Varicocoele. Classification and pitfalls.

BACKGROUND: Varicocoeles have been considered for a long time potentially correctable causes for male infertility, even though the correlation of this condition with infertility and sperm damage is still debated. OBJECTIVE: To present a summary of the evidence evaluation for imaging varicocoeles, to underline the need for a standardized examination technique and for a unique classification, and to focus on pitfalls in image interpretation. METHODS: Based on the evidence of the literature, the current role of ultrasound (US) imaging for varicocoeles has been reported and illustrated, with emphasis on examination technique, classification, and pitfalls. RESULTS: US is the imaging modality of choice. It is widely used in Europe, while in other countries clinical classification of varicocoeles is considered sufficient to manage the patient. A number of US classifications exist for varicocoeles, in which the examinnation is performed in different ways. DISCUSSION: An effort toward standardization is mandatory, since lack of standardization contributes to the confusion of the available literature, and has a negative impact on the understanding of the role itself of imaging in patients with varicocoeles. CONCLUSION: Use of the Sarteschi/Liguori classification for varicocoeles is recommended, since it is the most complete and widely used US scoring system available today. Tubular extratesticular structures resembling varicocoeles, either at palpation or at US, should be identified and correctly characterized.

Role of total motile sperm count in the evaluation of young men with bilateral subclinical varicocele and asthenospermia.

INTRODUCTION: In comparison to its clinical analogue, the subclinical varicocele represents a questionable entity and specific guidelines for the optimal management are lacking. In our previous study of patients with subclinical varicocele, we showed that bilateral condition is associated with risk of dyspermia. In the present study, we evaluated the risk of deterioration of semen quality in men with bilateral disease and impaired motility according to WHO criteria. MATERIALS AND METHODS: Men with bilateral subclinical varicocele, not desiring fatherhood at the time of presentation, were included in study. During initial evaluation, the number of Total Motile Sperm Count (TMSC) was calculated and the patients' age, total testicular volume (TTV), maximum venous size and mean resistive index (RI) of the intratesticular arteries were recorded. We classified the participants in five classes according to the TMSC reading: class A-: TMSC < 5 x 106, class A: TMSC between 5-10 x 106, class B: TMSC between 10-15 x 106, class C: TMSC between 15-20 x 106, and class D: TMSC > 20 x 106 per ejaculate. The participants were seen after 6 months for a repeat spermiogram and physical examination. If clinical varicocele was diagnosed or a new abnormality in the spermiogram was noted, the participants were excluded from the study. The remaining patients were allocated to two groups according to the repeat TMSC reading: patients sub-classified into a lower class (group 1), and patients remaining at the same class (group 2). A comparative analysis was performed between two groups. RESULTS: Nineteen men were included. Nine patients were subclassified (group 1). Three patients moved to A- class (< 5 x 106). Ten patients remained in the same class having no deterioration (group 2). Comparing the two groups, no statistically significant difference was recognized for age, TTV, maximum venous size on both sides, and mean RI (p > 0.05). However, the initial reading for TMSC was 14.57 x 106 in group 1, and 22.84 x 106 in group 2, respectively. This difference was statistically significant (p < 0.05). Additionally, in a paired analysis there was a significant difference in TMSC after 6 months (p < 0.05), too. Summary Conclusions: Young men with bilateral varicocele and asthenospermia seem to be at risk of deterioration in their semen quality after a follow-up of 6 months. The measurement of TMSC can unmask patients at risk, whereas men with the lowest readings seem to be at highest risk for deterioration. The possibility of a worsening sperm quality should be considered in the appropriate clinical context.

Ultrasound evaluation of varicoceles: systematic literature review and rationale of the ESUR-SPIWG Guidelines and Recommendations.

Although often asymptomatic and detected incidentally, varicocele is a relatively common problem in patients who seek medical attention for infertility problems. Ultrasound (US) is the imaging modality of choice for evaluation, but there is no consensus on the diagnostic criteria, classification, and examination technique. In view of this uncertainty, the Scrotal and Penile Imaging Working Group of the European Society of Urogenital Radiology (ESUR-SPIWG) undertook a systematic review of the available literature on this topic, to use as the basis for evidence-based guidelines and recommendations. This paper provides the results of the systematic review on which guidelines were constructed.

