Surgical Repair Of Varicocele Research Articles

Effect of varicocele surgery on sperm quality

Introduction: A varicocele is a vascular lesion characterised by dilatation and tortuosity of the veins of the pampiniform plexus and is found in approximately one-fifth of the adult male population. It is the most common cause of treatable infertility. Physical examination may or may not show a varicocele which is mostly diagnosed only when patients present with infertility or adolescents during a physical examination, like testicular hypotrophy, impairment in spermatogenesis mainly in the form of low or absent count, decreased sperm motility, and abnormal sperm morphology. Treatment for varicocele includes medical therapies, radiological embolization, and surgical techniques. Medical therapy, including antioxidants and anti-inflammatory agents, has been utilized with variable success. Radiological embolization of varicocele is a new technique in the treatment of varicocele, but it is associated with high recurrences and high cost. Varicoceles are surgically treated either by open or laparoscopic approaches the principal aim being occlusion of the dilated veins of the pampiniform plexus. A definitive conclusion of indication of medical treatment cannot be drawn at present because most published studies have inadequate design and lack controls. Various studies in the past have concluded significant changes in sperm parameters (total count, motility, morphology) post-varicocele repair. However, few other studies suggest no improvement in sperm parameters following surgical varicocele repair and studies that conclude recommendations against repair of varicocele. Thus, conflicting opinions have opened the scope to establish this fact by this study. Aim: To evaluate changes in sperm morphology, sperm count, and sperm motility in a patient with varicocele after varicocele surgery. Materials and methods: The study was conducted in the Department of Surgery, North Delhi Municipal Corporation Medical College & Hindu Rao Hospital, Delhi, India from August 2019 to February 2021. The sample size was calculated to be 50 using Slovin’s formula with a confidence level of 95% with a margin error taken as 5% (p - value 0.05). Sperm morphology, sperm count, and sperm motility were the parameters studied before and after 3 months of surgery. Results: The majority of patients belonged to the age group of 18 to 25 years (42%) followed by 26 to 35 years (40%) (27.78 ± 6.547 years). Left-sided varicocele was more common (54%), followed by bilateral varicocele (42%). Varicocele grade II was most common (58%) followed by grade I (30%) and lastly grade III (12%). Total sperm count improved by 8.88 million per ml after varicocelectomy. Total sperm motility improved by 6.08% after the surgery. Total normal sperm forms improved by 6.44% after varicocele repair. Conclusion: Based on the findings it was concluded that Varicocelectomy results in significant improvement in total sperm count, total sperm motility, and total normal sperm morphology. The best improvement was seen in sperm count followed by total normal sperm forms and lastly total sperm motility.

The effect of antioxidant supplementation on operated or non-operated varicocele-associated infertility: A systematic review and meta-analysis

ABSTRACT Introduction In patients with varicocele-associated infertility, the effect of antioxidant supplementation on fertility is unknown. Objectives To perform a systematic review and meta-analysis exploring the role of antioxidant supplementation in patients with operated or non-operated varicocele. Methods We searched PubMed, Cochrane Library, Web of Science and Scopus databases, as well as sources of grey literature until May 2021 (PROSPERO: CRD42021248195). We produced a qualitative synthesis of the main results extracted from the included studies. Based on data availability, we undertook an inverse variance, random effects meta-analysis of odds ratios (ORs) to determine the pregnancy rate after antioxidant supplementation versus no treatment in patients undergoing surgical repair of varicocele at three and six months of treatment. In these patients, we determined the effect of antioxidant supplementation versus no treatment or placebo on semen parameters (concentration, motility, morphology, and DNA fragmentation). Results We included 14 studies (980 individuals) in the systematic review. Of the 14 studies, 2 explored the effect of antioxidant supplementation in patients with non-operated varicocele, 1 compared antioxidants versus surgical repair of varicocele, while 11 explored antioxidants after surgical repair of varicocele and were also included in the meta-analysis. Regarding pregnancy rates, no significant differences were demonstrated after treatment with antioxidants versus no treatment at three (OR: 2.28, 95% CI: 0.7–7.48) and six months (OR: 1.88, 95% CI: 0.62–5.72). Accordingly, contradictory findings were reported in sperm concentration, morphology, and motility, as well as DNA fragmentation. Conclusions Our findings indicate that antioxidant supplementation does not improve pregnancy rates and semen parameters in patients with varicocele-associated infertility, in the absence of previous screening for oxidative stress. Based on the previous notion, most included studies also raised methodological concerns. Therefore, definitive conclusions about the efficacy of antioxidant supplementation in this setting cannot be drawn and further research on the field is mandatory. Disclosure Work supported by industry: no.

