Sub-inguinal interruption of dilated veins in adolescent varicocele: should it be considered a gold standard technique?

AIM: Surgeons of varicocele are at present still searching for a gold standard technique, which can correct varicocele without any recurrences, maintaining optimal testicular function, having got minimal current and future morbidity and being cost effective. We evaluated the presence of these criteria in the technique of sub-inguinal dilated vein interruption. METHODS: Between 1994 and 2001, 142 youngsters and adolescents underwent surgery for varicocele repair at our hospital. Average patient age was 12.4 years (range 8 to 15). One-hundred-six cases (74.7%) were grade III varicocele, while 36 (25.5 ) were grade II. Grade II varicoceles underwent surgery only if associated with scrotal discomfort, testicular softness or hypotrophy of the affected testis (differential volume between the 2 testicles more than 20% or more than 2 ml ). Varicoceles were repaired using a subinguinal ligation of intrafunicular and extrafunicolar dilated veins. The testicular vaginalis was not touched in 46 children (Group A) but it was reversed in 42 and resected in the other 54 cases to prevent postoperative hydrocele. RESULTS: In 126 cases (88.7%) varicocele disappeared after surgery, in 12 (8.4%) a mild residual vein dilatation persisted but without any sign of reflux at color-Doppler ultrasound, in 4 patients a postoperative venous reflux was found. Thus, our recurrence rate is nowadays 2.8%. Average postoperative follow-up was 2.3 years (range 1 to 5 years). No testicular atrophy was observed. Based on our last series, at 1 year follow-up control (26 cases throughout year 2000), mean testicular volume, assessed by ultrasound, increased not significantly after surgery from ml 4.69 (SD+/-1.46) preoperative volume to ml 5.19 (SD+/-1.36) postoperative (p=0.2). CONCLUSION: First of all, we found a recurrence rate of 2.9% similar to the lowest of the other procedures. Regarding morbidity, the main inconvenience consists in postoperative hydrocele. It occurred in 13% of our 1st series (group A), but only in 4.1% of patients after reversion or resection of the vaginalis tunica. Average postoperative testicular volume increases after varicocelectomy in our patients, even if not significantly. About sparing the testicular artery or not it has been demonstrated that ligation of this artery doesn't impair testicular growth up and our own observations confirm this evidence. Thus we believe it to be more useful and safe to interrupt this artery to avoid recurrences due to a periarterial venous network. Finally we can conclude that sub-inguinal ligature of dilated veins, when approached with rigorous understanding of the pathophysiology of varicocele is a very safe procedure and low cost effectiveness.     

Relationship between varicocele grade, vein reflux and testicular growth arrest

The development of testicular hypotrophy (or testicular growth arrest) in pediatric patients with varicocele is the first indication for surgery. The aim of this study is to identify the correlation between grade of varicocele, grade of vein reflux and testicular growth arrest. Between 2000 and 2001, we recruited 226 patients affected by varicocele without testicular hypotrophy and with grades 2-3 spermatic vein reflux observed during Doppler velocimetry. Medical examinations carried out every 6 months allowed the assessment of varicocele grade, testicular volume, and grade of vein reflux. Other parameters considered in the study were: mean time of grade deterioration, mean time to onset of testicular growth arrest and the relationship between varicocele grade and testicular growth arrest. Deterioration of the condition was experienced in 92 patients (40%) in which 60 patients showed higher varicocele grades without testicular growth arrest, while 32 patients developed testicular growth arrest. There was a statistically significant relationship between testicular growth arrest and varicocele grades (grade 2 and 3) and between grade of reflux and testicular growth arrest. Although it is not possible to determine which patients will develop testicular growth arrest, the assessment of vein reflux allows the identification of those subjects who may potentially develop such a condition.     