Varicocele embolization: Anatomical variations of the left internal spermatic vein and endovascular treatment with different types of coils.

PURPOSE: To present anatomical variations of left internal spermatic vein and a comparison between treatments with hydrogel-coated and non-coated platinum coils in patients with varicocele. MATERIALS AND METHODS: A total of 153 men (mean age, 27.5±6.7 [SD] years; range: 18-45 years) with left sided varicocele underwent coil embolization. Anatomic variants of gonadal vein were categorized into five subtypes (I-V). Additional venous collaterals were also recorded. Three types of coils were used (hydrogel coated platinum coils, fibered coils and non-coated platinum coils). Technical success, tolerance, efficacy and safety of hydrogel coated platinum coils were recorded. Comparison between different types of coils used was made. Fisher's exact test was used for statistical analysis. RESULTS: Varicoceles were classified as type I (26.1%), type II (13.7%), type III (32.1%), type IV (18.3%) and type V (9.8%). The internal spermatic vein - renal vein angle ranged from 32°-128° (mean angle, 93.5°). Technical success was achieved in 145 patients (94.8%) without complications. The mean number of coils used was 3 (range: 1-6 coils). A total of 260 hydrogel coated platinum coils in 95 patients and 135 non-coated coils in 50 patients were deployed with no complications. No differences were noted between the different types of coils used regarding embolic efficacy and safety. A 6.2% (9/145) recurrence rate and a 33.3% (14/42) fertility rate were observed. Clinical success regarding symptom relief after painful varicocele embolization was 100% (36/36) for technically successful cases. CONCLUSION: Varicocele embolization with the use of hydrogel coated or non-coated platinum coils is technically feasible and safe without complications. No superiority of one type of coil over the other was found.

Grade 3 varicocele in fertile men: a different entity.

PURPOSE: Although varicocele size has an inverse relationship with baseline semen parameters and a direct relationship with seminal reactive oxygen species in infertile patients, to our knowledge the effect of varicocele grade in fertile men is unknown. We evaluated the impact of varicocele grade on seminal parameters, testicular size and seminal reactive oxygen species in fertile men. MATERIALS AND METHODS: We prospectively evaluated 194 men from July 2004 to April 2010. Of the men 156 were fertile and classified by presence of varicocele. A total of 38 infertile patients with varicocele as the only identifiable cause of infertility comprised the control group. Physical examination, semen parameters and seminal reactive oxygen species were compared between the groups. RESULTS: Of 156 fertile men 43 (24.3%) had clinical varicocele, which was grade 1 to 3 in 22, 11 and 10, respectively. The remaining 113 men (72.7%) had no varicocele. Infertile men had smaller testes, decreased semen parameters and higher seminal reactive oxygen species than the fertile groups. Testicular size, reactive oxygen species and semen parameters did not differ between fertile men with vs without varicocele. Fertile men with varicocele grade 3 had higher seminal reactive oxygen species than those with lower grade varicocele. As varicocele grade increased, seminal reactive oxygen species increased and sperm concentration decreased. CONCLUSIONS: Although fertile men have more efficient defense mechanisms to protect against the consequences of varicocele on testicular function, these mechanisms may not be sufficient in those with varicocele grade 3. Further research is needed to clarify whether they are at increased risk for future infertility.

Effects of bioflavonoids in the management of subclinical varicocele.

BACKGROUND: Subclinical varicocele is a relative rare condition. The aim of this study is to identify the role of bioflavonoids in the management of subclinical varicocele. MATERIALS AND METHODS: We analyzed the medical charts of patients treated for subclinical varicocele with bioflavonoids between 1999 and 2004; inclusion criteria were created before treatment. Short and long-term results after treatment were studied and compared with untreated patients. RESULTS: One hundred and sixty-eight patients with left subclinical varicocele were included in the study. Long-term results showed a possible correlation between use of bioflavonoids and lesser rate of clinical progression to palpable varicocele (11 vs. 31%), higher rate of stable vein reflux (47 vs. 38%) and higher resolution rate (41 vs. 31%) (p > 0.05). Bioflavonoids did not show any protective factor against testicular growth arrest. CONCLUSIONS: Subclinical varicocele should be considered as the starting point of varicocele, and although the use of bioflavonoids in patients with subclinical varicocele could reduce the development of palpable varicocele, it cannot prevent the onset of testicular growth arrest.

