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Repair versus observation in adolescent varicocele: A prospective study
INTERNATIONAL
803
ABSTRACTS
Critical Analysis of the Clinical Presentation tum: A Nine-Year Experience at a Single Jeffersor2, L.M. Perez, and D.B. Joseph. J Urol158: ber), 1997.
of Acute ScroInstitution. R.H. 1198-1200, (Septem-
The authors retrospectively analyzed the records of 115 boys who underwent surgical exploration for acute scrotum between October 1986 and January 1996. The children were divided into three groups. Group 1 consisted of 83 patients with spermatic cord torsion (mean age, 14.4 years). Group 2, 27 patients, had torsion of a testicular appendage (mean age, 9.4 years). Group 3 consisted of 5 patients with epididymoorchitis (mean age: 14.1 years). Particular attention was given to nausea and vomiting, patient age, and duration of pain. Nausea and vomiting occurred in 69% and 60% (respectively) of the boys in group 1, 8% and 4% (respectively) in group 2, and none in group 3. Nausea and vomiting had positive predictive values of 96% and 98%, respectively, for spermatic cord torsion. Only 6 (7%) of the 83 boys with spermatic cord torsion were younger than 11 years, whereas 15 (56%) of the 27 with torsion of a testicular appendage were younger than 11 years. Of the 83 boys with spermatic cord torsion, the testes were salvaged in 51 (61%), and the duration of pain was 40 minutes to 12 hours (mean, 4 hours). The testes were not salvaged in any patient with pain of greater than 12 hours’ duration. The authors believe that any boy 11 years old or older with scrotal pain of less than 12 hours’ duration that is associated with nausea or vomiting should be considered to have torsion of the spermatic cord. In this day of cost-effective medical management, it is not necessary to perform imaging in this subset of boys before surgical exploration.-George W Holcomb, Jr Repair Versus Observation spective Study. D.A. Paduch 1132, (September), 1997.
in Adolescent Varicocele: and J. Niedzielski. J Urol
A Pro158:1128-
The authors evaluated 2,100 boys (10 to 20 years old) for genitourinary abnormalities. From this population, two groups of adolescents 15 to 19 years old with grade 2 or 3 varicoceles were created, including 88 who underwent varicocele repair and 36 controls. Testicular volume and pampiniform vein diameter were measured, and Doppler ultrasonography was performed. After 12 months, the volume of the involved left testis increased to almost normal in treated boys (mean atrophy index, 12.7% at surgery and 3% 12 months later). In controls the corresponding atrophy indexes were 10% and 9%, respectively. The relative increase in left testicular volume was 26% in the surgery group and 11% in controls. In the surgery group the mean pampiniform vein diameter decreased from 2.8 preoperatively to 2 mm postoperatively; there was no change in that of the controls. Varicocele repair in adolescents with moderate and severe varicocele reversed testicular growth arrest and resulted in catch-up growth within 12 months of surgery-George W Holcomb, Jr The Influence of Surgical Approach and lntraoperative Venography on Successful Varicocelectomy in Adolescents. L.S. Palmel; M. Muizels, WE. Kaplan, et nl. JUrol 158:1201-1204. (September), 1997. The authors reviewed the records of patients undergoing varicocele ligation behveen 1986 and 1995. Data were stratified by surgical approach and performance of venography, and were compared by cross-table analysis. Data were then compiled from the literature from series that included cases stratified according to surgical approach and/or performance of venography. The impact of these parameters on recurrence rates was assessed by computing success rates and crosstable analysis. Thirty-three boys underwent ligation via a suprainguinal (27) or inguinal (8) approach. Intraoperative postligation venography was performed in 16 cases and omitted in 19. Neither surgical approach nor performance of venography influenced the recurrence rate for these
patients (not statistically significant). Similarly, venography did not affect the recurrence rate after stratification by surgical approach (not significant). The overall success rate was 97% (34 of 35 cases). These data were added to those of three published studies, totaling 252 varicoceles with comparable groupings. The mean success rate after the suprainguinal approach was 95.6% (range, 93.2% to 97.4%); that for the inguinal approach was 88.3% (range, 82.7% to 100%). Recurrence was less common after the suprainguinal approach (P = .06). Postligation venography did not statistically affect the success rate after stratification according to surgical approach, but it was associated with a higher success rate when performed with the inguinal approach. Irrespective of the performance of venography, the suprainguinal surgical approach yields higher success rates than the inguinal approach to varicoceles in adolescents. Postligation intraoperative venography does not significantly affect the success rate of varicocele ligation, but it may be useful during an inguinal approach.