O-226 The microscopic se men improvement after surgical varicocele repair

Abstract Study question Evaluation of the effect of varicocele correction on conventional and microscopic seminal parameters and evaluation of which factors might predict sperm improvement after surgical treatment. Summary answer The detailed morphologic sperm evaluation has been identified as a novel parameter expressing the post-surgical semen amelioration after varicocelectomy. What is known already Generally, varicocele develops during puberty and occurs more often on the left side for anatomic reasons. However, its diagnosis is commonly delayed, especially in asymptomatic cases, until the man consults an andrologist for couple infertility. A causative relationship between varicocele and impairment of semen quality has been largely investigated in the context of male infertility. Despite the florid literature available on this topic, the clinical benefit in terms of semen quality improvement after varicocele surgical repair remains controversial. Study design, size, duration An observational, retrospective clinical trial was carried out including patients undergoing surgical treatment for varicocele at the Day Surgery of the Urology Operative Unit of the Santa Maria Nuova Hospital-IRCCS of Reggio Emilia from September 2011 to March 2020. Primary outcome was the detailed morphologic microscopic sperm evaluation. Secondary outcomes were conventional semen analyses. Each patient was considered two times (before and after the surgery) and evaluated by both physical examination and ultrasonography. Participants/materials, setting, methods The inclusion criteria considered the patients with diagnosis of varicocele at ultrasound examination, attending surgical resolution and with at semen analyses before and after the surgery, were excluded patients with diagnosis of varicocele without surgical indication, and/or semen analyses performed only before or only after the surgery. In the statistical analysis a logistic multivariate regression analysis was performed in order to evaluate the change before and after surgery. Main results and the role of chance The post-surgical semen analysis was performed after a mean of 183.7 + 112.5 days since the surgery for a total of 121 males (mean age 24.6 + 4.1 years) enrolled. The surgical treatment leads to a significant increase in sperm concentration (p = 0.015) and percentage of progressive and total motility (p = 0.022 and p = 0.039, respectively), with a significant decrease in the percentage of immobile sperms (p = 0.013). In particular, semen concentration improved in 71.7% of patients (p = 0.010). Considering the detailed morphologic microscopic evaluation, a significant improvement was detected: head abnormalities showed a significant reduction, considering microcephaly (3.3 + 3.6 versus 2.2 + 2.9%, p = 0.015), macrocephaly (1.4 + 0.6 versus 1.2 + 0.9%, p = 0.043) and cytoplasmic appendix (1.4 + 0.8 versus 0.9 + 1.2%, p = 0.041). Moreover, surgery led to a significant reduction of tails abnormalities, considering absence (0.6 +2.3 versus 0.1 + 0.7, p = 0.048) and coiled tail (5.2 + 1.5 versus 6.6 + 2.0, p = 0.037). Thus, surgical varicocele resolution leads to a significant improvement in specific morphological semen parameters. The multivariate logistic analysis identified the ultrasound varicocele degree before surgery as a main predictor of the sperm concentration improvement (p = 0.016). The semen parameters improvement was higher for varicocele of I and II degree (p = 0.008). Limitations, reasons for caution The retrospective study design precluded from carrying out a case-control study to compare the surgical techniques. Moreover, the study design limited the availability of patients’ clinical data in order to performed a more comprehensive predictive analysis. Wider implications of the findings Using a complex statistical approach, it emerged that the greatest improvement in semen quality was obtained in case of mild varicocele, increasing the knowledge on the therapeutic potential of surgery. This result has clinical implications, since it could help to select those patients ‘to treat or not to treat’. Trial registration number none

The Effect of Antioxidant Supplementation on Operated or Non-Operated Varicocele-Associated Infertility: A Systematic Review and Meta-Analysis

