Varicocele is one the most common genital issues referred to pediatric urologists. In the 15- to 19-year-old age group, the prevalence of varicocele is about 15%, which is similar to that seen in the adult population. Although varicocele repair in symptomatic adult men may improve their fertility potential, the majority of adult men with a varicocele will not encounter male factor infertility. In contrast, most adolescents who present with a varicocele are asymptomatic and their fertility future is unknown. Thus, the evaluation and treatment of the adolescent varicocele remains unclear and controversial despite significant research over the last several decades.
The authors have performed a meta-analysis of randomized controlled trials evaluating treatment of varicoceles in children and adolescents. Unfortunately, when examining the outcome of follow-up with surgery vs observation, only three studies meet those criteria, and only two of them examine semen analysis data. In the study by Laven et al (reference 12), pretreatment semen parameters were not significantly different among the three groups (varicocelectomy, observation, control without varicocele). Furthermore, the participants had normal semen analyses to start (47.4 × 106/mL in the varicocelectomy group) and would not have met our current criteria for intervention in the first place. In the study by Yamamoto et al (reference 16), they also noted that semen parameters were comparable in all groups initially (varicocele and no varicocele participants). Both studies also had a high rate of attrition bias due to incomplete outcome data. Thus, it is unclear from both studies whether any of the patients were different from the general population and whether intervention was needed.
To date, individual studies of adolescents with varicoceles have shown that testicular volume differential is a poor correlate of semen analysis and significant testicular catch-up growth can occur without surgery. Furthermore, total motile count may also improve over time in varicocele patients despite Tanner 5 development. As in the adult literature, microscopic subinguinal lymphatic- and artery-sparing repair seems to have the best risk:benefit ratio. Although the ultimate patient goal is paternity, currently, semen analysis remains critical to appropriate management of these patients. The key surgical question is whether adolescent varicocele repair has any effect on reversal of testicular hypotrophy or improvement in semen parameters compared with no treatment or controls without a varicocele. This randomized controlled trial has yet to be performed, and I agree with the authors that a multicenter study is needed. We need to examine a cohort of Tanner 5 adolescents with several semen analyses over time that are abnormal compared with controls and then randomize them to treatment vs observation. Participants will likely be hard to recruit, although it is worth the time and energy.
Written by Thomas F Kolon MD