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Contemporary approach to diagnosis, management, and treatment of varicocele in the adolescent.

Varicocele is the most common inguinoscrotal pathology among adolescents. It is of concern due to the potential effect on fertility. A review of the literature focusing on current guidelines regarding diagnosis, evaluation, and management of adolescent varicocele was conducted. An algorithm is provided as one method for approaching the adolescent varicocele.

Key Words: Varicocele, hypotrophy, infertility, adolescent, asymmetry.

Objectives:

1. Define varicoceles.

2. Explain the etiology of the development of varicoceles.

3. Discuss the recommended methods for assessing for varicoceles.

4. Describe the impact varicoceles may have on an adolescent.

5. Discuss follow-up measures for the treatment of varicoceles.

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Varicoceles are the most common inguinoscrotal pathology among adolescents, affecting approximately 15% of boys 10 to 19 years of age (Diamond, 2003). A varicocele is defined as the abnormal dilation of the pampiniform plexus, the collection of veins within the spermatic cord, which drains blood from the testes, epididymis, and vas deferens. The pampiniform plexus is believed to play an important role in maintaining optimal temperature for sperm production (Elmore, 2012). Varicoceles identified during adolescence persist and can progress with age (Jarow, 2001). In adults, the need for surgical correction is primarily determined by the impact on fertility, often determined by difficulties conceiving in conjunction with an abnormal semen analysis. In most adolescent males, however, testicular size and symmetry are used as substitutes for a semen analysis. Controversy exists as to the reliability of such markers in assessing future fertility potential in adolescents.

Methods

A PubMed search was performed using the search words "adolescent and varicocele." English language articles were included for this review, particularly those presenting more recent data. Selected articles focused on the diagnosis, evaluation, and management of adolescent varicoceles. The intent of this article was not meant to be a meta-analysis or comprehensive review of the world literature, but rather, to identify articles that would serve as guides to the current literature and recommendations regarding the evaluation and management of adolescent varicoceles.

Etiology

Several etiologies for the development of varicoceles have been proposed. The testicular vein has valves, which prevent retrograde back flow of venous blood. Thus, varicocele formation may be the result of an absent or defective valve, which allows retrograde flow (Elmore, 2012). Secondary compression of the testicular vein by a neighboring structure or retroperitoneal mass can prevent antegrade flow and also result in varicocele formation. Varicoceles are more commonly identified on the left side. The etiology of this difference may be related to anatomic differences between venous blood flow to the right and left testes. The left testicular vein feeds into the left renal vein at a 90-degree angle before draining into the inferior vena cava (IVC), whereas the right testicular vein inserts obliquely and directly into the IVC (Basu, 2011). Consequently, the left testicular vein drains more slowly and can frequently be compressed by the neighboring superior mesenteric artery and aorta (Basu, 2011; Elmore, 2012). The presence of an isolated right varicocele warrants evaluation for retroperitoneal malignancy (Canning & Lambert, 2011; Elmore, 2012).

Presentation

Similar to adults, most adolescents with varicoceles are asymptomatic. In adolescents, varicoceles are often identified during routine, well-child examinations. Symptoms, if present, include a feeling of fullness or pain in the affected hemi-scrotum that can vary from dull to sharp. Symptoms tend to be exacerbated with activities or maneuvers that increase intraabdominal pressure, such as standing for prolonged periods or physical exertion, and are relieved by positions that temporarily improve drainage, such as a supine position (Diamond et al., 2000; Elmore, 2012).

Adolescents are often referred to a pediatric urologist or urologist after the primary care provider has identified or confirmed the presence of an intrascrotal lesion suggestive of a varicocele. Parents and adolescents, upon hearing about the potential implications of a varicocele on fertility, often become very anxious in their attempts to learn more about a varicocele. Performing online computer searches can heighten this anxiety for the nonmedical person. The urologic nurse can help decrease the anxieties of the patient and parent during the initial and subsequent

visits by reviewing the current evaluation and treatment recommendations and addressing their questions and concerns. Providing patient education and knowledge of appropriate resources for additional information, if requested, are important aspects of the nursing role as well. Further, pediatric urologic nurse practitioners may indeed follow these patients, and thus, the information provided may assist in developing a management strategy.

