Varicocele in Adolescents Treatment & Management

Moderate evidence supports the view that varicocele treatment results in improvement of testicular volume and sperm concentration. ^{[23, 24]} To date, the physical findings or diagnostic criteria that dictate surgical intervention in adolescents have not been strictly defined. ^[25] Controversies and opinions regarding when to operate and on whom to operate abound. Each case is handled individually, with a discussion among the patient, parents, and physician regarding the risks of intervention and potential impact on future fertility.

Ipsilateral testicular growth retardation is the most frequent relative indication for varicocele repair in adolescents; the concern is that patients with varicocele and ipsilateral testicular growth retardation at that age may manifest impaired fertility in adulthood.

Although controversial, general guidelines used by the pediatric urologist to determine if surgery is indicated typically include the presence of one or more of the following:

• Varicocele associated with decreased ipsilateral testicular size - A generally accepted indication for correction is an orchidometer or ultrasonography (US) measurement revealing a 20% volume deficit in the involved testis
• Bilateral varicoceles
• Symptomatic painful varicocele
• Abnormal findings on semen analysis

Other disconcerting factors include grade 2 or 3 varicocele or significant difference in testicular consistency, with a softer ipsilateral testis.

The European Association of Urology (EAU) has published recommendations for management of varicocele in children and adolescents (see Guidelines). ^[26]

A 2019 review of childhood and adolescent varicocele from an endocrinologic perspective suggested the following ^[27] :

• In patients with peak retrograde flow (PRF) less than 30 cm/s, testicular asymmetry less than 10%, and no evidence of sperm and hormonal abnormalities, conservative management may be considered
• In patients with 10-20% testicular volume asymmetry or PRF greater than 30 cm/s but less than or equal to 38 cm/s or sperm abnormalities, careful follow-up may ensue
• In the case of absent catchup growth or sperm recovery, varicocele repair should be proposed
• In patients with painful varicocele, testicular volume asymmetry 20% or greater, PRF greater than 38 cm/s, infertility, and failure of testicular development, treatment can be proposed at the initial consultation

If the decision is made to defer surgery, the patient should be monitored every 6-12 months so that any deleterious effects can be detected as early as possible. The question of surgical intervention is readdressed at that time.

Varicocele ligation in a healthy patient has no specific contraindications, but various surgical approaches offer different advantages, and certain procedures should be avoided in specific settings. For example, a history of previous surgery may influence venous disruption within the site. With previous abdominal or retroperitoneal surgery, laparoscopic surgery is less desirable.

A history of inguinal surgery makes a second inguinal approach more difficult and potentially hazardous to the spermatic cord structures. Previous inguinal surgery may have also compromised the arterial supply of the testis.

For this reason, when an adolescent who has previously undergone inguinal hernia surgery develops a varicocele, the best technique involves an inguinal approach with microscopic magnification to optimally identify and preserve the testicular artery. A retroperitoneal approach with testicular artery ligation is contraindicated because the initial hernia surgery could have inadvertently injured the vasal artery, and high ligation of the internal spermatic artery may cause testis atrophy due to arterial insufficiency.

Further research may provide a method of adequately determining which adolescents with varicoceles are at significant risk for infertility and, thus, when intervention is warranted. This would resolve present controversies as to relative versus absolute indications for surgery. Modifications and improvements in surgical techniques are ongoing, and lower recurrence and complication rates are likely to result. Finally, better understanding of the impact of a varicocele on the germinal epithelium of the testis may provide alternative management options.

No known medical therapy is available for varicocele. Watchful management may be an option with yearly checkups and reevaluation of testis size.

Surgical ligation of the spermatic veins is the procedure used. Several methods are used, differing primarily in the level at which the vessels are approached. These include abdominal retroperitoneal (Palomo), inguinal (Ivanissevitch), and subinguinal approaches. Microsurgical techniques and laparoscopic-assisted transperitoneal or retroperitoneal approaches are also employed. ^{[28, 29, 30]}

In a comparison of subinguinal and high inguinal microsurgical techniques, Shiraishi et al found that the two approaches appear to have similar success rates with regard to testicular growth. ^[31] ​ However, the high inguinal approach, which involves fewer divisions of veins and is associated with a larger diameter of the spermatic artery, is easier to perform.

Interventional venography has also been used for transcatheter occlusion of the spermatic veins. This is accomplished by percutaneous embolization of the testicular veins, identified by means of transfemoral venography. Embolization materials include balloons, coils, ^[32] and dextrose.

A systematic review and meta-analysis by Fabiani et al compared surgical ligation with sclero-embolization for treatment of varicocele in children, adolescents and adults. ^[33]  There were no significant differences in in overall complications, wound infection, testis pain, surgical-site hematoma, total sperm count, sperm motility, pregnancy, or recurrence rate.

Operative details

The aim of varicocele surgery is to identify and ligate the ascending venous network that drains the testis, epididymis, and vas deferens. A thorough history and a careful physical examination, with particualr attention to past surgical procedures, are necessary to choose the best approach for ligation.

