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The aim of this study was to evaluate current practice patterns on diagnosis and management of pediatric varicoceles. Questionnaires of approaches to diagnosis and management of pediatric varicoceles were sent electronically to pediatric urologists. Of the 70 questionnaires e-mailed, 37 (53%) responded to the survey. 10 respondents (27%) chose to o...
Context in source publication
Context 1
... respondents (97%) see at least 6-10 patients with varicocele annually, with 9 respondents (24%) having more than 30 cases annually. (Table 1) 32 respondents (86%) used an ultrasonography (US) and/or Doppler US for the diagnosis of varicocele with most of those respondents (n=25, 68%) using US in 76%-100% of all cases. 29 respondents (78%) used objective US cri- teria, including testicular volume discrepancy, as well as venous dilation and/or backflow, but 8 respondents (22%) answered that US findings did not influence their decision making process. ...
Citations
... In addition, pediatric urologists were issued a questionnaire on the best strategy for treating pediatric varicocele. According to the responses, the subinguinal microsurgical technique was the most popular (51%), followed by inguinal (24%) and laparoscopic (14%) approaches (Lee et al., 2016). The MSV approach, according to experts, should be the standard gold technique for varicocelectomy since it properly analyzes the complete anatomical vasculature of the Our findings demonstrated that MSV significantly improved sperm volume, count, motility, progressive movement, and vitality in this study. ...
Background
Previously, we highlighted the benefits of magnified subinguinal varicocelectomy over conservative treatment on the semen of a small group of adolescents with varicoceles. In this report, we presented changes of semen parameters of 47 adolescents who underwent magnified subinguinal varicocelectomy (MSV) and followed-up for 6 months.
Methods
The present prospective controlled study was conducted on 47 adolescents with varicocele who underwent MSV and were followed up for 6 months. In addition, age and sex-matched patients were added as control group. The primary outcome of this study was to assess the postoperative change in semen analysis parameters.
Results
A significant increase in sperm volume from 2.5 (1.9–3) to 3.2 (2.6–4) mL at the end of the sixth month of follow-up. Likewise, the sperm count increased from 10.8 (3.51–21.6) to 20.3 (9.6–35) million. Notably, the percentage of rapid and slow sperms increased significantly from a median of 5% (0%–10%) and 15% (10 -20%) to a median of 10% (5%–15%) and 17.5% (15%–25%), respectively. The percentage of sperm with progressive movement increased from 35% (30%–40%) to 59% (45%–69%). The vitality of the sperms increased significantly as well. While the percentage of sperms with abnormal morphology decreased significantly at the end of follow-up.
Conclusion
Our findings support the safety and efficacy of MSV in patients with clinically detectable varicocele. MSV has improved the semen parameters of the included patients, including sperm motility, volume, count, and total progressive motility, which may positively impact their fertility potential.
... The most common surgical approach was subinguinal microsurgical (51%), followed by inguinal (24%) and laparoscopic (14%). 28 A US survey performed by Pastuszak and colleagues in 2014 found that varicocelectomy is most commonly performed for decreased ipsilateral testicular size (96%), testicular pain (79%), and altered semen analysis parameters (39%). The most common surgical approaches to varicocelectomy in this study were laparoscopic (38%), subinguinal microsurgical (28%), inguinal (14%), and retroperitoneal (13%). ...
A varicocele is an abnormal dilation of the pampiniform plexus of veins in the scrotum which begins at puberty in approximately 15% of males. Although common in the general population and often asymptomatic, varicoceles are associated with gonadal dysfunction including testicular atrophy, infertility, and hypogonadism in a subset of men diagnosed later in life. Because of the high prevalence and uncertain pathogenesis, definitive management guidelines for varicoceles diagnosed in the pediatric and adolescent population remain poorly defined. The varicocele is the most common etiology of male factor infertility, and treatment in the pediatric and adolescent population may improve semen quality and improve fecundity in adulthood. Evaluation of the pediatric and adolescent varicocele should include history, physical exam, and measurement of testicular volume with orchidometer or ultrasound. Testicular volume differentials and peak retrograde flow on Doppler ultrasonography are important factors in risk stratification of the pediatric varicocele population. Semen analysis and reproductive endocrine assessment should also be considered as part of the workup for adolescent patients. A variety of treatment approaches exist for varicocele, and while the microsurgical subinguinal approach is the gold standard for the adult population, it has yet to be confirmed as superior for the adolescent population. Referral to an andrologist for the adolescent patient with varicocele should be considered in equivocal cases. While active treatment of varicocele in the pediatric and adolescent population is controversial, it is clear that some untreated patients will suffer symptoms later in life, while overtreatment remains a concern for this large, vulnerable population. Therefore, surveillance strategies and improved accuracy in diagnosis of clinically important pediatric varicoceles prompting treatment are needed in the future.
... In a recent survey conducted in Korea in 2016, 32 respondents (86%) used US and/or Doppler US for the diagnosis of varicocele, with most of those respondents (n=25, 68%) using US in 76% to 100% of all cases. Twenty-nine respondents (78%) used objective US criteria, including testicular volume discrepancy, as well as venous dilation and/or backflow, but 8 respondents (22%) answered that US findings did not influence their decision-making process [24]. ...
