inferior epigastric (IE) veins also were ligated in 19 patients. The operating time was a mean of 1 hour. The postoperative follow-up for a median of 19.5 months (range, 3 to 36 months) included clinical and ultrasound assessment. RESULTS: Preoperative assessment confirmed left-sided testicular hypotrophy 35 patients (88%). Thirty-eight varicoceles were stage 3, and 2 were stage 2. Testicular discomfort was present in 13 patients. Complete correction of the varicocele was achieved in 33 (83%). At a mean of 5 months after LV open repair in 7 patients confirmed a dilated cremasteric vein connecting to the IE veins. Ligation of the IE veins at the time of LV was associated with a persistent varicocele in 3 of 19 patients (16%), similar to the nonligated group, 4 of 21 patients (19%). Five patients (12.5%) had a mild hydrocele. The left testicular volume increased 30% to 50% in 28 patients (70%) at a median of 6.5 months after repair. Testicular atrophy did not occur in any patients. The majority of patients went home within 6 hours of surgery. CONCLUSIONS: The laparoscopic technique with preservation of the TA is an acceptable alternative to open surgical treatment of varicoceles. Further, it eliminates the risk of testicular atrophy and is the technique of choice when previous inguinal surgery has been performed. Ligation of IE veins was not associated with a decrease in the persistence of varicocele postoperatively.     

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.     

Relationship between testicular volume and presence of varicocele. A comparative study

The varicocele, present in many of the male partners of infertile couples continues to generate controversy, particularly as related to its diagnosis and pathophysiology. The purpose of our study was to determine the relationship between testicular volume and the presence or absence of a varicocele. Testicular volume was determined by the use of an orchiometer; the presence of a varicocele was determined by palpation during a Valsalva maneuver. The patients utilized in the study were those seen in our Andrology and General Urology Clinics; 291 patients with varicoceles and 83 control patients (no evidence of varicocele) were used. The left (mean = 21.4 mL) and right (mean = 23.4 mL) testicular volumes of patients with a varicocele were significantly reduced compared with that of the control group (left, mean = 23.4 mL; right, mean = 26.2 mL; p = 0.0041 and p = 0.002, respectively). The testicular volume corrected on the basis of the body mass (V/m2) also was significantly reduced in the varicocele group compared with controls (left p = 0.007; right p = 0.001). Reduced testicular volume relative to body size may be detected prior to actual demonstration of the stress pattern and the presence of a varicocele, and may be useful in early diagnosis. It is suggested that measurement of testicular volume may be a useful adjunct to routine examination of the infertile male.     

Testicular hypotrophy does not correlate with grade of adolescent varicocele

PURPOSE: Testicular hypotrophy is the most widely accepted indication for correcting adolescent varicocele. Previous studies in adolescents have shown a relationship between increasing grade of varicocele and the likelihood of testicular hypotrophy. As this relationship has significant clinical implications, we studied the correlation between grade and testicular volume disproportion in our adolescent varicocele population. MATERIALS AND METHODS: We reviewed the adolescent varicocele database at our institution. A total of 168 patients 8 to 21 years old were studied. We routinely calculated testis volumes using scrotal ultrasound. Testicular disproportion was calculated using the equation [(size of unaffected testis) - (size of affected testis)]/(size of unaffected testis) x 100%. Disproportion was categorized as less than 10%, 10% to 20% and more than 20%. Varicoceles were graded by an attending urologist with the patient standing, using the system of Dubin and Amelar. Analysis of variance and Pearson chi-square indicated no significant differences in volume differential between varicocele grades. RESULTS: Mean +/- SD volume differential was 18% +/- 15% for grade I, 25% +/- 20% for grade II and 19% +/- 14% for grade III. ANOVA revealed no significant difference in mean volume differential between the 3 varicocele grades (p = 0.10). When categorizing patients into 3 levels of volume differential (less than 10%, 10% to 20%, more than 20%) no significant correlation was observed between varicocele and volume differential (p = 0.48, chi-square test). CONCLUSIONS: Grade of varicocele does not correlate with presence or severity of testicular disproportion in adolescent boys with varicocele as measured by scrotal ultrasound.     

The effect of post-pubertal varicocele on testicular volume

Paediatric varicocele is a well known entity but its effect on adult infertility has not been adequately clarified. Since measurement of testicular volume is currently the best method of estimating the male reproductive potential, 945 boys aged between 13 and 18 years were examined with regard to testicular volume and the incidence of varicocele. The average volumes for right and left testes were 15.087 +/- 0.237 and 14.514 +/- 0.347 ml respectively, and the incidence of varicocele was 16.7%. The incidence increased from 14.5 to 21.7% as the ages increased from 14 to 18. The differences in volume of the 2 testes in boys with varicocele were statistically significant when compared with the normal group, but this significance failed to become more pronounced when the slight varicocele group (grade I) was included with the normal group and compared with the severe varicocele group (grades II and III). There may be no significant differences between the volumes of the 2 testes in boys with varicocele when careful measurement and strict statistical analyses are applied. However, some boys in the varicocele group were found to have testicular volumes below the confidence interval (mean - SE) or under 1 SD, and the 2 testicular volumes differed in certain age groups. This group requires further follow-up. The results of this study have added further contradictory findings to the issue of paediatric varicocele in terms of testicular atrophy, estimation of potential fertility and the indications for immediate surgery. There is a need for further prospective controlled trials.