儿童精索静脉曲张患病情况的调查

目的　研究儿童精索静脉曲张的患病规律。方法　对山东省四地区4 274名男性儿童及青少年进行专科检查,计算精索静脉曲张的患病率,并对患病儿童的双侧睾丸大小进行比较。结果　山东省四地区4 274名在校儿童及青少年中共检出精索静脉曲张患儿 460人,总患病率为10.76%。青春前期组1 248人,检出患儿 70人,患病率为5.61%;青春期组3 026人,检出患儿 390人,患病率为12.89%。两组患病率进行χ2 test,P<0.05,差异具有显著性意义。所有患病儿童双侧睾丸大小进行比较,差异没有显著性意义。结论　精索静脉曲张发生于儿童期及青春期,且患病率随着青春期的到来而明显升高。在儿童及青春期,精索静脉曲张患儿两侧睾丸容积差异无显著性意义。     

Retrograde percutaneous sclerotherapy of left idiopathic varicocele in children: results and follow-up

Treatment of pediatric patients with varicocele is based on the desire to prevent testicular dysfunction and possible infertility that may become irreversible in adults. The authors reviewed their experience with retrograde percutaneous sclerotherapy (RPS) via a trans-femoral approach to assess its results in children. A retrospective study was conducted, including all the children admitted between 2000 and 2004 who underwent RPS with at least 24 months follow-up (FU). The indication for treatment was grade II and III varicocele (Dubin–Amelar classification), confirmed by Doppler US. Three per cent sodium tetradecyl sulfate was the sclerosing agent. FU included Doppler US 1 month after the procedure and then yearly for at least 2 years. Eighty-six children (mean age 13.8 years) underwent phlebography and, when feasible, RPS. Varicocele was grade II in 49 cases and grade III in 37. RPS was feasible in 72 (84%) children because of unfavourable anatomic features of the left spermatic vein. RPS was successful in 66 (92%) out of 72 treated children. Median FU was 29 months. During FU, five (8%) patients relapsed. RPS of varicocele is a simple and effective treatment. A minimum of 2 years FU is recommended, as a few cured cases may relapse during this period. Presented in part as scientific presentation at the 2006 RSNA (Radiological Society of North America) Annual Meeting, November 2006, Chicago, IL, USA.     

Varicocele in the adolescent

Varicocele is a dilatation of the veins of the pampiniform plexus caused by reflux within the spermatic venous system. In the majority of cases it becomes apparent during pubertal development. The etiology of varicocele is likely multifactorial. The varicocele may have a negative effect on gonadal growth in the pediatric-adolescent age group and may be associated with a significant reduction in testicular volume and progressive decline in testicular function. The most likely mechanism is an elevation of testicular temperature due to an impaired counter-current heat exchange mechanism. Initial diagnosis is based on the clinical examination, which, in selected cases, may be followed by other non-invasive evaluations: Doppler, color Doppler ultrasound of the spermatic cord (the examination of choice), or ultrasound of the testis. The role of hormonal studies (gonadotropin, testosterone and inhibin B levels) is controversial and analysis of seminal fluid may be difficult to obtain in a minor. This statement offers recommendations regarding the best practice policies for evaluation and treatment of varicocele in adolescents.     

Impact of internal spermatic artery preservation during laparoscopic varicocelectomy on recurrence and the catch-up growth rate in adolescents

ObjectiveTo investigate the effectiveness of laparoscopic varicocelectomy (LV) in adolescents with varicocele and analyze the impact of internal spermatic artery (ISA) preservation on surgical outcomes.Materials and methodsData on 92 adolescents with left varicocele who underwent LV between December 1998 and January 2011 were retrospectively analyzed. The mean age of the patients was 13.2 ± 2.1 years. Age, grade of disease, number of ligation veins, recurrence rates, and catch-up growth were analyzed in patients who underwent ISA preservation and ligation. The median duration of the follow-up was 21 months.ResultsISA preservation was performed on 50 patients (54%). There were no significant inter-group differences in terms of age, varicocele grade, number of ligation veins, and catch-up growth (93% vs. 90%). The patients who received artery preservation demonstrated a higher recurrence rate (22%) than those who received artery ligation (5%; p = 0.032). Among 13 patients who had persistent or recurrent varicocele, nine were treated with embolization and one was treated with magnification-assisted subinguinal varicocelectomy. None of these 10 patients demonstrated recurrence or testicular atrophy.ConclusionsLV with ISA ligation can reduce the recurrence rate and results in the same catch-up growth rate in comparison with LV with ISA preservation.     

