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PubMed2003

[A transbranchial approach for the percutaneous therapy of pediatric varicocele].

PURPOSE: Male varicocele affects children with the same incidence as it does adults. The association between asymptomatic idiopathic varicocele and male infertility and the poor recovery of testicular function after varicocele repair in adulthood have called for noninvasive clinical and instrumental diagnosis and increasingly early treatment. The department of Pediatric Surgery at our Hospital has screened schoolchildren for the early diagnosis and treatment of childhood varicocele. Our Vascular and Interventional Radiology department has proposed percutaneous treatment for varicocele correction. We report our 10-year experience with percutaneous sclerotherapy of pediatric varicocele with a retrograde transbranchial approach. MATERIALS AND METHODS: From a screening programme involving schools 467 boys were selected who were positive for idiopathic varicocele at clinical examination and at Doppler CW, at rest and during Valsalva manoeuvre. Patients with grade III, or symptomatic grade II varicocele, testicular hypotrophy, or with a dilation of the testicular veins greater than 2.2 mm at baseline were referred for percutaneous treatment. Percutaneous treatment was performed with a transbrachial approach in the basilic vein. After searching for incontinence of the internal right spermatic vein, left renal phlebography was performed in order to identify any incontinence of the left spermatic vein. This vein was then selectively catheterised to perform sclerosis. Tungsten coil embolisation was also performed over a number of years. Follow-up consisted of clinical examination, Doppler CW, Doppler US, or colour Doppler US performed at 3, 6, and 12 months. RESULTS: The radiological procedure was only diagnostic in 78 cases (16.7%). Basilic vein spasm and collaterally-supplied varicocele forced us to discontinue the procedure. The use of materials with smaller diameters and the professional development of the radiological team helped improve the catheterisation rate with time. Using the transbrachial approach alone a total of 287 left-sided, 15 right-sided and 52 bilateral varicoceles were treated. Whereas in two cases of bilateral varicocele a dissection at the origin of both spermatic veins prevented the use of sclerotherapy--though the patients were found to be cured at follow-up with Doppler US--on the left the procedures were continued with a transfemoral approach due to difficulties with the transbrachial catheterisation. As for the left-sided varicoceles, sclerosis were performed in 230 procedures, whereas sclerosis and embolisation on 87 patients. The success rate was 92% for sclerosis, and 86% for sclerosis and embolisation. No major complications were observed. DISCUSSION: Percutaneous treatment is a minimally invasive and relatively non-traumatic interventional radiology procedure, able to confirm the presence of varicocele, accurately map the venous system and allow selective therapy. Our experience with 467 patients over 10 years has allowed us to compare two therapeutic options: sclerosis and sclerosis combined with embolisation. CONCLUSIONS: Percutaneous treatment of varicocele with the transbrachial approach proved to be a safe, effective, inexpensive, and minimally invasive procedure. It can be suggested as the first therapeutic option for varicocele correction, especially for boys and for bilateral forms.

Adolescent↗
PubMed2004

Does varicocele grade predict vein number and size at microsurgical subinguinal repair?

OBJECTIVES: To correlate the varicocele grade on physical examination with the number and size of the veins present and ligated during surgery. Varicoceles are correctable causes of male factor infertility. No prior anatomic studies have correlated the preoperative clinical grade of a varicocele with the number of veins discovered and ligated during microsurgical subinguinal repair. METHODS: A total of 65 consecutive men (mean age 33.8 years) diagnosed during office evaluation with either unilateral left varicocele or bilateral varicoceles underwent microsurgical subinguinal varicocelectomy by one urologist. At surgery, the number and size (small, less than 1.0 mm; medium, 1.0 mm or greater to less than 4.0 mm; large, 4.0 mm or greater) of the spermatic cord veins present and ligated were recorded. These findings were correlated with the size of the preoperative varicocele grade. RESULTS: Of the 71 varicocele units, 65 qualified for analysis. Of the patients with a grade 1 varicocele, a mean (+/-SD) of 2.4 (+/-2.5) small veins, 4.7 (+/-2.1) medium veins, 0.3 (+/-0.58) large veins, and 7.5 (+/-3.0) total veins were ligated. Of patients with a grade 2 varicocele, a mean of 2.6 (+/-2.3) small veins, 5.3 (+/-3.1) medium veins, 0.47 (+/-0.78) large veins, and 8.3 (+/-3.2) total veins were ligated. Of patients with grade 3 varicoceles, a mean of 1.8 (+/-1.8) small veins, 4.6 (+/-2.3) medium veins, 1.0 (+/-0.75) large veins, and 6.9 (+/-2.6) total veins were ligated. Using analysis of variance, the grade 3 varicoceles had significantly more large veins than did grade 1 varicoceles (P <0.05). CONCLUSIONS: Grade 3 varicoceles have a greater number of large veins compared with grade 1 varicoceles.

