title: Effects of varicocele treatment in adolescents: a randomized study. The natural history of semen parameters in untreated asymptomatic adolescent varicocele patients: A retrospective cohort study. Varicocele and adolescents: semen quality after 2 different laparoscopic procedures. [Transumbilical single-site single-port versus single-site double-port laparoscopic varicocelectomy for varicocele in adolescents]. Laparoscopic surgery for pediatric varicoceles: Randomized controlled trial. Dye-assisted lymph vessels sparing laparoscopic varicocelectomy. Effects of varicocelectomy on testis volume and semen parameters in adolescents: a randomized prospective study. Repair versus observation in adolescent varicocele: a prospective study. Surgical comparison of subinguinal and high inguinal microsurgical varicocelectomy for adolescent varicocele. Shunt-type and stop-type varicocele in adolescents: prognostic value of these two different hemodynamic patterns.
abstract: OBJECTIVE To study the effects of varicocele treatment on  testicular function in adolescents . DESIGN A prospect i ve controlled study in 88 r and omly selected adolescents . SETTING All participants were referred to the fertility outpatient clinic of our university hospital . PARTICIPANTS All participants with a varicocele were r and omly assigned into two groups . Group 1 ( n = 33 ) was not treated , whereas group 2 ( n = 34 ) was treated . A similar group of healthy volunteers without a varicocele served as a control group ( group 3 , n = 21 ) . INTERVENTIONS  Testes volumes were measured at intake and during follow-up using an orchiometer .  Semen analysis was performed according to st and ard procedures both at intake and after 1 year of follow-up . Serum hormone levels were determined at intake using a radioimmunoassay . Treatment was performed by means of transcatheter embolization of the left testicular vein . MAIN OUTCOME MEASURES Testes volumes and semen quality at intake and after 1 year of follow-up were compared within and between the three groups . Hormonal parameters were determined at intake only . RESULTS Before treatment , the mean left testis volume in groups 1 ( n = 26 ) and 2 ( n = 27 ) ( 20.0 mL ; 95 % confidence interval [ CI ] : 18.2 to 21.8 and 21.6 mL ; 95 % CI : 19.4 to 23.8 , respectively ) were significantly smaller than those in the control group ( n = 19 ) ( 24.5 mL ; 95 % CI : 22.7 to 26.4 ) . During follow-up , left testis volumes of the treated group were comparable with those in the control group ( 24.2 mL ; 95 % CI : 22.2 to 26.1 and 24.8 mL ; 95 % CI : 23.0 to 26.7 respectively ) and significantly ( P < 0.001 ) different from the untreated group ( 20.3 mL ; 95 % CI : 18.8 to 21.8 ) . A significant increase in left ( P < 0.01 ) as well as right ( P < 0.05 ) testis volume was observed after treatment . Semen parameters before treatment were not significantly different between the three groups . Sperm concentration increased significantly ( P < 0.01 ) from 47.4 x 10(6)/mL ( 95 % CI : 42.5 to 53.3 ) to 68.9 x 10(6)/mL ( 95 % CI : 50.6 to 87.2 ) in the treated group , whereas semen quality in the untreated and control groups did not change . Although both testes volumes and sperm concentration improved in the treated group , these phenomena were not consistently correlated to each other . CONCLUSIONS Although not apparent in all adolescents , varicocele correction result ed in an increase in left testis volume and sperm concentration . At this moment , it is not clear if early preventive treatment of varicocele in adolescents , in time , will have a positive effect on testicular function INTRODUCTION Adolescent males with varicoceles present a dilemma for surveillance and treatment . Testicular volumetrics have not been shown to predict SA outcomes . Serial SAs are thus recommended in asymptomatic adolescent males with varicoceles and normal testicular development , but the natural history of semen parameters is unknown . OBJECTIVE To explore the natural history of semen parameters in adolescent boys with a left varicocele under active surveillance . STUDY DESIGN Adolescents with an asymptomatic unilateral left varicocele , Tanner V development , normal testicular volumes , and an initial SA were retrospectively review ed in a single-institution prospect ively followed cohort .  