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“REDO ADOLESCENT VARICOCELECTOMY”
THE JOURNAL OF UROLOGY®
Vol. 181, No. 4, Supplement, Sunday, April 26, 2009
173
480
482
THE PREPUBERTAL VARICOCELE: IS THERE A RISK OF TESTICULAR GROWTH FAILURE?
“REDO ADOLESCENT VARICOCELECTOMY”
Ulf Saeger*, Dietrich Pfeiffer, Juergen Berger, Andreas J Gross, Hamburg, Germany
INTRODUCTION AND OBJECTIVE: Theoretically, redo varicocelectomy is associated with an increased risk of postoperative testicular atrophy. We wanted to know the incidence of atrophy following redo surgery and the incidence of catch up growth when asymmetry was present prior to the redo surgery. METHODS: Fifteen boys, ages 13-21, who had redo varicocelectomy and who were evaluated at least 6 months post redo surgery were included in the study. Pre and post redo volume measurements and percent asymmetry were included. RESULTS: Of the 15 patients, the initial procedure was laparoscopic in 10, open Palomo in 3, and Ivannssevich in 2. In 5 of 15 patients the varicocelectomy had been done bilaterally but in all 5 the redo surgery was only on the left. None of the 15 left testicles developed atrophy post redo surgery. Two patients had no preop measurements for asymmetry and one had a partially infarcted right testicle following a bilateral microscopic varicocelectomy done elsewhere, making asymmetry measurements irrelevant. The latter patient was treated with embolization and the remaining 14 with an inguinal approach. Four of the 15 patients had >10% asymmetry prior to redo surgery; all 4 had post redo catch up growth. All 15 varicoceles were no longer present on follow up exam. CONCLUSIONS: Redo varicocelectomy can be done successfully without resultant ipsilateral testicular atrophy. When persistent testicular asymmetry is present prior to redo varicocelectomy, there is an excellent chance for post redo catch up growth.
INTRODUCTION AND OBJECTIVE: To evaluate the natural history of prepubertal varicoceles with regard to the severity of the disease and testicular growth development. METHODS: A total of 164 subjects with (median age 10,5 years) unilateral, left-sided varicocele were followed over a period of at least three years. On first visit, all subjects belonged to puberty stages I (n=121; 73,8%) and II (n=43; 26,2%) according to Tanner. Physcial examination, ultrasound of both testis and Doppler-studies were performed to identify the degree of varicocele and testicular volume. RESULTS: A complete regression of varicocele without any intervention was found in 11% (n=18) of all subjects. Those with persisting disease showed a significant progression in degrees (p<0,001). The Doppler-studies showed no change of severity of venous reflux. 12,2% (n=20) of all subjects developed additionally a mild contralateral rightsided varicocele. The proportion of patients with testicular volume loss has increased from n=44 (34,9%) to n=57 (45,2%). This was not statisticly significant (p=0,071). However, subjects with persisting unilateral varicocele had an increase of volume loss of the ipsilateral testis (p<0,01). Volume deficiencies of 15% and more were found. No correlation was found between the initial degree of varicocele and the proportion of volume deficiencies at the final evaluation (p=0,836). There was a correlation between the degree of varicocele and the proportion (p<0,004) and degree (p<0,013) of testicular volume deficiency at the final evaluation. CONCLUSIONS: Regarding to the degree of varicocele and the increase of volume deficiency, the varicocele shows to be a progressiv disease. The initial degree of varicocele does not predict the development of the testicular volume. A close observation of prepubertal boys with varicocele seems therefore not necessary. Observation or even therapy seems to be advisable during puberty and the period of testicular growing, when volume deficiencies become more evident. Source of Funding: None
481 VARICOCELE-RELATED RETARDATION OF TESTICULAR GROWTH AT PUBERTY. PROSPECTIVE CROSS-SECTIONAL STUDY. Dietrich Pfeiffer*, Juergen Berger, Ulf Saeger, Roland Tauber, Andreas J Gross, Hamburg, Germany INTRODUCTION AND OBJECTIVE: We prospectively assessed male students in the 4th and 8th forms to see whether varicoceles affect testicular growth. METHODS: Ultrasound measurements were performed in 700 boys with a left or bilateral varicocele to define the testicular size according the different pubertal stages. 257 children and 287 adolescents with unilateral varicoceles of different degrees (WHO, 1993) and proven venous reflux on CW-Dopplersonography were assessed for testicular size discrepancies in relationship to the varicocele size. RESULTS: Left testicular volume was median 0.6 ccm (range, 0.4-1.0) in children and 8.1 ccm (5.5-10) in adolescents. A rapid testicular growth occurred between the pubertal stages 1, 2 and 3 (p<0.0001). In adolescents significant differences were noted between the varicocele grades comparing the frequencies and the extent of testicular hypotrophies (p< 0.0005). Consistently, the frequencies of volume differentials q 15% were associated with the varicocele grades (p< 0.0001). CONCLUSIONS: Varicoceles may impair the rapid testicular growth at puberty. The severity of the growth failure depends on the varicocele size. Source of Funding: None