Evaluation

Varicocele is a clinical diagnosis made during physical examination. Examination of the scrotum should be performed in both a sitting and standing position. A valsalva maneuver at the time of examination may help identify the varicocele (Elmore, 2012). There are three grade classifications that can be assigned to a varicocele during examination. Grade 1 (small) is a varicocele that is felt by the examiner when the patient increases abdominal pressure by bearing down. Grade

2 (moderate) is felt without having the patient bear down but is not seen by the examiner. Grade

3 (large) can be seen by the examiner without having the patient bear down (Canning & Lambert, 2011; Elmore, 2012).

At the time of the physical examination, an assessment of testicular size should also be performed. The size of both the affected testis and the contralateral testis should be evaluated to determine the presence or absence of ipsilateral testicular hypotrophy. An objective determination of testicular size can be determined by a number of methods, including calipers, orchidometer beads, and ultrasound (Paduch & Skoog, 2004).

Methods for Assessing Testicular Size

The orchidometer and calipers are common office tools used to determine testicular size.

Although the orchidometer is useful, it is limited in evaluating volume differentials. Costabile, Skoog, and Radowich (1992) noted that a size discrepancy of 2 [cm.sup.3], enough to indicate testicular growth arrest, would have been missed in 24% of their cohort using only an orchidometer. Diamond et al. (2000) compared both Prader and Rochester orchidometers to ultrasound to determine their accuracy in measuring testicular size and volume differential. The Prader and Rochester orchidometer had a linear relationship with ultrasound but over-estimated testicular volume by 6 cc (Diamond et al, 2000). The Prader orchidometer had an average sensitivity of approximately 40% and specificity of approximately 75%, whereas the Rochester had an average sensitivity of approximately 35% and specificity of approximately 65% for detecting volume differentials (Diamond et al., 2000). They concluded that the orchidometer was valuable in assessing the size of the testes but less sensitive for volume differentials and recommended annual scrotal ultrasound to determine testicular volume (Diamond et al., 2000). Calipers have been compared to an orchidometer consisting of a graded series of punched-out elliptical rings in a study comparing the two devices to the testis volume of orchiectomy specimens assessed by the displaced water technique. The orchidometer volume assessment had a better correlation than the calipers (Takihara et al., 1983).

Ultrasound assessment of testicular size, although potentially more accurate than calipers and/or orchidometer beads, is not without limitations. Poon et al. (2010) cautioned that a difference in measurement of 1 mm or 2 mm in each testicular dimension could result in a large difference in volume. Further, the use of ultrasound is costly. Walker and Kogan (2010) determined that routine use of ultrasound to

evaluate varicoceles would result in an increase in annual costs, ranging from $364 to $795 million. Consequently, many physicians choose orchidometer as a first clinical evaluation versus ultrasound, and reserve ultrasound for evaluating cases of suspected asymmetry.

Impact of Varicoceles

The significance of varicoceles in adolescents is their potential effect on testicular function and growth. In the adult population, varicoceles are present in 35% of men with primary infertility and 80% of men with secondary infertility (Lacerda et al., 2011). The impact of testicular varicocele on fertility is believed to be attributed to increased testicular temperature secondary to the collection of venous blood, although the exact mechanism is unknown (Diamond, 2003; Elmore, 2012). Many theories explain the pathophysiology of this phenomenon, ranging from DNA synthesis alteration to hypoxia (Elmore, 2012). Although 80% of adult males with varico celes are fertile, infertility remains the overriding consideration when evaluating a patient with a varicocele (Diamond, 2009).

