Abstract
The primary indication for varicocele repair in adults, that of failed paternity, must be substituted in the adolescent population with surrogate parameters of testicular size differential and semen analysis. Making recommendations based on these two parameters is incredibly difficult because studies often have contradictory findings, different patient populations, and lack of long-term follow up of the key endpoint, paternity. Therefore, it is not a surprise that recommendations for adolescent varicocele repair are general (with some exceptions) and necessarily so because of limitations in quality of evidence. Apart from pain, all indications for varicocele repair in adolescence remain controversial. This highlights the most important task for future studies: to prevent pediatric urologists from allowing a potentially damaging process to go untreated, while at the same time avoiding unnecessary intervention on a highly prevalent condition.
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Papavramidou NS, Christopoulou-Aletras H. Treatment of "hernia" in the writings of Celsus (first century AD). World J Surg. 2005;29(10):1343–7.
Noske HD, Weidner W. Varicocele—a historical perspective. World J Urol. 1999;17(3):151–7.
Kendirci M, Kadioglu A, Boylu U, Miroglu C. Urogenital surgery of the 15th century in Anatolia. J Urol. 2005;173(6):1879–82.
Tulloch WS. Varicocele in subfertility; results of treatment. Br Med J. 1955;2(4935):356–8.
• Roque M, Esteves SC. A systematic review of clinical practice guidelines and best practice statements for the diagnosis and management of varicocele in children and adolescents. Asian J Androl. 2016;18(2):262–8. This review illustrates the rather general recommendations from different organizations and guidelines around the world.
Alsaikhan B, Alrabeeah K, Delouya G, Zini A. Epidemiology of varicocele. Asian J Androl. 2016;18(2):179–81.
Oster J. Varicocele in children and adolescents. An investigation of the incidence among Danish school children. Scand J Urol Nephrol. 1971;5(1):27–32.
Shridharani A, Lockwood G, Sandlow J. Varicocelectomy in the treatment of testicular pain: a review. Curr Opin Urol. 2012;22(6):499–506.
Han DY, Yang QY, Chen X, et al. Who will benefit from surgical repair for painful varicocele: a meta-analysis. Int Urol Nephrol. 2016;48(7):1071–8.
The influence of varicocele on parameters of fertility in a large group of men presenting to infertility clinics. World Health Organization. Fertil Steril. 1992;57(6):1289–1293.
•• Bogaert G, Orye C, De Win G. Pubertal screening and treatment for varicocele do not improve chance of paternity as adult. J Urol. 2013;189(6):2298–303. This study provides the only available data on paternity in adolescent varicocele patients. A good example of the type of longitudinal data we need more of.
Vanlangenhove P, Dhondt E, Van Maele G, Van Waesberghe S, Delanghe E, Defreyne L. Internal spermatic vein insufficiency in varicoceles: a different entity in adults and adolescents? AJR Am J Roentgenol. 2015;205(3):667–75.
Jargiello T, Drelich-Zbroja A, Falkowski A, Sojka M, Pyra K, Szczerbo-Trojanowska M. Endovascular transcatheter embolization of recurrent postsurgical varicocele: anatomic reasons for surgical failure. Acta Radiol. 2015;56(1):63–9.
Tilki D, Kilic E, Tauber R, et al. The complex structure of the smooth muscle layer of spermatic veins and its potential role in the development of varicocele testis. Eur Urol. 2007;51(5):1402–9. discussion 1410
Durairajanayagam D, Agarwal A, Ong C. Causes, effects and molecular mechanisms of testicular heat stress. Reprod BioMed Online. 2015;30(1):14–27.
Thonneau P, Bujan L, Multigner L, Mieusset R. Occupational heat exposure and male fertility: a review. Hum Reprod. 1998;13(8):2122–5.
Goldstein M, Eid JF. Elevation of intratesticular and scrotal skin surface temperature in men with varicocele. J Urol. 1989;142(3):743–5.
Mieusset R, Bujan L. Testicular heating and its possible contributions to male infertility: a review. Int J Androl. 1995;18(4):169–84.
Kanter M, Aktas C. Effects of scrotal hyperthermia on Leydig cells in long-term: a histological, immunohistochemical and ultrastructural study in rats. J Mol Histol. 2009;40(2):123–30.
Romeo C, Santoro G. Free radicals in adolescent varicocele testis. Oxidative Med Cell Longev. 2014;2014:912878.
Abrol N, Panda A, Kekre NS. Painful varicoceles: role of varicocelectomy. Indian J Urol. 2014;30(4):369–73.