In patients with varicocele-associated infertility, the effect of antioxidant supplementation on fertility is unknown. We performed a systematic review and meta-analysis to explore their role in patients with operated or non-operated varicocele. We searched major databases and sources of grey literature until May 2021 (PROSPERO: CRD42021248195). We included 14 studies (980 individuals) in the systematic review. Of the 14 studies, 2 explored the effect of antioxidant supplementation in patients with non-operated varicocele, 1 compared antioxidants versus surgical repair of varicocele, while 11 explored antioxidants after surgical repair of varicocele and were also included in the meta-analysis. Regarding pregnancy rates, no significant differences were demonstrated after treatment with antioxidants versus no treatment at three (OR: 2.28, 95% CI: 0.7–7.48) and six months (OR: 1.88, 95% CI: 0.62–5.72). Accordingly, contradictory findings were reported in sperm concentration, morphology, and motility, as well as DNA fragmentation. Our findings indicate that antioxidant supplementation does not improve pregnancy rates and semen parameters in patients with varicocele-associated infertility, in the absence of previous screening for oxidative stress. Based on the previous notion, most included studies also raised methodological concerns. Therefore, definitive conclusions about the efficacy of antioxidant supplementation in this setting cannot be drawn and further research on the field is mandatory.

Improvement of sperm morphology after surgical varicocele repair.

BackgroundA causative relationship between varicocele and impairment of semen quality has been largely investigated in the context of male infertility, although its clinical benefit remains controversial.ObjectiveTo investigate the effect of varicocele correction on detailed morphologic microscopic semen parameters in a large homogeneous cohort of patients and to evaluate which factors could predict semen improvement after the surgical treatment.Materials and methodsAn observational, retrospective cohort study was carried out including all patients undergoing surgical treatment for varicocele from September 2011 to March 2020 in the same clinical centre. Enrolled males performed at least one semen analysis before and one after surgical varicocele correction. Primary outcome was the detailed morphologic microscopic sperm evaluation. Secondary outcomes were conventional semen analyses.ResultsA total of 121 males (mean age 24.6 ± 6.1 years) were enrolled. Using detailed morphologic microscopic sperm evaluation, a significant morphological improvement was recorded, with a reduction in head and tail abnormalities. Moreover, a significant increase in sperm concentration (p = 0.015) and percentage of progressive and total motility (p = 0.022 and p = 0.039) were observed after surgery. The multivariate logistic analysis identified the ultrasonography varicocele degree before surgery as a main predictor of the sperm concentration improvement (p = 0.016), with the highest improvement for varicocele of I and II degree.DiscussionFor the first time, the detailed morphologic microscopic sperm evaluation highlights a relevant reduction in sperm abnormalities after varicocele surgery, showing its potential application in clinical practice.

Should we expand the indications for varicocele treatment?

Current guidelines suggest that treatment of varicocele should be considered in patients with clinically palpable disease and abnormal semen parameters. However, the clinicians are often challenged with the decision whether to treat varicocele in patients with testicular pain or low testosterone levels. Moreover, varicocele is highly associated with DNA fragmentation due to the oxidative stress and it has been demonstrated that surgical repair of varicocele ameliorates oxidative stress markers and consequently the sperm DNA integrity. These new markers could have an adjunctive role to standard semen parameters especially when normal semen analysis is found in adult men with conventional methods. This review presents a contemporary overview of the rationale for varicocele treatment, as well as of the relationship between varicocele and other novel parameters such as DNA fragmentation index and reactive oxygen species. We will also discuss data from several recent series demonstrating that surgical treatment and especially microsurgical approach could resolve testicular pain, increase testosterone levels and fertility rate both in patients with non-obstructive azoospermia as well as in normozoospermia men. The correlation with progressive testicular failure will be also examined. We hope that this overview will provide clinicians with an evidence-based approach to managing these unanswered and conflicting topics.

An update on the role of medical treatment including antioxidant therapy in varicocele.