Adolescent↗
PubMed2005

Inheritance of varicoceles.

OBJECTIVES: To evaluate the inheritance of varicoceles through examination of first-degree relatives of patients with known varicoceles. METHODS: A total of 44 patients with a known varicocele had available first-degree relatives (n = 62) examined for the presence of a varicocele between October 1997 and November 2003. An additional cohort of 263 men presenting for vasectomy reversal without a history of subfertility or varicocele was used as the control group. Varicocele grade and the presence of bilateral varicoceles were examined as predictive factors for inheritance. RESULTS: Of the 62 first-degree relatives of patients with a known varicocele, 35 (56.5%) had a clinically palpable varicocele on physical examination. This was significantly greater than the 18 (6.8%) of 263 men in the control group (P < 0.0001). Of the first-degree relatives, 20 (74%) of 27 brothers, 13 (41%) of 32 fathers, and 2 (67%) of 3 sons had palpable varicoceles. Neither varicocele grade nor bilaterality was predictive of inheritance in these first-degree relatives. CONCLUSIONS: The increase in varicocele prevalence is significant in the first-degree relatives (particularly brothers) of patients with known varicoceles. Given the detrimental effect of varicoceles on spermatogenesis and steroidogenesis, patients should be counseled about this increased risk in male family members.

Adolescent↗
PubMed1994

Varicocele related testicular atrophy and its predictive effect upon fertility.

Varicoceles are the most common reversible cause of male factor infertility, yet approximately 80% of men with varicoceles are fertile. Therefore, it is unclear whether all adolescents should undergo prophylactic varicocelectomy to prevent future infertility or whether a subgroup of patients who are at increased risk for future infertility can be identified and treated. Testicular size discrepancy or hypotrophy of the testis associated with a unilateral varicocele has been suggested as an indication for prophylactic varicocelectomy in adolescents. We examined 946 men attending a urological clinic for complaints other than infertility to determine whether testis size discrepancy was predictive of infertility in men with left varicoceles. A left varicocele was detected on physical examination in 211 men, of whom 173 (82%) had been able to father children and 38 (18%) had never fathered children. A group of 630 men without palpable varicoceles served as controls, including 528 (84%) with a history of fertility. Testicular size was measured using an orchidometer and the average testicular volume difference was obtained by subtracting left from right testicular volume. The mean testicular volume difference for the fertile men without varicoceles (1.6 +/- 0.3 ml.) was significantly lower than the fertile men with varicoceles (3.1 +/- 0.4 ml.) (p < 0.05) and infertile men with varicoceles (2.5 +/- 0.6 ml.) (p < 0.05). There was no significant difference between fertile and infertile men with varicoceles. This study confirms prior reports that the majority of men with left varicoceles are able to father children and that varicoceles cause significant ipsilateral testicular atrophy/hypotrophy. However, we were unable to demonstrate a correlation between loss of testicular volume and fertility status in men with left varicoceles. Further study is needed to identify the clinical parameters predictive of future infertility in adolescents with varicoceles.

Adolescent↗
PubMed1993

Relationship between varicocele size and response to varicocelectomy.

