What's New in Adolescent Varicocele?

Sungchan ParkKorea (Republic of) Speaker What's New in Adolescent Varicocele?Varicocele is defined as an abnormal dilatation of testicular veins in the pampiniformis plexus caused by venous reflux. It is unusual in boys under ten years of age and becomes more frequent at the beginning of puberty. It is found in 14-20% of adolescents, with a similar incidence during adulthood. In 70% of patients with grade II and III varicocele, left testicular volume loss was found. Abnormal reproductive hormonal levels (increased serum levels of FSH and LH, and decreased levels of inhibin B) and semen quality were reported in varicocele patients and were directly related to varicocele severity. In about 20% of adolescents with varicocele, fertility problems will arise. The adverse influence of varicocele increases with time. Surgical indications 1. The recommended indication criteria for varicocelectomy in children and adolescents - varicocele associated with a small testis (volume difference > 20%) This should be confirmed on two subsequent visits six months apart 2. Additional treatment can be considered on a case by case - additional testicular condition affecting fertility - bilateral palpable varicocele - pathological sperm quality (in older adolescents) - symptomatic varicocele (pain, 2-10%) - cosmetic reasons related to scrotal swelling - Repair of a large varicocele, causing physical or psychological discomfort, may also be considered. --> Other varicoceles should be followed-up until a reliable sperm analysis can be performed. Natural progression of testicular growth Surgical treatment Based on ligation or occlusion of the internal spermatic artery. Ligation is performed at different levels. - inguinal (or subinguinal) approach with or without microsurgical or macroscopic (loupe) assistance - suprainguinal ligation, using open or laparoscopic techniques (few report using robotic system) - Sclerosing therapy using retrograde or antegrade approach. For surgical ligation, some form of optical magnification (microscopic or laparoscopic) should be used because the internal spermatic artery is 0.5 mm in diameter at the level of the internal ring. In supra-inguinal approach, an artery sparing varicocelectomy may not offer any advantage in regards to catch-up growth and is associated with a higher incidence of recurrent varicocele. The success rates of the treatment (disappearance of varicocele) were between 85.1% and 100%. Whereas the complication rates were between 0% and 29% in the included studies. The most common complication reported was hydrocele. Resolution of pain after treatment was more than 90% in the reported series.