Kenneth I Glassberg*, Miguel A Mercado, Stephen A Poon, New York, NY
Source of Funding: None
483 EFFECTS OF GRADE 1 VARICOCELE DETECTED IN THE PEDIATRIC AGE ON TESTICULAR DEVELOPMENT Koji Shiraishi*, Yamaguchi, Japan; Hiroshi Takihara, Sanyo-onoda, Japan; Hideyasu Matsuyama, Yamaguchi, Japan INTRODUCTION AND OBJECTIVE: A number of reports have indicated the effectiveness of varicocelectomy on large varicoceles in adolescents. Grade 1 varicocele developed during the pediatric age might have a harmful effect on the future spermatogenesis, because of the developing testis and thus, the harmful effects of varicocele will continue for a long time. We carried out a 5-year followup of grade 1 varicocele detected, to examine the natural history and the effectiveness of varicocelectomy on testicular development. METHODS: Of the 31 boys with left grade 1 varicocele diagnosed by palpation and ultrasonography, 10 (mean12.5 years) underwent microsurgical varicocelectomy and 21 (mean13.0 years) were conservatively observed through the evaluations of varicocele grade and testicular volume using a orchidometer and ultrasonography. The control group consisted of age-matched 20 healthy boys without varicocele. The left testicular volume was compared with the right and the absolute bilateral testicular volumes among the boys in all the groups. If the testicular size discrepancy was more than 20% volume differential, it was considered as testicular growth delay. RESULTS: The mean followup periods for the observation and varicocelectomy group were 5.5 and 4.8 years, respectively. During the observation, 13 boys (62%) continued to have grade 1 varicocele, 4 (19%) developed grade 2 varicocele, while and the other four boys (19%) showed spontaneous resolution. Twelve testes (57%) were found to be developed in parallel with the right testis, and 1 boy (5%) who experienced spontaneous resolution of the varicocele had catch-up growth, while 8 boys (38%) had left testicular growth delay with or without the grade up of varicocele. The mean duration to cause the growth delay was 4.2±0.4 years. Furthermore, the right testicular volume compared to those in the other groups was also noted by observation. On the other hand, a significant left testicular growth was observed in the varicocelectomy group and left testicular catch-up growth was demonstrated in 30% of
Vol. 181, No. 4, Supplement, Sunday, April 26, 2009
173
480
482
THE PREPUBERTAL VARICOCELE: IS THERE A RISK OF TESTICULAR GROWTH FAILURE?
“REDO ADOLESCENT VARICOCELECTOMY”
Ulf Saeger*, Dietrich Pfeiffer, Juergen Berger, Andreas J Gross, Hamburg, Germany
INTRODUCTION AND OBJECTIVE: Theoretically, redo varicocelectomy is associated with an increased risk of postoperative testicular atrophy. We wanted to know the incidence of atrophy following redo surgery and the incidence of catch up growth when asymmetry was present prior to the redo surgery. METHODS: Fifteen boys, ages 13-21, who had redo varicocelectomy and who were evaluated at least 6 months post redo surgery were included in the study. Pre and post redo volume measurements and percent asymmetry were included. RESULTS: Of the 15 patients, the initial procedure was laparoscopic in 10, open Palomo in 3, and Ivannssevich in 2. In 5 of 15 patients the varicocelectomy had been done bilaterally but in all 5 the redo surgery was only on the left. None of the 15 left testicles developed atrophy post redo surgery. Two patients had no preop measurements for asymmetry and one had a partially infarcted right testicle following a bilateral microscopic varicocelectomy done elsewhere, making asymmetry measurements irrelevant. The latter patient was treated with embolization and the remaining 14 with an inguinal approach. Four of the 15 patients had >10% asymmetry prior to redo surgery; all 4 had post redo catch up growth. All 15 varicoceles were no longer present on follow up exam. CONCLUSIONS: Redo varicocelectomy can be done successfully without resultant ipsilateral testicular atrophy. When persistent testicular asymmetry is present prior to redo varicocelectomy, there is an excellent chance for post redo catch up growth.
