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Does the Degree of Preoperative Testicular Asymmetry or Length of Postoperative Follow-up Influence Testicular Catch-up Growth Results?

Saturday, October 20, 2012
Grand Ballroom A/B (Hilton Riverside)
Angela M. Fast, B.S., Jason P. Van Batavia, M.D., Shannon N. Nees, B.S. and Kenneth I. Glassberg, MD, FAAP, Division of Pediatric Urology, Department of Urology, Columbia University College of Physicians and Surgeons, Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY

Purpose:   While previous studies have reported that post-varicocelectomy catch-up growth is not related to age, Tanner stage, grade or ligation of lymphatics at the time of varicocelectomy, we are unaware of any reports that describe whether the degree of pre-varicocelectomy asymmetry or length of post-varicocelectomy follow-up are related to the incidence of  catch-up growth following varicocelectomy.  We sought to answer these questions.

Methods:   Using our adolescent varicocele database, we identified patients who had undergone a varicocelectomy and had both pre- and postoperative ultrasound testicular volume measurements.  Using the following testicular asymmetry formula: [right (cc) – left (cc)]/ right (cc) x 100%, catch-up growth was defined as achieving <10% asymmetry postoperatively.  Initial asymmetry was defined as ≥10% difference in testicular size with the left smaller than the right.  Only patients who had undergone laparoscopic or Palamo varicocelectomy and had preoperative testicular asymmetry were included.  Kaplan-Meier analysis was used to evaluate the incidence of catch-up growth over time along with its relationship to the degree of preoperative asymmetry (10 to 19.9%, 20 to 34.9% and 35% or greater testicular asymmetry) in patients who had either a unilateral or bilateral varicocelectomy.

Results:   Overall, 304 patients (mean age 15.4 years; range 6.5-20.6; mean follow-up 36.3 months, range 6.0-128.9) met inclusion criteria; 252 of 304 patients (82.9%) achieved catch-up growth.  Mean preoperative testicular asymmetry was 28%, with 88 patients (28.9%) having 10 to 19.9% asymmetry, 133 (43.8%) having 20 to 34.9% asymmetry, and 83 (27.3%) having 35% or greater asymmetry.  Kaplan-Meier analysis of overall catch-up growth is illustrated in Figure 1 with time point predictions in Table 1.  Catch-up growth was achieved in 34.5% by 12 months, 59.9% by 24 months and 75.3% in 48 months.  There were no differences in catch-up growth rate regardless of the degree of preoperative testicular asymmetry (Figure 2).  Varicocele repairs were left sided in 236 patients (77.7%) and bilateral in 68 patients (22.3%).  There was no significant difference in incidence or interval to catch-up growth between those who underwent unilateral versus bilateral repair (p=0.39).

Conclusion:   The incidence of catch-up growth following varicocelectomy increases with time with many patients demonstrating catch-up growth more than two years after surgery.  Catch-up growth was not influenced by the degree of preoperative asymmetry or whether the repair was unilateral or bilateral.  If a patient has significant testicular asymmetry 2.76 years (95% CI: 2.47-3.31 years) following surgery, there is little chance that catch-up growth will occur thereafter.

 

Table 1.  Kaplan-Meier time point predictions of expected postoperative catch-up growth

Percentage expected to achieve catch-up growth*

Time

(years)

95% Confidence Interval (years)

25%

0.82

(0.76, 0.92)

50%

1.31

(1.19, 1.47)

75%

2.76

(2.47, 3.31)

*Based on all patients with preoperative testicular asymmetry undergoing varicocelectomy regardless of outcome