The impact of the adolescent varicocele on fertility remains unclear. The effect of varicoceles on spermatogenesis is not well studied in adolescents because of the difficulty obtaining a semen sample. As a result, the focus has been placed on other measures thought to be substitutes of fertility potential, such as ipsilateral testicular size and catch up growth after puberty (Diamond, Gargollo, & Caldamone 2011; Elmore, 2012). Several studies have evaluated the use of testicular size as a proxy for assessment of testicular function (Diamond et al., 2007; Keene, Sajad, Rakoczy, & Cervellione, 2012; Pinto, Kroovand, & Jarow, 1994; Zampieri et al., 2007). Keene et al. (2012) and Diamond et al. (2007) found a significant difference in sperm concentration between varicocele patients with asymmetric or hypotrophic testes compared to patients with symmetric or non-hypotrophic testes.

However, the study by Zampieri and colleagues (2007) did not (see Table 1).

The evidence linking testicular hypotrophy (testicular asymmetry) to future infertility is controversial (Robinson, Hampton, & Koo, 2010). Nevertheless, testicular hypotrophy is a commonly identified abnormality found in adolescents with varicoceles, affecting as many as 70% (Van Batavia et al., 2010). Serial measurements can be used to track changes in testicular size over time. A limitation of this approach is the ability to distinguish true hypotrophy from transient asynchronous growth, a common finding in peri-pubertal boys (Chen et al., 2011; Kolon et al., 2008). Although some evidence shows that differences in testicular size may be transient in adolescents, some literature also supports the use of testicular size for varicocele evaluation (Chen et al., 2011; Mori, Bertolla, Fraietta, Ortiz, & Cedenho, 2008). A retrospective study demonstrated a significant size difference between the right and left testicle among boys with left sided varicoceles, and no significant difference among those without varicoceles (Chen et al., 2011). Further, a prospective study noted there is a higher prevalence of testicular asymmetry in adolescents with varicoceles compared to those without (see Table 2) (Mori et al., 2008). The grade of the varicocele does not appear to have an effect on testicular size in adolescents. Mori et al. (2008) did not identify any statistical difference in asymmetry between Grades 2 and 3 varicoceles [p > 0.05). Similarly, Alukal et al. (2005) did not find a correlation between grade of varicocele and severity of testicular size disproportion. The mean volume differentials they found for Grades I, 2, and 3 were 18%, 20%, and 19%, respectively, which were not statistically significant (Alukal et al., 2005).

Follow Up/Management

The natural history of adolescent varicoceles and the long-term effect on testicular size is not well defined. As a result, there has been wide variation in the management of adolescent varicoceles (Elmore, 2012; Fine & Poppas, 2012; Van Batavia et al., 2010). Studies such as those conducted by Van Batavia et al. and Korets et al. evaluated catch up growth to

determine the length of time and parameters to use when following adolescents with varicoceles expectantly (Korets, Woldu, Nees, Spencer, & Glassberg, 2011; Van Batavia et al., 2010). Catch-up growth is defined as the resolution of a significant size disparity. For example, if a patient has greater than a 20% differential in size, any asymmetry that is later noted to be less than 20% is deemed to be catch-up growth.

Van Batavia et al. (2010) studied the influence of Tanner Stage, or stage of pubertal development, on testicular size and catch up growth. These authors found that earlier Tanner Stages, specifically Stages 1 to 3, were associated with greater initial testicular asymmetry (64%) than later Tanner stages (Stages 4 and 5) (38%). They also noted that earlier Tanner stages had lower rates of catch up growth (27%) compared to later Tanner stages (53%) (Van Batavia et al., 2010). The difference in catch up growth rates was not found to be statistically significant.

In the absence of guidelines for long-term monitoring of adolescents with varicoceles and normal ipsilateral testicular size, Korets et al. (2011) conducted a retrospective study to examine the natural history of adolescent varicoceles and testicular sym metry from 1994 to 2009. Results showed those patients with an initial asymmetry of less than 15% who progressed tended to do so after two years (Korets et al., 2011). Preston, Carnat, Flood, Gaboury, and Leonard (2008) also evaluated patients with varicoceles who were managed conservatively. They noted that patients with less than an initial 20% differential that were managed conservatively did not progress to more than a 20% differential during a median follow up of two years (see Table 3) (Preston et al., 2008).

