Current management principles for adolescent varicocele

Transcription

1 Current management principles for adolescent varicocele David A. Diamond, M.D., a Patricio C. Gargollo, M.D., b and Anthony A. Caldamone, M.D. c a Department of Urology, Children s Hospital Boston, Boston, Massachusetts; b Department of Urology, University of Texas Southwestern, Children s Medical Center of Dallas, Dallas, Texas; and c Division of Urology, Hasbro Children s Hospital, Providence, Rhode Island The authors review the current approach to management of the adolescent varicocele which has evolved over the past two decades. Principles of observational, surgical and adjunctive management are discussed relative to significant clinical findings. A selective approach to surgical intervention is advocated with the goal of preserving fertility potential. (Fertil Steril Ò 2011;96: Ó2011 by American Society for Reproductive Medicine.) The adolescent varicocele remains one of the most interesting and controversial topics in pediatric urology. With an incidence of 15% it represents the most common surgically correctable urological abnormality among adolescent males (1). Yet, among adults with varicoceles, 80% are asymptomatic and 20% have fertility problems. Thus, the challenge in management of adolescent varicocele is determining who would most benefit from surgical correction and at what age. Etiology and Epidemiology Varicoceles are seen almost exclusively in pubertal or post-pubertal boys. They are rarely seen in boys under age 10 years or Tanner stage I (3% in the Children s Hospital Boston database) (2). A noticeable spike in clinical presentation begins at age 13. The incidence reaches 15% (approximately that in adults) between 10 and 19 years. Studies have noted a variability in incidence between 9 and 26% (3). Diagnosis The diagnosis of adolescent varicocele is usually made on a routine physical examination or by testicular self-examination as most boys are asymptomatic. A small percentage of patients (<5% in the Children s Hospital Boston database) will present with symptoms of scrotal or testicular discomfort. This is characterized most typically as heaviness exacerbated by prolonged standing or running, relieved by lying supine. Physical examination should be performed in a supine and standing position and while standing, patients should be asked to perform a valsalva maneuver to accentuate a small varicocele. Varicoceles can be appreciated as a plexus of veins with a consistency of a bag of worms adjacent to the testis, which typically decompresses with the patient supine. Varicoceles are graded according to the system of Dubin and Amelar as follows: Grade 0, subclinical varicoceles (not detectable on clinical examination; identified on scrotal ultrasound or venography); Grade I, small varicocele (palpated only during valsalva); Grade II, moderate size (readily palpable without valsalva); and Grade III, large (readily visualized) (4). Received October 7, 2011; accepted October 26, D.A.D. has nothing to disclose. P.C.G. has nothing to disclose. A.A.C. has nothing to disclose. Reprint requests: David A. Diamond, M.D., Department of Urology, Children s Hospital, 300 Longwood Ave., Boston, MA ( daviddiamond@childrens.harvard.edu). Approximately 90% of varicoceles are left sided and 3% are clinically palpable bilaterally. Subclinical, contralateral varicoceles have been described in up to 30% of males with a unilateral varicocele (5). Patients with a purely right sided varicocele, who are extremely young or who have a varicocele that does not decompress in the supine position, should be suspected of having a retroperitoneal mass and undergo ultrasonography. An important part of the physical examination and diagnosis is the assessment of testicular volume and consistency. This is important not only for clinical planning but also in assessing response to treatment. A comparison of the volume of each testis should be made to assess for asymmetry and volume differential may be calculated with the formula (volume of unaffected testis volume of affected testis volume of unaffected testis 100%). Testicular volumes can either be measured in the office setting with orchidometers comprised of comparitive ovoids (Prader) or cut out ellipses (Rochester or Takahara) or with scrotal ultrasonography (or both, as is our practice). While some favor orchidometers as an effective and inexpensive method for assessing testicular volumes, we have found ultrasound to be more sensitive in detecting volume differentials between testes (6). Therefore, we recommend an annual ultrasound calculation of testicular volume to evaluate the adolescent with varicocele. A softer consistency of the involved testis will be noted in a small percentage of boys, typically associated with decreased volume. As abnormal consistency is a subjective finding, it is has been poorly studied and its reversibility with surgery is not well established. Clinical Management of Adolescent Varicocele In the management of varicocele, fertility is the overriding consideration. For adolescents this entails preservation of fertility potential which, unlike adults, is unknown at