Varicocele is not uncommon in children and adolescents. Children with varicose spermatocele make parents very nervous and worried. What kind of disease is varicose spermatozoa? Should it be observed or operated? What is the definitive opinion on varicocele in children and adolescents? The following is an excerpt from the European Association of Urology Guidelines for Pediatric Urology (2014 edition) on “Varicocele in children and adolescents”.
I. Background.
Varicocele is an abnormal dilatation of the trabecular vascular plexus of the testicular veins due to venous reflux. It is uncommon in boys under 10 years of age and becomes more common as they enter adolescence. 14% to 20% of adolescents have varicocele, which is similar to the incidence in adults. It often occurs on the left side (78% to 93%). Varicocele on the right side is less common; it is often found only in bilateral varicocele and rarely occurs on the right side alone.
The reasons why varicocele appears during rapid physical growth and development are not well understood. Because of heat stress, androgen reduction, and the accumulation of toxic substances, varicocele leads to apoptosis (the autonomous, orderly death of cells controlled by genes). 20% of adolescents with varicocele have severe damage, and 46% of patients have abnormal effects. 70% of patients with second- and third-degree varicocele have affected testes on the left side that are smaller. A recent study suggests that the right testicle is also smaller than normal for the same age in patients in late adolescence, and comparing testicular size changes on both sides alone does not necessarily reflect a good testicle.
Some scholars have reported a reversal in testicular development after spermatic vein ligation during adolescence. However, this may be due in part to postoperative lymphatic drainage problems that lead to testicular edema, which may manifest as testicular enlargement.
About 20% of adolescents with varicocele will have fertility problems. Adverse effects increase with time. If the surgery is performed, there is an improvement in various test parameters of the sperm.
II. Diagnosis
Most varicocele is asymptomatic and rarely causes pain at this age. Sometimes it is discovered by the parents or by the child himself, sometimes by the doctor during a routine hospital examination. The diagnosis is based mainly on the clinical examination of the scrotum during standing and the presence of varicose, twisted vein masses, which are more visible during the Valsaval maneuver (deep inhalation followed by breath holding and forceful exhalation).
Varicocele can be classified into 3 grades”
Grade I: the varicose veins can be palpated only during the Valsaval maneuver (deep inspiration followed by breath holding and forceful exhalation).
Grade II: the varicose veins can be palpated
Grade III: the varicose vein can be seen.
The testicular size should be palpated at the same time during the examination to see if it is accompanied by a smaller testicle.
Venous reflux into the trabecular plexus can be visualized by ultrasound Doppler in both the lying and standing positions. The ultrasound should include testicular volume to describe the presence of testicular hypoplasia. In adolescents, a decrease in testicular volume greater than 2 ml or 20% compared to another testicle is considered testicular hypoplasia.
III. Treatment
Surgical intervention is based on the ligation or embolization of the spermatic veins. Ligation is performed at different levels.
Ligation by trans-inguinal (or sub-inguinal) microscopic technique.
supra-inguinal, open or laparoscopic techniques of ligation.
The advantage of the former is that the procedure is less invasive; the advantage of the latter is that fewer veins need to be ligated and that the spermatic artery has accessory branches on the groin, which is safer (translator’s note: testicular atrophy rarely occurs when the testicular artery is ligated together on the groin).
Some form of magnification (microscope or laparoscope) should be used during the ligation procedure because the diameter of the internal spermatic artery at the level of the internal ring is 0.5 mm. the recurrence rate is often less than 10%.
Spermatic cord vein ligation with preservation of the lymphatics is performed to prevent syringomyelia formation and testicular hyperplasia formation and to achieve better testicular function. Methods include subinguinal or transinguinal microscopic, or supra-inguinal open or laparoscopic lymphovascular preservation procedures. Angiographic intravesical vein embolization can also meet these requirements; it injects sclerosing agents into the intravesical vein either retrograde or cascade. However, although this approach is less invasive and may not require general anesthesia, it requires exposure to radiation and has poor technical controllability. Available data suggest that surgical failure is mainly due to anatomic failure to achieve the desired vascularity and recurrence.
There is no evidence that surgery in childhood or adolescence will have better treatment outcomes from a male perspective than surgery at a later date. The recommended indications for surgery for spermatic cord ligation in childhood and adolescence include.
1. varicocele with poor testicular development.
2. a condition of the testes that interferes with fertility
3. bilaterally palpable varicocele.
4, pathological changes in semen quality (in older adolescent patients).
5. symptomatic varicocele.
When once appropriate normal testicular data are available, the value of testicular (left + right) volume reduction should be a promising indicator by comparison with normal testes.
Surgical treatment may also be considered when the varicocele is relatively large and causes physical or psychological discomfort. Other varicocele should be observed until reliable semen analysis can be performed.
IV. Conclusions and recommendations
Varicocele becomes common as we enter adolescence, with approximately 14% to 20% of adolescents having varicocele and 20% of them will affect fertility.
Varicocele is examined in the standing position and is classified into 3 levels. Ultrasound Doppler in the prone and standing positions can diagnose venous reflux. Up to 70% of patients with grade II and III varicocele have a smaller volume in the left testicle, and perhaps also in the contralateral right testicle in late adolescence.
Recommendations.
(i) Surgery is recommended in the following cases.
1. varicocele with poor testicular development.
(2) The condition of the testes affecting fertility.
3. bilaterally palpable varicose veins of the spermatocele.
4, pathological changes in semen quality (in older adolescent patients)
5, symptomatic varicocele.
(ii) Some form of magnification equipment (microscope or laparoscope) should be used when performing surgical ligation.
(iii) Ligation of the spermatic veins with preservation of the lymphatics may prevent the occurrence of syringomyelia and testicular hyperplasia.