We studied the relationship between varicocele size and response to surgery in 86 men with a unilateral left varicocele who reported either infertility (83), pain (1) or pain and testicular atrophy (2). Varicoceles were graded according to size: grade 1--small (22 patients), grade 2--medium (44) and grade 3--large (20). Sperm count, per cent motility, per cent tapered forms and fertility index (sperm count times per cent motility) were measured preoperatively and postoperatively. Preoperatively, men with grade 3 varicocele had lower sperm counts and poorer fertility indexes compared to men with grades 1 and 2 varicocele. Sperm concentration improved significantly in men with grade 2 (33 +/- 5 million per cc preoperatively to 41 +/- 6 million postoperatively, p < 0.04) and grade 3 (18 +/- 5 million preoperatively to 32 +/- 7 million postoperatively) varicocele after microsurgical ligation of the varicocele. Motility improved significantly in men with grade 3 varicocele. Decrease in per cent tapered forms was significant in all groups. A comparison of per cent change in fertility index among the groups revealed that men with grade 3 varicocele improved to a greater degree (128%) than men with grade 1 (27%) or grade 2 (21%) varicocele. Pregnancy rates 2 years postoperatively were 40% for grade 1, 46% for grade 2 and 37% for grade 3 varicocele patients. The difference in pregnancy rates among the groups was not statistically significant. In conclusion, infertile men with a large varicocele have poorer preoperative semen quality but repair of the large varicocele in those men results in greater improvement than repair of a small or medium sized varicocele.

Adult↗
PubMed1995

Comparative study between scrotal physical examination and scrotal ultrasonography in the detection of varicocele in men with infertility.

From September 1989 to March 1991, we evaluated 110 men from our infertility clinic to determine the correlation between scrotal physical examination and scrotal ultrasonography in the detection of varicocele in men seeking clinical evaluation for infertility, depicting scrotal ultrasound as the gold standard. Of 110 men with infertility, clinically palpable varicocele was found in 40 patients (36.36%). Fifteen were of grade 1, nineteen of grade 2 and four of grade 3. Of these 40 patients, 32 (80%) had left sided varicocele 2 (5%) had right sided varicocele and the remaining 6 patients (15%) had bilateral varicoceles. Of the 40 patients with clinically palpable varicocele, 34 (85%) had the diagnosis confirmed by scrotal ultrasound. Of these 34 patients who had varicocele diagnosed by scrotal ultrasound, 17 (50%) had varicocele on the left side, 1 (2.94%) had varicocele on the right side and the remaining 16 patients (47.07%) had bilateral varicoceles. Seventy patients in whom initial scrotal physical examination failed to detect varicocele, 12 (17.14%) were found to have varicocele by scrotal ultrasound, all of which were on the left side. This group of patients was classified as subclinical varicocele. Statistical analysis revealed that scrotal physical examination in the detection of clinical varicocele has sensitivity of 73.90 per cent, specificity of 90.60 per cent and positive predictive value of 85.00 per cent with negative predictive value of 82.80 per cent.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2000

The role of reactive oxygen species in testicular dysfunction associated with varicocele.

OBJECTIVE: To determine the level of malondialdehyde (MDA), an indirect indicator of lipid peroxidation-induced injury by reactive oxygen species, in testicular biopsy specimens from infertile patients with and without varicocele. PATIENTS AND METHODS: Levels of MDA were measured in the testicular biopsy specimens from 25 infertile men (15 with varicocele, mean age 30.0 years, SD 5.7, range 23-45, and 10 without, mean age 28.7 years, SD 4.2, range 21-34). All patients were evaluated by a detailed history, physical examination, semen analysis (at least twice), serum follicle-stimulating hormone and free testosterone levels, testicular biopsy and contact imprint. Scrotal colour Doppler ultrasonography was used to confirm suspected varicocele. The level of MDA in testicular biopsy specimens was measured using the thiobarbituric acid test and the results expressed per unit tissue weight. RESULTS: As a causal factor for infertility, varicocele was identified in 15 men (60%), testicular failure in four (16%), idiopathic infertility in four (16%) and obstruction in two (8%). Of the 15 patients with varicocele, eight had bilateral varicocele and it was subclinical in three; the varicocele was grade I in four, grade II in six and grade III in two. The mean (SD) MDA level in the men with a subclinical varicocele was 15.7 (3.1) pmol/mg tissue, while in those with grade I-III varicocele it was 32.9 (12.25), 37.1 (12.25) and 86.9 (2.89) pmol/mg tissue, respectively. The levels in patients with grade III varicocele were significantly greater than in the other groups (P < 0.05). The mean MDA level in patients with or without varicocele was 38.3 (22.92) and 33.5 (18.93) pmol/mg tissue, respectively (P > 0.05). CONCLUSION: These results suggest that increasing levels of MDA are associated with higher grades of varicocele and support a possible rationale for controlled trials in infertile men with varicocele.