The testicular artery is generally spared with the use of a microscope in the inguinal approach. The artery and any branches are identified with direct visualization with administration of papaverine or lidocaine directly onto the vessels or with a Doppler probe. Placing the operating table in a slight reverse Trendelenburg position may help dilate the internal spermatic veins, facilitating their identification during surgery.

With the transperitoneal or retroperitoneal method, the internal spermatic artery is also usually divided in addition to the veins. Ligation of the internal spermatic artery in the retroperitoneum does not usually cause testicular atrophy because of the generous collateral circulation to the testicle.

Subinguinal approach

The incision is made over the external ring. Dilated cremasteric veins are ligated, and the spermatic cord is opened. The spermatic veins in the pampiniform plexus are separated and ligated, as are any dilated veins that accompany the vas deferens.

Microscopic subinguinal approach

The incision is made over the external ring, and the spermatic cord is dissected into the operative field. The operating microscope is used to identify and ligate the internal spermatic veins. Care is taken to identify and preserve the testicular artery by using Doppler US or by visually identifying a pulsatile artery in the spermatic cord. Lymphatic vessels are also preserved when possible to prevent future hydrocele formation.

If the procedure is performed with local anesthesia and light sedation, the patient can perform a Valsalva maneuver to fill any remaining veins. Some authors advocate the additional step of delivering the testicle into the wound and performing ligation of the external spermatic and gubernacular veins. Division of the veins after ligation is optional.

Inguinal approach

The incision is made over the course of the inguinal canal, and the external inguinal ring is incised toward the internal inguinal ring. Care is taken to preserve the ilioinguinal nerve coursing under the external oblique aponeurosis. After the spermatic cord is delivered, the internal spermatid fascia is incised, and the branches of the internal spermatic vein are identified and separated from the gonadal artery with the help of Doppler US. The branches of the internal spermatic vein are ligated.

A microscope may be used with this approach as well. Again, division of the veins after ligation is optional.

Retroperitoneal approach

This approach consists of high ligation of the entire spermatic pedicle, approached via a low abdominal incision above the internal inguinal ring. A laparoscopic-assisted approach is recommended in obese patients because of the limited exposure obtained with an open approach. Care is taken to sweep the peritoneum from the spermatic vessels and to stay extraperitoneal. This operation may also be performed as a testicular artery–sparing procedure by opening the spermatic fascia to identify and preserve the artery.

Laparoscopic-assisted retroperitoneal approach

A camera port is placed along the lower portion of the umbilicus, along with a single 3- to 5-mm instrument port placed just laterally. The internal inguinal ring, where the vas deferens joins the spermatic cord, is identified. The scrotum is compressed to dilate the spermatic veins.

An incision is made in the peritoneum over the gonadal vessels approximately 4-5 cm proximal to the internal ring, and dissection is used to mobilize the cord vessels. (See the video below.) Lymphatic vessels are dissected off the spermatic cord, and the remaining artery and veins are clipped, tied, or cauterized and may be divided. The artery may be spared, with division of the spermatic veins, but this lengthens the procedure, increases the risk of varicocele recurrence, and has not been shown to impact catchup growth. ^[8]

Varicocele ligation is an outpatient procedure. The patient is advised to expect postoperative wound and scrotal discomfort and possibly edema and ecchymosis. Proper wound care instructions are provided and oral analgesics prescribed. Icing and elevation of the scrotum may help reduce painful swelling. The patient may return to school or work in 2-3 days.

Varicocelectomy, regardless of the technique employed, carries a risk of complications. The complication rate varies with the surgical method used (see Table 2 below). ^[34] The microscopic-assisted procedures carry the lowest complication rates (< 1%). Inguinal, retroperitoneal, and laparoscopic ligations carry a postoperative hydrocele risk of less than 10%; embolization is very infrequently associated with hydrocele formation.

Table 2. Postoperative Complication Rates ^[34] (Open Table in a new window)

Hydrocele formation is the most common complication of varicocelectomy and most likely results from lymphatic obstruction. ^[35] An effort to spare lymphatics intraoperatively with the laparoscopic approach has been shown to result in lower hydrocele rates. ^[36]

Less common complications include testicular atrophy, hematoma, injury to the vas deferens, chronic testicular pain, and recurrence or persistence of the varicocele. Postoperative pain may be reducible with intraoperative administration of local anesthetics. ^[37]

Percutaneous embolization carries the unique, yet infrequent, risks of contrast reactions, puncture of the femoral artery, hemorrhage, extravasation, and migration of embolization balloons.

In a large multicenter analysis of complications and recurrence after treatment of varicocele in young (< 19 y) men, Lurvey et al found that the retreatment rate was significantly higher with percutaneous embolization than with either open or laparoscopic varicocelectomy and that open and laparoscopic varicocelectomy did not differ significantly from each other with regard to retreatment rate and hydrocele formation. ^[38]

Routine postoperative visits for wound and testicular assessment are standard. In the first year, testicular volume and scrotal texture are periodically assessed to ensure that testicular atrophy, recurrence of the varicocele, or hydrocele formation has not occurred.