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.     

Treatment of varicoceles in childhood and adolescence with Tauber's antegrade scrotal sclerotherapy

PURPOSE: The aim of this study was to evaluate surgical complications and the outcome of grade II and III varicoceles treated with Tauber's antegrade scrotal sclerotherapy. METHODS: A total of 21 patients with a median age of 13 (range, 10 to 21) years and left-sided grade II and III varicoceles were treated with Tauber's antegrade scrotal sclerotherapy and underwent follow-up over a median period of 23 months (range, 9 to 35). RESULTS: One grade II varicocele persisted after antegrade sclerotherapy for 6 months. After a second sclerotherapy 6 months later, no further recurrence was detected. One patient with a grade II to III varicocele had a grade I varicocele recurrence 14 months after operation. Three patients showed a slight hydrocele postoperatively. CONCLUSION: This limited series indicates that Tauber's antegrade scrotal sclerotherapy is a safe and effective treatment for grade II and III varicoceles in children and adolescents.     

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.     

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.     

Effects of surgical repair of first degree varicocele on gonadal function and testicular atrophy

Varicocele is one of the main causes of male infertility. This pathology, in fact, is responsible for progressive anatomical and functional testicular damage. Constant monitoring of subjects suffering from varicocele is therefore necessary. In the present study, we evaluated the effect of varicocele surgical treatment on seminal parameters, testicular growth and pregnancy rate in patients with grade I varicocele. We operated on 47 patients with left grade I varicocele associated with sperm abnormalities and with testicular hypotrophy. A high ligation of the internal spermatic vein and all its collaterals was performed in all patients. The postoperative follow-up showed a significant improvement in seminal parameters (motility, morphology and sperm count) and in testicular volumes. Moreover, a pregnancy rate of 58% was observed. These results confirm the observations of other investigators and suggest that surgical therapy of varicocele is capable of improving seminal parameters, of reversing varicocele-related testicular hypotrophy and of achieving high pregnancy rates even in patients with grade I varicocele.     

Recurrent varicocele: role of antegrade sclerotherapy as first choice treatment

OBJECTIVE: To underline the role of antegrade sclerotherapy as first choice treatment in recurrent varicocele. METHODS: In 53 patients, aged 11-38 years, observed over a 30-month period, antegrade sclerotherapy was carried out for the treatment of recurrent varicocele. In seven of these patients, varicocele was bilateral. The right varicocele, however, had not been previously detected and these patients were, therefore, submitted to simultaneous bilateral antegrade sclerotherapy. RESULTS: Antegrade sclerotherapy was feasible in all 53 patients (60 varicoceles) and no significant complications were observed. Unsuccessful results occurred in only two out of the 55 varicoceles observed over a minimum follow-up period of six months. CONCLUSIONS: Whilst antegrade sclerotherapy is recognized as a low-cost, safe and effective method in the management of varicocele, the success rate in recurrent varicocele is even greater than in primary varicocele. If, in the preceding treatment, the internal spermatic vein has presumably been occluded (percutaneous retrograde sclerotherapy, surgical or laparoscopic retroperitoneal ligation of the entire bundle), antegrade sclerotherapy should be considered the treatment of choice.     

LigaSure vessel sealing system in laparoscopic Palomo varicocele ligation in children and adolescents