Adult↗
PubMed2001

Varicocelectomy improves intrauterine insemination success rates in men with varicocele.

PURPOSE: We determined whether varicocele treatment before intrauterine insemination significantly affects intrauterine insemination success rates. MATERIALS AND METHODS: A total of 58 infertile couples, of whom the women had normal evaluations and men had abnormal semen analyses and a history of varicocele, were included in this study. They were identified after reviewing the charts of all women undergoing intrauterine insemination for male factor infertility at our center. Of the men 24 participated in 63 intrauterine insemination cycles without varicocele treatment, while in the remaining 34 varicocele was treated before a total of 101 intrauterine insemination cycles. Variables associated with pregnancy or live birth were analyzed using repeat measures logistic regression with generalized estimating equation techniques. An initial stepwise generalized estimating equation was performed without including varicocele treatment status. Subsequently varicocele treatment status and the significant associated factors were included in analysis. The semen characteristics of untreated and treated varicocele groups were compared with repeat measures analysis of variance. RESULTS: On pre-wash semen analysis patients with untreated varicocele had significantly higher mean motility plus or minus standard error than patients whose varicoceles were treated (48.6% +/- 2.3% versus 38.1% +/- 1.8%, p = 0.02). However, no statistically significant difference was noted in the mean post-wash total motile sperm count in the treated and untreated groups (7.2 +/- 1.0 versus 14.8 +/- 2.6, p = 0.1). Despite these findings the pregnancy and live birth rates per cycle were significantly higher in patients in whom varicocele was treated than in those without varicocele treatment (11.8% versus 6.3%, p = 0.04 and 11.8% versus 1.6%, p = 0.007, respectively). CONCLUSIONS: Varicocele treatment may not improve semen characteristics in all men but it appears to improve pregnancy and live birth rates among couples undergoing intrauterine insemination for male factor infertility. A functional factor not measured on routine semen analysis may affect pregnancy rates in this setting. Men should be screened for varicocele before intrauterine insemination is initiated for male factor infertility.

Female↗
PubMed2005

Color Doppler sonography in the intratesticular varicocele.

OBJECTIVE: We describe and discuss clinical and color Doppler ultrasound findings of intratesticular varicocele. MATERIAL AND METHODS: Since 1998 we evaluated 295 patients diagnosed with varicocele by scrotal color Doppler sonography Routine andrological assessment has entailed grading the varicocele (Dubin-Amelar scale and Dubin Doppler scale) and the assessment of testicular size. Intratesticular varicocele is defined as venous reflux detected into anechoic lesions of the testis with or without ypsilateral varicocele. RESULTS: We detected 4 intratesticular varicoceles (1.3%), in all cases left sided with ypsilateral extratesticular varicocele. Three patients had a large varicocele, one patient had a small varicocele and bylateral testicular hypotrophy. All patients had a slight to severe worsening of sperm quality. CONCLUSIONS: Intratesticular varicocele is an uncommon lesion, first described only after the color Doppler ultrasound studies have been a wide diffusion in the 1990s. A few cases are reported in literature and its incidence is unknown. Data about fertility in males with intratesticular varicocele are still anecdotic. Moreover, the knowledge of intratesticular varicocele may rule out patients for sclerotherapy procedures, or the awarness of potential gonadal damage by aetoxysclerol spread into the testis, may suggest some technical tricks. Since the simple detection of this lesion, further investigations are needed to clarify its clinical and pathophysiological significances. Color Doppler Sonography appears to be the only tool able to identify intratesticular varicocele in order to learn more about this rare condition.

Adolescent↗
PubMed1993

Loss of fertility in men with varicocele.

