30: Varicocele

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Introduction

Varicocele is defined as an abnormal dilation of the pampiniform plexus which may cause pain, an atypical appearance, or impair fertility. These occur in approximately 15% of males, usually first appearing in adolescence, and are overrepresented in the sub-fertile population (approximately 35–49% of sub-fertile males).1 As per all varicose veins, the primary pathophysiology relates to incompetent venous valves, which are not able to force the blood back to the major vessels against gravity.2 Testicular veins are at risk due to their length, with the left vein more so due to its higher insertion at almost 90˚ and insertion at right angle into the left renal vein.3

Therefore, the vast majority of unilateral varicoceles occur on the left hemiscrotum, and historically, right sided varicoceles have been a hallmark of a large renal mass.

The association with infertility was first described in 1952 by Tulloch. It has been shown that varicoceles result in a progressive and time dependent decline in testicular function, which may be arrested with varicocelectomy.4,5

The exact pathophysiological cause of infertility is not known, and it is likely multifactorial. Increased oxidative stress is commonly described, however, hyperthermia, hypoxia, and reflux of metabolites are also commonly cited contributing factors.

Evaluation and Diagnosis

The majority of varicoceles in adolescents are identified incidentally by the patient or a primary care practitioner. Evaluation of a varicocele should include examination with the patient in both a supine and standing position. Visually inspect the scrotum for any signs of swelling and palpate the spermatic cord both at rest and during Valsalva maneuver.

Severity of varicoceles are measured on a grade 0 (subclinical, detected on ultrasound only) to grade 3 scale (Table 1).6 It is important to assess if there is a significant difference in testicular size, as this may be a surrogate for impaired spermatogenesis, and can be an indication for surgical intervention.7,8 Ipsilateral testicular hypotrophy is often associated with varicoceles, with rates as high as 80% with grade 3 varicoceles.9 The most sensitive assessment of testicular volume is scrotal ultrasound, common formulas used to calculate testicular volume include the Lambert formula (volume = length × width × height × 0.71) and the ellipsoid formula (volume = length × width × height × 0.52). A significant difference in testicular volume is calculated as a 10–20% difference or 2 to 3 mL difference in size for more than 6–12 month, especially in prepubertal patients.

Management: Surgical Intervention Versus Observation

The decision to treat adolescents with varicoceles remains controversial, as there is no significant evidence or longitudinal studies demonstrating a significant correlation between adolescent varicoceles and future fertility. Chu et al followed over 200 adolescent males with asymptomatic varicoceles for a median of three years with serial examinations and demonstrated that 2/3 developed normal semen parameters without surgical intervention.10 An analysis in 2013 looked at the proteomic profile in adolescents with and without varicoceles with both normal and abnormal semen parameters, and did not find a difference.11 This is in keeping with current European and American guidelines which advise serial examinations or scrotal ultrasounds for male adolescents with varicoceles who are currently asymptomatic and have no evidence of testicular hypotrophy.7,12

Relative indications for surgical repair of adolescent varicoceles include 1) high grade varicocele, 2) hypotrophic left testicle, 3) pain, and 4) abnormal semen parameters. Using abnormal semen parameters is most reliable in boys who are in Tanner stage V of puberty or are at least 18 years of age.7,8,10

Varicoceles and Fertility

One of the primary concerns parents have when their child is diagnosed with a varicocele, is the effect it may have on the boy’s future fertility. When examining infertility rates in adult males, the incidence of varicoceles in infertile males is as high as 50%. Recent studies have demonstrated that there are significantly higher rates of pregnancy amongst couples if men with clinical varicoceles undergo any method of surgical repair (42% pregnancy rate) as opposed to no surgical repair (17% pregnancy rate), but many studies have been less conclusive, including meta-analyses and Cochrane review.12,13,14,15,16 Additionally, the improvement of sperm motility and sperm concentrations in adults who undergo repair of their varicocele, has a more significant effect the higher the varicocele grade. Asafu-Adjei et al reviewed over 2000 men with abnormal semen parameters who underwent surgical repair of their varicocele. The mean improvement in sperm motility post-repair increased with each varicocele grade; with a 10% improvement in grade 1 varicoceles, and an 18% improvement in grade 3 varicoceles. Additionally, mean sperm concentrations improved by 5.5 million in grade 1 varicoceles, and by 16 million in grade 3 varicoceles.17

The adolescent decision making algorithm can be considered more complex, as the vast majority will not be attempting conception. Therefore, definitive indications for repair are lacking. Furthermore, it is difficult to assess sperm parameters in adolescents, as there are no semen quality standards based on Tanner stage and age. Furthermore, some cultures will not support semen collection. Asymmetry in testicular size can be used as a surrogate for function, but differential growth will often result in spontaneous equalization of their sizes. Additionally, when reviewing studies and trials examining sperm parameters in adolescents with varicoceles, there is significant heterogeneity present in the studies and follow up times are not long enough to determine any significant effect on future paternity. If adolescents do fit within the parameters for surgical repair as per current guidelines, the success rates are very high regardless of surgical technique. Silay et al concluded that success rates (disappearance of varicocele) ranged from 87–100% with testicular catch-up growth seen in 86–100% of patients. No surgical repair technique was superior, and the most common complication observed was formation of a hydrocele at rates of 0–12%.14