Varicocele-associated male infertility has classically been managed using surgery or assisted reproductive techniques. With increasing evidence of oxidative stress as a pathophysiological factor in varicocele-associated infertility, medical therapy especially antioxidants might become a treatment option with lower risks. We reviewed the existing literature on the role of various medical agents in the management of male infertility attributed to varicoceles. Medical therapy is typically evaluated in three different situations such as (a) comparison of two drugs or one drug with placebo, (b) comparison of drugs versus surgery, and (c) comparison of drugs as adjuvant therapy with surgery versus drug therapy alone. Due to heterogeneity of data and lack of well-conducted studies, there is insufficient data to recommend routine use of medical therapy for men with varicocele-associated infertility and surgery remains the treatment of choice. Pregnancy and live birth rates are usually not reported in most studies and mere improvement in sperm parameters or antioxidant capacity is insufficient to support its routine use. Antioxidant therapy is a potential option due to its theoretical benefit, data from preclinical studies, and lack of major side effects. Adjuvant therapy with antioxidants after surgical repair of varicocele may improve the outcome and is a potential area for further research.

Summary evidence on the effects of varicocele treatment to improve natural fertility in subfertile men.

The objective of this review was to summarize the evidence concerning the benefit of varicocele treatment to improve natural fertility in subfertile males. We also analyzed the effect of varicocele treatment on conventional semen parameters and sperm functional tests. An electronic search to collect the data was performed using the PubMed/MEDLINE databases until July 2015. Data pooled from a variety of study designs indicate that varicocelectomy improves semen parameters in the majority of the treated men with clinical varicocele and abnormal semen parameters regardless of the chosen surgical method. Surgical varicocele repair was beneficial not only for alleviating oxidative stress-associated infertility but also to improve sperm nuclear DNA integrity. However, given the low magnitude of the effect size in sperm DNA integrity, further research is needed to elucidate its clinical significance. Conflicting results on the effect of varicocele treatment on natural fertility seem to be due to heterogeneous study designs and, more importantly, patient selection criteria. When these issues are controlled, current evidence indicates that treatment of subclinical varicocele is not warranted, as it does not seem to improve fertility. On the contrary, fair evidence indicates that varicocele treatment should be offered to infertile patients with palpable varicocele and abnormal semen parameters. This evidence supports the current guidelines issued by the American Urological Association and European Association of Urology, which state that varicocele treatment should be offered to male partners of infertile couples presenting for evaluation with clinical varicocele and semen parameters alterations.

Outcome of varicocele repair in men with nonobstructive azoospermia: systematic review and meta-analysis.

The objective of this systemic review was to evaluate the benefit of repairing clinical varicocele in infertile men with nonobstructive azoospermia (NOA). The surgically obtained sperm retrieval rate (SRR) and pregnancy rates following assisted reproductive technology (ART) with the use of retrieved testicular sperm were the primary outcomes. The secondary outcomes included the presence of viable sperm in postoperative ejaculate to avoid the testicular sperm retrieval and pregnancy rates (both assisted and unassisted) using postoperative ejaculated sperm. An electronic search to collect the data was performed using the MEDLINE and EMBASE databases until April 2015. Eighteen studies were included in this systematic review and accounted for 468 patients who were diagnosed with NOA and varicocele. These patients were subjected to either surgical varicocele repair or percutaneous embolization. Three controlled studies evaluating sperm retrieval outcomes indicated that in patients who underwent varicocelectomy, SRR increased compared to those without varicocele repair (OR: 2.65; 95% CI: 1.69–4.14; P < 0.001). Although pregnancy rates with the use of testicular sperm favored the varicocelectomy group, results were not statistically significant (clinical pregnancy rate OR: 2.07; 95% CI: 0.92–4.65; P = 0.08; live birth rate OR: 2.19; 95% CI: 0.99–4.83; P = 0.05). The remaining fifteen studies reported postoperative semen analysis results. In 43.9% of the patients (range: 20.8%–55.0%), sperm were found in postoperative ejaculates. Pregnancy rates for unassisted and assisted (after IVF/ICSI) were 13.6% and 18.9% in the group of men with sperm in postoperative ejaculates, respectively. Our findings indicate that varicocelectomy in patients with NOA and clinical varicocele is associated with improved SRR. In addition, approximately 44% of the treated men will have enough sperm in the ejaculate to avoid sperm retrieval. Limited data on pregnancy outcomes with both postoperative ejaculated sperm and harvested testicular sperm preclude any firm conclusion with regard to the possible increased fertility potential in treated individuals. In conclusion, the results of our study indicate that infertile men with NOA and clinical varicocele benefit from varicocelectomy. Given the low/moderate quality of evidence available, it is advisable that doctors discuss with their patients with NOA the risks and benefits of varicocele repair.