Kroese AC, de Lange NM, Collins J, Evers JL. Surgery or embolization for varicoceles in subfertile men. Cochrane Database Syst Rev. 2012;10:CD000479.
Abdel-Meguid TA, Al-Sayyad A, Tayib A, Farsi HM. Does varicocele repair improve male infertility? An evidence-based perspective from a randomized, controlled trial. Eur Urol. 2011;59(3):455–61.
Chiba K, Fujisawa M. Clinical outcomes of varicocele repair in infertile men: a review. World J Mens Health. 2016;34(2):101–9.
British Medical A, Levy A, British MA. Consent, rights, and choices in health care for children and young people. London: BMJ Books; 2001.
Alkaram A, McCullough A. Varicocele and its effect on testosterone: implications for the adolescent. Transl Androl Urol. 2014;3(4):413–7.
Goede J, Hack WW, Sijstermans K, et al. Normative values for testicular volume measured by ultrasonography in a normal population from infancy to adolescence. Horm Res Paediatr. 2011;76(1):56–64.
Kass EJ, Stork BR, Steinert BW. Varicocele in adolescence induces left and right testicular volume loss. BJU Int. 2001;87(6):499–501.
Paltiel HJ, Diamond DA, Di Canzio J, Zurakowski D, Borer JG, Atala A. Testicular volume: comparison of orchidometer and US measurements in dogs. Radiology. 2002;222(1):114–9.
Diamond DA, Zurakowski D, Bauer SB, et al. Relationship of varicocele grade and testicular hypotrophy to semen parameters in adolescents. J Urol. 2007;178(4 Pt 2):1584–8.
Christman MS, Zderic SA, Canning DA, Kolon TF. Active surveillance of the adolescent with varicocele: predicting semen outcomes from ultrasound. J Urol. 2014;191(5):1401–6.
Kurtz MP, Zurakowski D, Rosoklija I, et al. Semen parameters in adolescents with varicocele: association with testis volume differential and total testis volume. J Urol. 2015;193(5 Suppl):1843–7.
Chu DI, Zderic SA, Shukla AR, et al. The natural history of semen parameters in untreated asymptomatic adolescent varicocele patients: a retrospective cohort study. J Pediatr Urol. 2016; doi:10.1016/j.jpurol.2016.09.008.
Kolon TF, Clement MR, Cartwright L, et al. Transient asynchronous testicular growth in adolescent males with a varicocele. J Urol. 2008;180(3):1111–4. discussion 1114-1115
Khasnavis S, Kogan BA. Natural history of testicular size in boys with varicoceles. J Pediatr Urol. 2015;11(3):148 e141–5.
Seimens Medical Solutions USA I. Acuson Sequoia Ultrasound Systems User Manuel. 2006.
Kurtz MP, Migliozzi M, Rosoklija I, Zurakowski D, Diamond DA. Accuracy of orchidometry in boys with varicocele. J Pediatr Urol. 2015; doi:10.1016/j.jpurol.2015.02.011.
Diamond DA, Kurtz MP. Re: Evaluation and Management of the Adolescent Varicocele: T. F. Kolon J Urol 2015; 194: 1194–1201. J Urol. 2016;195(4 Pt 1):1173–1175.
Christman MS, Zderic SA, Kolon TF. Comparison of testicular volume differential calculations in adolescents with varicoceles. J Pediatr Urol. 2014;10(2):396–8.
Li F, Chiba K, Yamaguchi K, et al. Effect of varicocelectomy on testicular volume in children and adolescents: a meta-analysis. Urology. 2012;79(6):1340–5.
Spinelli C, Di Giacomo M, Lo Piccolo R, Martin A, Messineo A. The role of testicular volume in adolescents with varicocele: the better way and time of surgical treatment. J Urol. 2010;184(4 Suppl):1722–6.
Kocvara R, Dolezal J, Hampl R, et al. Division of lymphatic vessels at varicocelectomy leads to testicular oedema and decline in testicular function according to the LH-RH analogue stimulation test. Eur Urol. 2003;43(4):430–5.
Cooper TG, Noonan E, von Eckardstein S, et al. World Health Organization reference values for human semen characteristics. Hum Reprod Update. 2010;16(3):231–45.
Janczewski Z, Bablok L. Semen characteristics in pubertal boys. III. Semen quality and somatosexual development. Arch Androl. 1985;15(2–3):213–8.
