Peak Retrograde Flow Research Articles

MP18-04 TESTICULAR DEVELOPMENT IN HEALTHY BOYS WITH AND WITHOUT VARICOCELE AND THE INFLUENCE OF VARICOCELE PARAMETERS: LONGITUDINAL FOLLOW UP

You have accessJournal of UrologyCME1 Apr 2023MP18-04 TESTICULAR DEVELOPMENT IN HEALTHY BOYS WITH AND WITHOUT VARICOCELE AND THE INFLUENCE OF VARICOCELE PARAMETERS: LONGITUDINAL FOLLOW UP Gunter de Win, Judith Janssen, Judith Klein, Donald Vaganee, Stefan de Wachter, Karen de Baets, and Stefan van Dongen Gunter de WinGunter de Win More articles by this author , Judith JanssenJudith Janssen More articles by this author , Judith KleinJudith Klein More articles by this author , Donald VaganeeDonald Vaganee More articles by this author , Stefan de WachterStefan de Wachter More articles by this author , Karen de BaetsKaren de Baets More articles by this author , and Stefan van DongenStefan van Dongen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003238.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Main goal of this study was to construct longitudinal testicular growth charts for healthy adolescent boys with and without a varicocele, and evaluate the effect of varicocele grade, peak retrograde flow, and spontaneous reflux in standing position on testicular development. METHODS: Between march 2015 and January 2022, after local ethical approval, 775 adolescent boys were recruited for 6 monthly longitudinal follow up with testicular ultrasound. During each measurement, Tanner stage was assessed and testicular volume was calculated using the Lambert formula. In varicocele boys, the clinical grade was assessed, the peak retrograde flow (PRF) (during Valsalva in supine position) was measured as well as the spontaneous reflux in standing position. Boys with one measurement or with a medical condition (except varicocele) affecting testicular growth were excluded. (Generalized) Linear Mixed models were used to construct longitudinal growth charts and evaluate the effect of varicoceles with low PRF (<38.4 cm/s) and high PRF (>38.4 cm/s) on testicular development. A separate analysis was performed for the different varicocele grades and for the spontaneous reflux in standing position (SR>20 cm/s and SR<20 cm/s). RESULTS: After exclusion we analyzed 857 measurements of 399 healthy boys and 453 measurements of 143 varicocele boys. Varicocele boys tend to have a slower testicular development compared to healthy boys, however only the right testicular volume in varicocele boys with high PRF grew significantly slower compared to healthy boys during pubertal development. At Tanner 5 no significant difference in testicular volume was seen between the 3 groups. Similar results (significant slower right testicular growth) were found for grade 3 varicoceles as well as for SR>20 cm/s. When combing the different parameters only boys with grade 3 varicocele together with a high PRF had a significant slower growth curve, higher testicular volume in the earlier tanner stages and lower at the later tanner stages compared to healthy adolescent boys. The growth curves from those boys with grade 3 varicocele and low PRF and those with grade 2 varicocele with high or low PRF were not significantly different from the healthy boys CONCLUSIONS: The developed growth charts can be used as reference curves in clinical practice. A grade 3 varicocele combined with a high PRF is a negative prognostic factor for testicular development. Source of Funding: No funding © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e223 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gunter de Win More articles by this author Judith Janssen More articles by this author Judith Klein More articles by this author Donald Vaganee More articles by this author Stefan de Wachter More articles by this author Karen de Baets More articles by this author Stefan van Dongen More articles by this author Expand All Advertisement PDF downloadLoading ...

Evolution of peak retrograde flow in varicocele boys during pubertal development

Evolution of peak retrograde flow in varicocele boys during pubertal development

Peak retrograde flow a potential objective management tool to identify young adults with varicocele ‘at risk’ for a high sperm DNA fragmentation