Does varicocelectomy affect DNA fragmentation in infertile patients?

Introduction:The aims of this study were to investigate the effect of varicocelectomy on DNA fragmentation index and semen parameters in infertile patients before and after surgical repair of varicocele.Materials and Methods:In this prospective study, 72 men with at least 1-year history of infertility, varicocele and oligospermia were examined. Varicocele sperm samples were classified as normal or pathological according to the 2010 World Health Organization guidelines. The acridine orange test was used to assess the DNA fragmentation index (DFI) preoperatively and postoperatively.Results:DFI decreased significantly after varicocelectomy from 34.5% to 28.2% (P = 0.024). In addition all sperm parameters such as mean sperm count, sperm concentration, progressive motility and sperm morphology significantly increased from 19.5 × 106 to 30.7 × 106, 5.4 × 106/ml to 14.3 × 106/ml, and 19.9% to 31.2% (P < 0.001) and 2.6% to 3.1% (P = 0.017). The study was limited by the loss to follow-up of some patients and unrecorded pregnancy outcome due to short follow-up.Conclusion:Varicocele causes DNA-damage in spermatozoa. We suggest that varicocelectomy improves sperm parameters and decreases DFI.

Effects of supplement therapy on sperm parameters, protamine content and acrosomal integrity of varicocelectomized subjects.

Surgical repair of varicocele has long been a procedure to correct spermatogenesis. However, the outcome has been reported to be inadequate. We combined varicocelectomy with supplement therapy to evaluate the concurrent effect of these procedures. A prospective randomized controlled study was undertaken to investigate the effects of zinc sulfate, folic acid and zinc sulfate/folic acid on sperm quality, protamine content and acrosomal integrity following surgical repair of varicocele. Male subjects with palpable varicocele were included in the study and randomized into four groups. Subjects received Zinc sulfate, Folic acid, Zinc sulfate/Folic acid or placebo for 6 months. A semen sample was obtained before surgery and 3 and 6 months after surgical repair. Semen samples were evaluated for sperm parameters as well as chromatin content and acrosomal integrity. Most of the evaluated parameters showed a mild improvement after varicocelectomy in the placebo group. Interestingly, co-administration of Zinc sulfate and folic acid improved most factors significantly. Folic acid administration but not zinc sulfate could increase sperm number. Hence, Zinc sulfate was better than folic acid when change in morphology was assessed, and none of them was significantly effective in sperm motility. In Zinc sulfate and Folic acid groups, protamine content and halo formation rate significantly improved. We may conclude that co-administration of zinc and folic acid significantly improved sperm parameters and increased varicocelectomy outcomes. So, medical treatment with compatible drugs after surgery might be advantageous for obtaining acceptable results.

Impact of Surgical Varicocele Repair on Pregnancy Rate in Subfertile Men With Clinical Varicocele and Impaired Semen Quality: A Meta-Analysis of Randomized Clinical Trials

PurposeTo elucidate the impact of surgical varicocele repair on the pregnancy rate through new meta-analyses of randomized clinical trials that compared surgical varicocele repair and observation.Materials and MethodsThe PubMed and Embase online databases were searched for studies released before December 2012. References were manually reviewed, and two researchers independently extracted the data. To assess the quality of the studies, the Cochrane risk of bias as a quality assessment tool for randomized controlled trials was applied.ResultsSeven randomized clinical trials were included in our meta-analyses, all of which compared pregnancy outcomes between surgical varicocele repair and control. There were differences in enrollment criteria among the studies. Four studies included patients with clinical varicocele, but three studies enrolled patients with subclinical varicocele. Meanwhile, four trials enrolled patients with impaired semen quality only, but the other three trials did not. In a meta-analysis of all seven trials, a forest plot using the random-effects model showed an odds ratio (OR) of 1.90 (95% confidence interval [CI], 0.77 to 4.66; p=0.1621). However, for subanalysis of three studies that included patients with clinical varicocele and abnormal semen parameters, the fixed-effects pooled OR was significant (OR, 4.15; 95% CI, 2.31 to 7.45; p<0.001), favoring varicocelectomy.ConclusionsVaricocelectomy for male subfertility is proven effective in men with clinical varicocele and impaired semen quality. Therefore, surgical repair should be offered as the first-line treatment of clinical varicocele in subfertile men.