Recommendations regarding the management of adolescent varicocele vary. Poon et al. (2010) evaluated the duration patients with testicular asymmetry should be followed before proceeding with surgery. They suggested waiting at least 12 months between follow ups before intervening because they noted a better chance of resolution of asymmetry with longer follow up (Poon et al., 2010). Their recommendations conflict with the best practice guidelines published in 2002 by the Best Practice Policy Committee of the American Urological Association, which suggests that adolescents with varicoceles and decreased ipsilateral testicular size should be offered repair (Jarow et al., 2002).

However, Poon et al. (2010) acknowledge that when asymmetry is greater than 20% measured by serial ultrasound (79%) or serial orchidometer (21%), there is a lower chance of achieving catch-up growth. Kolon et al. (2010) recommend taking at least two ultrasound measurements one year apart before deciding to intervene. Preston et al. (2008) also recommend observation with serial ultrasound, and surgical intervention only when a patient demonstrates worsening asymmetry (see Table 4).

Overall, it appears that the presence of ipsilateral asymmetry (hypotrophy) does not affect the initial management of the adolescent varicocele. The literature supports continued follow up of adolescents with varicoceles for both those with testicular symmetry and asymmetry (hypotrophy) on an annual basis for at least two to three years prior to consideration of surgical intervention (Kolon et al., 2008; Korets et al., 2011; Poon et al., 2010; Preston et al., 2008). In older children who are Tanner Stage 5, Diamond et al. (2011) recommend that a semen analysis be obtained to decide the best course of management because it is a more definite variable.

Subclinical Varicocele

Subclinical varicoceles present unique challenges in the adolescent population. Unlike adults where subclinical varicoceles have shown to have an effect on blood flow and seminal function, the natural history of the subclinical varicocele in adolescents is not as well known (Cervellione, Corroppolo, & Bianchi, 2008). Cervellione et al. (2008) conducted a school-wide screening test of over 2,000 boys 10 to 16 years of age and performed both a clinical examination and venous Doppler study on all subjects. Of their cohort, 16.8% were found to have subclinical varicoceles. A random 10% sampling was selected to be prospectively followed for the next four years. Of those boys who were followed, 28% of patients went on to progress to a clinically detectable varicocele, and one patient demonstrated hypotrophy of greater than 20%. They concluded that their results were significant enough to recommend that children identified to have a sub clinical varicocele have longterm follow up (Cervellione et al., 2008).

Indications for Surgical Management

Testicular Hypotrophy

In adults, the primary indication for surgical management of a varicocele is an abnormal semen analysis. Because semen analyses are difficult to obtain in adolescents, testicular size and hypotrophy are used as alternative indicators for surgical intervention (Diamond, 2003). However, there is inconsistent data regarding which size discrepancy to use to determine the need for surgical intervention. The literature proposes two different criteria for surgical intervention: 1) a testicular size difference of greater than 15%, and 2) a testicular size difference of greater than 20%. Considerable literature supports at least a 20% size differential as the indication for surgery. More than half of Tanner Stage 5 adolescents with a varicocele and a testicular size difference greater than 20% have an abnormal semen analyses (Diamond et al., 2007). Poon et al. (2010) noted that adolescents who presented with a 20% or greater asymmetry and who were managed expectantly were less likely to achieve catch up growth than those who initially presented with less than 20% asymmetry (on ultrasound or orchidometer) after a median follow-up interval of 12 months. Kolon et al. (2008) showed that 85% of patients with a size discrepancy of at least 15% on ultrasound measurement normalized within an average of 3.5 years. Of the small percentage that did require surgical intervention, all of them had a discrepancy of greater than 20% (Kolon et al., 2008).