Keene DJ, Fitzgerald CT, Cervellione RM. Sperm concentration and forward motility are not correlated with age in adolescents with an idiopathic varicocele and symmetrical testicular volumes. J Pediatr Surg. 2016;51(2):293–5.
Keene DJ, Sajad Y, Rakoczy G, Cervellione RM. Testicular volume and semen parameters in patients aged 12 to 17 years with idiopathic varicocele. J Pediatr Surg. 2012;47(2):383–5.
Mori MM, Bertolla RP, Fraietta R, Ortiz V, Cedenho AP. Does varicocele grade determine extent of alteration to spermatogenesis in adolescents? Fertil Steril. 2008;90(5):1769–73.
Hamilton JA, Cissen M, Brandes M, et al. Total motile sperm count: a better indicator for the severity of male factor infertility than the WHO sperm classification system. Hum Reprod. 2015;30(5):1110–21.
Fine RG, Gitlin J, Reda EF, Palmer LS. Barriers to use of semen analysis in the adolescent with a varicocele: survey of patient, parental, and practitioner attitudes. J Pediatr Urol. 2016;12(1):41 e41–6.
Coutinho K, McLeod D, Stensland K, Stock JA. Variations in the management of asymptomatic adolescent grade 2 or 3 left varicoceles: a survey of practitioners. J Pediatr Urol. 2014;10(3):430–4.
Pastuszak AW, Kumar V, Shah A, Roth DR. Diagnostic and management approaches to pediatric and adolescent varicocele: a survey of pediatric urologists. Urology. 2014;84(2):450–5.
Ku JH, Kim SW, Park K, Paick JS. Benefits of microsurgical repair of adolescent varicocele: comparison of semen parameters in fertile and infertile adults with varicocele. Urology. 2005;65(3):554–8.
• Chu DI, Zderic SA, Shukla AR, et al. Does varicocelectomy improve semen analysis outcomes in adolescents without testicular asymmetry? J Pediatr Urol. 2016. The studies by Chu et al. demonstrate the importance to better understand the role of SA in the picture of varicocele pathophysiology: while over 80% of patients had improved TMC postoperatively, only half of patients achieved a normal TMC with repair while in the same cohort spontaneous improvement to normal TMC without repair does also exist.
Yaman O, Ozdiler E, Anafarta K, Gogus O. Effect of microsurgical subinguinal varicocele ligation to treat pain. Urology. 2000;55(1):107–8.
Chen SS. Factors predicting symptomatic relief by varicocelectomy in patients with normospermia and painful varicocele nonresponsive to conservative treatment. Urology. 2012;80(3):585–9.
Park HJ, Lee SS, Park NC. Predictors of pain resolution after varicocelectomy for painful varicocele. Asian J Androl. 2011;13(5):754–8.
Konforte D, Shea JL, Kyriakopoulou L, et al. Complex biological pattern of fertility hormones in children and adolescents: a study of healthy children from the CALIPER cohort and establishment of pediatric reference intervals. Clin Chem. 2013;59(8):1215–27.
Li F, Yue H, Yamaguchi K, et al. Effect of surgical repair on testosterone production in infertile men with varicocele: a meta-analysis. Int J Urol. 2012;19(2):149–54.
Hanna GB, Byrne D, Townell N. Right-sided varicocele as a presentation of right renal tumours. Br J Urol. 1995;75(6):798–9.
Wilms G, Oyen R, Casselman J, Peene P, Steeno O, Baert AL. Solitary or predominantly right-sided varicocele: a possible sign of situs inversus. Urol Radiol. 1988;9(4):243–6.
Meij-de Vries A, den Bakker FM, van der Wolf-de Lijster FS, Meijer RW, Goede J, Heij HA. High prevalence of intratesticular varicocele in a post-orchidopexy cohort. J Pediatr Urol. 2013;9(3):328–33.
Woldu SL, Van Batavia JP, Poon SA, Raimondi PM, Glassberg KI. Is adolescent varicocelectomy safe after previous inguinal surgery? J Urol. 2010;184(4 Suppl):1716–21.
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Bryan S. Sack, Mattias Schäfer, and Michael P. Kurtz each declare no potential conflicts of interest.
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Sack, B.S., Schäfer, M. & Kurtz, M.P. The Dilemma of Adolescent Varicoceles: Do They Really Have to Be Repaired?. Curr Urol Rep 18, 38 (2017). https://doi.org/10.1007/s11934-017-0686-7
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DOI: https://doi.org/10.1007/s11934-017-0686-7