PURPOSE: We review our experience with laparoscopic Palomo varicocele ligation using the LigaSure device in children and adolescents. MATERIALS AND METHODS: Between June 2003 and December 2004, 25 varicoceles were treated by laparoscopic Palomo varicocele ligation using LigaSure vascular sealing. Patient ages ranged from 10 to 19 years (mean, 14.5 years). Indications for surgery included grade II-III varicocele or ipsilateral testicular hypotrophy. One patient was affected by recurrent contralateral inguinal hernia and 2 presented with an ipsilateral patent processus vaginalis. We placed a 5-mm umbilical port for access, and kept pneumoperitoneum below 15 mm Hg. Under laparoscopic guidance, two additional ports of 3 and 5 mm were inserted in the lower right and left quadrants, respectively. Once the vessels were isolated, the vascular sealant was applied 3-4 times to ensure coagulation of the spermatic vessels; the vessels were then divided with laparoscopic 5-mm scissors. Inguinal hernia and patent processus vaginalis were treated according to Schier's technique. All procedures were performed in our day surgery facility. RESULTS: Mean operative time was 18 minutes, which is significantly less than the time required in a similar group of 12 patients who underwent laparoscopic clip ligation. There were no perioperative complications. Eleven of 16 patients recovered testicular size. Two patients had postoperative hydrocele: the first was treated successfully with scrotal aspiration, while the other patient required scrotal hydrocelectomy. CONCLUSION: Laparoscopic Palomo varicocele sealing can be performed safely and rapidly and is highly successful in correcting varicoceles in young males. We also found it to be the ideal technique to correct the associated inguinal hernia or patent processus vaginalis.     

Laparoscopic surgery versus antegrade scrotal sclerotherapy: Retrospective comparison of two different approaches for varicocele treatment

OBJECTIVE: Both laparoscopic surgery and antegrade sclerotherapy are effective treatment options in the management of varicoceles. However, very limited data comparing these two approaches are available in the literature. We present our experience regarding outcome and complications with each treatment modality. PATIENTS AND METHODS: During a 10-year period, 122 cases of laparoscopic varicocelectomy (LV) and 108 cases of antegrade sclerotherapy (AS) were performed in our institution. Diagnosis and postoperative results were established clinically and using Doppler ultrasonography. Data regarding failure rate, complications, operative time and length of hospital stay of each procedure were retrospectively evaluated. RESULTS: Median follow-up was 59 months (5-130). Failure rates for LV and AS were 4.9% and 15.7%, respectively (p < 0.01). Complications occurred in 13.1% after LV, including 13 cases (10.7%) of hydrocele formation, and 4.6% after AS. Hydroceles following LV were significantly more frequent in patients with compared to patients without previous inguinal surgery (27.8% vs. 8.5%; p < 0.05). There was no significant difference between LV and AS regarding operative time (36 vs. 34 min, p > 0.05) and hospital stay (2.2 vs. 2.1 days, p > 0.5). CONCLUSIONS: In our experience, LV was more effective than AS in correcting varicoceles. Complications other than hydroceles were higher after AS. The higher incidence of postoperative hydrocele formation following LV warrants strategies such as the lymphatic sparing approach, especially in patients with previous inguinal surgery.     

Predictors of pain resolution after varicocelectomy for painful varicocele

Varicocelectomy is a management option for patients with painful varicocele. In this study, we assessed the effectiveness of varicocelectomy for painful varicocele and examined the factors that might be predictive of outcome. All patients who underwent a varicocelectomy for pain between February 2007 and July 2009 were included. A review of patient medical records was conducted; patient age, body mass index (BMI), grade, location of the varicocele, testicular volume, duration and quality of the pain (dull, dragging, throbbing or sharp) and surgical technique (inguinal versus subinguinal) were documented. All parameters were compared with the resolution of pain (complete, partial or failure). We followed up on 53 of 104 patients (51.0%). Complete postoperative resolution of pain was reported by 28 patients (52.8%), whereas 22 (41.5%) reported partial resolution. Only three patients (5.7%) reported failure. No relationship was observed between postoperative pain resolution and age, BMI, grade of varicocele, location of varicocele, ipsilateral testicular hypotrophy, quality of pain or surgical technique. The duration of pain before surgery was the only factor that correlated with postoperative pain resolution (univariate, P=0.004; multivariate, P=0.002). Our results indicate that varicocelectomy is an effective treatment for painful varicocele in properly selected patients, and that duration of pain before surgery may be predictive of outcome.     

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.     

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.     

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.     