... The most common surgical approaches to varicocelectomy were laparoscopic (38%), subinguinal microsurgical (28%), inguinal (14%), and retroperitoneal (13%), and most physicians used loupes for these procedures. Recently, Lee et al [24] surveyed pediatric urologists to determine the current practices for the diagnosis and management of pediatric and adolescent varicoceles in Korea. Ten respondents (27%) chose to operate on varicoceles, whereas 9 (24%) chose to observe them, and 18 (49%) decided upon the treatment strategy depending on the clinical situation. ...
... This reflects the fact that laparoscopic surgery has gained popularity in the United States over time. Contrary to the United States survey, in the Korea practice survey, the most common surgical approach for pediatric and adolescent varicocele was subinguinal microsurgical (51%), followed by inguinal (24%), laparoscopic (14%), and open retroperitoneal (Palomo) (11%) [24]. ...
While varicocele is the most common cause of surgically correctable infertility in adult males, with repair resulting in improved
semen parameters in 60% to 80% of men and a higher likelihood of conception in up to 60% of men, the rationale
for varicocele repair in the pediatric population is less clear. Additionally, prepubertal varicoceles are much less common
and their management is controversial. Adolescents with a varicocele are often in the midst of a progressive disease process.
Despite the high prevalence of varicocele and its association with progressive disease processes, the indications for adolescent
varicocele repair and the effects thereof on paternity have been persistently challenging to study. This review will briefly
present some of the current issues regarding adolescent varicocele from a pediatric urological point of view, including the
evaluation of adolescent varicocele, the optimal surgical indications, the optimal choice of surgical intervention to be performed,
and outcomes.
Background
Elimination of varicocele in adolescent with lower complication rates is the best treatment modality. Therefore, the ideal technique should aim to ligate all internal and external spermatic veins with preservation of spermatic arteries and lymphatics.
Aim
We compared the outcome of magnified subinguinal varicocelectomy versus conservative methods in the treatment of adolescent varicocele.
Patients and methods
A total of 40 adolescent males (aged between 15 and 19 years) with refluxing varicocele and affected semen parameters and testicular volume were included. Overall, 20 patients were treated by magnified subinguinal varicocelectomy and 20 patients treated by conservative methods. All patients were reevaluated and followed for 6 months by several semen parameters and changes in testicular size by Doppler ultrasound.
Results
A significant improvement was seen in postmagnified subinguinal varicocelectomy group regarding sperm volume, sperm motility, sperm count, progressive movement, vitality, abnormal morphology, testicular volume, and varicocele grade, but in conservative method group, patients showed significant improvement regarding percent of rapid sperm, progressive movement and vitality, and a slight increase in testicular volume. After 6 months, there was a significant difference between both groups regarding sperm volume, progressive movement, vitality, testicular volume, and varicocele grade, so magnified subinguinal varicocelectomy is superior to conservative methods in the management of adolescents with symptomatic 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.
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.
Introduction:
Testicular volume (TV) can be obtained by either scrotal ultrasound (SU) or orchidometer. Scrotal ultrasound allows for a more objective measurement; however, the interobserver and intra-observer variability of TV measurements has not been rigorously studied.
Objective:
The authors measured intra-observer and interobserver variability of SU TV measurements in pediatric patients to assess the reliability and reproducibility of SU. Special attention was paid to how often a 20% discrepancy in TV was noted as this has previously been utilized as an indication for varicocelectomy.
Design:
Patients with an indication for SU or undergoing an ultrasound for another reason were prospectively recruited. Two different urologic specific ultrasound technicians (A and B) performed SU to assess interobserver variability. A second measurement was taken by technician A within 90 days to assess intra-observer variability (A vs A1). The technicians were blinded to other ultrasound results.
Results:
Fourteen patients (28 testes, 56 volume measurements) were included in the intra-observer group and 17 patients (34 testes, 68 volume measurements) in the interobserver group. The mean time to repeat intra-observer ultrasound measurements (range) was 46 days (23-84). Mean age (range) in the intra-observer group was 14.3 years (11-19) and 14.1 years (11-19) in the interobserver group. Indication for ultrasound was varicocele (n = 6), scrotal pain (4), hydronephrosis (3), hydrocele (2), epididymal cyst (2), posterior urethral valves (1), and testis asymmetry (1). Utilizing Bland-Altman analysis and plots, variability was seen in both intra-observer and interobserver measurements. The mean values for testicular sizes for technician A and technician B were 13.0 ± 9.7 cm3 vs 13.8 ± 9.9 cm3, respectively. The mean values for TV measurement for technician A's first and second measurements (A, A1) were 14.3 ± 9.7 cm3 and 14.8 ± 8.9 cm3, respectively. An errant 20% difference in TV measurements for the same testis was seen in 25% (7 of 28) of intra-observer measurements and 35% (12 of 34) of interobserver measurements. These 20% differences were more common with a lower body mass index (odds ratio, OR = 0.74, p = 0.01) in the interobserver group, and lower TV was a predictor in the intra-observer group (OR: 0.82, p = 0.009).
Conclusions:
Variability exists in both interobserver and intra-observer measurements of TV by dedicated urologic ultrasonographers, and greater than 20% of differences in measured TV in same testicles occurred in over 25% of cases. Caution should be exercised in basing operative decisions and scientific studies on limited measurements of TV.