Peak Retrograde Flow

Peak retrograde flow (PRF) has been proposed as a method to determine those adolescents who may not experience catch-up growth (Poon et al., 2010). PRF is a value that can be obtained from a duplex Doppler ultrasound. It has been theorized that a high PRF increases the temperature of the testes and increases exposure to toxic metabolites contributing to testicular damage (Goldstein & Eid, 1989). Kozakowski et al. (2009) demonstrated that a PRF of greater than 38 cm/second is a poor prognostic indicator for catch-up growth and a good predictor of persistent and/or worsening asymmetry in an adolescent population (mean 14.3 years) with both 15% and 20% asymmetry at the time of initial evaluation. Korets et al. (2011) conducted a retrospective review of adolescents with varicoceles and initial asymmetry of less than 15%. Those adolescents whose varicoceles progressed were found to have a PRF of 30 cm/second or greater (Korets et al., 2011). These studies suggest that PRF may be a useful assessment to help guide which patients with testicular asymmetry should proceed to surgical intervention in lieu of observation.

Semen Analysis: Correlation With Testicular Size, Peak Retrograde Flow, and Varicocele Grade

Limited data exist in adolescents correlating semen analysis with testicular size, PRF, and varicocele grade. Diamond et al. (2007) found that there was a 50% incidence of abnormal semen parameters in those adolescent boys with greater than 20% asymmetry. Varicocele grade, however, was found by Mori et al. (2008) to have no association with sperm motility or concentration in 14- to 18-year-olds. Semen analysis remains the gold standard indicator for determining the need for surgical intervention. However, because it is not feasible in pre-pubertal boys, testicular size and peak retrograde flow remain the mainstay as the most reliable objective criteria for indicating treatment in this age group, despite limited data supporting a correlation with semen analysis.

Surgical Management Approaches

Varicocele repair involves the ligation of the dilated veins of the pampiniform plexus. Multiple options are available for repair, including both minimally invasive approaches and open approaches. These options vary from isolated venous ligation to enblock ligation of the testicular vessels (Hawkins, Racadio, McKinney, Racadio, & Vu, 2012; Healey, Lisle, & Mahomed, 2010; Raheem, 2013). Open approaches include an inguinal (Ivanissevich), subinguinal, and retroperitoneal (Palomo) approach. In the Ivanissevich approach, testicular artery and lymphatics are spared and the testicular veins are ligated at the inguinal ring (Raheem, 2013). The Palomo technique involves mass ligation of the testicular vessels including the testicular artery and veins and the lymphatics. The modified Palomo involves "ligation of the vascular pedicle above the vas deferens with preservation of the testicular artery" (Raheem, 2013 p136).

Minimally invasive approaches can be accomplished via laparoscopic, inguinal, and subinguinal approaches. Methods of minimally invasive treatment include embolization, laparoscopic ligation, and percutaneous retrograde endovascular occlusion (Barone, Johnson, Sterlin, & Ankem, 2011; Hawkins et ah, 2012; Mendez-Gallart, Bautista-Casasnovas, EstevezMartinez, & Varela-Cives, 2009; Storm, Hogan, & Jayanthi, 2010).

Surgical Outcomes

The goal of surgical intervention is to improve fertility potential by improving abnormal semen analysis parameters. Because semen analysis in the adolescent is difficult to obtain, an increase in ipsilateral testicular size is more commonly the desired outcome. Unfortunately, the lack of prospective studies directly comparing each surgical and minimally invasive treatment approach makes it difficult to determine which therapy is more efficacious. Diamond et al. (2009) conducted a retrospective study comparing the success rates and post-operative complications of hydrocele and testicular atrophy of various open procedures. The laparoscopic (100%) and Palomo (93%) approaches had the high est rate of success, defined as no evidence of a varicocele on postoperative clinical exam compared to the subinguinal (88%) and Ivanissevich (69%) approaches (Diamond et al., 2009).