Late results following sclerotherapy of varicocele

Between May 1981 and December 1982 244 patients with varicocele were scheduled for percutaneous sclerotherapy which is performed as an out-patient procedure. In around 80% of the patients sclerotherapy was possible. Failures were due to anatomical and technical factors. Three months after treatment a persisting varicocele was observed in 3.3% as evidenced by control phlebography; 3.9% of our patients developed a painful induration of the plexus pampiniformis which necessitated a 3-day hospitalization. Six months after sclerotherapy spermiography was repeated and compared to the pretreatment results: in 50% of the patients the sperm density was significantly improved, however, sperm morphology and mobility remained virtually unchanged. The sclerotherapy of varicoceles can be recommended as an alternative procedure to surgery. The effect on sperm quality of both therapies is equal, but the sclerotherapy is performed as an outpatient procedure (sick-leave 2 days), is cheaper, better tolerated and has a lower rate of persisting varicoceles than surgical repair.     

Should varicoceles be treated in the adolescent? How?]

Adolescents rarely consult for painful varicocele. The condition has to be confirmed by physical examination and a detailed Doppler exam. An ultrasound may be necessary to measure the size of the testis. About 15% of all adolescents have varicoceles. One out of three is graded II or III in the Dubin and Amelar classification. About 20% of varicoceles graded III occur in association with testicular hypotrophy. We do not know whether boys with a varicocele will fertility problems later on, but only 13% of adult men with varicocele are infertile. Surgery can be considered as necessary only after studying a large number of patients, comparing at random patients operated at a young age and followed for 15-20 years with patients not operated and with a group of healthy controls. The best treatment has to be selected because of the low risk of testicular atrophy and the disappearance of the varicocele in more than 90% of the cases. Inguinal root with microsurgery, and pre or intra-operative radiologic opacifications are the usual choice of most pediatric surgeons. Laparoscopy or retroperitoneoscopy have no major impact on the postoperative results. They are expensive and require great experience. Embolization and other radiological techniques induce a long period of radiation, are not always possible, expensive and demand an experienced radiologist. General anesthesia is required because of the time involved and finally the success rate is low. Microsurgical venous reanastomosis is still confidential probably because of technical difficulties. Scrotal anterograde sclerotherapy is the simplest and cheapest treatment and can be performed with a local anesthetic due to the short time required. But like other procedures, it can induce testicular ischemia.     

Antegrade scrotal embolization of varicocele: results

The aim of this study is to judge the effectiveness of the new treatment of varicoceles, introduced in 1987 by Tauber: the antegradal scrotal sclerotherapy of varicoceles. From february 1996 to april 1998, we have realised 150 antegrade embolisations of varicoceles. The study is lead on 75 patients with mean time follow-up of 12 months. Patient's mean age is 20 years. 85% of patients had a grade 3 left varicocele and 15% a grade 2 left varicocele. The criterium of success rests on the lack of veinous flow-back during clinical examination, which is than confirmed by doppler-ultrasound. Clinical success is obtained in 87% of the cases and the doppler control is normal in 80% of the cases. We have 9% of minor complications, and no major complication. The number of failures in our study is higher than in Tauber' study, but is the same as those described in the other procedures of treatment of varicocele. On the other hand the surgical procedure is simple and the morbidity is low.     

Five mm laparoscopic varicocelectomy versus conventional varicocele ligation in young men with symptomatic varicocele: A randomized clinical study

ObjectivesTo compare the therapeutic success, morbidity and the costs of 5 mm laparoscopic varicocele ligation (LV) compared to inguinal varicocelectomy (IV).Patients and methodsEighty patients with idiopathic symptomatic varicocele of grades I–III diagnosed by clinical examination and Doppler ultrasonography were randomly assigned to LV or IV (40 patients in each group). The mean patient age was 25.2 ± 1.4 (range 18–40) years. Of the 80 patients treated 21.3% had a left-sided varicocele, 70% had bilateral varicoceles and 8.8% a right-sided varicocele. Of 136 varicoceles, 37 (27.2%) were grade III, 51 (37.5%) grade II and 48 (35.3%) were grade I. The indications for varicocele ligation were: abnormal spermiogram in 47 patients (58.7%), scrotal pain in 19 (23.8%) and cosmetic impairment in 14 (17.5%). A total of 136 varicocele ligations were performed (67 IV and 69 LV). All patients were followed up for 4–8 months to assess early complications, testicular size, late complications and persistence or recurrence of the varicocele.ResultsLV was associated with shorter operative time, shorter hospital stay and lower cost compared to IV. The overall incidence of postoperative complications including hydrocele, epididymitis and local pain was significantly higher among patients undergoing IV compared with LV (17.5% vs 5%). The incidence of persistent varicoceles was not significantly different between the 2 groups, but the varicocele recurrence rate was significantly lower in the LV compared to the IV group (5% vs. 17.5%, p ≤ 0.02).ConclusionsLV is a less invasive treatment than IV for managing male varicoceles. It is also associated with lower costs and better outcomes and should therefore be the preferred method of treatment for male varicoceles.     