Testicular volume and fertility potential in men operated due to varicocele and testicular hypotrophy in adolescence.

IntroductionFailure to perform surgical repair of varicocele before puberty is among the common causes of male infertility. The purpose of this study was to evaluate the testicular volume and fertility potential in men after laparoscopic varicocelectomy conducted in adolescence due to varicocele and concomitant testicular hypotrophy.Material and methodsFrom 1996 through 2011, eighty–two adolescents were operated on for unilateral primary varicocele with testicular hypotrophy. Sixty–eight patients were subject to the current analysis. The age of the patients was 13 to 17 years (mean 15.3 years). Clinical diagnosis was established on the basis of andrologic examination and ultrasonography with an assessment of testicular size and varicocele severity. Laparoscopic surgical repair was performed by a transperitoneal approach with division of testicular vein only.ResultsAn increase in left testicular volume when compared with the contralateral testis was found in 25 (78.1%) young men with clinical grade 2 varicocele (p = 0.02) and in 32 (88.8%) subjects with grade 3 abnormality (p = 0.04). An increase in left testicular volume was found in 46 (85.1%) of 54 patients with unilateral varicocele and in 12 (85.7%) of 14 subjects operated on for bilateral disease. A left testicular volume increase was comparable independent of the use of uni– or bilateral repair. Fifty–eight (85.2%) of our 68 patients had normozoospermia.ConclusionsLaparoscopic varicocele repair resulted in a significant increase of hypotrophic testicular volume in 83.8% of our subjects.

Decreased Sperm DNA Fragmentation After Surgical Varicocelectomy is Associated With Increased Pregnancy Rate

We prospectively evaluated changes in sperm chromatin structure in infertile patients before and after surgical repair of varicocele, and the impact on the pregnancy rate. Included in the study were 49 men with at least a 1-year history of infertility, a palpable varicocele and oligospermia. World Health Organization semen analysis and sperm DNA damage expressed as the DNA fragmentation index using the sperm chromatin structure assay were assessed preoperatively and postoperatively. Pregnancy (spontaneous and after assisted reproductive technique) was recorded 2 years after surgery. Mean sperm count, sperm concentration and sperm progressive motility improved significantly after varicocelectomy from 18.3 × 10(6) to 44.4 × 10(6), 4.8 × 10(6)/ml to 14.3 × 10(6)/ml and 16.7% to 26.6%, respectively (p <0.001). The DNA fragmentation index decreased significantly after surgery from 35.2% to 30.2% (p = 0.019). When the definition of greater than 50% improvement in sperm concentration after varicocelectomy was applied, 31 of 49 patients (63%) responded to varicocelectomy. After varicocelectomy 37% of the couples conceived spontaneously and 24% achieved pregnancy with assisted reproductive technique. The mean postoperative DNA fragmentation index was significantly higher in couples who did not conceive spontaneously or with assisted reproductive technique (p = 0.033). After varicocelectomy sperm parameters significantly improved and sperm DNA fragmentation was significantly decreased. Low DNA fragmentation index values are associated with a higher pregnancy rate (spontaneous and with assisted reproductive technique). We suggest that varicocelectomy should be considered in infertile men with palpable varicocele, abnormal semen analysis and no major female factors.