Surgical Outcomes: Testicular Hypotrophy

Woldu, Van Batavia, Poon, Raimondi, and Glassberg (2010) evaluated the effect of both laparoscopic and open varicocelectomies on testicular atrophy in adolescents with previous inguinal surgery. They found an overall mean decrease in testicular asymmetry from 27.6% to 10.5%, and no post-operative testicular atrophy in those adolescents requiring either treatment (Woldu et al., 2010). Similarly, Kaneko, Sasaki, Yanai, Umemoto, and Kohri (2007) observed a rate of 62.5% of boys experiencing catch-up growth after microsurgical repair. A comparison between laparoscopic and open procedures demonstrated that the subinguinal approach and laparoscopic Palomo approach had comparable persistence, recurrence rates, and catch-up growth (Castagnetti et al., 2008). Similarly, Woldu et al. (2010) found no difference in atrophy or catch up growth after varicocelectomy between laparoscopic and open surgery.

Surgical Outcomes: Semen Analysis

Lacerda and colleagues (2011) conducted a prospective study that looked at sperm function in the form of DNA integrity and mitochondrial activity after varicocelectomy in adolescents 14 to 19 years of age. Their study demonstrated more spermatozoa with intact nuclear DNA and fewer cells with inactive mitochondria after surgery (Lacerda et al., 2011). Lenzi, Gandini, Bagolan, Nahum, and Dondero (1998) found that patients with varicoceles, who were surgically treated as adolescents, had superior sperm motility (55.7% vs. 46.32%) two to eight years after surgery. However, no significant difference in sperm concentration was seen compared to those patients with varicoceles that were not treated (59.05% vs. 45.58%, p-value not significant) (Lenzi et al., 1998). In contrast, Yamamoto, Hibi, Katsuno, and Miyake (1995), in their prospective study, found that adolescents 15 to 21 years of age with subclinical varicoceles who were surgically treated had improved sperm concentration at one year follow up after treatment compared to those who were not treated.

Complications of Surgical Treatment

The risks of varicocele repair can include wound infection, bleeding, post-operative hydrocele, varicocele recurrence, and injury to the vas deferens and testicular artery (Nees & Glassberg, 2011). Storm et al. (2010) noted that 91% of patients treated with varicocele embolization had resolution of the varicocele without hydrocele. The laparoscopic Palomo repair has been associated with an increased risk of postprocedural hydrocele (13.5%) (Mendez-Gallart et al., 2009). The use of laparoscopic lymphatic sparing procedures decreases the risk of hydrocele incidence (3.4%) versus using laparoscopic non-lymphatic sparing surgery (11.4%) (Glassberg, Poon, Gjertson, DeCastro, & Misseri, 2008; Healey et al., 2010). In their meta-analysis, Diamond et al. (2011) found that the open subinguinal and modified open Palomo had the lowest rates of recurrence and hydrocele compared to other open and laparoscopic procedures. Barroso, Andrade, Novaes, Netto, and Andrade (2009), however, found that the open Palomo procedure was associated with a higher rate of post-operative hydrocele (9.7%) compared to a laparoscopic approach (6.9%). Further, the classic Palomo had a higher hydrocele rate (7.7%) than the modified Paolmo (3.2%) (Barroso et al., 2009). Conversely, Borruto et al. (2010) conducted a meta-analysis of 11 studies comparing laparoscopic and open Ivanissevich and Palomo procedures, and found no difference between recurrence and hydrocele.

Summary

Varicoceles are the most common inguinoscrotal pathology among male adolescents (Diamond, 2003). The most common presentation of a varicocele is an asymptomatic, incidental finding during a routine physical exam. Currently, the most important parameter to assess in adolescents is the size and symmetry of the testicles if a semen analysis cannot be obtained. Orchidometer and calipers are a costeffective method currently available for testicular measurement. However, ultrasound appears to be a better alternative for accuracy and volume measurements. Adolescent boys may exhibit variation and asymmetry in testicular size with the onset of puberty. Adolescent boys with varicoceles who present with less than 15% asymmetry can experience spontaneous catchup growth within two to three years, and thus, should be managed conservatively (Kolon et al., 2008; Korets et al., 2011; Preston et al., 2008).