OBJECTIVE: To test the hypothesis that men with varicocele who have already fathered children are immune to the detrimental effect of varicocele on their fertility and will continue to be fertile. If this were the case, one would expect a very low incidence of varicocele in currently infertile men who were able to father a child in the past (secondary infertility) compared with men who have never been fertile (primary infertility). DESIGN: Survey of men with male factor infertility. SETTING: Tertiary care university medical center. PATIENTS: One thousand ninety-nine infertile men of whom 98 (9%) met our criteria for secondary infertility. Men with prior vasectomy and men whose partners were over age 40 were excluded. MAIN OUTCOME MEASURE: Difference in the incidence of varicocele in men with secondary infertility versus primary infertility. RESULTS: A varicocele was palpable in 35% (352/1,001) of men with primary infertility and 81% (79/98) of men with secondary infertility. This difference in the incidence of varicocele was highly significant. Men with secondary infertility and varicocele were slightly older (37.9 versus 33.5 years), had a 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. CONCLUSIONS: The incidence of varicocele is much higher in male factor secondary infertility compared with primary infertility. These 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. Men with a varicocele may benefit from early evaluation and prophylactic varicocelectomy to prevent future infertility.

Adolescent↗
PubMed2004

Varicocele and sport in the adolescent age. Preliminary report on the effects of physical training.

The effect of physical training on the natural history of varicocele has received little attention. The aim of the present pilot study was to evaluate the prevalence of idiopathic varicocele in young athletes, in the attempt to find a correlation between the training workload and the clinical grade of varicocele. We evaluated 150 adolescents with an age of 10-16 yr (median age: 13 yr). All these subjects were athletes practicing different sport at agonistic level. One hundred and fifty non-athlete adolescents of matched age (median: 13.5 yr) were used as controls. All underwent physical examination, and if a varicocele was suspected, the diagnosis was confirmed or excluded by echo-color-Doppler examination. The young athletes were stratified into two groups according to the different time spent for training: Group 1-6 h training per week; Group 2-7 to 12 h per week. Statistical analysis was performed. A p<0.05 was considered significant. The physical examination revealed a clinical varicocele on the left side in 20 athletes. A significant positive correlation was observed between the Group 2 and the highest grade of varicocele (r2=0.9918, p=0.0041). In the adolescent group used as control we observed a varicocele in 16 cases. A positive correlation was observed between the number of athletes with varicocele and the highest grade of varicocele (r2=0.96, p=0.02). Sport training does not modify the prevalence of varicocele compared to the general population, but physical activity has to be considered as an aggravating factor in the natural history of varicocele. In countries where sport eligibility is necessary for agonistic sport practice, varicocele should be then considered as a conditioning factor.

Adolescent↗
PubMed1992

Clinical versus subclinical varicocele: improvement in fertility after varicocelectomy.

OBJECTIVE: To assess the fertility after varicocelectomy in men with subclinical varicocele. DESIGN: We define subclinical varicocele as the varicocele detected by Doppler examination of the scrotum, in which no varicocele was found on clinical examination. Varicocelectomy was performed on subclinical varicocele, and fertility was assessed. SETTING: We reviewed the records of 54 men who underwent unilateral varicocelectomy at the Department of Urology, Wayne State University, between 1986 and 1987. PATIENTS: Records of 54 men were analyzed. Thirty-eight (70%) of the varicocele were diagnosed clinically (confirmed by Doppler examination) in group 1. In 16 (30%) men, the varicocele was diagnosed by Doppler examination only, with no varicocele detectable clinically, subclinical varicocele (group 2). RESULTS: Spermiograms improved in 76% of the patients in group 1 and in 81% of the patients in group 2. Fertility was assessed after 2 years of varicocelectomy. Eighteen (47%) of 38 patients in group 1 and 8 (50%) of 16 men in group 2 managed to impregnate their partners. Statistical analysis by chi 2 shows similar improvement in fertility potential between the two groups (P = 0.86). Multivariate repeated measure analysis showed significant improvement in sperm density (P = 0.0006) and sperm morphology (P = 0.0016) after varicocelectomy. CONCLUSIONS: These data suggest that varicocelectomy, in infertile men with subclinical varicocele, leads to fertility in 50% of the patient population as compared with 47% in clinical varicocele group. We suggest that the use of sophisticated, noninvasive techniques such as Doppler may have a place in the management of male infertility to detect subclinical varicocele.

