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Outcomes of the techniques for varicocele treatment in the literature
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Varicocele is a progressive disease, and the incidence of varicocele and varicocele related testicular hypotrophy increases with puberty. This review updates novel management and future paternity potential in adolescents with varicocele. Main goal of treatment of the adolescent varicoceles is preservation of fertility. Current recommendations for a...
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Context 1
... microsurgical method results in a significant decrease in the incidence of hydrocele forma- tion, testicular artery injury and varicocele recurrence. Table 1 shows outcomes of varicocele treatment in pediatric population in the literature. Although most of varicocelectomy methods result in similar short term results, open microsurgical inguinal or subinguinal varicocelectomy techniques have been shown to result in fewer recurrences and postoperative compli- cations than conventional varicocelectomy in adults (Level of evidence 2; grade B recommendation). ...
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Objective: To evaluate the outcome of microscopic subinguinal varicocelectomy on sperm DNA fragmentation (SDF) and pregnancy rate in men with normal semen parameters.
Patients and methods: A pilot study that included male patients with a minimum of a 1-year history of male subfertility, normal semen parameters, a high percentage of SDF, and clinica...
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Citations
... Postoperative hydrocele has been a potential problem among children and adolescents who undergo varicocelectomy, with incidence rates ranging between 0 and 32% [6]. Hydrocele following varicocelectomy occurs due to disruptions in lymphatic outflow from the tunica vaginalis upon vessel ligation. ...
... Among the multiple techniques for varicocele treatment among adults and children or adolescents presented in the literature, MSV has been considered the best given its high success rates and low complication rates [6]. Despite being generally performed as a standard treatment for adult male patients with infertility [12,13], MSV as a treatment for pediatric and adolescent varicoceles does not share the same renown. ...
The purpose of this study is to clarify the safety and efficacy of indigo carmine dye–assisted lymphatic-sparing microsurgical subinguinal varicocelectomy for children and adolescents in our institution. Medical records of boys aged ≤ 15 years who underwent varicocelectomy between November 2008 and December 2019 at our institution were retrospectively reviewed. Microsurgical subinguinal varicocelectomy was performed using indigo carmine injection under the tunica vaginalis to preserve lymphatics. A total of 29 patients underwent varicocelectomy, among whom six underwent retroperitoneal high ligation (modified Palomo technique), nine underwent laparoscopic varicocelectomy, and 14 underwent microsurgical subinguinal varicocelectomy. The median operative time for retroperitoneal high ligation, laparoscopic varicocelectomy, and microsurgical subinguinal varicocelectomy was 71 ( IQR : 59–82.5) min, 131 (95–151) min, and 125.5 (112–134.25) min, respectively. Among the patients who underwent laparoscopic varicocelectomy, one and two experienced hydrocele and varicocele recurrence as postoperative complications, respectively. None of the patients who underwent microsurgical subinguinal varicocelectomy developed hydrocele and varicocele recurrence during 15.5-month median follow-up period ( IQR : 11.25–25.75 month). Indigo carmine dye–assisted lymphatic-sparing microsurgical subinguinal varicocelectomy can be a safe and efficient treatment modality among children and adolescents.
... In adolescents, a varicocele is more likely to cause testicular dysfunction due to the rapid increase in the testicular volume and the inability to meet the increased energy requirements. Stimulation with a testosterone surge rapidly increases the testicular volume in adolescence, and in this particular age group, the testicles become more susceptible to hypoxia and stress (Çayan, Bozlu, & Akbay, 2017). A delayed diagnosis of the disease in this progressive process may cause not only greater testicular dysfunction, but also epididymal damage, and consequently, impaired spermatogenesis (Ozturk et al., 2008;Witt & Lipshultz, 1993). ...
Impacts of a subinguinal microsurgical varicocelectomy on the sperm parameters and fertility rates were investigated in three different ages according to their age at the time of the varicocelectomy: Group 1 was ≤20 years old, Group 2 was 21–30 years old, and Group 3 was ≥31 years old. The patients were also classified both preoperatively and post‐operatively according to the total motile sperm count (TMSC) into the following categories: invitro fertilisation, intrauterine insemination and naturally fertile. The proportion of patients who upgraded to a higher TMSC category level was calculated, and natural fertility rates were recorded. The mean infertility duration was statistically longer in Group 3, compared to Group 1 and 2. The mean TMSCs and normal sperm morphology rates increased in all groups. The mean post‐operative natural fertility rates were similar. The highest rate of TMSC upgrade was observed in Grade 3 varicocele patients under 20 years of age, compared to other grades of varicocele in patients older than 20 years. A microsurgical subinguinal varicocele repair, which is an effective treatment modality reduces the need for any type of ART, has an important impact on the TMSC increase in patients, particularly in the younger population.