Total motile count ( TMC ) was calculated . A cutoff of TMC Z 20 million was used to dichotomize SA results into " normal " or " poor . " Those with poor SA were offered repeat SA . Cumulative probabilities of normal TMC over successive rounds of SA were calculated . Bivariate models were used to explore associations of a second consecutive poor TMC with age and varicocele grade . RESULTS A total of 216 patients provided an initial SA between 1992 and 2015 . We excluded 17 for a history of cryptorchidism or incomplete SA data for a final cohort of 199 patients with median follow-up of 3.3 years ( interquartile range 1.5 - 5.6 years ) . The  mean age at initial SA was 17.9 years ( range 14.8 - 21.8 years ) . One hundred and nine out of 199 had an initial normal TMC . Of the 90 out of 199 with an initially poor TMC , 51 had repeat SA and 24 of the 51 patients improved to normal TMC . Of the 27 patients with two consecutive poor TMCs , 15 had a third SA and five out of 15 improved to normal TMC . Thus , cumulatively , 55 % , 67 % , and 69 % of all patients had a normal TMC after an initial , second , and third SA , respectively . However , fewer patients in each round of SA normalized their TMC ( Figure ) . Neither age nor varicocele grade was associated with a second consecutive poor TMC . DISCUSSION Two-thirds of Tanner V boys with an uncorrected varicocele and normal testicular volumes achieve a normal TMC regardless of varicocele grade or age . Despite Tanner V development , 47 % with an initial " poor " SA will improve to normal status without surgery . However , a small subgroup of patients will have persistently poor TMC and thus should be targeted in future research for timely intervention . CONCLUSION Semen parameters improve over time . SA should be followed and repeated at least once in symptomatic Tanner V boys with varicoceles The aim of this prospect i ve study was to assess long-term functional results ( spermiograms ) in subjects who underwent laparoscopic varicocelectomy via either of 2 procedures ( ligation or preservation of testicular artery ) . A total of 122 patients underwent laparoscopic varicocelectomy performed via either of the 2 different procedures : complete ligation of the spermatic vessels or preservation of the spermatic artery . After surgery when patients achieved 18 years , they were asked to undergo semen analysis . Spermiogram results were divided into 2 subgroups : " normal " and " abnormal . " We analyzed volume , sperm count per mL , percentage of motile spermatozoa , percentage of normal spermatozoa , and percentage of vitality for each group . Both groups showed the same results in terms of " normal " and " abnormal " spermiograms ( World Health Organization criteria ) , but analysis showed higher sperm concentration per mL , sperm motility , volume , vitality , and rate of morphologically normal sperm for the group with arteries preserved and " normal " spermiograms ( P < .01 ) . Analysis of data from the spermiograms showed that preservation of the testicular artery was the best possible option in terms of semen quality . Therefore , we believe that surgical treatment of varicocele should be carried out using procedures involving artery preservation OBJECTIVE To compare the effect of transumbilical single-site single-port with that of transumbilical single-site double-port laparoscopic varicocelectomy in the treatment of varicocele in adolescents . METHODS We r and omly assigned 80 varicocele patients aged 10 - 16 years to two groups of equal number to receive transumbilical single-site single-port and single-site double-port laparoscopic varicocelectomy , respectively . We compared the operation time , postoperative hospital stay , incisional pain , complications and satisfaction with the abdominal cosmetic outcomes between the two groups . RESULTS All the operations were successfully performed . The double-port group showed a significantly higher score on the Visual Analogue Scale than the single-port group ( 4.8 + /- 1.4 vs 3.6 + /- 1.1 , t = -4.986 , P < 0.01 ) , but there were no significant differences between the two groups in the operation time ( [ 29.8 + /- 4.2 ] vs [ 31.2 + /- 4.6 ] min , t = 1.383 , P = 0.171 ) , postoperative hospital stay ( [ 1.95 + /- 0.7 ] vs [ 1.82 + /- 0.8 ] d , t = -0.784 , P = 0.436 ) , complications ( 0 vs 0 ) and scores on the satisfaction with abdominal cosmetic outcomes ( 4.6 + /- 0.6 vs 4.8 + /- 0.5 , t = 1.253 , P = 0.214 ) . No recurrence , umbilical hernia , hydrocele and orchiatrophy were found in the two groups of patients at 6 months after operation , and no visible scar was observed on the abdominal surface . CONCLUSION With strict surgical indications , single-site single-port and single-site double-port laparoscopic varicocelectomies have similar clinical effects in the treatment of varicocele , which leave no scar on the abdominal surface . Single-site double-port laparoscopy needs no special instruments and therefore is worthier of wide clinical application BACKGROUND / PURPOSE The purpose of this investigation was to evaluate the advantages and the shortcomings of laparoscopic varicocelectomy compared with open traditional treatment of varicoceles . METHODS A total of 654 patients were