MODULAR COURSE IN PAEDIATRIC SURGERY

ADOLESCENT VARICOCELE

GUINEVA JP WILSON

AUGUST 2002
1.What are the theories of aetiology of varicocoele?

lack of valves in the left testicular vein:

post mortem study: left testicular vein contains no valves in 40% of specimens,
compared with absence of valves in 23% of right spermatic veins (1)
study of patients undergoing spermatic venography: absence of valves in the left
testicular vein documented in 484 of 659 patients undergoing venography for the
evaluation of idiopathic left varicocele before sclerotherapy) (5)

right angle entry of the left spermatic vein into the high pressure venous system of the left
renal vein (2)

long pressure column in pampiniform plexus creates poor venous return and varicose
distension of veins (3)

disruption of venous pump created by the coverings of the spermatic cord (4)

compression of the left renal vein between the superior mesenteric artery and the aorta (4)

extrinsic compression on the left testicular vein by a full sigmoid colon (4)

vascular spasm at the origin of the left testicular vein caused by adrenaline coming from
the left adrenal gland (4)

competent valves or absent insertions of the left spermatic vein at the typical point on the
left renal vein plus retrograde flow over persistent intercardinal anastomoses. (172 of 659
patients undergoing venography for the evaluation of idiopathic left varicocele before
sclerotherapy) (5)

renal vein stenosis (103 of 659 patients undergoing venography for the evaluation of
idiopathic left varicocele before sclerotherapy) (5)

dilation of the external spermatic vein: noted in 49.5 percent of 93 varicoceles in 67

patients (6)
2. What is the optimal time for surgical intervention?

operation in early adolescence may facilitate normal growth and development of the testis
testicular size in men with varicocoele compared with age matched
controls:
left side significantly smaller, and often right side also (7)
30 males age 8-18 years with clearly palpable left varicocele presenting as
asymptomatic scrotal mass or scrotal ache after physical exercise:
77 % the left testis was smaller than right
16/17 males age 8-15 years had a smaller left testis. (8)
20 males age 11-19 years with grade 2 or 3 varicocele and ipsilateral
testicular volume loss, asymptomatic and presenting at routine physical
examination
significant increase in volume of the testis ipsilateral to the
varicocele observed following varicocele ligation in 16/20 patients
(9)

early varicocele correction may prevent irreversible damage to testicular structure:

abnormal testicular histology occurs in infertile adult males in association
with unilateral varicocoele; changes include maturation arrest and
decreased spermatogenesis; abnormalities are bilateral, more marked on the
ipsilateral side (10)
testicular biopsy carried out in boys with varicocele demonstrates
essentially the same changes of tubules,interstitium and blood vessels seen
in adults, though in a less severe form (12)
severity of histological change is associated with persistent low sperm
count following operation
88 biopsies from 44 patients with varicocele and infertility;
separated into 4 groups with different pathophysiological
conditions.
Group 1: atrophy of the Leydig cells, decreased Leydig cell
ratio, low plasma testosterone, and normal luteinizing and
follicle-stimulating hormone levels; surgery resulted in a
significant improvement in sperm count.
Group 2: attempted repair of Leydig cells, normal Leydig
cell ratio, and normal testosterone, luteinizing hormone and
follicle-stimulating hormone plasma values.
Group 3: hyperplasia and increased Leydig cell ratio, high
luteinizing and follicle-stimulating hormone values, and
relatively high testosterone values.
Group 4: increased Leydig cell ratio but severe atrophy of
the Leydig cells and tubuli, indicating burned out testes with
high luteinizing and follicle-stimulating hormone but low
testosterone levels.