Adult↗
PubMed2001

Oxidative damage to proteins and decrease of antioxidant capacity in patients with varicocele.

To examine oxidative damage to blood proteins in the spermatic vein and seminal plasma antioxidant capacity of patients with varicocele, 30 young male patients with varicocele (group 1), 25 young male patients with subclinical varicocele (group 2), and 15 normal young males without varicocele (group 3) were recruited in this study. Varicocele and subclinical varicocele were confirmed by physical examination and Doppler ultrasonography. Blood samples were drawn from peripheral and spermatic veins before varicocelectomy. Plasma protein carbonyls were measured by a spectrophotometric assay after reacting with 2,4-dinitrophenylhydrazine. Protein thiols and ascorbic acid of seminal plasma were measured by spectrophotometric methods. We found that plasma protein carbonyls in the spermatic veins were significantly higher than those of corresponding peripheral veins in all 30 patients in group 1 and 12 patients in group 2 receiving varicocelectomy. Protein carbonyls in the spermatic veins of patients with varicocele (3.72 +/- 0.56 nmole/mg protein) and patients with subclinical varicocele (3.50 +/- 0.30 nmole/mg protein) were found to be higher than those of the control (2.35 +/- 0.33 nmole/mg protein). Protein thiols were 0.97 +/- 0.96, 1.50 +/- 0.89, and 3.49 +/- 0.81 nmole/ml, and ascorbic acid levels were 1.87 +/- 0.42, 2.13 +/- 0.24, and 2.38 +/- 0.07 mg/dl, in seminal plasma of the patients in groups 1, 2, and 3, respectively. Seminal plasma protein thiols and ascorbic acid levels in group 1 were significantly lower than those in groups 2 and 3, respectively. These results indicate that oxidative stress in the patients with varicocele and subclinical varicocele was higher than that of the control. We suggest that plasma protein carbonyls, and protein thiols and ascorbic acid of seminal plasma are useful markers for the assessment of oxidative stress in patients with varicocele and subclinical varicocele.

Adult↗
PubMed1998

Improvement of sperm count and motility after ligation of varicoceles detected with colour Doppler ultrasonography.

The debate regarding the efficacy of varicocele ligation for improvement of semen parameters and pregnancy rates is ongoing. In addition, no consensus exists as to the benefit of treatment of subclinical varicoceles. The aim of this study was to investigate, retrospectively, the effect of high ligation of both subclinical and clinical varicoceles on sperm count and motility. The value of several factors from history-taking and physical examination for the prediction of successful varicocelectomy was analysed. A total of 139 patients, operated on for a unilateral varicocele on the left side, were studied. Varicoceles were subclinical in 73 patients, based on colour Doppler ultrasonography, and 66 varicoceles were clinical, based on palpation in addition to ultrasonography. Comparison of semen parameters before and after surgery revealed a significant improvement. The median sperm count increased from 10.0 to 14.7, and from 18.2 to 28.6 million/ejaculate, in patients with subclinical and clinical varicoceles, respectively (p < 0.001). The percentage improvement in median sperm count in subclinical varicoceles was not statistically different from the improvement in clinical varicoceles. Mean progressive motility improved significantly after ligation (p < 0.001). The improvement in motility in subclinical varicoceles, from 16 to 23%, was significantly larger than the 24 to 27% improvement in clinical varicoceles. The increase in sperm count was related positively to testicular volume before surgery (p < 0.05). The increase in sperm motility was significantly lower in patients with a history of cryptorchidism (n = 22, p < 0.05). The present data show that ligation of varicoceles detected using Doppler ultrasonography, whether palpable or not, results in an increase in sperm concentration and motility.

Adult↗
PubMed2002

Diagnosis of pediatric varicoceles by physical examination and ultrasonography and measurement of the testicular volume: using the prader orchidometer versus ultrasonography.

