A new clinical grading system for varicocele

A-292 A NEW CLINICAL GRADING SYSTEM FOR VARICOCELE. H. H. Kim, M. Goldstein. Urology and Reproductive Medicine, Weill Medical College of Cornell University, New York, NY. OBJECTIVE: Varicocele grade correlates with its effects on testis function and outcomes of repair. The 3 varicocele sizes described in 1970 by Dubin and Amelar remain the default grading system. We propose a more refined and standardized grading system. DESIGN: Retrospective review. MATERIALS AND METHODS: We describe 6 grades that fully integrate the original grades. The scrotum is warmed with a heating pad to relax the dartos muscle; this aids evaluation and decreases inter-observer variability. The traditional and updated classifications were applied to 200 consecutive men (293 total varicoceles). RESULTS: Varicocele size ranged from 0 to IIIc (Table). The terms subclinical, small, medium, large, very large and huge correspond to the numerical grades. Specific signs for each category are explicit and descriptive. The subgroup ‘‘p’’ indicates pathological varicocele requiring further work up. In our series, the distribution for the traditional grades of subclinical, I, II and III was 2.7%, 21.8%, 30.7% and 44.7%, respectively and for the new grades of 0, I, II, IIIa, IIIb and IIIc was 2.7%, 21.8%, 30.7%, 37.2%, 6.8% and 0.7%, respectively. TABLE 1. A Comparison of Classification Systems

Traditional Grade

II

III

A-293 THE EFFECTS OF VARICOCELECTOMY ON MEN WITH AZOSPERMIA AND SEVERE OLIGOSPERMIA: A RETROSPECTIVE REVIEW AND META-ANALYSIS. M. Fine, H. Mirheydar, P. Jon, M. Antoine. University of Minnesota, Minneapolis, MN. OBJECTIVE: To evaluate the role of varicocelectomy in subfertile men with azospermia and severe oligospermia (<1 million/cc). DESIGN: Restrospective chart review and meta-analysis of literature. MATERIALS AND METHODS: Retrospective chart review identified 479 men who underwent varicocelectomy at a single institution between 2001 and 2007. Of these, 26 men had azospermia, and another 26 had severe oligospermia (defined as <1 million/cc). Data were collected on pre-operative semen parameters, Testosterone, FSH, testicular volume and varicocele grade. Main outcome measure was increase in sperm concentration. RESULTS: 6 of 26 (23%) azoospermic men had sperm in the ejaculate post-operatively (table 1), but only one patient had a count in excess of 10 million/cc. 12 of 26 (43%) of oligospermic men had improvement in counts to a mean of 3.22 million/cc. None of the patients in either group were able to achieve pregnancy with natural conception or IUI [table 1].

New Clinical Criteria

Grade

Subclinical Veins not palpable or 0/Subclinical visible, with or without Valsalva

I

CONCLUSIONS: Clinical grade remains the most important factor in determining varicocele management. Our proposed system uses specific criteria to refine and standardize the grading of varicocele. Supported by: Valentine Fellowship & Wallace Fund.

i. Veins not palpable or visible, with or without Valsalva ii. No change in cord or testis upright vs. supine Palpable only with I/Small i. Full veins when Valsalva; invisible upright, collapse when supine ii. Increased turgidity of veins with Valsalva; minimal or no impulse with Valsalva iii. Firm testis upright, soft testis supine Palpable even without II/Medium i. Full tortuous veins Valsalva, but still upright; palpable invisible but still invisible ii. Increased turgidity of veins and distinct impulse with Valsalva iii. as above Easily visible through IIIa/Large i. Easily visible scrotal skin through scrotal skin when standing upright ii. & iii. as above IIIb/Very Large i. Veins fill entire ipsilateral hemiscrotum ii. & iii. as above IIIc/Huge i. Veins fill entire scrotum, displacing contralateral testis ii. & iii. as above Subgrade p/pathologic Varicocele of any grade that does not collapse in the supine position; retroperitoneal pathology must be ruled out

FERTILITY & STERILITYÒ

TABLE 1. Response to varicocelectomy

Clinical Criteria

Azospermia

Severe Oligospermia

Baseline 0 0.31 M/cc concentration Post-op concentration 0.58 M/cc 4.06 M/cc Number improved 6 (23%) 12 (46%) N¼26 in each group. Concentration expressed as mean. Comparison of responders versus non responders showed no difference in age (32.7 vs 32.3 years respectively), FSH (15.6 vs 17.26 IU/L), Testosterone (329 vs 310 ng/dl), combined testicular volume (33.5 vs 35.6 cc) or varicocele grade. Review of published studies shows that our results are in line with others (table 2). Mean percent of patients improved among all studies was 33%. TABLE 2. Studies of varicocelectomy in azospermic men

Study

Mean post-op concentration (M/cc)

% improved

N

Matthews 1998 Kim 1999 Cakan 2004 Kadioglu 2004 Schlegel 2004 Pasquolotto 2005 Esteves 2005 Fine 2008 TOTAL

2.20 4.07 0.73 0.04 N/R 4.1 0.53 0.58 0.73 M/cc (median)

54 % 42 % 23 % 21 % 23 % 33 % 47% 23 % 33.25 %

22 28 13 24 31 27 17 26 188

CONCLUSIONS: Varicoelectomy is not effective in significantly improving sperm parameters in azospermic or severely oligospermic men. A minority of previously azospermic men will have sperm in the ejaculate post-operatively, thereby avoiding the need for TESE or use of cryopreserved sperm. Supported by: None. A-294 SPERM DNA FRAGMENTATION DECREASES AFTER ORAL ANTI-INFLAMMATORY AND ANTIBIOTIC TREATMENT. M. Bibancos, A. M. Rocha, P. A. Hassun, G. D. Smith, E. L. A. Motta, P. C. Serafini. Huntington Medicina Reprodutiva, Sa˜o Paulo, Brazil; Genesis Genetics Brazil, Sa˜o Paulo, Brazil; Department of Ob/Gyn, Urology, Physiology, University of Michigan, Ann Arbor, MI. OBJECTIVE: Sperm oxidative stress can be caused by intrinsic sperm production of reactive oxygen species or by inflammatory processes and/or subclinical infections of the genital tract. The aim of this study was to evaluate

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