INTRODUCTION AND OBJECTIVE: To evaluate the natural history of prepubertal varicoceles with regard to the severity of the disease and testicular growth development. METHODS: A total of 164 subjects with (median age 10,5 years) unilateral, left-sided varicocele were followed over a period of at least three years. On first visit, all subjects belonged to puberty stages I (n=121; 73,8%) and II (n=43; 26,2%) according to Tanner. Physcial examination, ultrasound of both testis and Doppler-studies were performed to identify the degree of varicocele and testicular volume. RESULTS: A complete regression of varicocele without any intervention was found in 11% (n=18) of all subjects. Those with persisting disease showed a significant progression in degrees (p<0,001). The Doppler-studies showed no change of severity of venous reflux. 12,2% (n=20) of all subjects developed additionally a mild contralateral rightsided varicocele. The proportion of patients with testicular volume loss has increased from n=44 (34,9%) to n=57 (45,2%). This was not statisticly significant (p=0,071). However, subjects with persisting unilateral varicocele had an increase of volume loss of the ipsilateral testis (p<0,01). Volume deficiencies of 15% and more were found. No correlation was found between the initial degree of varicocele and the proportion of volume deficiencies at the final evaluation (p=0,836). There was a correlation between the degree of varicocele and the proportion (p<0,004) and degree (p<0,013) of testicular volume deficiency at the final evaluation. CONCLUSIONS: Regarding to the degree of varicocele and the increase of volume deficiency, the varicocele shows to be a progressiv disease. The initial degree of varicocele does not predict the development of the testicular volume. A close observation of prepubertal boys with varicocele seems therefore not necessary. Observation or even therapy seems to be advisable during puberty and the period of testicular growing, when volume deficiencies become more evident. Source of Funding: None
481 VARICOCELE-RELATED RETARDATION OF TESTICULAR GROWTH AT PUBERTY. PROSPECTIVE CROSS-SECTIONAL STUDY. Dietrich Pfeiffer*, Juergen Berger, Ulf Saeger, Roland Tauber, Andreas J Gross, Hamburg, Germany INTRODUCTION AND OBJECTIVE: We prospectively assessed male students in the 4th and 8th forms to see whether varicoceles affect testicular growth. METHODS: Ultrasound measurements were performed in 700 boys with a left or bilateral varicocele to define the testicular size according the different pubertal stages. 257 children and 287 adolescents with unilateral varicoceles of different degrees (WHO, 1993) and proven venous reflux on CW-Dopplersonography were assessed for testicular size discrepancies in relationship to the varicocele size. RESULTS: Left testicular volume was median 0.6 ccm (range, 0.4-1.0) in children and 8.1 ccm (5.5-10) in adolescents. A rapid testicular growth occurred between the pubertal stages 1, 2 and 3 (p<0.0001). In adolescents significant differences were noted between the varicocele grades comparing the frequencies and the extent of testicular hypotrophies (p< 0.0005). Consistently, the frequencies of volume differentials q 15% were associated with the varicocele grades (p< 0.0001). CONCLUSIONS: Varicoceles may impair the rapid testicular growth at puberty. The severity of the growth failure depends on the varicocele size. Source of Funding: None
Kenneth I Glassberg*, Miguel A Mercado, Stephen A Poon, New York, NY
Source of Funding: None
483 EFFECTS OF GRADE 1 VARICOCELE DETECTED IN THE PEDIATRIC AGE ON TESTICULAR DEVELOPMENT Koji Shiraishi*, Yamaguchi, Japan; Hiroshi Takihara, Sanyo-onoda, Japan; Hideyasu Matsuyama, Yamaguchi, Japan INTRODUCTION AND OBJECTIVE: A number of reports have indicated the effectiveness of varicocelectomy on large varicoceles in adolescents. Grade 1 varicocele developed during the pediatric age might have a harmful effect on the future spermatogenesis, because of the developing testis and thus, the harmful effects of varicocele will continue for a long time. We carried out a 5-year followup of grade 1 varicocele detected, to examine the natural history and the effectiveness of varicocelectomy on testicular development. METHODS: Of the 31 boys with left grade 1 varicocele diagnosed by palpation and ultrasonography, 10 (mean12.5 years) underwent microsurgical varicocelectomy and 21 (mean13.0 years) were conservatively observed through the evaluations of varicocele grade and testicular volume using a orchidometer and ultrasonography. The control group consisted of age-matched 20 healthy boys without varicocele. The left testicular volume was compared with the right and the absolute bilateral testicular volumes among the boys in all the groups. If the testicular size discrepancy was more than 20% volume differential, it was considered as testicular growth delay. RESULTS: The mean followup periods for the observation and varicocelectomy group were 5.5 and 4.8 years, respectively. During the observation, 13 boys (62%) continued to have grade 1 varicocele, 4 (19%) developed grade 2 varicocele, while and the other four boys (19%) showed spontaneous resolution. Twelve testes (57%) were found to be developed in parallel with the right testis, and 1 boy (5%) who experienced spontaneous resolution of the varicocele had catch-up growth, while 8 boys (38%) had left testicular growth delay with or without the grade up of varicocele. The mean duration to cause the growth delay was 4.2±0.4 years. Furthermore, the right testicular volume compared to those in the other groups was also noted by observation. On the other hand, a significant left testicular growth was observed in the varicocelectomy group and left testicular catch-up growth was demonstrated in 30% of