Testicular asymmetry and adolescent varicoceles managed expectantly.
ABSTRACT Adolescent varicocele is often associated with testicular asymmetry. Depending on the degree of asymmetry, some physicians will recommend surgery. However, given the possibility that asynchronous growth may be transient, others advocate for a period of observation. We reviewed our outcomes in such patients who were initially treated expectantly.
We retrospectively reviewed our pediatric varicocele database. We analyzed the outcomes of patients presenting for evaluation of varicocele who were followed with serial testicular volume measurements using scrotal ultrasound or ring orchidometry and who had at least a 6-month interval between measurements. Fisher's exact test was used to compare groups based on initial and final testicular asymmetry.
We identified 181 patients (median age 13.8 years) who were followed expectantly. Serial volume measurements had been obtained at a median interval of 12 months (interquartile range 8 to 21) between first and most recent visits. Mean percent asymmetry for the group did not change with time. Among patients who initially had less than 20% asymmetry 35% had 20% or greater asymmetry on followup, and among those with 20% or greater asymmetry initially 53% remained in that range (p = 0.007).
Asymmetry can be a transient phenomenon. Patients with initial asymmetry can end up with significant asymmetry, and many with significant asymmetry can have catch-up growth. However, when patients have a peak retrograde flow of 38 cm per second or greater on duplex Doppler ultrasound in association with 20% or greater asymmetry spontaneous catch-up growth is unlikely to occur.
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ABSTRACT: The aim of this study was to report our long-term diagnostic and surgical outcome during the last 18 years, in paediatric and adolescent management of varicocoele. The present retrospective study enrols 374 patients observed at our institution between 1994 and 2011. Patients were divided into three groups: Group A includes 142 youngsters and adolescents treated with open surgery for left varicocoele, in which a pre-operative CDUS was not performed; Group B includes 65 patients treated with open surgery in which a pre-operative CDUS evaluation was carried out, to assess varicocoele haemodynamic pattern and testicular volume. Group C includes 167 patients treated by laparoscopy and with pre-operative CDUS assessment. For all groups post-operative follow-up consisted of CDUS evaluation performed 1, 3, 6, 12 months after surgical treatment, than every year. Persistence/recurrence of varicocoele, testicular volume and presence of hydrocele were evaluated. Recurrence rate was significatively higher in group A (11.2%) than B (no recurrence, p = 0.003) or C (no recurrence, p = 0.000). Post-operative hydrocele was not significantly observed overall in group A in 9.8% of cases (13% if tunica vaginalis was left untouched, 4.2% if everted or resected p = 0.005), in group B in 3% and in group C in 7.1% of cases (p = NS). In conclusion, open and laparoscopic surgery offers similar results. In our opinion, the key-point in paediatric and adolescent varicocoele is not the surgical approach to use, but the exact diagnosis. Careful CDUS evaluation is, in our opinion, a valid, safe, cost-effective and immediate tool to accurately detect all refluxing venous system and for achieving a comprehensive evaluation of the vascular anatomy of varicocoele in paediatric and adolescent age. Laparoscopic Palomo or open subinguinal microsurgical varicocelectomy offer similar results in terms of recurrence; meanwhile the use of a lymphatic sparing surgery with or without blue-dye is recommended to reduce post-operative hydroceles.International Journal of Andrology 06/2012; 35(5):700-5. · 3.37 Impact Factor
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ABSTRACT: The prevalence of varicocoeles is 15% in the general adolescent and adult male population and in 35-40% of men evaluated for infertility. While varicocelectomy can be performed using various methods and techniques, the laparoscopic approach allows for clear visualization of the testicular artery and lymphatics. Amongst urologists, particularly paediatric urologists, and andrologists there is much debate regarding the significance of testicular artery sparing when performing a varicocelectomy, with some believing that ligating the testicular artery impairs catch-up growth and future fertility. On the other hand, several studies have reported higher failure rates with artery preservation. To help resolve the debate regarding the significance of artery sparing, we sought to compare varicocoele recurrence rate and catch-up growth in patients who underwent artery sparing laparoscopic varicocelectomy compared with those who had the artery sacrificed. We identified 524 laparoscopic varicocelectomies in 425 patients from our adolescent varicocoele database. Only patients who had ultrasound determined testicular volume measurements pre-operatively and at least 6 months post-operatively were included. Post-operative persistence/recurrence of varicocoele, testicular atrophy and repeat varicocelectomy were noted. Catch-up growth was compared between procedures in those with significant pre-operative asymmetry. Four hundred and forty primary laparoscopic varicocelectomies were performed in 355 patients (mean age: 15.5 years, range 9.3-20.6; mean follow-up: 32.9 months, range 6.0-128.9) who had both pre- and post-varicocelectomy scrotal Duplex Doppler ultrasound performed. The testicular artery was preserved in 54 varicocoeles (41 patients) and ligated in 384 varicocoeles (312 patients). We observed an increased rate of persistent/recurrent varicocoele in the artery-sparing vs. artery ligating patients (12.2% vs. 5.4%, p = 0.09). In addition, there was no difference in catch-up growth and no instance of testicular atrophy. As artery sparing varicocelectomy offered no advantage in regards to catch-up growth and was associated with a higher incidence of recurrent varicocoele, preservation of the artery does not appear to be routinely necessary in adolescent varicocelectomy.Andrology 12/2013; · 3.37 Impact Factor
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ABSTRACT: INTRODUCTION: Part of the management of adolescents with a varicocele is trying to prognosticate who with testicular asymmetry will have CUG with observation and who will have persistent asymmetry. We previously reported that CUG is rare when PRF ≥38cm/sec is associated with ≥20% asymmetry (ie, the "20/38" harbinger). We sought to determine if this 20/38 cut-off held true with a larger series and what PRF value should be used when 15% instead of 20% asymmetry was chosen as the cut-off. METHODS: Patients from our larger varicocele registry who had at least 2 DDUS evaluations with ≥10month period of observation in between were analyzed. Outcomes were determined as regards those who met the 20/38 cut-off and what PRF value could be used to recommend surgery when 15-19.9% asymmetry is included in the asymmetry cut-off value. RESULTS: Of 355 adolescent boys with left varicocele, 44 (mean age 14.0years, range 9-20) were followed with observation initially and met the 20/38 cut-off, while another 9 met the 15/38 cutoff (initial asymmetry 15-19.9%). When combining both groups, only 3 boys had CUG to <15% on follow-up. Thus, 50 of 53 patients did not demonstrate CUG after mean follow-up of 15.5 months (range 10-44). CONCLUSION: Not only does a PRF of ≥38cm/sec hold up for predicting persistent/worsening asymmetry when combined with a 20% asymmetry cut-off, it also is an excellent predictor of persistent and/or worsening asymmetry when combined with a 15% asymmetry cut-off. Therefore, it might be unnecessary to follow an adolescent boy with observation when at or above this 15/38 cut-off.The Journal of urology 11/2012; · 4.02 Impact Factor