Insight into oxidative stress in varicocele-associated male infertility: part 2

Varicocele, the leading cause of male infertility, can impair spermatogenesis through several pathophysiological mechanisms. Of these, current evidence suggests that oxidative stress is the central element contributing to infertility in men with varicocele, to which the testis responds by way of heat stress, ischaemia or production of vasodilators, such as nitric oxide. Surgical varicocele repair (varicocelectomy) is beneficial not only for alleviating oxidative stress-associated infertility, but also for preventing and protecting against the progressive character of varicocele and its consequent upregulations of systemic oxidative stress. However, antioxidant therapy in infertile men with surgically treated and those with untreated varicocele is poorly studied, and well-designed trials are needed.

IJU this issue

Kazunori Kihara M.D., Ph.D. Associate Editor This issue, which covers a wide variety of meaningful topics, contains two Perspectives, one Review Article, seven Original Articles, two Short Communications, one Procedure and two Letters to the Editor. The Perspective, by Oya (Tokyo, Japan), concerns the eradication of cancer cells in advanced renal cell carcinoma. It emphasizes that elucidating the molecular phenotype of the resistant cancer cells is important in determining the molecules to be targeted, and that molecules involved in the epithelial-mesenchymal transition are candidates for targeting. The Perspective by Tanaka (Fukuoka, Japan) gives us a serious warning on the wide dissemination of multidrug-resistant Neisseria gonorrhoeae strains of sequence types 1407 and 2958. The effect of population-based screening on the incidence of prostate cancer, cancer stage and grade, cancer-specific mortality, and overall mortality remains controversial. The review by Lumen et al. (Ghent, Belgium) consists of an overview of available studies and a meta-analysis on population screening for prostate cancer, and they conclude that by excluding the main shortcomings in screening studies, screening is able to reduce prostate cancer mortality. Hinotsu (Kyoto, Japan) makes an Editorial Comment in response to this. In the first of seven Original Articles, Maru et al. (Sapporo, Japan) investigated the influence of baseline renal function and dose reduction of chemotherapeutic agents on the outcome of metastatic urothelial carcinoma patients with renal impairment. The data show that “unfit (baseline 24-h creatinine clearance <60 mL/min/1.48 m2)” is a poor prognostic factor and that dose reduction contributed to continuous treatment in the unfit group, although its contribution to the prognosis is uncertain. Canter (Atlanta, USA) makes an Editorial Comment on this article. Urinary proteome analysis for prostate cancer diagnosis, carried out by Schiffer et al. (Hannover, Germany), shows that it is a cost-effective application for use in routine clinical practice. The interesting finding that combined histoarchitectural and cytological biopsy grading improves grading accuracy in low-grade prostate cancer is reported by Helpap et al. (Singen, Germany). Liu et al. (Hangzhou, China) show through a meta-analysis that cruciferous vegetables intake is related to a decreased risk of prostate cancer, and Hori (Cambridge, UK) makes an Editorial Comment on this. The relationship between alcohol consumption and female urinary incontinence is investigated by Lee et al. (Perth, Australia), who observed only a weak association in middle-aged and older Japanese women. Hsieh (Taipei, Taiwan) makes an Editorial Comment in response to this. Li et al. (Kobe, Japan) report, based on a meta-analysis, that surgical varicocele repair significantly increases testosterone production and improves testicular Leydig cell function. Yamamoto et al. (Osaka, Japan) report that water avoidance stress induces frequency through cyclooxygenase-2 expression in a rat bladder model. In a Short Communication, the applicability of five published criteria for active surveillance for prostate cancer to Japanese patients was evaluated by Goto et al. (Yokohama, Japan), who concluded that they appear to be appropriate. An Editorial Comment on this is given by Suzuki (Tokyo, Japan). The additive effect of zoledronic acid on serum prostate-specific antigen changes was reported by Kamiya et al. (Chiba, Japan) in hormone-sensitive prostate cancer patients with bone metastasis treated by combined androgen blockade, which suggests a potential antitumor effect of zoledronic acid. In the Procedure, Furubayashi et al. (Fukuoka, Japan) describe cutaneous ureterostomy using the transverse mesocolon. In one Letter to the Editor, Guo et al. (Beijing, China) present clinical characteristics of malignant solitary fibrous tumors of the kidney with thoracic vertebral metastasis. In the other, Ito et al. (Yokosuka, Japan) show a case of struma testis with seminoma arising from an undescended testis, on which an Editorial Comment by Chen (Suzhou, China) is given. None declared.