腹腔镜Palomo手术治疗青少年精索静脉曲张112例

目的探讨腹腔镜下Palomo手术治疗青少年精索静脉曲张的临床疗效。方法总结本院2001年7月至2014年3月,采用腹腔镜Palomo手术治疗,并具有术前、术后3、6、12个月完整B超随访资料的112例精索静脉曲张青少年患儿临床资料。结果共112例患儿,均为左侧,年龄11岁至16岁6个月,中位年龄14岁3个月,年龄≥12岁108例,占96.4%。病史最长3年,平均1.3年。患儿治疗前均行阴囊彩色超声检查确诊,并根据B超测量结果计算睾丸体积。112例中,Ⅱ度25例,Ⅲ度87例,全部在腔镜下完成Palomo手术,手术时间20~35 min,平均27 min。无术后出血、阴囊水肿,平均住院时间5 d。112例均完成术后3、6、12个月随访,并复查B超,无一例复发,发现鞘膜积液6例,附睾囊肿1例。Ⅱ度25例中,术前左右睾丸体积差异在10%~15%者11例(44%);体积差异15%共4例(16%)。Ⅲ度87例,术前左右睾丸体积差异在10%~15%者48例(55.2%);体积差异15%共18例(20.6%)。术后112例中,96例(85.7%)患侧睾丸存在显著的"追赶"生长。术后12个月,Ⅱ度25例中,左右睾丸体积差异在10%~15%者4例(16%),15%共2例(8%);Ⅲ度87例中,左右睾丸体积差异在10%~15%者18例(20.6%),15%者8例(9.1%),手术后睾丸体积差异明显缩小(P0.01)。结论青少年Ⅱ、Ⅲ度精索静脉曲张已经存在两侧睾丸差异性生长,随着临床分度的增加,差异越发显著。Palomo手术后可观察到患侧睾丸显著的"追赶"性生长,左右睾丸体积差异明显缩小。腹腔镜palomo手术具有复发率低,睾丸萎缩可能小等特点,是一种安全可靠的手术方法 。     

The Palomo procedure in the treatment of boys with varicocele: a retrospective study of testicular growth and fertility

The Palomo procedure has often been criticized with regard to possible atrophy of the testis. Measuring the testicular volume is mainly used in pre- and postoperative assessment. Evidence concerning fertility remains unclear. The aim of this study was to learn whether now-adult former patients had any disturbance of their testicular growth and/or fertility. Out of 79 patients operated upon with Palomo's procedure between 1979 and 1990, 33 could be evaluated. They all had grade II or III left-sided varicoceles. Investigations consisted of: the patient's history, testicular-volume measurement by means of an orchidometer (OM) (Prader) and ultrasonography (US), and semen analysis (27/33) 6–17 years after surgery. No recurrence of grade II varicoceles was observed. Only 1 of the 33 patients might have had testicular atrophy, yet he had already fathered 3 children! Twenty-three had a normal sperm count and 24/27 showed normal sperm motility. Eight hydroceles were either present at the time of investigation or had been operated upon in the past. Estimations of testicular volume by OM and US showed significant differences between the two methods concerning volume and relation of right to left side. In general, the volume was overestimated by the OM. The study shows that in boys the simple surgical technique proposed by Palomo has – in the long run – no disadvantages for testicular development and sperm production. Fertility should therefore not be compromised. Accepted: 8 April 1998     

Laparoscopic Palomo varicocele surgery: Lessons learned after 10 years’ follow up of 156 consecutive pediatric patients

ObjectivesTo evaluate our experience using laparoscopic Palomo varicocele ligation in a population under 18 years, and confirm the factors involved in postoperative hydrocele formation.Patients and methodsBetween 1997 and 2007, 156 boys diagnosed as having varicocele were evaluated retrospectively. Outcome variables recorded for analysis were age at presentation, symptoms, varicocele grade (Dubin–Amelar classification), testicular atrophy, length of hospital stay, perioperative complications, recurrence and hydrocele formation after surgery. Mean follow up was 5.6 years (6 months– 9 years).ResultsAge at diagnosis ranged between 9 and 18 years. Mean age at operation was 14.1 ± 1.8 years. There were 153 left-side varicoceles (98%) and three cases were bilateral. All patients had grade II or III varicocele (38%/62%) and testicular atrophy was noted in 43.8%; 8.1% mentioned testicular pain at diagnosis. All boys underwent Palomo laparoscopic ligation of the spermatic vessels. Mean operative time was 38 min (25–82 min). The last 51 surgeries were performed on a two-trocar basis with Ligasure^® vascular sealing device and operative time decreased significantly to 22 min (16–32 min) (P < 0.05). Median hospital stay was 31 ± 8 h. Conversion rate was 1.28%. Twenty-one patients developed hydrocele (13.5%); 11 of these underwent Winkelman–Lord's hydrocelectomy at least 1 year after Palomo (9% of total). Of the remaining 10, two resolved spontaneously and eight were stable at mean 4-year follow up.ConclusionsLaparoscopic Palomo varicocele surgery for pediatric patients is a safe and effective procedure. Recurrence and complication rates are similar to those reported with open surgery.     

