Guidelines for the management of adolescent varicocele: 2015 Edition EUA Pediatric Urology Varicocele is rare in children under 10 years of age; the incidence increases from prepubescence onwards and is 14-20% in adolescents, similar to that of adults. They occur mainly on the left side (78-93%); lesions on the right side are uncommon and rarely occur alone, but usually coexist with the left side.
The mechanism of the increased incidence of the disease in children and adolescents during a period of rapid physical growth and increased blood supply to the testes is unknown. Apoptosis of testicular germ cells is caused by increased local temperature, androgen deficiency, and accumulation of toxic substances in the blood.
Twenty percent of children have more severe testicular damage, while 46% have no testicular abnormalities. The pathological damage to the testis is similar in children and adults. In grade 2-3 varicocele, more than 70% have left testicular hypoplasia. About 20% of children with fertility problems have progressively more testicular damage.
Several reports suggest a rapid “catch-up” development of the testis after spermatic vein surgery, with 76.4% (52.6-93.8%) having testicular enlargement. The reason for this may also be related to postoperative testicular lymphedema.
Semen quality may improve after surgery.
Varicocele is classified into 3 grades.
Grade 1 Invisible, palpable varicose veins only in the Valsalva manoeuvre).
Grade 2 varicose veins are not visible and can be palpated without Valsalva maneuvers.
Grade 3: The varicose veins are directly visible.
（Note
Valsalva maneuver: deep inspiration followed by breath-holding and forceful exhalation for 10-15 seconds, which increases intrathoracic pressure and significantly reduces venous reflux).
Diagnosis
It is usually detected during a routine physical examination of the child, his parents or physician. Most children are asymptomatic and rarely have pain. A dilated trapezius varicose vein plexus may be present in the standing position. The varicosities are more pronounced with the Valsalva maneuver. The size of the testes should be compared bilaterally.
Using color Doppler ultrasound flowmetry, blood reflux in the trapezius plexus of the spermatic cord can be detected in the standing and supine positions. If there are no abnormal clinical findings and the ultrasound shows only blood reflux, subclinical type of varicocele is considered. The testicular volume is assessed using ultrasound or molds to clarify the presence of testicular hypoplasia, which is defined as a 2 ml or 20% reduction in the affected testicle compared to the healthy side in adolescents. grade 2.
In children with Wilms’ tumor, secondary varicocele can occur when the tumor embolus enters the renal vein and inferior vena cava. If the child has a right spermatic varicocele alone, the renal vein should be routinely examined. grade 4.
A luteinizing hormone-releasing hormone (LHRH) stimulation test should be applied to assess the degree of testicular damage. If follicle cell stimulating hormone (FSH) and luteinizing hormone are abnormally high, this suggests histopathologic damage to the testis.
Treatment
Internal spermatic vein ligation procedure.
1, inguinal or subinguinal microscopic technique, with the advantage of lesser damage.
2, Superior inguinal level (high), open or laparoscopic procedure. Characterized by less ligation of branch veins and higher safety.
Apply optical magnification (microscopic or laparoscopic) to the procedure to facilitate identification of the internal spermatic artery in the lesser spermatic cord: just 0.5 mm in diameter at the internal ring.
Aim to preserve the lymphatics to stop the development of testicular edema and syringomyelia and to increase the testicular response to LHRH stimulation and improve function. grade 2.
Recurrence rate < 10%.
Retrograde or paracrine vascular sclerosis
Internal spermatic vein infarction can also be treated and is more minimally invasive, without general anesthesia. However, the radiation load has to be considered; the amount of radiation is higher with a paralleling approach. Anomalies in the anatomic structure can affect the success rate and make it more likely to lead to postoperative recurrence. level 2
Recommended indications for surgery in adolescent children.
1. small testes associated with varicocele.
2, coexistence of other lesions in the testes that affect fertility.
3, bilaterally palpable varicocele.
4, abnormal semen (late adolescence).
5.Significant symptoms.
Secondary bilateral testicular dysplasia, or varicocele obviously affects the physical and mental health of the child, all need to consider surgery.
For other children, follow up to the appropriate age and perform semen examination if necessary before determining the next step. (Grade 4). Current data do not support early surgery.
Conclusions and recommendations
Varicocele is more common in early adolescence, with an incidence of 14-20% in adolescents. Of these, 20% of affected children face fertility problems.
The lesions were classified into 3 grades based on the findings of the standing physical examination. In children with grade 2-3 varicose veins, more than 70% have left-sided testicular hypoplasia; the right testicle is also affected in late adolescence.
Indications for surgery (2, B).
1. testicular hypoplasia due to varicocele.
2, coexistence of other testicular pathologies that affect fertility.
3, abnormal semen (late adolescence).
4, bilaterally palpable varicocele.
5.Significant symptoms.
It is recommended to perform a more delicate surgery using microscopic magnification or laparoscopic magnification.2 , B
Preservation of lymphatic reflux to stop testicular syringomyelia and testicular edema.2 , A