However, the presence of a varicocele and a testicular size difference of at least 20% warrant careful follow-up and surgical consideration, but not necessarily immediate surgical intervention. The literature supports expectant management, even in adolescents with testicular asymmetry at the time of presentation, for at least one year. If asymmetry progresses or if there is a lack of demonstrated ipsilateral testicular catch up growth after two years of follow up, then surgical repair is indicated. Semen analysis is the gold standard for assessing the impact of a varicocele on testicular function but has limitations in the adolescent population. Testicular size and peak retrograde flow can be used to assess the need for whether surgical intervention is warranted when a semen analysis cannot be performed. The use of retrograde flow is a more recently identified indicator for the need for surgical intervention. A peak retrograde flow of greater than 30 to 40 cm/second has been associated with a greater risk of varicocele progression or persistence, and is a good indicator for surgical intervention (Gitlen & McCullough, 2014; Korets et al, 2011; Van Batavia, Badalato, Fast, & Glassberg, 2013). As a result of our review of the literature, an algorithm for the evaluation and management of the adolescent presenting with a varicocele was developed and is currently used in our practice (see Figure 1). This algorithm may also serve as a guideline for other practitioners.

Surgery is the most definitive treatment for a varicocele. Based on the literature reviewed, the decision to proceed with surgery should be considered once the presence of a significant decrease in testicular size (i.e., greater than 20%) with little improvement in size and/or worsening size discrepancy has been demonstrated over a one to two-year surveillance period along with documented abnormal semen analysis, or chronic scrotal pain related to the varicocele. There are many surgical options available, including both minimally invasive and open approaches (inguinal, subinguinal, and retroperitoneal). A minimally invasive, subinguinal incision decreases morbidity associated with open surgery. However, the results of both minimally invasive and open approaches are comparable in terms of persistence, recurrence, and catch-up growth (Borruto et al., 2010). Thus, the type of surgical repair will often vary with surgeon preference and training, patient risk factors, availability of resources and patient and parent decision.

doi: 10.7257/1053-816X.2014.34.6.271

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Christi Butler, MD, BA, is a Urology Resident, University of California--San Francisco, San Francisco, CA.

Pamela Ellsworth, MD, is a Professor of Urology and Chief, Division of Pediatric Urology, Department of Urology, UMass Memorial Medical Center, Worcester, MA.

Table 1.
Effect of Testicular Size Differential on Semen Analysis

                    Age
                 Population
                  of Boys
                    with                                Volume (mL)
Study           Varicoceles           Groups              (Median)

Keene, Sajad,      12 to       Symmetric testes        1 (0.5 to 3.0)
Rakoczy, &        17 years
Cervellione,                   Asymmetric testes      1.5 (0.5 to 6.0)
2012                           (greater than 20%
                               volume difference)

Zampieri et        11 to       Varicocele and no            2.3
al., 2007         14 years     hypotrophy (greater
                               than 20% volume
                               difference)

                               Treated varicocele           3.25
                               with hypotrophy

                               Treated varicocele           2.6
                               no hypotrophy

Diamond et        14 to 20     Less than 10%                 --
al., 2007          years       hypotrophy

                               10% to 20%                    --
                               hypotrophy

                               Greater than                  --
                               20% hypotrophy

                    Age
                 Population                               Motility
                  of Boys                                (% Motile
                    with                                   Sperm)
Study           Varicoceles           Groups              (Median)

Keene, Sajad,      12 to       Symmetric testes        60 (43 to 84)
Rakoczy, &        17 years
Cervellione,                   Asymmetric testes       28 (18 to 80)
2012                           (greater than 20%
                               volume difference)

Zampieri et        11 to       Varicocele and no             43
al., 2007         14 years     hypotrophy (greater
                               than 20% volume
                               difference)

                               Treated varicocele            47
                               with hypotrophy

                               Treated varicocele            47
                               no hypotrophy

Diamond et        14 to 20     Less than 10%                 63
al., 2007          years       hypotrophy

                               10% to 20%                    58
                               hypotrophy

                               Greater than                  41
                               20% hypotrophy

                    Age
                 Population
                  of Boys                              Concentration
                    with                                (Million/mL)
Study           Varicoceles           Groups              (Median)