The role of varicocele sclerotherapy in men with severe oligo-astheno-teratozoospermia

The aim of this study was to verify the role of antegrade scrotal sclerotherapy for the treatment of varicoceles in infertile men with severe oligo-astheno-teratozoospermia (OAT). The 59 patients with severe OAT in this study underwent antegrade scrotal sclerotherapy for the treatment of varicoceles. The outcome was assessed in terms of improvement in semen parameters and spontaneous conception rate. Semen parameters and reproductive hormones were evaluated before antegrade sclerotherapy (AS) and 6 months after AS. After an average follow-up time of 34.8±3.2 months, significant improvement was noted in the mean sperm concentration, motility and morphology in 36 patients (61%). Spontaneous pregnancy occurred in nine couples (15%). Six months after treatment, inhibin B levels were significantly higher (P<0.04), whereas follicle-stimulating hormone (FSH) levels were significantly lower (P<0.001) than before treatment. Antegrade internal spermatic vein sclerotherapy can significantly improve seminal parameters and hormonal parameters in men with severe OAT and may even result in spontaneous pregnancy in couples who would otherwise be candidates for intracytoplasmic sperm injection (ICSI).     

The relationship between varicoceles and obesity

PURPOSE: To determine if a relationship between weight and varicocele occurrence exists, the prevalence of varicoceles was determined in a population of patients presenting with infertility. MATERIALS AND METHODS: Records of 3,213 males presenting with infertility were examined. Patients underwent physical examinations for varicocele presence and grade. Body mass index was calculated. Patients were categorized as normal weight, overweight and obese using National Institutes of Health criteria. Means were compared with Student's t test. Frequencies were compared by chi-square analysis and statistical significance was considered at p < 0.05. RESULTS: A total of 1,093 (34%) patients had varicoceles. The mean body mass index of those without varicoceles was 28.5 (+/- 5.6) kg/cm2, which was greater than the body mass index of those with varicoceles (26.7 [+/- 4.0] kg/cm2) (p < 0.001). Varicocele frequency was calculated for each body mass index group. In the normal weight group (body mass index less than 25) 378 of 884 patients (43%) had varicoceles. In the overweight group (body mass index 25 to less than 30) 540 of 1,549 patients (35%) had varicoceles. In the obese group (body mass index 30 or greater) 175 of 780 patients (22%) had varicoceles (p < 0.001). Analysis comparing varicocele frequency based on varicocele grade per body mass index group was performed. Prevalence of varicocele decreased with increasing body mass index for all varicocele grades (p < 0.001). CONCLUSIONS: Prevalence of varicocele decreases with increasing body mass index. One explanation is increased adipose tissue preventing compression of the left renal vein. Another explanation is decreased detection due to adipose tissue in the spermatic cord. The decrease in varicocele prevalence as a function of body mass index regardless of varicocele grade suggests this explanation is less likely.     

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.     

The enigma of varicocele in children

After a review of the literature and their own experience, the authors relate the various dilemmas of infantile varicocele. These dilemmas are diagnostic and therapeutic. On the basis of clinical, epidemiological, etiological and pathological studies, the authors conclude that grade III and grade II varicoceles associated with testicular hypotrophy must be operated, while the others must be followed.