Scrotal antegradesclerotherapy demonstrates anatomical variations on venous drainage in paediatric, adolescent and young adult varicoceles

Aim of the study

Anatomical variations on venous drainage in varicoceles are under-reported. We report our experience in scrotal antegrade sclerotherapy (SAS) for adolescent varicoceles.

Methods

Since 2011, 15 consecutive boys with left varicoceles were recruited. Under general anaesthesia, a 5-mm transverse incision was made at scrotal neck, testicular vein was cannulated at pampiniform plexus with venogram performed. Foam sclerosant by mixing sodium tetradecyl sulphate (STS), Lipiodol^® and air was slowly injected under fluoroscopy. Postoperatively the patients were followed-up for varicocele grading, testicular size, and complications.

Main results

Median age at operation was 14 (10–19) years. 80 % had grade three varicoceles, 33.3 % had smaller left testis before operation. Intra-operative venogram showed three different anatomical variations. Group I: eleven patients (73.3 %) had single distinct internal spermatic vein; Group II: two patients demonstrated duplication of internal spermatic vein draining into left renal vein; Group III: two patients had pampiniform plexus draining to iliac and/or paraspinal veins. SAS was performed in Group I and II patients. Sclerosant volume injected ranged from 1.5 to 4.5 ml. In Group III patients, surgical ligation of testicular veins was performed rather than SAS to avoid uncontrolled systemic sclerosant spillage. Mean length of stay was 1.13 day. One patient with scrotal haematoma and one other with minor wound dehiscence were managed conservatively. Mean follow-up period was 10.9 (1–22) months. Thirteen patients (86.7 %) achieved varicocele grading ≤1. There was no postoperative testicular atrophy, hydrocele and epididymo-orchitis.

Conclusion

Scrotal antegrade sclerotherapy using STS foam is a safe and effective treatment for adolescent varicoceles. Anatomical variations on venous drainage in varicoceles are common.     

Ultrasonographic late results after surgically treated cryptorchidism

Background. Because uncorrected cryptorchidism is accompanied by the high risk of later disturbed testicular function and cancer, early surgery in the second year of life is recommended. Objective. To evaluate testicular morphology, the sonomorphologic testicular long-term outcome and additional complications, as well as possible differences depending on varying ages at surgery. Materials and methods. Seventy-five previously maldescended testes in 68 boys were studied with US, 2–11 years after intrascrotal orchidopexy. Nineteen had been operated on in the first or second year of life, while the other 49 boys underwent surgery at a later age (up to 7 years). Each examination utilised conventional B-mode and colour Doppler (7-MHz linear ART probe, Acuson XP 128) to examine the scrotal and inguinal regions on both sides; testicular volume and perfusion were assessed. Ultrasound changes in testicular volume, architecture and Doppler flow rates were regarded as the most valid indirect indices of testicular damage. Histopathological correlation was not obtained, for ethical reasons, in any of the probands. Results. Thirty-five of the surgically fixed testes were normal with regard to position, volume, structure and perfusion. The other 40 (53 %) showed abnormalities of one or more of these parameters without any correlation with the patient's age at surgery or the time interval between surgery and US. Additional relevant findings, which were also found on the non-operated side, were: microlithiasis (n = 6), inguinally retained testis (n = 6), hydrocoele (n = 5), hydatid (n = 5) and varicocoele (n = 1). Conclusions. Ultrasound, including colour Doppler, enables an exact morphological analysis of the late results after surgically corrected cryptorchidism. The spectrum of findings does not show any correlation with the time of surgery. Thus, the value of even early surgery has to be questioned. Pre-existent primary damage (dysplasia) seems more important for long-term outcome of the testis. Additionally, US was of high value in demonstrating additional unexpected anomalies, the majority of which needed sonographic follow-up or even surgery. Received: 30 June 1999/Accepted: 12 August 1999     