Effect of surgical repair on testosterone production in infertile men with varicocele: A meta‐analysis

To determine the effect of surgical varicocele repair in improving testicular Leydig cell function as shown by increased testosterone production. Eligible studies were searched in Medline and the Pubmed database, and cross-referenced as of 31 May 2011 using the terms "varicocele,""testosterone" and "surgery." The database search, quality assessment and data extraction were independently carried out by two reviewers. Only studies including patients with testosterone evaluation before and after surgery were considered for the analysis. A systematic review and meta-analysis was carried out for continues variables using random effect models. Out of 125 studies, a total of nine were selected, including 814 patients. The combined analysis showed that mean serum testosterone levels after surgical treatment increased by 97.48 ng/dL (95% confidence interval 43.73-151.22, P=0.0004) compared with preoperative levels. Surgical treatment of varicocele significantly increases testosterone production and improves testicular Leydig cell function.

Clinical Characteristics and Surgical Outcomes in Adolescents and Adults with Varicocele

PurposeTo compare clinical characteristics and surgical results in adolescents and adults with varicocele.Materials and MethodsWe retrospectively analyzed the characteristics of 93 patients, 34 adolescents (mean age, 14.4±2.1 years) and 59 adults (mean age, 30.4±12.4 years), who underwent surgical repair of varicocele between 2006 and 2009. Median follow-up time in all patients was 18.7 months. The most bothersome symptoms, bilaterality, grades, surgical methods, artery-sparing rates, operation times, semen analysis, success rates, and recurrence-free period were compared between the two groups.ResultsThe overall success rate of surgical repair was 92.5%. The most bothersome symptoms were scrotal mass, pain, and hypotrophy in adolescents and pain, scrotal mass, infertility, and hypotrophy in adults (p=0.008). There were no significant between-group differences in bilaterality, grades, surgical methods, operation times, pre- or postoperative semen analyses, success rates, or recurrence-free periods. Patients who underwent artery-sparing surgery had higher recurrence rates than did those who underwent surgery that did not spare arteries. In adults, semen density increased significantly after surgery, from 35.6 million/ml to 49.6 million/ml (p=0.046).ConclusionsThere were no significant differences in clinical characteristics or surgical results between adolescents and adults with varicocele, except for the most bothersome symptoms. Semen density increased after surgery in both groups.

Decreased Sperm DNA Fragmentation After Surgical Varicocelectomy is Associated With Increased Pregnancy Rate

We prospectively evaluated changes in sperm chromatin structure in infertile patients before and after surgical repair of varicocele, and the impact on the pregnancy rate. Included in the study were 49 men with at least a 1-year history of infertility, a palpable varicocele and oligospermia. World Health Organization semen analysis and sperm DNA damage expressed as the DNA fragmentation index using the sperm chromatin structure assay were assessed preoperatively and postoperatively. Pregnancy (spontaneous and after assisted reproductive technique) was recorded 2 years after surgery. Mean sperm count, sperm concentration and sperm progressive motility improved significantly after varicocelectomy from 18.3 x 10(6) to 44.4 x 10(6), 4.8 x 10(6)/ml to 14.3 x 10(6)/ml and 16.7% to 26.6%, respectively (p <0.001). The DNA fragmentation index decreased significantly after surgery from 35.2% to 30.2% (p = 0.019). When the definition of greater than 50% improvement in sperm concentration after varicocelectomy was applied, 31 of 49 patients (63%) responded to varicocelectomy. After varicocelectomy 37% of the couples conceived spontaneously and 24% achieved pregnancy with assisted reproductive technique. The mean postoperative DNA fragmentation index was significantly higher in couples who did not conceive spontaneously or with assisted reproductive technique (p = 0.033). After varicocelectomy sperm parameters significantly improved and sperm DNA fragmentation was significantly decreased. Low DNA fragmentation index values are associated with a higher pregnancy rate (spontaneous and with assisted reproductive technique). We suggest that varicocelectomy should be considered in infertile men with palpable varicocele, abnormal semen analysis and no major female factors.

Hemodynamic results after surgical repair of varicocele

Hemodynamic results after surgical repair of varicocele