Management of prepubertal varicoceles—results of a questionnaire study among pediatric urologists and urologists with infertility training

Abstract

Objectives. Varicoceles are a common condition affecting male fertility seen by urologists. However, prepubertal varicoceles are much less common and their management is controversial. We designed a questionnaire to assess the practice patterns among urologists (pediatric urologists/urologists with infertility training) with regard to prepubertal varicocele management. Methods. A 15-point questionnaire pertaining to management issues of prepubertal varicoceles was sent to 150 pediatric urologists and 150 urologists with infertility training. Two clinical scenarios referring to treatment algorithms of prepubertal varicoceles were included. Results. Of the 300 questionnaires mailed, 174 urologists (58%) responded. Seventy-five of the respondents were urologists with an interest in infertility, and 99 were pediatric urologists. Of the 174 respondents, 86.2% treated prepubertal varicoceles and 13.8% referred patients to interventional radiologists for embolization. The ratio of varicocelectomy to expectant management was about equal between urologists with infertility training and pediatric urologists (46% versus 54%). A difference in testicular size was the most common indication for varicocelectomy (80.5%), followed by pain (51.1%) and potential fertility problems (24.7%). About one third of all urologists would perform varicocelectomy on patients of any age and seven (4%) would not operate before puberty. In 136 responses (78.2%), follow-up information was not available. Among the 35 respondents with follow-up information (21.8%), 21 reported infertility occurring after varicocelectomy and 16 after expectant management. If varicocelectomy was performed, most urologists (47.2%) used magnification loupes, 29.3% used microscopes, and 29% used no magnification. The preferred approach was inguinal (Ivanissevich) in 35.6% followed by subinguinal in 30%; 21% performed retroperitoneal varicocelectomy (Palomo) and 9.8% used a laparoscopic approach. Of the 300 complications reported, postoperative hydroceles were the most common (40.4%), followed by recurrence (20.8%) and hematomas (17.4%). Conclusions. The management of prepubertal varicoceles is controversial among different urologic subspecialties (pediatric urology/infertility). Differences include indications, timing, and techniques used for varicocelectomy. Accurate follow-up information for children with prepubertal varicoceles is rare. A prospective randomized study comparing varicocelectomy versus expectant management of prepubertal varicoceles is needed to assess the outcomes and define uniform treatment criteria.