If one day, male compatriots find themselves with a vague feeling of swelling in the testicles, which is aggravated by standing and relieved by lying down at rest, then beware of the possibility of varicose spermatocele. Varicocele is relatively uncommon in boys before the age of 10, but the prevalence increases to 8-16% during adolescence. 15-19 year olds have a prevalence of varicocele of about 15%, which is comparable to that of the entire adult male population.
Professor Kolon from the Perelman School of Medicine at the University of Pennsylvania has analyzed the literature from Embase, PubMed, and Google Scholar to provide a systematic review of the diagnosis and treatment of adolescent varicocele.
Early diagnosis
Commonly used indicators to evaluate reproductive function are: varicocele score, testicular volume measurement, spermatozoal ultrasound, hormone level measurement, and semen analysis. In adults, abnormal results of hormone level measurement and semen analysis indicate more serious lesions in the testes, and are generally not an early diagnostic option for adolescents who are still developing.
Varicocele is scored in three levels: level 1, where the varicose veins can be palpated with increased abdominal pressure, level 2, where the varicose veins can be palpated when standing, and level 3, where the varicose veins are visible when standing. However, studies have shown that there is no significant correlation between this and abnormal testicular development and it is not used as an indicator for surgical repair.
Testicular volume measurement is considered by many physicians as an indicator to assess spermatogenesis. Some patients who have undergone varicocele repair have experienced some recovery of testicular atrophy, suggesting a link between varicocele and testicular volume abnormalities.
Paltiel et al. found that ultrasound measurements were more accurate than testicular measurements and that the more accurate algorithm was volume = long diameter x short diameter x deep diameter x 0.71 (Lambert formula). However, there is some subjective error in ultrasound testicular measurements.
The urologist may consider a combination of measurements to be used, but it is important to note that the data from any single measurement should not be used as a reference for judging surgical treatment. It is extremely important to note that in adolescents, continuous measurement of testicular volume at multiple time points throughout adolescence can provide extremely clinically relevant data.
Indications for surgery
The management of adolescent patients with varicocele has been controversial. Although early repair of varicocele may prevent infertility, most patients do not become infertile because of varicocele. If all such patients were treated with surgical repair, a large number of patients would be included who do not require surgery, resulting in a waste of medical resources. Only with validated inclusion criteria can varicocele repair be properly practiced in the clinical setting.
Many studies have discussed the selection of inclusion criteria from different perspectives. Some surgeons consider a difference in testicular volume of more than 10% (or 20%) between the two sides to require surgical treatment, but some studies have shown that nearly 80% of patients with such differences resolve spontaneously without surgical treatment later.
There is a correlation between testicular volume loss and abnormal semen analysis, and Paduch et al. found that patients with a varicocele score of 2 to 3 had poorer semen quality and higher levels of venous reflux and testicular atrophy. It is important to note that the standard grading of semen analysis in adolescents differs from the WHO standards for adults. Patients with abnormal testicular volumes and small total testicular volumes measured prior to semen analysis have a higher risk of abnormalities.
Although endocrine disorders have been suggested in some patients, there is no consensus that tests including luteinizing hormone (LH), follicle-stimulating hormone (FSH), testosterone, inhibin B, and anti-mullerian hormone (AMH) are relevant only for adult disease assessment.
The American Urological Association Committee on Optimal Decision Making in Male Infertility and the Practice Committee of the American Society for Reproductive Medicine gave four inclusion criteria, but all were applicable for adults. Adolescent varicocele repair should be considered only in the presence of objective testicular volume loss. The European Association of Urology has recently given several references for varicocele, which include the adolescent population.
Treatment should only be used in patients with clinically proven testicular developmental abnormalities; infertile patients with no evidence of normal semen analysis or infertile patients without clinical signs of varicocele who have benefited from treatment of varicocele; and only in patients with clinical signs of varicocele, spermopenia, infertility for more than 2 years, or other unexplained infertility, should spermatic varicose vein repair.
Commonly used procedures and complications
There are many surgical options for varicocelectomy, including transabdominal, retroperitoneal, inguinal microscopic, and laparoscopic routes for arteriovenous ligation and resection and flow restriction. Arteriovenous embolization and sclerotherapy are not surgical treatment options.
The choice of surgical treatment depends on its ability to reverse testicular atrophy and abnormalities in semen composition in adolescent patients with varicocele. Several studies have concluded that surgical treatment can improve the patient’s semen analysis to varying degrees, gradually restoring testicular volume and benefiting the patient in terms of fertility. Thus, there is sufficient evidence to support surgical treatment in patients who meet the aforementioned guidelines.
The main complications of varicocelectomy include syringomyelia, treatment failure or recurrence of the condition, and testicular atrophy.
Syringomyelia most often occurs in patients who have had non-microsurgical procedures, most often due to inadvertent ligation of the associated lymphatic vessels during surgery. The surgical microscope allows the surgeon to clearly separate the inguinal lymphatic vessels and arterioles, greatly avoiding inadvertent ligation.
Treatment failure or recurrence of the disease is mainly related to the operator’s level of surgical operation and the use of the surgical microscope. It is recommended that the surgical operator perform tissue separation from below the inguinal canal, which provides a good operational view and a path for vein ligation.
Injury or ligation of the testicular artery can cause testicular atrophy and damage to the spermatogenic epithelium. Surgical microscopy, laparoscopic magnification imaging techniques, and intraoperative Doppler measurements can prevent arterial injury. If the testicular artery is inadvertently ligated, most of the blood supply to the testis is then provided by the vas deferens artery, and the patient needs to be informed of the risk of testicular atrophy in the event of a future vasectomy.
The incidence of postoperative complications is lowest for both adults and adolescents with subinguinal microseminomegaly. The advantages of microsurgical repair over open and laparoscopic surgery are even more pronounced and can improve semen quality while reducing the incidence of syringomyelia and varicocele recurrence rates.
Other treatments
Although most physicians recommend surgical options, percutaneous spermatic vein embolization remains a well-tolerated and cost-effective treatment. Studies have shown that its treatment can increase sperm concentration, activity and improve sperm morphology, but does not alter the patient’s endocrine status. There is a high incidence of complications such as syringomyelia and a risk of radiological damage.
Prognosis
The goal of treatment of varicocele is to achieve fertility success. While treatment during adolescence, ultimate fertility is not obtained until they reach adulthood. Several studies have demonstrated a high rate of spontaneous pregnancy and a low likelihood of recurrence after microsurgical varicocelectomy, and META analysis confirms this conclusion.
Some investigators have proposed to study the endocrine profile of patients before and after surgery. Some studies have shown some increase in testosterone levels and increased responsiveness of FSH regulated by GnRH in postoperative patients. However, most of the studies on endocrine levels have been performed in adults, and the levels of hormonal changes in adolescent patients before and after surgery have yet to be studied.