Research Signpost 37/661 (2), Fort P.O. Trivandrum-695 023 Kerala, India

Essentials in Pediatric Urology, 2012: 21-26 ISBN: 978-81-308-0511-5 Editor: George Sakellaris

3. Adolescent varicocele Dimitris Antoniou and Fotini Gentimi Department of Pediatric Surgery, “Aghia Sophia” Children’s Hospital, Athens, Greece

Definition Varicocele is an abnormal dilatation of the pampiniform plexus composed of the testicular veins of the spermatic cord which drain blood from the testes, epididymis and vas deferens. Although the cremasteric and the deferential vein also drain blood from the testicle, they are rarely involved in the varicocele process. In 1980, Coolsaet described three types of venous reflux: type 1occurs only in the internal spermatic vein, type 2- in the extrafunicular veins draining into the iliac vein (cremasteric, deferential, external pudendal), type 3- in both systems1.

Incidence The incidence of varicocele isestimated to be approximately 6% in 10-year old boys and 15% in 13-year old adolescent males, similar to that reported for thegeneral male population (15-20%). It is most frequently diagnosed among patients 15-30 years old, and is extremely rarein children younger than 5 years. Varicocele is considered one of the leading causes of male infertility and is usually detected in the subfertile male population (40%) 2, 3, 4. Correspondence/Reprint request: Dr. Dimitris Antoniou, Department of Pediatric Surgery, “Aghia Sophia” Children’s Hospital, Athens, Greece.

22

Dimitris Antoniou & Fotini Gentimi

Etiology The etiology of varicocele is unknown; various theories have been proposed to explain the fact that more than 90% of varicoceles are left-sided. The cause seems to be multifactorial, implicating several anatomic factors such as (1) the absence of antireflux valves at the juncture of the testicular and renal vein. These valves normally prevent the retrograde flow of blood in the upright position, (2) the right angle at which the left testicular vein inserts into the left renal vein, predisposing a slower drainage of the blood in the left testicular vein. In contrast, the right testicular vein drains directly into the inferior vena cava, (3) the increased pressure in the left testicular vein due to the compression of the left renal vein between the aorta and the superior mesenteric artery5. This is called “the nutcracker” phenomenon and (4) the increased length of the left testicular vein (8-10 cm longer). In up to 40% of casesa bilateral varicocele may be discovered upon examination. Gat et al suggested that up to 80% of men with a left clinical varicocele have bilateral varicoceles revealed by noninvasive radiologic testing 6. An isolated right varicocele is rare and should raise the suspicion of a possible retroperitoneal pathology. Thus, thrombosis or occlusion of the inferior vena cava should be ruled out in all patients with a single right-sided varicocele. In addition a situs inversus could also explain of a right-sided varicocele.

Presentation The majority of patients with varicoceles are asymptomatic; occasionally some present with acute or chronic scrotal discomfort by palpation of the distended veins in the scrotum during physical examination points out the diagnosis of varicocele. The patient should be examined in both standing and supine position, with and without the Valsava maneuver. In the standing position the scrotum and spermatic cord are palpated. A small varicocele may feel like a thickened spermatic cord whereas a larger varicocele is likened to feeling a bag of worms within the scrotum. These physical findings are accentuated when the patient perform the Valsalva maneuver which increases intra-abdominal pressure, distending the pampiniform venous plexus and increasing varicocele size. In the supine position the varicocele should be reduced; if not occur an obstructive etiology should be considered. According to Hudson, varicoceles are classified according to a 4-grade scale: • •

Grade 0: Subclinical; the varicocele cannot be identified by palpation, only by Doppler ultrasonography. Grade I: palpable only on Valsava maneuver (2 cm)

Indications for treatment To date, varicocele treatment in children and adolescents is controversial and each case should be approached individually. In general, subclinical and grade I should be closely followed; surgery is indicated when the varicocele is associated with testicular growth retardation, and in bilateral or painful varicoceles. In adolescence, grade I varicocele has no effect on normal testicular growth. In contrast, 34% of adolescent boys with a grade II varicoceleare at risk of left testicular volume loss over time and should be monitored every 6-12 months7. Up to 80% of patients with a grade III varicocele may present testicular atrophy or growth arrest and early surgical intervention is recommended8.

Imaging studies •

• •

When the physical examination findings are equivocal and the diagnosis of varicocele is not confirmed, color-flow Doppler ultrasonography with and without the Valsalva maneuver is the diagnostic method of choice. Ultrasound is superior to the orchidometer in the assessment of testicular volume. The volume is calculated using the formula V= length x width x depth x 0.53. The average volume of male testis is 23 ± 3cm3. CT scanning is indicated when a retroperitoneal pathology is suspected in patients presenting a single right-sided varicocele or a non-reducible varicocele in a supine position.

Treatment 1.

Percutaneous Embolization: This approach is usually reserved for recurrent varicoceles after surgical repair. A catheter is introduced via the femoral vein into the left renal vein and through this into the spermatic vein. After catheterization, coils are inserted or sclerosant NBCA glue is injected with subsequent varicocele occlusion. The advantages of percutaneous embolization include preservation of the testicular artery and the noninvasive nature of the method. Disadvantages include risk of contrast allergies, injury of the femoral artery, hemorrhage, thrombophlebitis and coil migration9.

24

Dimitris Antoniou & Fotini Gentimi

2.

Surgical approach: The aim of surgery is to identify and ligate the spermatic veins, preserving the testicular artery. Several approaches are used, differing in the level at which the veins are ligated10. These include: a.

b.

c.