Surgical management of nutcracker phenomenon presenting as left varicocele in adolescents: A novel approach

ObjectiveTo present a new approach using a shunt operation for the management of nutcracker phenomenon presenting as left varicocele in adolescent patients.Materials and methods12 adolescent patients with the nutcracker phenomenon presenting as left varicocele underwent a shunt operation consisting of anastomosis of the proximal part of the spermatic vein and inferior epigastric vein to lower the left renal vein (LRV) pressure. A simple ligation of the left spermatic vein was then used to repair the varicocele.Results12 patients underwent surgery, and symptoms of hematuria, proteinuria, scrotum discomfort, and flank pain disappeared post surgery in all patients. Patients were followed for 24–72 months (mean 48 months). The diameters of the proximal LRV and the peak velocities in the aortomesenteric portion of the LRV were significantly decreased after surgery (p < 0.001). Left testicular volume significantly increased after surgery. One patient had recurrence of the left varicocele and one adolescent had minimal hydrocele requiring no intervention. No major complications were observed during and after surgery.ConclusionAnastomosis of the proximal part of the spermatic vein and inferior epigastric vein is an efficacious and safe surgical approach for the management of nutcracker phenomenon presenting as left varicocele in adolescents.     

Testicular volume in Japanese boys up to the age of 15 years

Previous studies have indicated that Japanese children grow and mature significantly faster than Caucasian children, thus calling for a separate reference standard for each skeletal and sexual maturity index. To establish normal reference values for testicular volume in Japanese boys, we studied from 1985 to 1995, 900 healthy male children of 0 to 15 years of age for medical history, physical examination, height, weight, sitting height, and head circumference measurements, Tanner sex maturity stage, and testicular size. The testicular volume was determined using a Prader orchidometer by the same observer (N.M.). Based on these data, we established the cross-sectional percentile growth curves (90th, 50th, 10th percentiles) for testicular volume of Japanese boys. The testicular volume of 3 ml was attained at 9.3 years of age (90th percentile), 11.0 years of age (50th percentile), and 12.1 years of age (10th percentile), respectively. Conclusion Swelling of the testis in Japanese children begins approximately 1 year earlier than in Swiss children in accordance with the earlier skeletal maturation in Japanese children. Received: 24 January 2000 and in revised form: 22 April 2000 / Accepted: 25 April 2000     

北京市儿童青少年青春期发育与肥胖相关关系的研究

目的 分析北京市6~18岁儿童青少年青春期发育与超重肥胖的关系。方法 利用2004年北京市儿童青少年代谢综合征调查总样本中19 085名6~18岁儿童青少年的青春期发育、体重指数（BMI）和体脂含量百分比（FMP）等数据。采用女性乳房和男性睾丸容积Tanner分期指标衡量青春期发育，结合个体年龄将群体分为早、晚发育组；以BMI和生物电阻抗法所测FMP作为反映体脂含量的指标；7~18岁人群超重和肥胖的诊断采用中国肥胖问题工作组（WGOC）推荐的中国学龄儿童青少年超重、肥胖筛查BMI值分类标准进行，6岁组采用美国疾病预防与控制中心 2000年发布的儿童超重和肥胖BMI标准第P85和第P95分位值进行诊断；采用多元线形回归、Logistic回归分析早发育与体脂含量和超重、肥胖的相关联系。结果 早发育组的超重（合并肥胖）率和肥胖率均高于晚发育组，女性两组间差异大于男性；控制可能的混杂因素后，女性BMI和FMP与早发育呈正相关（BMI：β=2.25，P<0.001；FMP：β=4.55，P<0.001）；而男性BMI和FMP与早发育的联系相反，早发育组的BMI高于晚发育组，而FMP却低于晚发育组；以晚发育为参照组，控制年龄、城郊居住地等因素的影响后，早发育预测超重、肥胖的OR值（95%CI）：女性为3.39（2.94~3.92）和3.12（2.53~3.85），男性为1.12（0.96~1.31）和1.31（1.06~1.62）。结论 北京市儿童青少年青春期发育与肥胖密切相关，在评价超重、肥胖率及进行不同地区间肥胖流行状况的比较时，要注意青春期发育的效应修正作用。     