Determining which patients are negatively affected by varicocele would enable clinicians to better select those men who would benefit most from surgery. Since conventional semen parameters, have been limited in their ability to evaluate the negative effects of varicocele on fertility, specialized laboratory tests have emerged. To identify clinical and ultrasound parameters (including PRF) which would negatively influence standard and functional semen variables in young adults with a varicocele. Prospective, cross-sectional observational study. Antwerp University Hospital, Belgium. Young volunteers between 16 and 26 years, Tanner 5, were recruited. Every participant had a scrotal ultrasound to calculate testicular volumes. If a varicocele was present, the grade, vein diameter, peak retrograde flow (PRF) in supine position and spontaneous reflux in standing position were measured. All participants provided a semen sample. Standard semen parameters were analyzed and sperm DNA fragmentation. Of all clinical and ultrasound parameters tested, PRF was an objective tool identifying young adults with a varicocele. PRF was highlighted by the prevalence of SDF, both in the total and vital fractions of the spermatozoa, providing opportunities to manage such 'at-risk' adolescents/young adults. Total SDF was significantly increased in grade 3 varicocele compared to grade 1 and 2 but no significant difference with vital SDF or standard descriptive semen parameters was seen. Total and vital SDF on the other hand were significantly increased when PRF was above 38.4cm/s. Standard semen analysis showed no difference with PRF as an independent predictor. Testicular atrophy index, varicocele vein diameter and spontaneous reflux revealed no significant differences in both the descriptive and functional semen variables. Descriptive semen parameters showed no significant difference between the non-varicocele controls and the varicocele group with low and high PRF. Increased PRF negatively influenced sperm quality via increased DNA fragmentation both in the total as in the vital fractions of the semen. Of all clinical and ultrasound parameters tested, PRF was an objective non-invasive tool to identify varicocele patients at risk for a high SDF.

Management and Treatment of Varicocele in Children and Adolescents: An Endocrinologic Perspective.

Pediatric varicocele has an overall prevalence of 15%, being more frequent as puberty begins. It can damage testicular function, interfering with Sertoli cell proliferation and hormone secretion, testicular growth and spermatogenesis. Proper management has a pivotal role for future fertility preservation. The aim of this review was to discuss the diagnosis, management and treatment of childhood and adolescent varicocele from an endocrinologic perspective, illustrating the current evidence of the European Society of Pediatric Urology (ESPU), the European Association of Urology (EAU), the American Urological Association (AUA) and the American Society for Reproductive Medicine (ASRM) scientific societies. According to the ASRM/ESPU/AUA practice committee, the treatment of adolescent varicocele is indicated in the case of decreased testicular volume or sperm abnormalities, while it is contraindicated in subclinical varicocele. The recent EAS/ESPU meta-analysis reports that moderate evidence exists on the benefits of varicocele treatment in children and adolescents in terms of testicular volume and sperm concentration increase. No specific phenotype in terms of testicular volume cut-off or peak retrograde flow (PRF) is indicated. Based on current evidence, we suggest that conservative management may be suggested in patients with PRF < 30 cm/s, testicular asymmetry < 10% and no evidence of sperm and hormonal abnormalities. In patients with 10–20% testicular volume asymmetry or 30 < PRF ≤ 38 cm/s or sperm abnormalities, careful follow-up may ensue. In the case of absent catch-up growth or sperm recovery, varicocele repair should be suggested. Finally, treatment can be proposed at the initial consultation in painful varicocele, testicular volume asymmetry ≥ 20%, PRF > 38 cm/s, infertility and failure of testicular development.

Best practice in the diagnosis and treatment of varicocele in children and adolescents.

A varicocele is an abnormal dilation of the pampiniform plexus of veins in the scrotum which begins at puberty in approximately 15% of males. Although common in the general population and often asymptomatic, varicoceles are associated with gonadal dysfunction including testicular atrophy, infertility, and hypogonadism in a subset of men diagnosed later in life. Because of the high prevalence and uncertain pathogenesis, definitive management guidelines for varicoceles diagnosed in the pediatric and adolescent population remain poorly defined. The varicocele is the most common etiology of male factor infertility, and treatment in the pediatric and adolescent population may improve semen quality and improve fecundity in adulthood. Evaluation of the pediatric and adolescent varicocele should include history, physical exam, and measurement of testicular volume with orchidometer or ultrasound. Testicular volume differentials and peak retrograde flow on Doppler ultrasonography are important factors in risk stratification of the pediatric varicocele population. Semen analysis and reproductive endocrine assessment should also be considered as part of the workup for adolescent patients. A variety of treatment approaches exist for varicocele, and while the microsurgical subinguinal approach is the gold standard for the adult population, it has yet to be confirmed as superior for the adolescent population. Referral to an andrologist for the adolescent patient with varicocele should be considered in equivocal cases. While active treatment of varicocele in the pediatric and adolescent population is controversial, it is clear that some untreated patients will suffer symptoms later in life, while overtreatment remains a concern for this large, vulnerable population. Therefore, surveillance strategies and improved accuracy in diagnosis of clinically important pediatric varicoceles prompting treatment are needed in the future.