INTRODUCTION: The differentiation of unilateral versus bilateral varicoceles and testicular volume measurements are important in determining the need for adolescent varicocele surgery and also in following patients after varicocelectomy. The aim of this study was to prospectively compare the findings of physical examination and color Doppler ultrasonography in the diagnosis of pediatric varicoceles and to compare the findings using the Prader orchidometer and scrotal ultrasonography in the measurement of testicular volumes. PATIENTS AND METHODS: This study included 68 boys with varicoceles, ranging in age from 8 to 19 years. Varicoceles were diagnosed using both physical examination and scrotal color Doppler ultrasonography. The testicular volumes of 136 testicles were measured using the Prader orchidometer and scrotal ultrasonography. A difference of more than 10% or 2 ml in each testicular volume was considered significant. RESULTS: The mean age of the boys was 13.5 +/- 2.3 years. On physical examination, a left unilateral varicocele was diagnosed in 46 boys (67.6%). The other 22 boys (32.4%) had bilateral varicoceles. Color Doppler ultrasonography detected bilateral varicoceles in 4 of the 46 boys (8.7%) who were diagnosed by physical examination as having only left unilateral varicoceles (grade 3 in 3 patients and grade 2 in 1 patient). A different of more than 10% or 2 ml in testicular volume using the Prader orchidometer versus scrotal ultrasonography was detected in 3 out of 136 testicles (2.2%). The correlation between ultrasonography and Prader orchidometer results in the measurement of testicular volumes was statistically highly significantly consistent using the intraclass correlation test (r = 0.997 and p < 0.001 for the left testis; r = 0.998 and p < 0.001 for the right testis). CONCLUSIONS: Although the management of subclinical varicoceles remains controversial, these data show that color Doppler ultrasonography may be necessary in the diagnosis of bilateral varicoceles, especially in boys with high-grade left varicoceles. In contrast, scrotal ultrasonography, if considered the gold standard, did not show superiority over the Prader orchidometer in measuring testicular volumes.

Adolescent↗
PubMed2001

[Percutaneous treatment of varicocele. 13-year experience with the transbrachial approach].

PURPOSE: To report our experience using the transbrachial approach, which is easily accepted by the patient, in the treatment of varicocele. MATERIAL AND METHODS: Between January 1986 and December 1998, 1490 patients with clinical or subclinical varicocele, but with seminal fluid alterations, underwent spermatic phlebography using the transbrachial approach. Since 1991 the procedure has also been adopted at the Unit of Pediatric Surgery of our hospital, which proposes it as a first choice treatment in adolescents with varicocele. The procedure consists in accessing the basilic vein at the elbow level percutaneously and using a hydrophile guidewire and multipurpose angiographic catheter to reach and catheterise the spermatic vein responsible for the varicocele. During the first years, we used sclerotherapy alone; subsequently, if the varicocele recurred or if the reflux was refractory to sclerotherapy or if the veins were large we adopted vein embolisation. Follow-up was one year and consisted of testicular ultrasound, Doppler flowmetry and/or color Doppler ultrasound at one, six and twelve months after the procedure. Patients were considered restored if they were free of symptoms, showed no venous reflux and/or had normal seminal fluid parameters and improved if they were free of symptoms but still presented venous reflux. Varicocele was considered persistent if the procedure failed to produce any beneficial effects, and recurrent if, although absent at the first follow up, it reappeared after the fifth month. RESULTS: We found 1296 (86.9%) cases of left varicocele, 25 of right varicocele and 169 (11.3%) of bilateral varicocele. In all cases, the symptoms disappeared after the percutaneous procedure. Duration of radioscopy was reduced to 3.5'; the procedure lasted 90' for the monolateral varicoceles and 120' for the bilateral forms. 313 diagnostic procedures were performed (20.7%). The procedure could not be completed in 104 patients (6.8%) due to basilic vein spasms, difficulties encountered in catheterizing the spermatic vein and, particularly in pediatric patients, anatomic variations. A total of 1195 (79.2%) procedures were completed: sclerotherapy alone in 642 patients and sclerotherapy followed by scleroembolisation in 527. Sclerotherapy alone was sufficient to restore 524 patients (86.6%), while 384 (78.5%) required scleroembolization. A small number of patients underwent scleroembolization alone, which brings the success rate for the two procedures to 82% and 84%, respectively. No serious side-effects were noted. DISCUSSION: The transbrachial approach in spermatic phlebography has proved to be a safe and effective technique for the treatment of both monolateral and bilateral varicocele. Furthermore, the procedure is well accepted by patients and can be performed in a day-care setting. In some cases, we only obtained partial results because of the large caliber of the spermatic vein; in other cases, we were unable to complete the procedure due to anatomic variations or to the spasm of the basilic vein. CONCLUSION: The safety and effectiveness of this procedure make it a valid alternative to traditional surgery, that should be considered as a possible first-choice treatment for varicocele in adolescents.