-George W Holcomb, Jr The Adolescent Varicocele: What’s New With an Old Problem in Young Patients. S.J. Skoog, K.P. Roberts, M. Goldstein, et al. Pediatrics 100:12-22, (July), 1997. In this special article, the authors address the difficult questions of whether and which adolescents with varicocele should undergo surgery. The incidence of adults with varicocele is approximately 15%; a similar figure has been noted in adolescent surveys. Most males with varicocele do not seek treatment for infertility; nevertheless, studies have documented diminished testicular function with long-standing varicoceles. Testicular vascular anatomy is described, with particular attention to venous drainage. Several hypotheses regarding the etiology of left varicoceles (which constitute 85% to 90%) are offered, the most cogent of which relates to possible compression of the left renal vein, resulting in increased testicular vein pressure. The authors review experimental studies that suggest how varicoceles might relate to diminished testicular function under the subcategories of hyperthermia, hypoxia, adrenal, reflux, endocrine imbalances, testicular paracrine imbalances, and altered blood flow. Bilateral testicular dysfunction associated with the varicocele is discussed. Pathological and histological changes in the ipsilateral testis are described and, notably, 77% of boys with a varicocele are reported to have significant volume loss of the ipsilateral gonad. Accurate measurements of testicular size are necessary to best determine testicular volume. Ultrasonography is the most accurate and reproducible technique to measure testicular volume. The authors note that the literature does not uniformly show that the size of the varicocele correlates with the degree of testicular damage. Nevertheless, over time, larger varicoceles tend to produce more consistent damage than do smaller ones. The techniques for treating varicocele are presented in a single table that includes their complication and failure rates. Microscopic inguinal or subinguinal approaches are recommended. The psychological impact of varicoceles is addressed briefly. The authors note that after corrective surgery, catch-up growth of the testicle occurs and infertility can be expected to improve. They conclude by recommending correction where there is a ~2 mL size discrepancy between the left and right testicle. Correction also should be considered where there is a decrease in testicular growth by two standard deviations from growth curves and in cases with testicular pain or a large (grade 3) varicocele.Jeffrey L. Zitsman Two-Stage Fowler-Stephens Clipping of the Spermatic Joseph. J Urol 158:1205-1207,
Orchiopexy With Laparoscopic Vessels. G.S. Law, L.M. Perez, and D.B. (September), 1997.
The authors retrospectively reviewed the records of 441 boys (547 undescended testes). There were 105 boys (24%) with 124 nonpalpable testes (23%). All patients underwent laparoscopy. Ligation of spermatic vessels was performed as stage 1 on 20 abdominal testes (4%) in 18 boys (4%). Stage 2 orchiopexy was done using an open technique.
803
ABSTRACTS
Critical Analysis of the Clinical Presentation tum: A Nine-Year Experience at a Single Jeffersor2, L.M. Perez, and D.B. Joseph. J Urol158: ber), 1997.
of Acute ScroInstitution. R.H. 1198-1200, (Septem-
The authors retrospectively analyzed the records of 115 boys who underwent surgical exploration for acute scrotum between October 1986 and January 1996. The children were divided into three groups. Group 1 consisted of 83 patients with spermatic cord torsion (mean age, 14.4 years). Group 2, 27 patients, had torsion of a testicular appendage (mean age, 9.4 years). Group 3 consisted of 5 patients with epididymoorchitis (mean age: 14.1 years). Particular attention was given to nausea and vomiting, patient age, and duration of pain. Nausea and vomiting occurred in 69% and 60% (respectively) of the boys in group 1, 8% and 4% (respectively) in group 2, and none in group 3. Nausea and vomiting had positive predictive values of 96% and 98%, respectively, for spermatic cord torsion. Only 6 (7%) of the 83 boys with spermatic cord torsion were younger than 11 years, whereas 15 (56%) of the 27 with torsion of a testicular appendage were younger than 11 years. Of the 83 boys with spermatic cord torsion, the testes were salvaged in 51 (61%), and the duration of pain was 40 minutes to 12 hours (mean, 4 hours). The testes were not salvaged in any patient with pain of greater than 12 hours’ duration. The authors believe that any boy 11 years old or older with scrotal pain of less than 12 hours’ duration that is associated with nausea or vomiting should be considered to have torsion of the spermatic cord. In this day of cost-effective medical management, it is not necessary to perform imaging in this subset of boys before surgical exploration.-George W Holcomb, Jr Repair Versus Observation spective Study. D.A. Paduch 1132, (September), 1997.