765 - Peak retrograde flow in varicoceles influences sperm DNA integrity in adolescents

765 - Peak retrograde flow in varicoceles influences sperm DNA integrity in adolescents

Significant predictive factors for subfertility in patients with subclinical varicocele.

We made a retrospective study to determine useful parameters for predicting subfertility in patients with subclinical varicocele (SV). One hundred and fifty men with SV and 17 age-matched men without SV were divided into three groups: Group 1, subfertile patients (n=15); Group 2, fertile patients (n=135); and Group 3, control patients (n=17). Their age, body mass index (BMI), semen analysis, scrotal temperature, testicular volume, resistive index (RI), pulsatility index (PI) and peak retrograde flow (PRF) were compared. Subfertile patients (Group 1) with SV had significantly lower testicular volume and higher scrotal temperature, RI, PI and PRF than fertile men with SV (Group 2) and the control group (Group 3). Elderly men (>50years, n=30) with SV had a significantly higher incidence of bilateral SV than young men with SV (10/30; 33.3% vs. 12/120; 10%). There was no difference in age and BMI among the three groups. Patients with SV and RI >0.55ml/s, PI >0.99ml/s, total testicular volume <27cc, scrotal temperature >34.9°C and PRF >29cm/s have higher incidence of subfertility. Patients with SV may suffer from subfertility regardless of age. Close follow-up with colour Doppler ultrasound may be beneficial.

Prognostic Predictors of Fertility in Young Adult Patients With Varicocele: Peak Retrograde Flow Velocity and Reflux Grade.

The purpose of this study was to determine prognostic factors affecting semen parameters in patients with varicocele during the postadolescent period. This study was approved by the Institutional Review Board. Between May 2013 and May 2015, we prospectively obtained demographic and sonographic data from postadolescent patients with varicocele. Potential risk factors affecting semen parameters, including age at diagnosis, height, weight, body mass index, varicocele laterality, varicocele grade, left testicular volume, right testicular volume, total testicular volume, testicular atrophy index, testicular volume differential, right and left maximum vein diameters, peak retrograde flow velocity, reflux flow volume, and reflux grade in both supine and standing positions, were recorded. The left peak retrograde flow velocity, reflux flow volume, and reflux grade in the supine and standing positions, left testicular volume, right testicular volume, total testicular volume, and follicle-stimulating hormone level were found to be associated with abnormal semen parameters (P < .05). By multivariate analysis, the follicle-stimulating hormone level was associated with the sperm concentration and morphologic characteristics, and the left peak retrograde flow velocity in the standing position was associated with deterioration of sperm motility and morphologic characteristics. Additionally, the left reflux grade in the standing position was associated with the sperm concentration, and the left testis volume was associated with motility. The left peak retrograde flow velocity and reflux grade in the standing position were significantly associated with all semen analysis parameters. This finding supports the use of testicular duplex Doppler sonography as a noninvasive tool for evaluation of testicular function in patients with varicocele and helps clinicians determine patients' fertility status.

My indications for treatment of the adolescent varicocele (and why?).