At present, treatment of varicocele is still controversial in adolescents for at least three reasons. Firstly, the long-term outcome of treatment is not known in the absence of spermiogram support and in terms of long-term follow-up. Secondly, it is still uncertain which is the best type of operation for children/adolescents. Thirdly, the principle that if a technique is designed for adults, it can also be safely performed in adolescents cannot be applied. A recent systematic literature review and meta-analysis demonstrated that open and laparoscopic techniques appear to yield better results with a microsurgical approach compared with laparoscopy. However, laparoscopic techniques that preserve the lymphatic vessels appear to have a clear advantage by preventing postoperative hydrocele. At present, the evaluation and choice of treatment for adolescent varicocele patients are based not on objective fertility criteria (paternity) but on indirect evidence that testicular function or spermatogenesis and thus ultimately also fertility may be compromised. In the absence of sufficient data regarding the treatment of varicocele at a pediatric age, the choice of the technique appears to depend largely on the experience and preferences of the surgeon rather than on a shared option.
In varicocele, the main cause of sperm DNA damage is oxidative stress (OS). Resveratrol, a polyphenol with antioxidant properties, can protect cells from injuries caused by OS. We investigated the benefits of resveratrol against reproductive damage caused by experimental varicocele induced from peripuberty. Eighty peripubertal male rats were distributed into 4 groups: sham–control (S), varicocele (V), resveratrol (R) and varicocele treated with resveratrol (VR). Varicocele was induced through the partial ligature of the left renal vein. Resveratrol was given in a daily dose of 300 mg/kg body weight (gavage). Sperm samples were collected at 100 days of age for vitality, DNA fragmentation and chromatin protamination evaluations. OS analyses were carried out. Rats from all groups were mated with healthy primiparous females for evaluation of reproductive capacity and embryonic quality. The V group showed reduction of sperm vitality, altered chromatin protamination and sperm DNA integrity and high levels of OS. The VR group showed an improvement of oxidative status, sperm vitality, DNA integrity and chromatin structure, and an enhancement in the gestational index and embryonic quality. Therefore, we showed in this experimental model that resveratrol is a promising nutraceutical adjuvant and should be deeply studied to mitigate subfertility in varicocele.
In recent years, cases of detection of varicocele in adolescent age have increased and the using methods of treatment for this population remain controversial. The literature analysis revealed a variety of approaches to the therapy of the pathology: there are supporters of both surgical treatment and conservative therapy and dynamic surveillance. It is known that about 20-40% of adolescents with varicocele are potentially infertile, and they need early surgery for indications such as testicle hypotrophy, pathospermia. However, the existing methods of treatment of varicocele are accompanied by the recurrence, with hydrocele development, and progressive testicle injuries. Furthermore, the results of applicable methods of treatment are limited, characterized by low evidence, lack of randomized controlled researches.
Male and Sperm Factors that Maximize IVF Success - edited by John Aitken April 2020
We aimed to define which method would be the best for the treatment of recurrent varicoceles. We analysed 21 studies to compare post‐treatment improvement in semen parameters, spontaneous pregnancy and complication rates between the treatment methods. Overall spontaneous pregnancy rate was significantly higher in the surgical methods (44.3%) than in the radiological interventions (17.9%; p = .007). Post‐treatment improvement rates in sperm parameters were significantly higher in the open surgical methods (77.5%) than in the radiological interventions (62.5%; p = .032). Post‐treatment recurrence rates were 3.8% in the open surgical methods, 17.6% in the laparoscopic surgery and 3.3% in the radiological interventions. However, technical failure rate was 11.8% in the radiologic interventions. To analyse open surgical methods, recurrence rate was 0.6% in the microsurgical methods and 19% in the macroscopic methods, revealing significant difference (p < .001). Post‐treatment testicular atrophy rate was significantly higher in the laparoscopic surgery (2.9%) than in the open surgery (0.3%; p = .033). In conclusion, surgical methods have higher pregnancy rates and higher improvement rate in sperm parameters than radiological interventions for the treatment of recurrent varicocele. Microsurgical redo varicocelectomy has lower recurrence and testicular atrophy rates than macroscopic varicocelectomy series. Therefore, patients with recurrent varicoceles should be informed based on these findings.
The condition known as varicocele has been described for centuries. Literature defines varicocele as a cause of infertility for 50% of cases of male component. Today, there is a discrete agreement regarding the need for intervention in case of high-grade varicocele with marked seminal alterations while the management of low-grade varicocele with modest changes in the sperm is still debated. The main problem is therefore to define what to do when we are facing a patient who has a modest alteration of the semen analysis.
Objective:
To evaluate the paternity rate in a large cohort of asymptomatic adult varicocele patients undergoing nonsurgical management and surgery.
Methods:
The study population included 1845 men with varicocele and 9286 healthy controls. All data were retrospectively obtained from the Israeli Defense Forces medical database. Patients were divided according to the management strategy: 1758 (95.2%) were followed up nonsurgically, 63 (3.4%) had preventive surgery (patients without known infertility), and 24 (1.4%) had secondary surgery (patients with varicocele and primary infertility) as young adults. The primary outcome was the live birth rate.
Results:
The live birth rate was similar in the preventive surgery and control groups. Both preventive surgery and control groups had higher live birth rate than the nonsurgical group. Finally, the secondary surgery group had the lowest live birth rate of all groups.
Conclusion:
Preventive surgery for asymptomatic varicocele provides similar fertility outcomes to control groups, whereas nonsurgical strategy provides inferior outcomes and may be overutilized.