operation failed to increase the sperm count in the latter

groups. (11)
 abnormality detected on gonadotropin-releasing hormone stimulation studies may help
identify a group at risk for fertility problems and best managed by early varicocele
treatment
55 normal fertile men, 42 fertile men with varicoceles, and 24 infertile men
with varicoceles:
semen analyses, baseline serum testosterone and
gonadotropin levels and the gonadotropin response to
luteinizing hormone-releasing hormone (LH-RH)
measured
infertile men with varicoceles exhibited lower sperm
counts, abnormal sperm morphologic features, increased
baseline serum gonadotropins, and increased gonadotropin
responses to LH-RH, compared with normal fertile men
fertile men with varicoceles showed similar abnormalities,
although not statistically significant in all cases,
suggesting that the presence of a varicocele can be
associated with some degree of primary testicular
dysfunction, regardless of present fertility status (14)
15 adolescents 10-17 years old with a grade II-III left-sided varicocele:
gonadotropin response to LHRH stimulation evaluated
preoperatively and compared to histological findings from
bilateral testicular biopsies
abnormal left testicular histology was observed in 7 boys
(46.6%) but only 3 of them (20%) showed severe testicular
damage
good correlation was found between testicular injury and an
increased response of gonadotrophins to the
administration of LHRH. (15)

In summary, the evidence of improved testicular growth following varicocele repair

coupled with the potential for irreversible testicular damage in untreated varicocele
supports early surgical intervention.
The adolescent patient with varicocele may present with scrotal swelling, or may have the
varicocele detected at routine clinical examination (ie. Grade II or III varicocele). A large
symptomatic varicocele or evidence of impaired testicular growth in association with the
varicocele are clear indications for intervention at the time of diagnosis. In the otherwise
asymptomatic varicocele with no evidence of testicular growth impairment the use of Gn-RH
stimulation studies may be useful in identifying a group of patients with sub-clinical evidence
of testicular damage who can benefit from prompt surgical intervention. It should be noted
that the potential for future infertility and the inability to predict this absolute certainty, are
grounds for discussing with the patient and parents the option surgical intervention for a
grade II or III varicocele at the time of diagnosis.
3. Should prophylactic varicocele repair be performed to prevent future infertility?

progressive deterioration in spermatic quality is a recognised occurrence in males with

untreated varicocele
semen parameters in 13 men with varicocele presenting to an outpatient male
fertility clinic:
normal semen parameters were found at initial presentation, and re-
evaluated at a 9 to 96-month interval because of continued fertility
problems
semen parameters, especially sperm density, sperm mobility, and total
sperm demonstrated statistically significant deterioration from normal to
abnormal. (15)

treatment of varicocele appears to improve semen parameters

40 pubertal boys with varicocele; comparative followup study to evaluate
efficacy of surgical correction of varicocele in this age group in regard to
improvement of fertility after completion of sexual maturation.
varicocele corrected surgically in 24 patients and left uncorrected in 16
corrected patients: 16/24 testicular atrophy before surgical treatment, 7/24
atrophy after followup
uncorrected patients: 8/16 testicular atrophy noted at initial visit, 12/16
atrophy after followup.
semen examination of 23 corrected patients who had completed sexual
maturation: demonstrated higher quality of routine seminal parameters,
including sperm density, sperm motility and percentage of morphologically
normal spermatozoa, in the corrected group than in the uncorrected group
(17)

prospective controlled study of the effects of varicocele treatment on testicular

function; 88 adolescents: group 1 (n = 33) varicocele not treated, group 2 (n = 34)
varicocele treated, group 3 (n = 21) healthy volunteers without varicocele as a
control group
before treatment: mean left testis volume in groups 1 and 2 significantly
smaller than those in the control group
during follow-up: left testis volumes of treated group comparable with
those in the control group and significantly (P < 0.001) different from the
untreated group; significant increase in left (P < 0.01) and right (P < 0.05)
testis volume observed after treatment.
before treatment: semen parameters not significantly different between the
three groups.
during follow up: sperm concentration increased significantly (P < 0.01) in
the treated group; semen quality in the untreated and control groups did
not change. (18)
 A greater incidence of varicocele in males with secondary infertility versus primary
infertility reflects a progressive decline in fertility in males with varicocele
one thousand ninety-nine infertile men of whom 98 (9%) met with criteria for
secondary infertility.
varicocele palpable in 35% (352/1,001) of men with primary infertility and
81% (79/98) of men with secondary infertility; difference highly significant
men with secondary infertility and varicocele slightly older (37.9 versus
33.5 years), lower mean sperm concentration (30.2 versus 46.1 x
10(6)/mL), more abnormally shaped sperm (72% versus 40%), and higher
mean serum follicle-stimulating hormone levels (17.6 versus 7.9 mIU/mL,)
compared with men with primary infertility and varicocele.
findings suggest that varicocele causes a progressive decline in fertility and
that prior fertility in men with varicocele does not predict resistance to
varicocele induced impairment of spermatogenesis (16)