What to do with the adolescent varicocele? With merging the information obtained from an extensive review of the literature with our own clinical research, I believe that we already have knowledge enough to say that the adolescent with a varicocele often is in the midst of a progressive disease process. Strong evidence already exists that well more than the majority of Tanner 5 boys with a varicocele and 20% asymmetry will already have abnormally low total motile sperm counts (TMCs) and likely abnormally low sperm concentration as well. There are now many studies in addition to common sense to support the value of % asymmetry as a marker of future abnormal sperm parameters. While we know that some boys at lower Tanner stages who present with asymmetry will have catch-up growth during adolescence, we also know that almost all boys with 15% asymmetry or greater in conjunction with a Doppler detected peak retrograde flow (PRF) of 38 cm/s or greater will end up with greater than 20% asymmetry on follow-up. There also are some boys of concern with less asymmetry but instead have small testes bilaterally, perhaps as a result of the left varicocele slowing the growth of the right testicle and/or an associated undetected or overlooked palpable right varicocele that is also negatively affecting the right testicle. Fortunately, we now have another marker available, i.e., total testicular volume (TTV), to assist in decision making for the adolescent falling into this scenario. Once markers are in place in an early Tanner stage boy with a varicocele that indicate that abnormal semen parameters will likely be present when a Tanner 5 stage of development is reached, there is no reason to wait until the child is older so that a semen analysis can be comfortably requested for the documentation. One argument in favor of waiting is that abnormal semen parameters in a Tanner 5 male usually are reversible. However, how do we know that once abnormal parameters are reversed they then will stay normal in a testicle that already has incurred damage. In other words, I feel it is best to operate once the indicators are in place. We do not want to be suddenly surprised when that individual when older has difficulty fathering a child at a time in life when surgery might be too late to resolve what has taken years to develop. Within this manuscript I will try to document my reasons for the aforementioned rationale.

Active Surveillance of the Adolescent with Varicocele: Predicting Semen Outcomes from Ultrasound

We hypothesized that active surveillance of the adolescent varicocele is not associated with a high prevalence of suboptimal semen analysis and that patients with abnormal semen analysis have smaller testicular volumes and larger volume differentials. We conducted an institutional review board approved retrospective cohort study of adolescents with a clinically detected varicocele. Patients were initially observed by serial scrotal ultrasound evaluating testicular size and differential. Semen analysis was routinely collected in Tanner V cases, around age 18 years. Prevalence of normal semen analysis parameters was calculated, and logistic regression was used to model the ability of age at presentation and testicular volume parameters to predict a normal semen analysis. A cohort of 73 patients underwent surveillance with a mean ± SD age at presentation of 15.5 ± 2.3 years. Median followup was 2.7 years, during which time subjects underwent a median of 3 scrotal ultrasounds. A low total motile count was found in 48 patients (66%). Neither age at presentation nor testicular volume differential could predict normal semen volume, density, sperm motility or total motile count. Total testicular volume from the final ultrasound predicted total motile count (p = 0.008). However, the collective observations of volume during the entire period of surveillance could not predict total motile count (p = 0.847). There is a high prevalence of suboptimal semen analysis in adolescents with a varicocele who are followed with active surveillance. Total testicular volume can predict total motile count at the end of adolescence but not throughout.

Physical exam and ultrasound characteristics of right varicocoeles in adolescents with left varicocoeles

The published incidence of bilateral varicocoeles in adults is much higher than among adolescents. We investigated our adolescent varicocoele database to determine (i) the presence of subclinical and palpable right varicocoele s in boys with a left varicocoele, (ii) the effect, if any, of right varicocoele on asymmetry measurements and (iii) the difference in duplex doppler ultrasound (DDUS) findings between left varicocoele s and contralateral right varicocoele s. Among 506 boys with a known left varicocoele who underwent DDUS, the incidence of right clinical and subclinical varicocoele s as well as the influence of Tanner stage, varicocoele grade, laterality, peak retrograde flow (PRF) and maximum vein diameter (MVD) on testicular volume and asymmetry was examined using univariate and multivariate linear regression. Right retrograde flow was detected in 204 of 506 (40.3%) boys. Varicocoele grades were subclinical in 89 (18%), grade I in 51 (10%), grade II in 63 (12%) and grade III in 1 (0.2%). In patients with bilaterally palpable varicocoele s, increasing left grade was associated with greater testicular asymmetry (p=0.02) and increasing right grade was associated with less testicular asymmetry (p=0.01). Mean PRF and MVD values were lower in right as compared to left varicocoele s. Contrary to common perception, both subclinical and palpable right varicocoele s are frequently associated with left varicocoele s in adolescents. Although the contribution of right varicocoele s to fertility is controversial, these right varicocoele s can influence clinically relevant parameters, particularly testicular asymmetry, and thus influence which left varicocoele s undergo surgery.