operated on for left-sided varicoceles over 5 years from 1995 to 2000 . To evaluate the clinical efficiency of the treatment , the patients were divided r and omly into 2 groups . Laparoscopic varicocelectomy ( LV ) was performed on 434 patients , and  open varicocelectomy ( OV ) in 220 patients . Outcome data looked at relapse rate , presence of hydrocele , wound complications , and testicular or scrotal edema . Operating time , postoperative length of stay , and pain control also were compared . In both groups , the operations were performed by Palomo 's technique with preservation of lymphatics and mass ligation of the artery and veins in the retroperitoneum above the internal inguinal ring . RESULTS In LV versus OV , relapse rates were 1.84 % versus 1.36 ( P < 0.5 ) , hydrocele occurrence was 0.23 % versus 1.82 % ( P < 0.1 ) , wound complication was 0.23 % versus 7.73 % , and testicular or scrotal edema was 3.9 % versus 13.1 % . LV hospital stay was an average of 3 days versus 7 days for OV . Operating time was 15 minutes for LV versus 26 minutes in open . Postoperative analgesic use was almost cut in half with LV . CONCLUSION The clinical efficacy of LV is superior to traditional OV OBJECTIVE Hydrocele , the main complication of laparoscopic varicocelectomy , is thought to result from a disruption of gonadal lymphatics . The aim of this study was to evaluate the effectiveness of patent blue V dyeing to identify and preserve lymphatic vessels and to assess whether the lymphatic sparing technique avoids postoperative hydrocele in adolescent boys undergoing a laparoscopic procedure . MATERIAL S AND METHODS Fifty-two ( 52 ) boys affected by varicocele Grade III ( range , 12 - 16 years ) underwent a left-sided laparoscopic varicocelectomy . Twenty-six ( 26 ) boys were r and omly assigned to a lymphatic nonsparing ( LNS ) group , and the others to a lymphatic sparing ( LS ) group . Before surgery in the LS group , 2 mL of patent blue V was injected under the tunica dartos on the left side . RESULTS All varicocelectomies were performed laparoscopically . Lymphatic vessels were identified in 23 ( 88.5 % ) boys of the LS group . In the remaining three ( 11.5 % ) , the lymphatics could not be identified clearly . No adverse local or generalized reactions were noted . At a mean follow-up of 14 months , no recurrent varicocele or testicular volume reduction were detected . Hydrocele developed in 4 LNS patients and 1 was operated on . No patient from the LS group developed a hydrocele . CONCLUSIONS Staining gonadal lymph vessels with patent blue V is an effective and simple method of visualization of the lymphatic drainage from the testis . Blue-stained lymph vessels could be readily distinguished and preserved during a laparoscopic varicocelectomy , which results in a decrease of hydrocele development . To vali date an efficacy of vital staining of lymphatic vessels in avoiding hydrocele formation , a larger series and longer follow-up are necessary Because the treatment of a varicocele in adolescents remains controversial , we undertook a prospect i ve study in 51 male adolescents , aged 15 - 21 years , who were referred for a varicocele . Twenty-nine patients were treated with high retroperitoneal ligation of the left spermatic vein , and 22 were untreated . Eighteen healthy adolescent volunteers without a varicocele were also assessed .  Testicular volume was measured using an orchiometer , and semen analyses were carried out at referral and after 1 year of follow-up . In addition , serum luteinizing hormone ( LH ) , follicle-stimulating hormone ( FSH ) and testosterone levels were estimated by radioimmunoassay . Both patient groups had significantly smaller testis volumes than the controls at the outset . In the follow-up , the treated patients had testis volumes similar to those of the controls . Both testes increased significantly in volume after treatment . Although semen parameters were comparable in all groups initially , sperm concentration increased significantly after treatment of the varicocele . We concluded that varicocele treatment in adolescents leads to increased testis volume and a higher sperm concentration ; however , whether early treatment will improve testicular function remains to be eluci date PURPOSE We design ed a r and omized prospect i ve study of male adolescents with moderate and severe varicoceles to determine whether prophylactic varicocele repair is beneficial . MATERIAL S AND METHODS We evaluated 2,100 boys ( 10 to 20 years old ) for genitourinary abnormalities . From this population 2 groups of adolescents 15 to 19 years old with grade 2 or 3 varicoceles were created , including 88 who underwent varicocele repair and 36 controls .  