in Adolescent Varicocele: and J. Niedzielski. J Urol
A Pro158:1128-
The authors evaluated 2,100 boys (10 to 20 years old) for genitourinary abnormalities. From this population, two groups of adolescents 15 to 19 years old with grade 2 or 3 varicoceles were created, including 88 who underwent varicocele repair and 36 controls. Testicular volume and pampiniform vein diameter were measured, and Doppler ultrasonography was performed. After 12 months, the volume of the involved left testis increased to almost normal in treated boys (mean atrophy index, 12.7% at surgery and 3% 12 months later). In controls the corresponding atrophy indexes were 10% and 9%, respectively. The relative increase in left testicular volume was 26% in the surgery group and 11% in controls. In the surgery group the mean pampiniform vein diameter decreased from 2.8 preoperatively to 2 mm postoperatively; there was no change in that of the controls. Varicocele repair in adolescents with moderate and severe varicocele reversed testicular growth arrest and resulted in catch-up growth within 12 months of surgery-George W Holcomb, Jr The Influence of Surgical Approach and lntraoperative Venography on Successful Varicocelectomy in Adolescents. L.S. Palmel; M. Muizels, WE. Kaplan, et nl. JUrol 158:1201-1204. (September), 1997. The authors reviewed the records of patients undergoing varicocele ligation behveen 1986 and 1995. Data were stratified by surgical approach and performance of venography, and were compared by cross-table analysis. Data were then compiled from the literature from series that included cases stratified according to surgical approach and/or performance of venography. The impact of these parameters on recurrence rates was assessed by computing success rates and crosstable analysis. Thirty-three boys underwent ligation via a suprainguinal (27) or inguinal (8) approach. Intraoperative postligation venography was performed in 16 cases and omitted in 19. Neither surgical approach nor performance of venography influenced the recurrence rate for these
patients (not statistically significant). Similarly, venography did not affect the recurrence rate after stratification by surgical approach (not significant). The overall success rate was 97% (34 of 35 cases). These data were added to those of three published studies, totaling 252 varicoceles with comparable groupings. The mean success rate after the suprainguinal approach was 95.6% (range, 93.2% to 97.4%); that for the inguinal approach was 88.3% (range, 82.7% to 100%). Recurrence was less common after the suprainguinal approach (P = .06). Postligation venography did not statistically affect the success rate after stratification according to surgical approach, but it was associated with a higher success rate when performed with the inguinal approach. Irrespective of the performance of venography, the suprainguinal surgical approach yields higher success rates than the inguinal approach to varicoceles in adolescents. Postligation intraoperative venography does not significantly affect the success rate of varicocele ligation, but it may be useful during an inguinal approach.-George W Holcomb, Jr The Adolescent Varicocele: What’s New With an Old Problem in Young Patients. S.J. Skoog, K.P. Roberts, M. Goldstein, et al. Pediatrics 100:12-22, (July), 1997. In this special article, the authors address the difficult questions of whether and which adolescents with varicocele should undergo surgery. The incidence of adults with varicocele is approximately 15%; a similar figure has been noted in adolescent surveys. Most males with varicocele do not seek treatment for infertility; nevertheless, studies have documented diminished testicular function with long-standing varicoceles. Testicular vascular anatomy is described, with particular attention to venous drainage. Several hypotheses regarding the etiology of left varicoceles (which constitute 85% to 90%) are offered, the most cogent of which relates to possible compression of the left renal vein, resulting in increased testicular vein pressure. The authors review experimental studies that suggest how varicoceles might relate to diminished testicular function under the subcategories of hyperthermia, hypoxia, adrenal, reflux, endocrine imbalances, testicular paracrine imbalances, and altered blood flow. Bilateral testicular dysfunction associated with the varicocele is discussed. Pathological and histological changes in the ipsilateral testis are described and, notably, 77% of boys with a varicocele are reported to have significant volume loss of the ipsilateral gonad. Accurate measurements of testicular size are necessary to best determine testicular volume. Ultrasonography is the most accurate and reproducible technique to measure testicular volume. The authors note that the literature does not uniformly show that the size of the varicocele correlates with the degree of testicular damage. Nevertheless, over time, larger varicoceles tend to produce more consistent damage than do smaller ones. The techniques for treating varicocele are presented in a single table that includes their complication and failure rates. Microscopic inguinal or subinguinal approaches are recommended. The psychological impact of varicoceles is addressed briefly. The authors note that after corrective surgery, catch-up growth of the testicle occurs and infertility can be expected to improve. They conclude by recommending correction where there is a ~2 mL size discrepancy between the left and right testicle. Correction also should be considered where there is a decrease in testicular growth by two standard deviations from growth curves and in cases with testicular pain or a large (grade 3) varicocele.Jeffrey L. Zitsman Two-Stage Fowler-Stephens Clipping of the Spermatic Joseph. J Urol 158:1205-1207,
Orchiopexy With Laparoscopic Vessels. G.S. Law, L.M. Perez, and D.B. (September), 1997.
The authors retrospectively reviewed the records of 441 boys (547 undescended testes). There were 105 boys (24%) with 124 nonpalpable testes (23%). All patients underwent laparoscopy. Ligation of spermatic vessels was performed as stage 1 on 20 abdominal testes (4%) in 18 boys (4%). Stage 2 orchiopexy was done using an open technique.