In summary, the deterioration in spermatic quality that may be noted in association with a
varicocele coupled with demonstrable improvement in semen parameters after correction
of a varicocele, supports prophylactic repair of varicocele to prevent future infertility.
Prophylactic repair on these grounds is further supported by the observation of a greater
incidence of varicocele in males with secondary infertility versus those with primary
infertility, indicating potential progressive fertility decline in males with varicocoele.
4. Currently, what is the best form of treatment for varicoceles?

comparison of inguinal approach, retroperitoneal approach with testicular artery

preservation and Palomo mass retroperitoneal ligation with respect to operative failure
rate, demonstrates superiority of the Palomo technique
102 varicocelectomies on 91 adolescents
varicocele persistence rate :16% with modified Ivanissevich inguinal approach
and 11% with high retroperitoneal technique with preservation of testicular artery;
Palomo mass high retroperitoneal ligation produced significantly better results
compared to the artery sparing techniques (19)

40 boys 9-16yrs; laparoscopic varicocelectomy with preservation of the testicular

artery
persistent varicocele 17%
hydrocele occurrence 12.5% (29)

ligation of testicular artery appears safe with regard to testicular atrophy, also in the
subpopulation of patients who have undergone previous inguinal surgery
102 varicocelectomies on 91 adolescents
inguinal vs. high approach with and without ligation of testicular artery
testicular atrophy did not occur in any patient regardless of the surgical technique
(19)

14 patients with unilateral varicocoele managed by laparoscopic clipping of

testicular vein and artery
no patients found to have testicular atrophy on clinical follow-up
doppler ultrasound follow up: no difference in arterial perfusion of the testes (20)

193 patients; open high ligation of the testicular veins (n=65) vs laparoscopic
varicocelectomy (n=128)
no incidence of testicular atrophy in any case, regardless of whether the testicular
artery was ligated or preserved during surgery (24)

44 patients laparoscopic Palomo varicocelectomy; both testicular artery and vein

ligated high above the internal ring
13 patients previous ipsilateral inguinal surgery: inguinal hernia repair (n=5),
orchidopexy (n=2), communicating hydrocele repair (n=3) previous varicocele
repair (n=3)
no patient developed ipsilateral testicular atrophy; testis size remained stable or
was associated with compensatory growth in all patients (23)
 preoperative assessment of venous flow patterns with color doppler ultrasound can refine
decision making with regard to best operative technique resulting in diminished operative
failure rate
79 patients; high ligation performed when reverse blood flow demonstrable in
varicocele during Valsalva maneuver (n=53), and low approach when absent
(n=26).
incidence of recurrence (3.8%) lower than that encountered by the same surgical
team prior to introduction of CDUS (20.5%) (P = 0.004) (22)

comparison of Palomo mass ligation with open vs. laparoscopic technique suggests
superiority of laparoscopic technique
654 patients operated for left-sided varicoceles; randomised surgical technique:
laparoscopic varicocelectomy 434 patients, open varicocelectomy 220 patients
both groups used Palomo's mass ligation technique modified to include
preservation of lymphatics
relapse rates and hydrocele occurrence not significantly different between groups
wound complications, analgesia requirement and post operative length of stay
significantly less in the laparoscopic population (21)

193 patients; open high ligation of the testicular veins (n=65) vs laparoscopic
varicocelectomy (n=128)
recurrence rate and hospital stay diminished in laparoscopic group, return to
normal activity earlier in laparoscopic group (24)

hydrocoele formation appears to occur more commonly using the Palomo technique than
with an inguinal approach; hydrocoele formation rate and recurrence rate may be
significantly diminished using microscopic surgical techniques in association with an
inguinal approach; active measures to preserve the lymphatic vessels during the Palomo
approach can also diminish hydrocoele formation rate
77 boys; 95 varicocelectomies; standard Palomo procedure (n=67) vs modified
Ivanissevich repair (n=28)
hydrocoele formation: Palomo 24% vs. Ivanissevich 14% (P=0.034) (25)