Table 1 Varicocele grading system1

Varicocele Grade	Description
0	Only detected on ultrasound, not palpable
1	Palpable only when standing and performing Valsalva
2	Palpable with patient standing without performing Valsalva
3	Visible when standing

Indications for Intervention

In the pediatric population, the vast majority of varicoceles can be observed and managed conservatively until an indication to intervene occurs. These indications include unilateral testicular hypotrophy >20% which persists over several (>3 examinations), bilateral testicular hypotrophy, significant symptoms, or abnormal semen analysis. Pain attributable to varicoceles is classically dull and achy in nature and occurs with prolonged periods of standing. Adolescents often have vague, chronic testicular pain, but this is usually readily differentiated from the varicocele. With many technical and technological advancements in the field since the first historical treatments, a variety of approaches currently exist for the surgical management of varicoceles.18

Repair Techniques

Endovascular Varicocelectomy

The radiographic endovascular technique is one approach which may be performed under local anesthetic and endovascular access is obtained with a small incision over the femoral vein. Occlusion of the internal spermatic vein and associated collateral vessels is performed with multiple coils or balloon occlusion.19 The reported success rates in contemporary literature range from 90–97% with a recurrence rate of 2–24%.20,21,22 Possible complications include hydrocele formation, inguinal hematoma, femoral vein thrombosis, and contrast allergy.23,24,25 Additionally, rare complications include coil migration into the heart and pulmonary vessels.26,27

Laparoscopic Varicocelectomy

Laparoscopy allows for excellent visualization of anatomic structures. This approach can be especially useful in experienced hands in a patient with bilateral varicoceles. Various port placement configurations have been described, however a supraumbilical camera, with the ipsilateral port -lateral to the epigastric vessels, and the other in the midline between the umbilicus and the pubic symphysis. Once access is gained and pneumoperitoneum is achieved, the spermatic cord is identified at the internal inguinal ring and then the spermatic veins can be isolated and ligated individually, or mass ligation (Palomo technique) of artery, lymph, and veins can be performed.28

Success rates of 85–100% have been reported.14 Recurrence rates ranging from 2.9% up to 17% have been described with additional possible complications consistent with laparoscopic surgery including injury to bowel, vessels, or other intra-abdominal structures, intra-abdominal infection, and air embolism.29,30,31,32 Reported rates of post-operative hydrocele formation range from 0–29% in contemporary literature.14 In order to minimize these rates, ligation of the testicular artery with preservation of lymphatics has been proposed with sufficient collateral arterial blood supply to preserve the teste via the cremasteric and deferential arteries.33

Inguinal Varicocelectomy

The traditional open inguinal or sub-inguinal approaches to varicocelectomy offer the advantages of greater experience and familiarity for most surgeons. The primary difference is the location of the ligation, which will either require opening the external oblique aponeurosis or performing the ligation just distal to the external ring, which may be less morbid. The inguinal approach exhibits a similar rate of success, recurrence, and hydrocele to the laparoscopic approach.14,18,32,34

In patients with significant prior inguinal surgery, a sub-inguinal approach may be advantageous by avoiding any significant scarring and adhesions that may be present. Significantly more vein branches and plexus are usually encountered more distally, however, and this can make the process of dissection and ligation more involved with arterial identification for preservation also being potentially more difficult.18

Microsurgical approaches offer high rates of success with a reported failure rate of 0.5–1% in appropriately trained hands, This approach requires more surgical time and requires highly specialized resources and training not present at all centers. However, it can minimize the risk of hydrocele formation by preserving lymphatics, and may have better improvements in improved sperm count and motility when compared to other approaches.14,18,32

Retroperitoneal Varicocelectomy

Through an open retroperitoneal approach, an incision is made at the level of the internal inguinal ring. The external and internal obliques are split which allows for retroperitoneal exposure of the internal spermatic vein near the ureter.35 This approach requires the ligation of the fewest number of veins, however, it does incur a higher risk of varicocele recurrence estimated at 15–30% in the setting of more distal collateral vessels, and a risk of postoperative hydrocele in up to 30% of cases. As with other approaches, by intentionally ligating the testicular artery and the network of periarterial veins, recurrence rates can be reduced.

Non-Operative Management

For the patients who choose not to undergo surgery, some follow up is required. Although no guidelines exist, Kolon et al recommend every 6–12-month clinical evaluation with semenanalysis through adulthood, although the manuscript admits this is required for long-term population data, and probably won’t affect individual outcomes. My personal practice is to assess with a history, physical exam, and ultrasound every 1–2 years until the age of 18 years.

Key Points

• Varicoceles are common, many are asymptomatic, and mostly occur on the left side
• Reasons for intervention include chronic pain, persistent size discrepancy, or fertility concerns
• There are many different techniques for repair, each with pros and cons

Conclusions

Varicoceles in the pediatric and adolescent population are relatively common, but management can be controversial. Surgery for unsatisfactory appearance is straightforward, and assuming the pain has been appropriately vetted, usually successful. However, the benefits of performing surgery to improve semenanalysis or to prevent fertility problems is harder to demonstrate. Therefore, upon making the diagnosis, the surgeon must weigh all indications and options to ensure successful results.

References

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