presentation. Because 80% of adult males with varicocele will be fertile, a selective approach to surgical management of adolescent varicocele has been advocated. A number of studies have attempted to characterize the clinical progression of adolescent varicocele and identify criteria to select those who might benefit from surgical intervention. These studies have focused on varicocele grade, presence of testicular disproportion and, more recently, semen parameters. The importance of grade of varicocele in the pediatric literature has been controversial, with some earlier studies correlating increasing grade with greater testicular disproportion. A recent study from Children s Hospital Boston found grade and testicular disproportion to be independent variables (7). Another recent study noted no 1294 Fertility and Sterility â Vol. 96, No. 6, December /$36.00 Copyright ª2011 American Society for Reproductive Medicine, Published by Elsevier Inc. doi: /j.fertnstert

2 difference in semen parameters between adolescents with Grade II versus Grade III varicocele (8). Currently, it appears that high grade of varicocele, alone, is not an indication for surgical correction. Historically, testicular disproportion has been the predominant indicator for surgical intervention for adolescent varicocele. This has been the case due to absence of other objective criteria, typically present in the adult (semen parameters, paternity). But, there are nuances to this indicator, such as the precise volume difference which is significant and the period of observation advised to allow for spontaneous catch up growth. Kolon and colleagues found that 71% of boys with varicoceles and 15% testicular disproportion exhibited catch up growth to less than 15% discrepancy within 2 years of observation (9). Van Batavia and colleagues noted 33% to exhibit catch up growth (somewhat greater in Tanner stages IV and V) but 43% to develop worsening testicular asymmetry with time (10). Spinelli et al. also noted spontaneous catch up growth in 30% with asymmetric testes after one year of observation (11). As a result of these studies, we believe that testicular disproportion should be observed for at least one year to allow for potential spontaneous catch up growth prior to surgical intervention. The testicular volume differential that is considered of physiological significance has been a matter of debate for a number of years. A recent study from Children s Hospital Boston in Tanner stage V adolescents with varicocele correlated testicular volume differentials with total motile sperm counts. With greater than a 20% volume differential, 59% of boys had an abnormal total motile sperm count whereas one third had a normal total motile sperm count. At volume differentials of 10-20%, 11% were abnormal whereas two thirds had normal total motile sperm counts (12). As a result, a 20% volume differential that is persistent for over one year in a Tanner stage I IV boy is regarded as an indication for surgical correction. Of interest, varicocele grade did not correlate with abnormal semen parameters in the Children s Hospital Boston study. Clinical Management While testicular volume differentials of 20% or greater may serve as a marker for potentially abnormal semen parameters, it is always preferable to obtain a semen analysis, if possible, to guide clinical decision making. A normal semen analysis trumps a testicular volume differential and justifies an observational approach. The question of reversibility of function with early versus delayed surgical intervention often arises. DeCastro et al. studied testicular catch-up growth following spermatic vein ligation in 163 boys from ages (13). They found no difference in prevalence of catch-up growth as a function of Tanner stage or age with a good response even into the 20 year range. A recent study from Turkey of the impact of patient age on semen parameters following varicocelectomy comparing young adults (18 25 years) with older patients (26 35 years and >36 years) found no difference in outcomes (14). There appears to be little evidence that waiting for a few years to correct an adolescent varicocele results in worse functional outcomes. In an attempt to identify earlier prognostic factors for varicocele management than testicular volume disproportion or abnormal semen parameters, Kozakowski et al. studied peak retrograde flow using duplex Doppler ultrasound. They noted that a peak retrograde flow of over 38 cm/sec in conjunction with a 20% or greater volume differential at presentation uniformly resulted in >20% volume disproportion with longer observation. They argued for early surgery in this group (15). This technique remains experimental and has not yet been duplicated but warrants further study. Subclinical Varicocele The routine use of scrotal Doppler ultrasonography to assess varicocele (and other scrotal pathology) has resulted in an increasingly frequent diagnosis of subclinical varicocele, i.e. varicoceles not clinically palpable but visible on ultrasound. An important caveat in discussion of subclinical varicocele is lack of a widely accepted radiologic definition of the condition. An improved