654 patients; Palomo's mass ligation technique modified to include preservation of

lymphatics; laparoscopic varicocelectomy 434 patients, open varicocelectomy 220
patients
hydrocele occurrence: 0.23% laparoscopic and 1.82% open (21)

640 varicocelectomies in 429 men using inguinal approach with microsurgical

technique
382 men available for followup examination from 6 months to 7 years
postoperatively: no hydroceles and no testicular atrophy
retrospective comparison with non-magnified and 2.5X loupe magnification
techniques performed by the same group demonstrated highly significant decrease
in the incidence of hydrocele formation and varicocele recurrence (p < 0.001). (26)

30 boys ;42 microsurgical varicocelectomies (12 bilateral)

persistent or recurrent varicoceles n=0; postoperative hydrocele n=1 (27)
 alternative "non-operative" approach is sclerotherapy; this may be retrograde or
antegrade; antegrade affords a higher success rate with regard to recurrent varicocele; of
further note is the ability to perform the procedure under local rather than general
anaesthesia
antegrade sclerotherapy; 65 patients 11-19yrs
varicocele recurrence 7.6%
hydrocele occurrence 1/65 (28)

In summary, currently the best form of treatment for varicocele accessible to the non-
microsurgeon appears to be high ligation with mass ligation of the testicular veins and
artery. This technique affords a low rate of varicocele recurrence or persistence, with the
theoretical complication of testicular atrophy in association with ligation of the testicular
artery appearing in practice not to occur, even in association with previous inguinal
surgery.
The complication of hydrocele formation, frequently seen following high mass ligation, may
be ameliorated by active preservation of the lymphatic vessels at the time of arterial and
venous ligation.
The access to the vascular pedicle for high ligation may be via an open retroperitoneal or a
laparoscopic approach. The literature appears to suggest superiority of the laparoscopic
approach, certainly with regard to wound outcome and analgesia requirements.
An inguinal approach to varicocele using the operating microscope gives a low rate of
varicocele recurrence and hydrocele formation, demonstrably superior to the inguinal
approach without such magnification. This approach is a valid alternative to high ligation for
the surgeon proficient in microsurgical technique.
Sclerotherapy offers a "non-operative" alternative, but with a relatively high recurrent
varicocele incidence. Incidence of hydrocele formation is low with this technique. A feature
that sets this technique apart and may make it attractive in certain patients and patient
populations is the ability to offer treatment without the need for general anaesthesia.
References

1. Ahlberg NE, Bartley O, Chidekel N: Right and left gonadal veins: an anatomical and
statistical study, Acta Radiol (Diagn) 4:517, 1966

2. Cromie WJ: Varicocele and other abnormalities of the testis. In Welch KJ, Randolph JG,
Ravitch MM, et al, editors: Paediatric Surgery, ed 4, Chicago, 1986, Year Book Medical
Publishers

3. Hutson JM: Undescended testis, torsion and varicocele. In O'Neill JA, Rowe MI, Grosfeld
JL, Fonkalsrud EW, Coran AG, editors: Paediatric Surgery, ed 5, 1998, Mosby

4. Skandalakis JE et al: The anterior abdominal wall. In Skandalakis JE, Gray SW, editors:
Embryology for Surgeons, ed 2, Baltimore, 1994, Williams & Wilkins

5. Braedel HU, Steffens J, Ziegler M, Polsky MS, Platt ML.A possible ontogenic etiology
for idiopathic left varicocele.J Urol.1994 Jan;151(1):62-6.

6. Chehval MJ, Purcell MH Varicocelectomy: incidence of external spermatic vein

involvement in the clinical varicocele. Urology.1992 Jun;39 (6):573-5.

7. Lipschultz LI, Correre JN Jr: Progressive testicular atrophy in the varicocele patient. J
Urol 1977 Feb;117(2):175-6.

8. Lyon RP, Marshall S, Scott MP. Varicocele in childhood and adolescence: implication in
adulthood infertility? Urology 1982 Jun;19(6):641-4

9. Kass EJ, Belman AB.Reversal of testicular growth failure by varicocele ligation.J Urol
1987 Mar;137(3):475-6

10. Ibrahim AA, Awad HA, El-Haggar S, Mitawi BA. Bilateral testicular biopsy in men with
varicocele. Fertil Steril. 1977 Jun;28(6):663-7

11. Hadziselimovic F, Leibundgut B, Da Rugna D, Buser MW.The value of testicular biopsy

in patients with varicocele. J Urol. 1986 Apr;135(4):707-10.