Updated terminology of chronic venous disorders: the VEIN-TERM transatlantic interdisciplinary consensus document.

Non-uniform terminology in the world's venous literature has continued to pose a significant hindrance to the dissemination of knowledge regarding the management of chronic venous disorders. This VEIN-TERM consensus document was developed by a transatlantic interdisciplinary faculty of experts under the auspices of the American Venous Forum (AVF), the European Venous Forum (EVF), the International Union of Phlebology (IUP), the American College of Phlebology (ACP), and the International Union of Angiology (IUA). It provides recommendations for fundamental venous terminology, focusing on terms that were identified as creating interpretive problems, with the intent of promoting the use of a common scientific language in the investigation and management of chronic venous disorders. The VEIN-TERM consensus document is intended to augment previous transatlantic/international interdisciplinary efforts in standardizing venous nomenclature which are referenced in this article.

Dye-assisted lymph vessels sparing laparoscopic varicocelectomy.

OBJECTIVE: Hydrocele, the main complication of laparoscopic varicocelectomy, is thought to result from a disruption of gonadal lymphatics. The aim of this study was to evaluate the effectiveness of patent blue V dyeing to identify and preserve lymphatic vessels and to assess whether the lymphatic sparing technique avoids postoperative hydrocele in adolescent boys undergoing a laparoscopic procedure. MATERIALS AND METHODS: Fifty-two (52) boys affected by varicocele Grade III (range, 12-16 years) underwent a left-sided laparoscopic varicocelectomy. Twenty-six (26) boys were randomly assigned to a lymphatic nonsparing (LNS) group, and the others to a lymphatic sparing (LS) group. Before surgery in the LS group, 2 mL of patent blue V was injected under the tunica dartos on the left side. RESULTS: All varicocelectomies were performed laparoscopically. Lymphatic vessels were identified in 23 (88.5%) boys of the LS group. In the remaining three (11.5%), the lymphatics could not be identified clearly. No adverse local or generalized reactions were noted. At a mean follow-up of 14 months, no recurrent varicocele or testicular volume reduction were detected. Hydrocele developed in 4 LNS patients and 1 was operated on. No patient from the LS group developed a hydrocele. CONCLUSIONS: Staining gonadal lymph vessels with patent blue V is an effective and simple method of visualization of the lymphatic drainage from the testis. Blue-stained lymph vessels could be readily distinguished and preserved during a laparoscopic varicocelectomy, which results in a decrease of hydrocele development. To validate an efficacy of vital staining of lymphatic vessels in avoiding hydrocele formation, a larger series and longer follow-up are necessary.

Resistance and pulsatility index increase in capsular branches of testicular artery: indicator of impaired testicular microcirculation in varicocele?

PURPOSE: To evaluate the effect of clinical varicocele on testicular microcirculation using spectral Doppler analysis. METHODS: Forty-nine young and healthy volunteers were enrolled in this prospective study. Varicocele grades were determined according to sonographic parameters. Patients with left-sided clinical varicocele were classified as the patient group (n = 15), while the remaining patients served as controls (n = 34). Spectral Doppler measurements of testicular arteries (peak systolic/end diastolic velocity, resistance index, pulsatility index) were measured from capsular and intratesticular branches. RESULTS: No statistically significant difference was found between the Doppler parameters obtained from the intratesticular branches of both testes and the capsular branches of the right testis. On the other hand, in left-sided clinical varicocele cases, the average resistance index (RI) and pulsatility index (PI) of capsular branches of the left testes (RI, 0.68 +/- 0.04; PI, 1.22 +/- 0.15) were significantly greater than in the control group (RI, 0.64 +/- 0.06; PI, 1.07 +/- 0.18) (p < 0.05 and p < 0.01, respectively). CONCLUSIONS: Increased RI and PI of capsular branches of testicular arteries on spectral Doppler examination may be an indicator of impaired testicular microcirculation in patients with clinical varicocele. Further studies addressing the correlations with sperm counts are needed to determine the cut-off values for these indices.

[Children and adolescent varicocele]. / Varicocèle de l'enfant et de l'adolescent.