understanding of the significance of subclinical varicocele is essential. Cervellione et al. reported a 28% rate of progression from subclinical to clinical varicocele, occurring with left sided but not bilateral subclinical varicoceles (16). In a recent study at Children s Hospital Boston, Yu also noted that right subclinical varicoceles did not progress to clinically apparent lesions whereas left subclinical varicoceles did progress in 27% of cases, thus justifying careful observation (Yu RN, et al. Left subclinical varicoceles are associated with clinical progression. American Academy of Pediatrics Meeting 2010; abstract). Options for Surgical Therapy There are several surgical approaches to the varicocele, all of which produce consistent results. As such the approach is largely dependent on surgeon preference. All surgical repairs involve the ligation of the spermatic veins with the main differences between the techniques involving the surgical approach to the testicular vessels, the level of the ligation (proximal or distal) and whether the testicular artery and lymphatic vessels are spared or ligated along with the veins. The techniques include abdominal retroperitoneal (Palomo), inguinal (Ivanissevitch), and subinguinal approaches. Microsurgical techniques and laparoscopic-assisted transperitoneal or retroperitoneal approaches are also currently used. Some authors have advocated the use of isosulfan blue to aid in lymphatic identification (17). The risks for any of these techniques include varicocele recurrence, testicular atrophy, hydrocele formation, and damage to the vas. The subinguinal technique with microscopic magnification seems to be the gold standard for varicocele surgery in the adult patient. In adult series this technique seems to have the highest success and lowest complication rate (18). Table 1 summarizes recent surgical series comparing different techniques as well as their complication and recurrence rates. As can be seen there is wide variability in the success rates although it seems that a subinguinal approach (19, 20) and a modified Palomo (lymphatic sparing approach) (21) have the lowest hydrocele and recurrence rates. In a recent report of a series of 233 patients undergoing the Palomo technique with complete retroperitoneal ligation of the internal spermatic veins and arteries, the persistent varicocele rate was 3.9% with 29% presenting with a secondary hydrocele, of whom 18% required hydrocele correction. Therefore, while the recurrence rate from the complete ligation Palomo approach is very low, one must accept a higher secondary hydrocele rate. It is worthwhile to note that in this particular series by Feber and Kass, postoperative testicular atrophy was not seen in any patients (22). In a systematic literature review on the surgical treatment of varicocele in children with the open and laparoscopic Palomo technique, Barroso et al found that the modified Palomo procedure with preservation of the testicular artery resulted in a significiantly lower incidence of postoperative hydrocele development (23). Persistence of varicocele in the modified approach versus the classic approach was not significantly different, however. In addition, testicular catch up growth was similar in the three groups. It is clear, therefore, that there is insufficient evidence to determine which technique is superior in this age group and that larger, prospective randomized trials need to be designed and carried out. Fertility and Sterility â 1295

3 TABLE 1 Contemporary outcomes in adolescent varicocele surgery. Study Technique Patients, n Artery spared? Lymphatics spared? Hydrocele Recurrence Kass and Marcol (37) Inguinal 53 Yes Yes NA 16.0% Palomo (modified) 17 Yes No NA 11.0% Palomo 32 No No NA 0.0% Feber and Kass (38) Palomo 312 No No 29.0% 3.9% Misseri et al. (39) Inguinal 21 Yes Yes 14.0% 14.0% Palomo 56 No No 28.0% 3.0% Schiff et al. (40) Subinguinal 97 Yes Yes 1.0% 1.0% Yaman et al. (41) Subinguinal 92 Yes Yes 0.0% 1.6% Glassberg et al. (42) Laparoscopic 132 Yes Yes 3.4% 2.9% Laparoscopic 59 Yes No 11.4% 4.5% Hassan et al. (43) Laparoscopic 89 No No 22.8% 1.3% Kocvara et al. (44) Laparoscopic 104 Yes Yes 1.9% 6.7% Laparoscopic 67 Yes No 2.9% 8.9% VanderBrink et al. (45) Subinguinal 31 Yes Yes 0.0% 3.2% Laparoscopic 28 No Yes 3.6% 0.0% Riccabona et al. (46) Laparoscopic 19 Yes No 5.0% 11.0% Inguinal 21 Yes Yes 0.0% 14.0% Palomo (modified) 32 No Yes 13.0% 0.0% Note: Revised from Gargollo and Diamond (36). Diamond. Adolescent varicocele. Fertil Steril There have been no reports of testicular infarction occurring with spermatic vein ligation performed above the internal ring, whereas testes have been lost with the inguinal and subinguinal approaches. Minimally invasive approaches to various urologic conditions in children and adolescents have been gaining in popularity. The use of these technologies for varicocele is no exception. The laparoscopic approach to varicocele correction has been proven to be a safe and effective technique even in patients who have previously undergone ipsilateral inguinal or scrotal surgeries (24, 25). In a series reported by Koyle et al. with 103 patients who were