Predictive factors of successful redo varicocelectomy in infertile patients with recurrent varicocele

To examine the predictive factors of successful redo varicocelectomy in infertile patients with recurrent varicocele, we made a retrospective study. Twenty-one patients who had improved quality of spermatozoon 6 months after RV were designated as group 1, those with no improvement as group 2 (17 subjects) and those who received close surveillance as group 3 (10 patients) were recruited. The predictive factors included were time to recurrent varicocele; semen quality; testicular volume; number of ligated veins; body mass index; serum levels of follicle-stimulating hormone (FSH), luteinising hormone and testosterone; scrotal temperature; and peak retrograde flow (PRF) and maximal vein diameter (MVD) by colour Doppler ultrasound. The quality of spermatozoon improved significantly 6 months after RV in group 1 patients (21, 55.3%), and no improvement in group 2 and 3 patients. Patients in group 1 also had significantly lower FSH and PRF, longer time to recurrent varicocele, higher number of ligated veins and larger testicular volume than the group 2 (17, 44.7%) and group 3 patients. The significant predictive factors of successful RV were lower FSH and PRF; longer time to recurrent varicocele; and larger testicular volume preoperatively and a higher number of ligated veins during redo varicocelectomy.

Incidence, Significance and Natural History of Persistent Retrograde Venous Flow After Varicocelectomy in Children and Adolescents: Correlation with Catch-up Growth

Varying incidences and levels of persistent retrograde venous flow have been reported following adult and adolescent varicocelectomy but the significance remains unclear. We sought to determine the incidence and natural history of persistent flow and whether it had any effect on postoperative testicular catch-up growth. We retrospectively analyzed pre-varicocelectomy and post-varicocelectomy Doppler duplex ultrasound findings. Peak retrograde venous flow, maximum vein diameter, flow quality and varicocele grade were recorded at each visit. Catch-up growth was defined as less than 15% testicular asymmetry at final visit. Of 330 patients (median age 15.4 years) undergoing varicocelectomy (laparoscopic in 247, open in 83) 145 had residual retrograde venous flow after Valsalva maneuver with a mean peak of 13.3 cm per second. Of 290 patients with repeat Doppler duplex ultrasound (median followup 2.6 years) 124 had initial peak retrograde venous flow less than 20 cm per second (43%) and only 17 (6%) had flow 20 cm per second or greater. Incidence of post-varicocelectomy retrograde venous flow at last visit (48%) was similar to that at initial postoperative visit (49%). Of 330 boys 20 had recurrence of palpable varicocele (grade 2 or 3), of whom 18 (90%) had initial retrograde venous flow. Catch-up growth was more likely in patients with no retrograde venous flow, and rates of catch-up growth decreased as peak retrograde venous flow increased. All 5 patients with initial testicular asymmetry and persistent retrograde venous flow at levels greater than 30 cm per second had continued testicular asymmetry (ie none had catch-up growth). Retrograde venous flow is frequently present after varicocelectomy and is almost always associated with peak retrograde venous flow rates significantly lower than those seen in patients who are recommended for initial varicocelectomy. Retrograde venous flow tends to persist during followup at stable peak retrograde venous flow rates. Palpable recurrence and persistent testicular asymmetry are most often associated with postoperative peak retrograde venous flow rates 20 cm per second or greater.

Clinical and laboratory profiles of a large cohort of patients with varicocoele.