Keene, Sajad,      12 to       Symmetric testes        26 (8.1 to 91)
Rakoczy, &        17 years
Cervellione,                   Asymmetric testes       3 (0.7 to 31)
2012                           (greater than 20%
                               volume difference)

Zampieri et        11 to       Varicocele and no             58
al., 2007         14 years     hypotrophy (greater
                               than 20% volume
                               difference)

                               Treated varicocele            46
                               with hypotrophy

                               Treated varicocele            42
                               no hypotrophy

Diamond et        14 to 20     Less than 10%                 70
al., 2007          years       hypotrophy

                               10% to 20%                    35
                               hypotrophy

                               Greater than                  15
                               20% hypotrophy

Table 2.
Effect of Varicocele Severity on Testicular Volume and Differential

                                       Mean         Mean
                                      Length       Volume      Greater
                                    Difference   Difference    than 10%
                                        of          of        Asymmetry
Study      Population  Groups         Testes       Testes     Prevalence

Chen       Greater     L side          1.62        996.4
et. al.,   than 10     Grade
2011       years       2 to 3
                       Varicocele

                       No              0.18        188.2
                       varicocele

Mori,      14 to       Grade 2                                   41.7
Bertolla,  18 years    Varicocele
Fraietta,
Ortiz, &               Grade 3                                   51.9
Cedenho,               Varicocele
2008
                       No                                         11
                       varicocele

Table 3.

Trend of Testicular Symmetry with Expectant Management
of Patients with Initial Symmetry

                                                          Percentage
                                                            (%) of
                                                           Patients
                                            Duration of   with Less
                                             Expectant     than 10%
Study             Population     Groups      Follow Up    Asymmetry

Korets, Woldu,     12 to 18     Less than    28 months        50
Nees, Spencer,    years with       10%
& Glassberg,       less than
2011                  15%        10% to
                   asymmetry     14.90%      20 to 25        32.4
                                              months

Preston,          8.8 to 16.1   Less than      2.12           25
Carnat, Flood        years         10%
Gaboury, &
                                 10% to        2.12          66.7
Leonard, 2008                     14.9%

                                 15% to        2.12           75
                                  19.9%

                                                   Percentage
                   Percentage      Percentage        (%) of
                     (%) of          (%) of         Patients
                  Patients with   Patients with   with Greater
                  10% to 14.9%    15% to 19.9%      than 20%
Study               Asymmetry       Asymmetry      Asymmetry

Korets, Woldu,         9.6            15.4             25
Nees, Spencer,
& Glassberg,
2011
                      24.3            13.5            29.8

Preston,               50              25
Carnat, Flood
Gaboury, &
                                      33.3
Leonard, 2008

                       25

Table 4.

Trend of Testicular Symmetry with Expectant Management of
Patients with Initial Asymmetry

                                                         Duration of
                                                          Expectant
Study                   Population           Groups       Follow Up

Poon et al.,        Median age             10% to 19%     12 months
2010                13.9 years at least     initial
                    2 orchiodometer,
                    2 visits 6 months     Greater than    12 months
                    apart                 20% initial

Preston, Carnat,    8.8 to 16.1 years,    15% to 9.9%    2.12 years
Flood Gaboury,      median age 13.4
& Leonard, 2008     years, at least 2     Greater than   2.12 years
                    u/s                       20%

Kolon et al.,       Less than 18          Greater than    3.5 years
2008                years, median age         15%
                    13.2 years, Greater
                    than 2 to 3 u/s

                    Percentage   Percentage    Percentage
                      (%) of       (%) of        (%) of
                     Patients     Patients      Patients
                    with Less     with 10%    with Greater
                     than 10%      to 19%       than 20%
Study               Asymmetry    Asymmetry     Asymmetry

Poon et al.,            50           19            31
2010

                        18           29            53

Preston, Carnat,        75           25
Flood Gaboury,
& Leonard, 2008         21           29            50

Kolon et al.,       71 (< 15)    29 (> 15)
2008
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Date:Nov 1, 2014
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