郑州地区男童阴茎和睾丸发育现状及超重/肥胖对其的影响

目的了解和评价河南省郑州地区男童的阴茎和睾丸发育现状及超重/肥胖对其的影响。方法对河南省郑州地区3 546名4~12岁男童进行身高、体重、腰围、臀围、阴茎长度及睾丸容积的测定,并将超重/肥胖组和体重正常组阴茎长度及睾丸容积进行比较。结果 9岁前,男童睾丸容积逐渐变小,而9岁后睾丸容积逐渐增加,11岁后睾丸容积迅速增加。阴茎长度在4~11岁期间增加缓慢,11岁后迅速增加。包茎(144例,4.01%)、隐睾(18例,0.51%)是常见的阴茎、睾丸发育问题。3 546名男童中,超重/肥胖639名(18.02%)。6岁、7岁时超重/肥胖组睾丸容积大于体重正常组(P0.05)。11岁时超重/肥胖组的阴茎长度小于体重正常组(P0.05)。相关分析提示4岁、5岁时超重/肥胖男童睾丸容积均与身高、体重、BMI、腰围、臀围呈正相关;7岁、8岁时超重/肥胖男童阴茎长度均与体重、腰围、臀围呈负相关,12岁时与身高呈正相关。结论郑州地区男童的阴茎、睾丸发育基本符合中国儿童性发育规律;超重/肥胖对男童的阴茎和睾丸发育产生不利影响。     

腹腔镜Palomo术式丝线结扎治疗精索静脉曲张17例

目的评价腹腔镜Palomo术式丝线结扎治疗儿童精索静脉曲张的安全性和有效性。方法回顾性分析2009年1月-2011年2月在本院行腹腔镜Palomo术式治疗的17例精索静脉曲张患儿的临床资料。均为左侧单发精索静脉曲张,诊断依据查体及超声检查结果。术前行超声检查,静脉直径(3.03±0.69)mm,手术指征为有临床症状或重度(Ⅱ～Ⅲ度)精索静脉曲张,术式为腹腔镜Palomo术式。二氧化碳气腹压力1.33 kPa,置入3个Trocar。直视下于脐下置入第1个Trocar作为镜鞘,另2个置于左腹股沟区及耻骨联合上方。采用丝线双重结扎增粗的精索血管,间隔1.0～1.5 cm,双极电凝离断。结果手术均顺利完成。手术效果依据查体及术后超声检查结果综合评定。术后2 d复查彩超,患儿静脉直径明显缩小[(1.66±0.31)mm],睾丸血运良好。无手术并发症发生。术后2个月曲张的精索静脉均消失。随访无睾丸萎缩及鞘膜积液发生。结论腹腔镜下Palomo术式是治疗儿童精索静脉曲张安全有效的手术方法。     

Microsurgical spermatico-epigastric venous anastomosis in the treatment of varicocele in children: assessment of long-term patency.

AIM: To demonstrate the long-term patency of microsurgical anastomoses between the internal spermatic vein and the inferior epigastric vein, constructed in the treatment of essential varicocele in paediatric patients to supplement ligation of the spermatic veins. MATERIALS AND METHODS: We submitted 66 patients to inguinopelvic colour-flow Doppler ultrasonography. The patients had been treated 18 - 36 months earlier for essential varicocele by microsurgical inguinal ligation of the testicular venous pedicle and anastomosis between the internal spermatic vein and the inferior epigastric vein. RESULTS: Preoperatively, the 66 patients operated on at ages ranging from 10 to 16 years (13 +/- 1.4) presented with Dubin and Amelar grade II (14 patients) or grade III (52 patients) left varicocele with ipsilateral testicular hypotrophy. The postoperative follow-up showed 2 cases of persistence of disease and 3 cases of persistence of "medium" spermatic vein reflux without clinical evidence of varicocele. Seven patients developed left hydrocele which resolved spontaneously in 5 cases, whereas in 2 cases it proved necessary to perform an eversion of the tunica vaginalis of the testis. The results obtained in patients treated for Coolsaet type I varicocele (64 patients) were as follows: long-term patency of the anastomosis was observed in 58/64 patients (90.6 %); in 4 patients (6.2 %) the left inferior epigastric vein presented a position in relation to the homologous artery that prevented adequate sampling and thus made it impossible to assess the patency of the anastomosis; in 2 patients (3.1 %) the anastomosis was closed. In the two patients who had submitted to anastomosis for Coolsaet type III varicocele, colour-flow Doppler failed to identify the shunt. CONCLUSIONS: The results of this study demonstrate that microsurgical anastomosis between the internal spermatic vein, and the inferior epigastric vein remains competent in the long term, thus confirming the validity of this technique for the treatment of essential varicocele in children.     