The prevalence of varicocele is 7% and 10–25% in pre pubertal and post pubertal males, respectively [1]. Varicoceles are found in 21–41% of men with primary infertility and 75–81% of those with secondary infertility. Physical examination of varicocele has a sensitivity and specificity of around 70%. The Color Doppler ultrasound (7MHz) has sensitivity of 50% and specificity of 90%. A pencil probe of 9 MHz is good in detecting subclinical varicocele. This has advantage when bilateral varicoceles are suspected [2]. The effect of varicocele on the testis is due to stasis of blood, increased testicular temperature, and reflux of toxic metabolites from the kidney and adrenal gland. This leads to oxidative stress, apoptosis, a deleterious effect on DNA integrity, and the OAT syndrome [3]. The indications for varicocele treatment are pain, arrest of testicular growth, and infertility. Varicoceles in early adolescence should be followed up and treated if there is persistent discrepancy of testicular size by >20% or >2 cm. However, this should be taken in to consideration together with the peak retrograde flow. A peak retrograde flow of 38cm/s or more may indicate that the arrest of testicular growth is likely to worsen [4]. Research by Goldstein's group in 2011 showed that men with varicoceles have lower testosterone than a comparison group (men without varicoceles presenting for reversal of vasectomy). There was a 70% improvement in testosterone levels of men who had varicocelectomy. The mean increase was 178 ng/dl [5]. Controversies have dominated research on varicocelectomy as a treatment for infertility in the last decade, but research in the last couple of years tends to favor treatment of varicoceles in the presence of abnormal semen parameters and infertility. A prospective randomized trial by Abdel Meguid et al. in which 150 men were randomized to either observation or a microscopic subinguinal varicocelectomy revealed an overall improvement in the odds of achieving pregnancy with varicocelectomy. After 12 mos. of follow–up, 13.9% of the observation group and 32.9% of the treatment group had achieved pregnancy (odds ratio [OR]: 3.04; 95% confidence interval [CI], 1.33–6.95). The authors found a number needed to treat of 5.27 (95% CI, 1.55–8.99), which suggests that 5.27 men need to undergo varicocelectomy to achieve one spontaneous pregnancy [6]. A meta–analysis of outcomes of varicocelectomy in the treatment of infertility in oligospermic men in 2011 by Bazeem and coexperts in the field revealed that combined odds ratio was 2.23 (95% CI, 0.86–5.78; p = 0.091), showing varicocelectomy is moderately superior to observation, but the effect is not statistically significant. They concluded that there is no evidence that a varicocele repair improves spontaneous pregnancy rates. They had observed that varicocelectomy improves sperm parameters (count, total, and progressive motility), reduces sperm DNA damage and seminal oxidative stress, and improves sperm ultramorphology [7]. An updated Cochrane systemic review in 2012 involving 894 men from 10 studies found out that the combined fixed–effect odds ratio (OR) of the 10 studies for the outcome of pregnancy was 1.47 (95% CI 1.05 to 2.05). The number needed to treat for an additional beneficial outcome was 17. A sub analysis of five studies in which patients had normal semen analysis, but were subfertile also favored treatment with a combined OR 2.39 (95% CI 1.56 to 3.66). The number needed to treat for an additional beneficial outcome was seven. The authors concluded that treatment of varicocele in men from couples with otherwise unexplained subfertility may improve a couple's chance of pregnancy. However, the findings are inconclusive as the quality of the available evidence is very low and more research is needed with live birth or pregnancy rate as the primary outcome [8]. Analyzing the different meta–analyses, the European Association of Urology guidelines recommended varicocele repair in cases of infertility with clinical varicocele and oligospermia, as well as in adolescents with progressive failure of testicular development (Grade B). It recommended against treatment of varicocele in infertile men with normal semen parameters and subclinical varicocele (Grade A) [9]. The current popular methods of varicocele treatment are microsurgical lymphatic and arterial sparing, subinguinal varicocelectomy, and radiological embolization. The authors, with over one thousand patients in their study, have added one of the largest series of clinical and laboratory profiles on men with varicoceles to the literature on the subject. Their finding of slightly higher level of testosterone in men with grade 3 varicocele compared to grade 1 and 2 has defied most studies as discussed above, but their explanation is plausible though more research is needed on it. However, it is a known fact that precision and standardization of testosterone assay is a challenge in itself [10].

Intratesticular varicoceles: Are they significant?