Adolescent↗
PubMed1990

[Scrotal scintigraphy in the diagnosis and grading of varicocele].

Scrotal scintigraphy with 99mTc-red blood cells has been reported as a useful method for detecting varicocele. In this study we analysed the scintigraphy of 251 infertile males with clinically diagnosed or suspected varicocele, in an attempt to establish a grading system of varicocele. Scintigraphically varicocele was diagnosed in 207 patients on the basis of pooling in hemiscrotum in static images and/or early flow through the spermatic cord vessels in dynamic images; physical examination overlooked 17 of them. Of the 207 patients, all had pooling (153 left-sided, 1 right-sided, and 53 bilateral pooling) and 52 had early flow. The early flow was a less sensitive sign for varicocele than the pooling and invariably accompanied by the intense pooling. The early flow may be related to increased shunt flow through varicocele. According to the scintigraphic findings, varicocele was classified as follows: Grade I (small varicocele with faint early flow or mild localized pooling, n = 103), Grade II (medium varicocele with obvious early flow or curvilinear mottled pooling, n = 67) and Grade III (large varicocele with marked early flow or pooling, n = 37). Clinical assessment (93 small, 68 medium, and 54 large varicocele) supported the scintigraphic classification. Scrotal scintigraphy, therefore, facilitates precise evaluation of varicocele based on its morphology and hemodynamics.

Adult↗
PubMed1998

Comparison of radionuclide scrotal blood-pool index versus gonadal venography in the diagnosis of varicocele.

UNLABELLED: The purpose of our study was to assess the value of a radionuclide scrotal blood-pool index (SBPI) in diagnosing and grading clinical and subclinical varicocele. METHODS: Scrotal scans were performed on 1360 infertile patients. Thirty fertile patients with a normal scrotum on palpation served as controls. The patients' red blood cells were labeled in vivo by administration of stannous ions of pyrophosphate followed by the intravenous administration of 99Tc-pertechnetate. The scans initially were inspected visually and, when bilateral varicocele was excluded, a computerized analysis of the ratio of the blood-pool activity in each hemiscrotum (SBPI) permitted accurate grading of the varicocele. A subgroup of 224 patients was selected randomly and had gonadal venography. The results of physical examination, scrotal scan, gonadal venography and semen analysis were compared. RESULTS: Normal values of SBPI (0.9-1.1) were derived from the control group. There was a 93.5% correlation between palpation and SBPI grade in diagnosing palpable varicocele. When compared to gonadal venography, subclinical varicocele was demonstrated by scrotal scan in 54.8% of infertile male patients with abnormal semen analysis, normal female partners and no other cause of infertility. Of these patients, 32.6% had, unexpectedly, Grade 2 or 3 varicocele. Right and bilateral varicocele were demonstrated three times as often by scrotal scan than by palpation. SBPI was accurate in diagnosing recurrent varicocele but there was a low correlation (61.1%) between SBPI and gonadal venography grade. There was a high correlation between SBPI grade and sperm analysis grade. CONCLUSION: SBPI grading of varicocele was validated as an accurate, quantitative and noninvasive method of grading varicocele, equivalent to the grading system by palpation in a large group of infertile patients. The main contribution of SBPI was in detecting and grading subclinical varicocele in infertile patients with no other cause of infertility. SBPI also was accurate in diagnosing but not in grading recurrent varicocele.

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