Management of adolescent varicocele

Varicocele is defined as an abnormal dilation and tortuosity of the internal spermatic veins found within the pampiniform plexus. It is a common finding in adolescents and adult men alike, however its diagnosis in the adolescent population poses different dilemmas in regard to indications for treatment than in adults. Failed Paternity is a clear-cut indication for repair in adult men attempting to father children. In adolescents, the physicians, family and patients must consider potential for future fertility problems which may or may not actually become of concern. Assessing the degree of negative effect of the varicocele on an adolescent's testicular health can also be difficult as teenagers typically are not asked to provide semen for analysis and thus surrogate markers for testicular health such as testicular size differentials must be used. Treatment options for the adolescent varicocele are similar to options in adult populations. While risks and benefits of various techniques can be considered, the gold standard for varicocele repair in adolescents has not been clearly defined.We aim to discuss diagnosis of varicocele, considerations for initiating treatment of varicocele in the adolescent, and techniques for management.     

Nonpalpable testes: is there a relationship between ultrasonographic and operative findings?

Background Ultrasonography (US) as a diagnostic tool in the work-up of boys with nonpalpable testes (NPT) is still controversial. Objective To evaluate the relation between US and operative findings in boys with NPT. Materials and methods During a 7-year period we saw 135 boys with 152 NPT. All were examined by the referring physician or a paediatric surgeon, underwent US examination, and were then re-examined afterwards by a specialist. Finally, all boys were surgically explored for testicular position. Results US located 103 NPT (68%), 16 within the abdomen and 87 in the inguinal canal. With knowledge of the US result, 37 testes were palpable on re-examination. The sensitivity of US was 97% for inguinal and 48% for abdominal viable testes. Of the 49 testes (32%) missed by US, 16 were viable in either the abdominal (n = 14) or the inguinal (n = 2) position. Conclusion All boys with presumed NPT should be referred to a specialist. US is useful to determine localization of NPT, which facilitates planning the surgical procedure. An inguinal exploration is called for when US identifies the testis in the inguinal canal. Because the sensitivity of US for viable abdominal testes is only 48%, we now always perform laparoscopic exploration when US is negative. Sigrid Nijs and Sebastiaan Eijsbouts contributed equally to this work.     

中国九大城市男孩睾丸发育、阴毛发育和首次遗精年龄调查

目的 调查中国九大城市男孩青春发育的平均年龄.方法 采用全国协作性横向调查,于2003-2005年间进行.对象为代表中国东、西、南、北、中部地区的九大城市(包括北京、天津、青岛、上海、武汉、南宁、重庆、广州、福建)城区3-19.83岁的19 054名健康男孩.用睾丸计(Preder orchidometer)测量睾丸容积(ml);通过视诊法进行阴毛发育Tanner分期;发放调查表,由家长和(或)男孩本人填写遗精与否及具体日期.采用概率单位回归法(Probit analysis)计算睾丸发育、阴毛发育和首次遗精的平均年龄及95%可信区间(CI).以睾丸容积4 ml作为青春期启动的标志.将本次调查结果 与国内外文献报道的结果 相比较,并将首次遗精(初遗)年龄与1979年以来进行的五次全国性学生体质健康调查中的相似人群的初遗年龄进行比较.结果 9岁组12.99%的男孩睾丸发育已达4 ml.中国男孩青春期启动的中位年龄是10.55(95% CI 10.27～10.79)岁.阴毛发育Ⅱ期的中位年龄是12.78(95% CI 12.67～12.89)岁,首次遗精的中位年龄是14.05(95% CI 13.80～14.32)岁.1979年以来,中国城区男孩初遗年龄呈现年代提前的变化.结论 中国大城市城区男孩睾丸发育年龄较目前临床所用正常值早,并属当今睾丸青春发育较早、阴毛发育较迟的人群之列;自1979年以来,以呈现首次遗精为特征的性成熟年龄呈年代提前趋势.