ObjectiveVaricoceles occur in 15% of adult and adolescent males and are generally considered to be an extratesticular phenomenon. However, an intratesticular component has been reported in up to 2% of adult and 2% of adolescent varicoceles. We sought to determine the incidence of intratesticular varicoceles (ITV) in adolescents in our practice, its significance, associated findings and response to treatment. Materials and methodsWe retrospectively reviewed 684 adolescent males who were diagnosed with varicoceles and had at least one Doppler ultrasound (DUS) prior to any surgery to identify those with an intratesticular component. Testicular volumes, maximum vein diameter (MVD) and peak retrograde flow (PRF) were determined by DUS and recorded. ResultsA total of 6 (0.9%) patients were found to have an intratesticular component with a mean PRF of 43.7 cm/s, mean MVD of 3.3 mm and mean asymmetry of 20%. Mean PRF, MVD, and asymmetry of those without an intratesticular component who underwent surgery was 44.8 cm/s, 2.9 mm, and 21.8%, respectively (PNS for all parameters). Four of the 6 patients had 2 or more DUS, and all 4 had worsening testicular asymmetry and PRF over time. Five patients underwent laparoscopic varicocelectomy and all five had catch-up testicular growth. One patient refused surgical repair and has had subsequent worsening testicular asymmetry and softening of the testicle. ConclusionsOur findings suggest that adolescents who present with an intratesticular varicocele in association with testicular asymmetry will develop worse asymmetry over time. Therefore, adolescents with intratesticular varicoceles and initial asymmetry should be scheduled for surgery rather than followed.

Adolescent Varicocele—Is the 20/38 Harbinger a Durable Predictor of Testicular Asymmetry?

Part of the management of adolescent varicocele is trying to prognosticate who with testicular asymmetry will have catch-up growth with observation and who will have persistent asymmetry. We previously reported that catch-up growth is rare when peak retrograde flow greater than 38 cm per second is associated with 20% or greater asymmetry (ie the 20/38 harbinger). We sought to determine if this 20/38 cutoff held true with a larger series, and what peak retrograde flow value should be used when 15% instead of 20% asymmetry is chosen as the cutoff. We analyzed patients from our large varicocele registry who had undergone at least 2 duplex Doppler ultrasounds and had been observed for at least 10 months in the interim. Outcomes were determined regarding those who met the 20/38 cutoff and what peak retrograde flow value could be used to recommend surgery when 15% to 19.9% asymmetry was included in the cutoff value. Of 355 adolescent boys with left varicocele 44 (mean age 14.0 years, range 9 to 20) were followed with observation initially and met the 20/38 cutoff, while 9 additional patients met the 15/38 cutoff (initial asymmetry 15% to 19.9%). When combining both groups, only 3 boys had catch-up growth to less than 15% on followup. Thus, 50 of 53 patients did not demonstrate catch-up growth after a mean followup of 15.5 months (range 10 to 44). Not only does a peak retrograde flow of greater than 38 cm per second hold up for predicting persistent/worsening asymmetry when combined with a 20% asymmetry cutoff, it also is an excellent predictor of persistent and/or worsening asymmetry when combined with a 15% asymmetry cutoff. Therefore, it might be unnecessary to follow an adolescent boy with observation who is at or above this 15/38 cutoff.

Varicocele

This review provides timely and relevant information to address the indications for repair of the adolescent varicocele. In this review, we summarize the most recent available evidence and provide clinical guidelines. The indications for adolescent varicocelectomy commonly include testicular hypotrophy and pain but become confusing and contradictory when discussing potential infertility as an indication for repair. The preponderance of patients with varicocele in the infertile population leads to the search for causality and reversibility. However, in the era of assisted reproduction, the question of early prevention of infertility is brought to the forefront of discussion. Recent attempts have been made to determine the patient parameters that predict future infertility. Current publications have focused on predictors for clinically significant varicoceles that would benefit from intervention, such as hormonal profile and peak retrograde flow. Contradictory evidence exists regarding the significance of testicular asymmetry in adolescence. Substantial effort has been made to tease out the clinically significant adolescent varicocele. However, definitive evidence regarding fertility outcomes and adolescent varicocele repair remains limited and controversial. Large-scale, long-term follow-up studies are necessary to determine the true benefit of adolescent varicocele repair on decreasing the risk of fertility problems in adulthood.