About 15% of adolescent males present with a varicocele. It rarely causes symptoms and is often diagnosed on the routine physical examination. There are evidences of an association between duration of a varicocele and testicular impairment. Surgical treatment is indicated in case of testicular growth arrest, testicular asymmetry, grade II or more, symptoms i.e. pain or swelling, parental or patient's anxiety. Several treatment options include open surgery (with or without micro-anastomosis), laparoscopy, embolization by interventional radiology, antegrade scrotal sclerotherapy. Informations should include a recurrence rate as hight as 15% whatever the technique may be, postoperative hydroceles and some testicular atrophies. Those complications can be delayed.

A Doppler-based study on the prevalence of varicocele in German children and adolescents.

The prevalence of varicocele was estimated among pupils of forms 4 and 8 in the city of Hamburg and the severity of the associated venous reflux was analysed. In the school year of 1998/99, a genital examination was performed on 2756 children (median age 10.2 years) and 2008 adolescents (14.6 years). The varicocele degree was determined according to the WHO. Venous reflux was proven by CW-Doppler sonography, distinguishing between Valsalva-induced reflux (VR) and continuous reflux (CR). As a result, varicoceles were detected in 18.0% of the children (1.2% bilaterally) and 42.7% of the adolescents (7.2%). High-graded forms (palpable/visible) occurred with increasing rate (from 7% to 22.9%) on the left side. Subtle forms (subclinical/during Valsalva) counted for >90% of all right-sided findings, whilst an age-related shift towards higher degrees was noted left-sided. VR occurred bilaterally, CR was almost only established left-sided. VR was mainly associated with subtle varicoceles, CR was predominantly found in the high-graded forms. These results suggest that even in children varicoceles are not a rare phenomenon. However, adolescence is the main period of manifestation. A major venous malfunction is already evident in maturing boys, which seems to be associated with the formation of high-graded varicoceles.

The interventional therapy of varicoceles amongst children, adolescents and young men.

The retrograde sclerotherapy of the internal spermatic vein is a simple and safe method for the treatment of a varicocele. Approximately 5500 patients had so far undergone the interventional therapy in our departments. The methods of retrograde sclerotherapy will be described and alternative methods of treatment will be given in detail. The minor trauma, the low gonad dose and fast implementation coupled with a high success rate show that this method is very safe and efficient. We have, therefore, chosen it as the primary therapy.

Color Doppler ultrasound investigation of varicocele.

Varicocele, whose association with male infertility has been clearly documented in the literature, is a common finding in adolescents and adult men, being diagnosed in 20-40% of infertile patients. A correct and early diagnosis of this affliction is of great importance because, in most cases, a timely correction, usually performed using percutaneous sclerotherapy, leads to an improvement in semen quality. Currently, physical examination in a warm room is the mainstay of diagnosis, but this is affected by a low sensibility and specificity, especially in cases of low grade varicocele. Colour Doppler ultrasound (CDU) is a new, reliable and non-invasive diagnostic method for the evaluation of varicocele testes which allows the detection of even subclinical varicocele thanks to its capacity for measuring the size of the pampiniformis plexus and blood flow parameters of the spermatic veins. At present, there is a lack of completely standardised diagnostic criteria, but when this problem is solved, clinical examination and CDU will certainly become the "gold standard" in the investigation of varicocele.

The influence of antegrade scrotal sclerotherapy on the diameter of the spermatic cord veins in men with varicocele.

OBJECTIVE: To assess the influence of antegrade scrotal sclerotherapy on diameter of veins of the pampiniform plexus of the spermatic cord by comparison of the vein diameter before and after the operation in patients with varicocele; to evaluate the rate of recurrence of the disorder after antegrade scrotal sclerotherapy and significance of color Doppler ultrasonography in the diagnosis of varicocele; and to estimate the efficacy of the treatment. MATERIAL AND METHODS: Forty-one patients with various degrees of varicocele treated by antegrade scrotal sclerotherapy were included in the study. The size of the pampiniform plexus of veins of the patients was evaluated clinically during physical examination, and its diameter was measured by color Doppler ultrasonography before and after the operation in the upright and the supine positions during the Valsalva maneuver and without it. RESULTS: After antegrade scrotal sclerotherapy, the diameter of the studied veins was found reliably decreased while examined in all four patient's examining positions, independently of the degree of the preoperative varicocele and recurrence of the disorder. The postoperative decrease of diameter of veins was inversely proportional to the degree of varicocele, i. e. the diameter of veins in the third degree varicocele became most reduced. The recurrence of varicocele after antegrade scrotal sclerotherapy was revealed in 21.9% of the operated patients. The diameter of veins in the recurrent varicocele, assessed by physical examination, and venous blood reflux, detected by ultrasound, reliably decreased in the upright position of patients (p<0.005), whereas in the supine position, diameter of the studied veins remained almost the same as it was before the operation (p=0.9). CONCLUSIONS: After antegrade scrotal sclerotherapy, the diameter of the varicocele vein decrease was statistically significant. It was mostly expressed after the operation in the cases of the third degree varicocele. The postoperative diameter of veins in the recurrent varicocele of the examined patients in the upright position was also reliably smaller than before the operation, but it practically did not differ from the preoperative diameter when the patients were examined in the supine position.