12. Hienz HA, Voggenthaler J, Weissbach L. Histological findings in testes with varicocele
during childhood and their therapeutic consequences.Eur J Pediatr. 1980 Mar;133(2):139-46.

13. Aragona F, Ragazzi R, Pozzan GB, De Caro R, Munari PF, Milani C, Glazel GP.
Correlation of testicular volume, histology and LHRH test in adolescents with
idiopathicvaricocele. Eur Urol. 1994;26(1):61-6.

14. Nagao RR, Plymate SR, Berger RE, Perin EB, Paulsen CA Comparison of gonadal
function between fertile and infertile men with varicoceles. Fertil Steril 1986 Nov;46(5):930-
3.

15. Chehval MJ, Purcell MH. Deterioration of semen parameters over time in men with
untreated varicocele: evidence of progressive testicular damage Fertil Steril 1992
Jan;57(1):174-7
16. Gorelick JI, Goldstein M. Loss of fertility in men with varicocele. Fertil Steril 1993
Mar;59(3):613-6

17. Okuyama A, Nakamura M, Namiki M, Takeyama M, Utsunomiya M, Fujioka H, Itatani H,

Matsuda M, Matsumoto K, Sonoda T. Surgical repair of varicocele at puberty: preventive
treatment for fertility improvement. J Urol 1988 Mar;139(3):562-4

18. Laven JS, Haans LC, Mali WP, te Velde ER, Wensing CJ, Eimers JM. Effects of
varicocele treatment in adolescents: a randomized study. Fertil Steril 1992 Oct;58(4):756-62

19. Kass EJ, Marcol B. Results of varicocele surgery in adolescents: a comparison of

techniques. J Urol 1992 Aug;148(2 Pt 2):694-6

20. Sun N, Cheung TT, Khong PL, Chan KL, Tam PK. Varicocele: Laparoscopic clipping and
color Doppler follow-up. J Pediatr Surg. 2001 Nov;36(11):1704-7.

21. Podkamenev VV, Stalmakhovich VN, Urkov PS, Solovjev AA, Iljin VP. Laparoscopic
surgery for pediatric varicoceles: Randomized controlled trial. J Pediatr Surg. 2002
May;37(5):727-9.

22. Nagar H, Mabjeesh NJ. Decision-making in pediatric varicocele surgery: use of color
Doppler ultrasound. Pediatr Surg Int. 2000;16(1-2):75-6.

23. Barqawi A, Furness P 3rd, Koyle M. Laparoscopic Palomo varicocelectomy in the

adolescent is safe after previous ipsilateral inguinal surgery. BJU Int 2002 Feb;89(3):269-72

24. Bebars GA, Zaki A, Dawood AR, El-Gohary MA. Laparoscopic versus open high ligation
of the testicular veins for the treatment of varicocele. JSLS 2000 Jul-Sep;4(3):209-13

25. Misseri R, Gershbein AB, Horowitz M, Glassberg KI. The adolescent varicocele. II: the
incidence of hydrocele and delayed recurrent varicocele after varicocelectomy in a long-term
follow-up BJU Int. 2001 Apr;87(6):494-8.

26. Goldstein M, Gilbert BR, Dicker AP, Dwosh J, Gnecco C. Microsurgical inguinal
varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique. J Urol
1992 Dec;148(6):1808-11

27. Lemack GE, Uzzo RG, Schlegel PN, Goldstein M. Microsurgical repair of the adolescent
varicocele. J Urol 1998 Jul;160(1):179-81

28. Mazzoni G. Adolescent varicocele: treatment by antegrade sclerotherapy. J Pediatr Surg.

2001 Oct;36(10):1546-50.

29. Cohen RC. Laparoscopic varicocelectomy with preservation of the testicular artery in
adolescents J Pediatr Surg 36:394-396, 2001