Testicular volume and pampiniform vein diameter were measured , and Doppler ultrasound was performed . RESULTS After 12 months volume of the involved left testis increased to almost normal in treated boys ( mean atrophy index 12.7 % at surgery and 3 % 12 months later ) . In controls the corresponding atrophy indexes were 10 and 9 % , respectively . The relative increase in left testicular volume was 26 % in the surgery group and 11 % in controls . In the surgery group mean pampiniform vein diameter decreased from 2.8 preoperatively to 2 mm . postoperatively but there was no change in controls . CONCLUSIONS Varicocele repair in adolescents with moderate and severe varicocele reversed testicular growth arrest and result ed in catch-up growth within 12 month of surgery OBJECTIVE To compare the surgical outcomes of subinguinal and high inguinal approaches for microsurgical varicocelectomy . METHODS A total of 81 patients with left varicocele were r and omly assigned to undergo  microsurgical left varicocelectomy by the subinguinal ( n = 41 ) or high inguinal ( n = 40 ) approach . These two techniques were compared with regard to the operative parameters , complications and testicular growth . Anatomical parameters , including the numbers and diameters of internal spermatic arteries , veins and lymphatic vessels , were recorded . RESULTS The microsurgical step was significantly shorter for the high inguinal approach compared with the subinguinal approach ( 25.5 vs 33.3 min , respectively , P < 0.01 ) . The numbers of preserved arteries and ligated veins were significantly greater and the artery size was significantly smaller for the subinguinal ( 1.6 arteries , 11.5 veins and 1.1 mm , respectively ) compared with the high inguinal approach ( 1.2 arteries , 7.3 veins and 1.3 mm ; P < 0.001 , < 0.0001 and < 0.01 , respectively ) . There was one patient with postoperative hydrocele , and three with persistent scrotal pain after treatment with the subinguinal approach . The postoperative catch-up growth rates at 24 months were 70 % and 78 % for the subinguinal and high inguinal approaches , respectively . CONCLUSIONS The microsurgical subinguinal and high inguinal approaches seem to yield similar success rates in terms of testicular growth . However , the high inguinal approach is easier to carry out , as it requires fewer divisions of veins and is associated with a larger diameter of the spermatic artery OBJECTIVE To investigate different varicocele hemodynamic patterns ( shunt type vs. stop type ) as predictors of new-onset testicular hypotrophy or recurrence after varicocelectomy . DESIGN Prospect i ve clinical study . SETTING Department of pediatric urology , children 's hospital medical center . PATIENT(S ) Seventy-four children and adolescents with varicocele . INTERVENTION(S ) Based on ultrasound findings , patients were classified into shunt-type or stop-type varicocele groups . All patients with stop-type varicocele and testicular volume discrepancy of ≥20 % underwent retroperitoneal varicocelectomy and internal spermatic vein ligation .  Patients with shunt-type varicocele and ≥20 % testicular asymmetry were r and omly divided to undergo either retroperitoneal varicocelectomy ( ligation of internal spermatic vein ) or inguinal varicocelectomy with ligation of both internal and external spermatic veins . Patients with testicular volume discrepancy of < 20 % were put on conservative management . MAIN OUTCOME MEASURE(S ) Occurrence of new-onset asymmetry among untreated patients and recurrence rate among operated patients . RESULT ( S ) Patients with shunt-type varicocele who did not undergo surgery revealed a higher risk of developing asymmetry during follow-up ( odds ratio 10.5 ) . Ligation of both internal and external spermatic veins in shunt-type patients was associated with significantly decreased rate of recurrence ( 6.3 % ) compared with retroperitoneal approach ( 30.8 % ) . CONCLUSION ( S ) Shunt-type varicocele is associated with a higher risk of testicular hypotrophy among untreated patients . In addition , recurrence rate in shunt-type patients who underwent inguinal varicocelectomy was lower compared with retroperitoneal approach
target: Based on current available r and omized controlled trials , there is low to moderate level of evidence that radiological or surgical treatment of adolescent varicocele is associated with improved testicular size/growth and sperm concentration .
background: BACKGROUND The prevalence of varicoceles is as high as 15 % in children and adolescents .
  Optimal management of varicoceles has not been consoli date d. Options include observation , radiological intervention , or surgical varicocelectomy .
  OBJECTIVE Herein , we aim to assess the outcomes of radiological and surgical interventions for varicocele in children and adolescents evaluated by RCTs .