evaluated after undergoing laparoscopic Palomo varicocele ligation, one developed a recurrent varicocele and 6 developed reactive hydroceles (26). Of those with hydroceles two have required surgical repair. One patient had a sigmoid serosal tear. The obvious advantage of this technology would be a quicker return to full activities and a potentially reduced need for postoperative narcotic analgesia. One must accept, however, that this technique as performed by most laparoscopists, involved the inclusion of not only the spermatic veins, but also the spermatic artery and lymphatics. The long-term implication of this is uncertain. Adjunctive and Non-Surgical Techniques Vascular ablation/embolization as well as percutaneous antegrade sclerotherapy have been described as non-surgical techniques for treating varicoceles (27). Percutaneous embolization carries the unique, yet infrequent, risks of contrast reactions, puncture of the femoral artery, extravasation, and migration of embolization balloons or coils. These techniques seem to have higher complication rates than published surgical series and in addition a higher rate of persistent varicocele (28). Recent reports reflect a more positive experience with percutaneous embolization and sclerotherapy in the adolescent varicocele population. This may represent better technologies than those from previously reported series. In a series of 21 evaluable patients reported by Storm et al, there was a cure rate of 91% with no evidence of hydrocele formation (29). In two patients access to the lower spermatic vein was not possible due to the large number and tortuosity of the vessels. Beutner et al. compaired three minimally invasive techniques for varicocele correction: laparoscopic varicocelectomy, antegrade sclerotherapy, and retrograde embolization in children and adults. While complication rates did not differ significantly for the three techniques, laparoscopic varicocelectomy was significantly more effective in correcting the varicocele (30). In a recent report of 756 adolescent and adult varicocele patients who underwent antegrade subinguinal sclerotization with cord clamping for 8 to 10 minutes, the rate of persistence of the varicocele measured by color Doppler ultrasound demonstration of reflux was 1.9% (31). Six patients developed a hydrocele requiring surgical correction (0.7%). In addition, 50 patients (6.6%) developed superfical penile lymphangiitis. Persistent Varicocele As previously noted the recurrence rate for varicocele repair regardless of the technology varies from 4% following a Palomo repair to as high as 35% following a radiographic retrograde embolization or sclerotherapy. When faced with a failed repair, the most common recommendation is that of a radiographic embolization as this may afford the least risk to the blood supply of the testis (32, 33). However in a recent series by Glassberg et al., an open redo approach was undertaken in 17 boys with persistent varicocele (34). One of the reoperative patients developed ipsilateral loss of testicular size postoperatively and three developed hydrocele requiring correction. Eight of the 9 boys who had preoperative asymmetry, however, demonstrated catch-up growth following redo repair. The most common intraoperative finding in the redo population was the persistence of large veins within the spermatic cord Diamond et al. Adolescent varicocele Vol. 96, No. 6, December 2011

4 Observational Approach An observational approach to the adolescent with a varicocle is predicated on the inability to predict the effect of the varicocle on fertility, and, in some cases, cultural or psycho-social reasons which would obviate obtaining a semen analysis. While the concern is that the length of time that one has a varicocle may influence the likelihood of success from corrective surgery, there is unfortunately no data to corroborate that. The AUA Best Practice Guidelines for varicocle recommends that adolescents who have a varicocele with normal ipisilateral testicular size should be offered follow-up monitoring with annual objective measurements of testicular size and/or semen analysis. For those young men who have a varicocle and a normal semen analysis, the recommendation is that they should be followed with semen analysis every one to two years (35). It is possible that these young adult males who have varicoceles with normal semen parameters maybe at risk for later testicular dysfunction,and, therefore, if fertility is a concern for the future, it should be monitored with semen analyses on a regular basis. At the first sign of varicocele related testicular dysfunction, be it a change in testicular size (in the absence of a semen analysis) or an abnormality on semen analysis, varicocele repair should be offered. In the event of a significant size discrepancy and normal semen analysis results, the semen analysis result should be the more important management determinate. Conclusion Based on available evidence in the literature, we would recommend correction of a varicocele in an adolescent patient if there is a persistent size discrepancy of greater than 20%. 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