Factors Predicting Symptomatic Relief by Varicocelectomy in Patients With Normospermia and Painful Varicocele Nonresponsive to Conservative Treatment

To assess the factors predicting symptomatic relief by varicocelectomy in patients with normospermia and painful varicocele nonresponsive to conservative treatment. A total of 76 men with left painful varicocele and normal semen quality were recruited for the present prospective study. The patients who showed complete or partial resolution of pain 6 months after varicocelectomy were designated as responders, and those who did not have improvement were designated as nonresponders. The predictive factors examined included the number of ligated veins, preoperative pain score, duration of pain, body mass index, scrotal temperature, the distance from the renal hilum to the scrotum, the serum concentration of follicle-stimulating hormone, luteinizing hormone, and testosterone, grade of varicocele, peak retrograde flow, and maximal vein diameter on color Doppler ultrasound scans. Of the 76 patients, 55 (72.4%) were responders and 21 (27.6%) were nonresponders, with a mean age of 31.8 and 32.4 years, respectively. The responders had a significantly greater number of ligated veins, preoperative pain score, and longer duration of pain than the nonresponders. No significant differences were found in body mass index, scrotal temperature, distance from the renal hilum to the scrotum, peak retrograde flow, follicle-stimulating hormone, luteinizing hormone, testosterone, and maximal vein diameter between the responders and nonresponders. The findings of the present study suggest that the factors predicting symptomatic relief by varicocelectomy in patients with normospermia and painful varicocele nonresponsive to conservative treatment are a greater number of ligated veins (>7), greater preoperative pain score (>6), and longer duration of pain (>9 months).

The hemodynamic approach to evaluating adolescent varicocele

During adolescence, the risk of developing a varicocele increases. Prevalence is less than 1% in boys aged younger than 10 years, but approaches that of the general adult population (about 15%) during puberty. For adolescent males with varicoceles, surgical risk factors have not yet been clearly delineated and clinical severity correlates poorly with prognosis. Fortunately, the widespread use of Doppler ultrasonography is transforming the diagnostic work-up for this demographic. A continuous reflux detected by color Doppler ultrasound (CDUS) is thought to have a negative prognostic value and evidence suggests that a peak retrograde flow above 38 cm per second is a powerful predictor of lack of spontaneous improvement in adolescent patients with ≥ 20% asymmetry between testes. CDUS also enables the detection of varicocele resulting from reflux in the deferential vein adjunctive to a refluxing internal spermatic vein; a causality that accounts for approximately 15% of cases. In addition to a diagnostic role, hemodynamic parameters can be used to predict the risk of persistence or worsening asymmetry. Although further studies are necessary to validate single parameters, it seems that the more severe the reflux, the greater the likelihood that the patient will develop testicular asymmetry.

Differences in the clinical characteristics between young and elderly men with varicocoele

Information concerning the clinical characteristics in elderly men with varicocoele is relatively limited. This study was assessed to evaluate the differences in clinical characteristics between young and elderly patients with varicocoele by retrospective chart review. Between June 2003 and February 2011, 169 young (18-30 years) men and 156 elderly (45-55 years) men with varicocoele, and 30 age-matched men without varicocoele were recruited for this study. All the patients were divided into six groups. Thirty-one infertile patients were assigned to Group 1, 138 fertile patients to Group 2, 35 infertile patients to Group 3 and 121 fertile patients to Group 4. Group 5 (15 young) and 6 (15 elderly) were control groups. The parameters for comparison included body mass index (BMI), semen quality (sperm motility, morphology and density) and pH value, serum concentration of follicle-stimulating hormone (FSH), luteinizing hormones (LH), testosterone, testicular volume, grade of varicocoele and peak retrograde flow (PRF) and maximal vein diameter (MVD) by colour Doppler ultrasound (CDS). Elderly men with varicocoele had a higher incidence of bilateral varicocoele (25.5% vs. 14.8%), but a lower incidence of unilateral right varicocoele (2.6% vs. 7.7%) than young patients with varicocoele. In addition, patients with varicocoele had lower BMI than those without, and infertile young patients with varicocoele had the lowest levels of BMI. Furthermore, infertile patients (Groups 1 and 3) with varicocoele had significantly lower testicular volume and semen pH, lower levels of testosterone, higher levels of FSH and LH and higher PRF than fertile men with varicocoele (Groups 2 and 4). In conclusion, infertile elderly patients with varicocoele had significantly lower levels of testosterone and higher levels of FSH and LH than infertile young men with varicocoele. In addition, infertile elderly patients with bilateral varicocoele (Group 3, n = 8) had the lowest levels of testosterone.