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The Natural History of Adolescent Varicoceles

Monday, October 22, 2012: 3:41 PM
Grand Ballroom B (Hilton Riverside)
Aaron Krill, MD1, Nikhil Waingankar, MD1, Suzanne Sunday, PhD1, Jordan Gitlin, MD1, Steven Friedman, MD2, Lori Dyer, MD3, Paul Zelkovic, MD3, Israel Franco, FACS, FAAP3, Edward F. Reda, MD, FAAP3 and Lane S. Palmer, MD, FAAP1, (1)Pediatric Urology, Cohen Children's Medical Center of NY, New Hyde Park, NY, (2)Urology, Maimonides Medical Center, Brooklyn, NY, (3)Pediatric Urology, Maria Fareri Children's Hospital, Valhalla, NY

Purpose

Varicoceles have been linked to ipsilateral testis hypotrophy, and abnormal semen parameters. Some suggest that hypotrophy may result from transient asynchronous growth, and advocate extended follow-up and reserve varicocelectomy for sustained asymmetry. We propose to document the natural history of adolescent varicoceles with grade change, timing, duration and resolution of testis asymmetry as primary endpoints.

Methods

We included adolescents with isolated left varicoceles having ≥2 visits.  In surgical patients, only preoperative visits were analyzed. Patients with prior inguinal surgery, cryptorchidism or endocrinologic disorders were excluded. Varicocele grades were assigned by an attending urologist. Testis volume was calculated via sonogram using Lambert's equation or estimated via disc orchidometer; one modality was used per patient. Testis symmetry was calculated using the equation (R-L/R) and defined as ≥ 20% difference. Statistical analysis was performed using ANOVA, t-test, and Chi square as appropriate.

Results

479 patients were included with a mean age at diagnosis of 14.2±1.9yrs. Mean follow-up was 1.7±1.3 yrs. All had ≥2 visits, 25% had 3, 14% had 4 and 5% had 5; visit intervals were approximately 1 year. Initial grade distribution was: 1- 4.6%, 2- 52.6%, 3- 42.7%. Progression occurred in 82% of grade 1 (to grade 2-59%, to grade 3-23%), and in 33% of grade 2. Testicular symmetry at diagnosis was present in 380 patients: 75% remained symmetric, 2.6% developed temporary asymmetry, 19.5% developed asymmetry at last visit, 1.8% had persistent asymmetry for ≥ 2visits, 0.8% had fluctuating asymmetry and were asymmetric at last visit. Among 99 patients with asymmetry at diagnosis, 48.4% resolved, 51.6% were asymmetric at last visit. Among 193 with at least 1 asymmetric episode, 30.5% resolved. Mean duration of asymmetry was 0.99 yrs. Age at asymmetry was 14.1±2yrs and 14.9±1.9yrs at resolution. Patients asymmetric at diagnosis were more likely asymmetric at last follow-up than those symmetric at diagnosis (51% vs 21%; p<0.001). Asymmetry associated with grade 3 varicoceles at diagnosis were less likely to resolve (p=0.025). Magnitude of asymmetry was greater in the persistent group versus those that resolved (0.24 vs 0.32, p=0.004). Maximum testis asymmetry that resolved was 43%.

Conclusion

Grade progression occurred in 82% of grade 1, and in 33% of grade 2. 79% presented with symmetric testes, and the majority remained symmetric. Half of the patients that presented with asymmetry remained asymmetric at last followup. Asymmetry occurred at any time in 40.2%, but only 28% were asymmetric at last followup. Grade 3 at diagnosis and asymmetry>32% were predictors of persistent asymmetry.  No patient with >43% asymmetry resolved.

 

Followup

Grade 1

(diagnosis)

Grade 2

(diagnosis)

Grade 3

(diagnosis)

Symmetry

 

 Symmetry Change

Resolved

N=57

1.66±1.2

3(5.3%)

35 (61.4%)

19*

(33%)

0.24+0.1**

(0.2-4.3)

0.23***

Persistent

N=51

1.36±1.1

1(2%)

19(37%)

31*

(60.8%)

0.32+0.12**

(0.2-0.67)

-0.004***

*p=0.025, **p=0.004, ***p<0.001