3.

Inguinal approach (Ivanissevich technique): After incising the inguinal canal, the testicular artery is preserved and all cremasteric, deferential and spermatic veins are ligated and divided. Subinguinal approach: The incision is made near the pubic tubercle, over the external inguinal ring. The use of microscope allows optimal visualization, facilitating the identification of small periarterial anastomotic veins that might otherwise be missed. The advantages of this approach include decreased postoperative pain, lower risk of testicular artery ligation and easier access to the spermatic cord. Retroperitonealapproach (Palomo technique): a transverse abdominal incision is performed above the internal inguinal ring. The testicular vessels are identified extraperitonealy above the point they diverge from the vas deferens. At this point the testicular artery and vein may en bloc be ligated. Failure to preserve the lymphatic vessels is associated with an excessive increase in testicular volume due to lymphedema, and a reduced testicular function according to higher LH and FSH stimulated values. Preservation of lymphatics is strongly advised in varicocelectomy in adolescents to ensure better andrological outcome11, 12.

Laparoscopic-assisted retroperitoneal approach: A 5mm, 0o telescope is inserted via an open transumbilical approach. One 5mm operating port is placed in the right iliac fossa and another on the left flank at the level of the umbilicus. An incision is made in the peritoneum over the spermatic cord and the cord vessels are dissected. In this technique, lymphatic vessels are preserved and the vein is clipped, ligated or cauterized en bloc with the artery. Preservation of the testicular artery increases the risk of varicocele recurrence and lengthens the procedure 13, 14.

Follow up Testicular size, consistency and volume are periodically evaluated to ensure that testicular atrophy, recurrence of the varicocele, or hydrocele formation has not occurred.

Adolescent varicocele

25

Complications The most common complications following varicocele repair include hydrocele and recurrence of the varicocele. Hydrocele formation occurs in less than 10% of patients and is the result of lymphatic obstruction due to ligation of the lymphatic vessels during surgery. Percutaneous embolization is not associated with hydrocele formation and microscopic assisted procedures are related to a complication rate less than 1%. The reported rate of recurrence rate is as high as 20%, depending on the surgical method. The use of optical magnification is associated with a recurrence rate of less than 5%, as opposed to a 15% rate recorded with other approaches, and 10-25% with embolization. Testicular atrophy, injury of the vas deferens and chronic testicular pain may occur, but these complications are uncommon15.

Conclusion Adolescents with varicoceles represent a large and heterogeneous group. A standard protocol for such patients may not be possible and an individualized approach is recommended. Physical findings, testicular asymmetry, and abnormal Doppler Ultrasound parameters are considered and used as part of an overall clinical decision. Currently, there are no parameters that can predict impairment of fertility in adulthood for these patients.

References 1. 2. 3. 4. 5.

6. 7. 8.

Coolsaet BL. The varicocele syndrome: venography determining the optimal level for surgical management. J Urol 1980; 124: 833-839. Mohammed A, Chinegwundoh F. Testicular varicocele: an overview Urol Int 2009;82: 373-379. Gargollo PC, Diamond DA. Current management of the adolescent varicocele. CurrUrol Rep 2009;10:144-152. Robinson SP, Hampton LJ, Koo HP. Treatment strategy for the adolescent varicocele. Urol Clin North Am 2010;37:269-278. Rudloff U, Holmes RJ, Prem JT, Faust GR, Moldwin R, Siegel D. Mesoaortic compression of the left renal vein (nutcracker syndrome): case reports and review of the literature. AnnVascSurg2006; 20: 120-129. Gat Y, Bachar GN, Zukerman Z, Belenky A, Gornish M. Varicocele: a bilateral disease. Fertil Steril 2004; 81: 424-429. Steeno OP. Varicocele in the adolescent. Adv Exp Med Biol 1991; 286: 295-321. Lyon RP, Marshall S, Scott MP. Varicocele in youth. West J Med 1983; 138: 832- 834.

26

9.

10. 11.

12. 13.

14.

15.

Dimitris Antoniou & Fotini Gentimi

Fayad F, Sellier N, Chabaud M, Kazandjian V, Larroquet M, Raquillet et al. Percutaneous retrograde endovascular occlusion for pediatric varicocele. J Pediatr Surg 2011; 46: 525-529. Williams DH, Karpman E, Lipshultz LI. Varicocele: surgical techniques in 2005. Can J Urol 2006; 13 Suppl 1:13-17. Moreira-Pinto J, Osório AL, Carvalho F, de Castro JL, de Sousa JF et al. Varicocelectomy in adolescents: Laparoscopic versus open high ligation technique. Afr J Paediatr Surg. 2011; 8:40- 43. Healey C, Lisle R, Mahomed A. Outcome of lymphatic –and-artery sparing surgery for pediatric varicocoele. J Laparoendosc Adv Surg Tech A 2010;20:387-389. Borruto FA, Impellizzeri P, Antonuccio P, Finocchiaro A, Scalfari G et al. Laparoscopic vs open varicocelectomy in children andadolescents: review of the recent literature and meta-analysis. J Pediatr Surg2010;45:2464-2469. Pini Prato A, MacKinlay GA. Is the laparoscopic Palomo procedure for pediatric varicocele safe and effective? Nine years of unicentric experience. Surg Endosc 2006; 20: 660-664. Wein AJ, Kavoussi LR, Novick AC, et al. Campbell-Walsh Urology. 3rd ed. Saunders; 2007:560.