Assessment of the effects of varicocelectomy on the thermoregulatory control of the scrotum.

Infrared functional imaging was successfully used to assess restoration of the normal thermal control of the scrotum after surgical treatment of varicoceles. The technique may be used to study the relationship between impaired scrotal thermoregulation and spermatogenesis.

[Should varicoceles be treated in the adolescent? How?]. / Faut-il traiter la varicocèle de l'adolescent? Comment?

Adolescents rarely consult for painful varicocele. The condition has to be confirmed by physical examination and a detailed Doppler exam. An ultrasound may be necessary to measure the size of the testis. About 15% of all adolescents have varicoceles. One out of three is graded II or III in the Dubin and Amelar classification. About 20% of varicoceles graded III occur in association with testicular hypotrophy. We do not know whether boys with a varicocele will fertility problems later on, but only 13% of adult men with varicocele are infertile. Surgery can be considered as necessary only after studying a large number of patients, comparing at random patients operated at a young age and followed for 15-20 years with patients not operated and with a group of healthy controls. The best treatment has to be selected because of the low risk of testicular atrophy and the disappearance of the varicocele in more than 90% of the cases. Inguinal root with microsurgery, and pre or intra-operative radiologic opacifications are the usual choice of most pediatric surgeons. Laparoscopy or retroperitoneoscopy have no major impact on the postoperative results. They are expensive and require great experience. Embolization and other radiological techniques induce a long period of radiation, are not always possible, expensive and demand an experienced radiologist. General anesthesia is required because of the time involved and finally the success rate is low. Microsurgical venous reanastomosis is still confidential probably because of technical difficulties. Scrotal anterograde sclerotherapy is the simplest and cheapest treatment and can be performed with a local anesthetic due to the short time required. But like other procedures, it can induce testicular ischemia.

Echo-colour doppler ultrasonography in the diagnosis of varicocele.

The relationship between varicocele and infertility has long been defined. About a third of the male patients undergoing evaluation for infertility present with a varicocele. Sixty male patients between 17 and 35 years of age (mean 25.6) were examined with a colour-doppler flow imaging system. The diameters of the veins in the pampiniform plexus were measured by gray-scale sonography. Our findings were classified with regard to venous diameter, the existence or non-existence of reflux, the circumstances under which these findings were recorded (e.g. during normal respiration and standing position or during Valsalva manoeuvre and supine position). Finally our results suggest that: (a) the clinical significance of the presence of dilated veins or reflux during increased intraabdominal pressure and under similar circumstances should be regarded with caution; (b) positive findings during normal inspirium are highly significant (grades III and IV).

[Varicocelectomy by an inguinal approach. Our experience]. / Varicocelectomia per via inguinale. Nostra esperienza.

Varicocele is a dilatation of the spermatic plexus due to a pathologic venous reflux in the testes. It affects about 15-18% of adolescents. The modern diagnostic tools allow an early identification and a thorough staging. Surgical treatment in this phase seems to be useful for the preservation of gonad integrity. Recently, the interest in varicocele in pediatric surgery has increased because of the close relationship of this disease to male infertility. We performed a diagnostic-therapeutic protocol with a follow-up to evaluate the trophism and functional state of testes and to identify early recurrence of venous reflux. In our Institute, the surgical treatment usually performed is resection of spermatic plexus through an inguinal approach. This technique is simple, yields good outcome and has no morbidity.