international journal of andrology ISSN 0105-6263

ORIGINAL ARTICLE

Focus on paediatric and adolescent varicocoele: a single

institution experience
M. Cimador, M. Pensabene, M.Sergio, A. M. Caruso and E. De Grazia
Department for Mother & Child Care, Pediatric Urology, Universita` di Palermo, Palermo, Italy

Summary
Keywords:
adolescent, laparoscopy, paediatric,
ultrasound, varicocele
Correspondence:
Marcello Cimador,
Dipartimento Materno-Infantile, Universita` di
Palermo, Via A.Giordano, 3, 90127 Palermo,
Italy.
E-mail: marcello.cimador@unipa.it
Received 23 November 2011; revised 28
February 2012; accepted 9 April 2012
doi:10.1111/j.1365-2605.2012.01283.x

The aim of this study was to report our long-term diagnostic and surgical outcome during the last 18 years, in paediatric and adolescent management of
varicocoele. The present retrospective study enrols 374 patients observed at our
institution between 1994 and 2011. Patients were divided into three groups:
Group A includes 142 youngsters and adolescents treated with open surgery for
left varicocoele, in which a pre-operative CDUS was not performed; Group B
includes 65 patients treated with open surgery in which a pre-operative CDUS
evaluation was carried out, to assess varicocoele haemodynamic pattern and
testicular volume. Group C includes 167 patients treated by laparoscopy and
with pre-operative CDUS assessment. For all groups post-operative follow-up
consisted of CDUS evaluation performed 1, 3, 6, 12 months after surgical treatment, than every year. Persistence recurrence of varicocoele, testicular volume
and presence of hydrocele were evaluated. Recurrence rate was significatively
higher in group A (11.2%) than B (no recurrence, p = 0.003) or C (no recurrence, p = 0.000). Post-operative hydrocele was not significantly observed overall in group A in 9.8% of cases (13% if tunica vaginalis was left untouched,
4.2% if everted or resected p = 0.005), in group B in 3% and in group C in
7.1% of cases (p = NS). In conclusion, open and laparoscopic surgery offers
similar results. In our opinion, the key-point in paediatric and adolescent varicocoele is not the surgical approach to use, but the exact diagnosis. Careful
CDUS evaluation is, in our opinion, a valid, safe, cost-effective and immediate
tool to accurately detect all refluxing venous system and for achieving a
comprehensive evaluation of the vascular anatomy of varicocoele in paediatric
and adolescent age. Laparoscopic Palomo or open subinguinal microsurgical
varicocelectomy offer similar results in terms of recurrence; meanwhile the use
of a lymphatic sparing surgery with or without blue-dye is recommended to
reduce post-operative hydroceles.

Introduction
The widespread use of testicular ultrasound has helped to
further define scrotal anatomy and identify subclinical
varicocoeles (Cervellione et al., 2008), thus the incidence
of adolescent varicocoeles is up-to-date estimated from
15% to as high as 29% (Zampieri & Cervellione, 2008).
Its prevalence is up to 40% in men who undergoes infertility evaluation and quite 80% of those with secondary
infertility (Jarow et al., 1996; Zini et al., 2008). Fertility is
the main issue when considering appropriate varicocoele
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700

treatment. In men with varicocoele, semen abnormalities

are considered the main determinant when deciding
whether varicocelectomy should be carried out (Jarow
et al., 2002). In adolescent boys the usefulness of semen
analysis is unclear, thus testicular size has been used as a
more effective parameter to determine spermatogenic
potential in adolescents with varicocoele (Akbay et al.,
2000). In adult population all refluxing systems are easily
detected by phlebography. In paediatric population,
instead, the colour Doppler ultrasound (CDUS) evaluation is reported as a non-invasive and equally effective
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M. Cimador et al.

tool to evaluate all refluxing venous systems, saving the

paediatric patient from radiation (Cimador et al., 2006).
The aim of this study was to report our long-term
diagnostic and surgical outcome during the last 18 years,
in paediatric and adolescent management of varicocoele.
This study, moreover, highlights the importance of an
accurate diagnostic approach with CDUS in pre-operative
assessment, to reduce the risk of varicocoele persistence recurrence because of collateral refluxing veins not
interrupted at surgery.
Materials and methods
The present retrospective study enrols 374 patients
observed at our institution between 1994 and 2011. Varicocoeles were classified according to Dubin-Amelar clinical classification (grade 13) after physical examination
(Dubin & Amelar, 1970) and to Coolsaet classification
(type IIII) (Coolsaet, 1980) after CDUS assessment. By
CDUS, we have also identified haemodynamic patterns,
which have been classified according to Hirsh (Hirsh
et al., 1980), modified by Sarteschi (Sarteschi et al., 1993)
and Liguori (Liguori et al., 2004). Venography was never
used in our series. Indications for surgery were varicocoeles grade 3 or 2, the latter if associated with scrotal discomfort, scrotal pain or testicular hypotrophy.
Patients were divided into three groups:
Group A includes 142 youngsters and adolescents treated with open surgery for left varicocoele, between 1994
and 2001, in which a pre-operative CDUS was not performed.
A Prader orchidometer was used to measure testicular
volume. Varicocoeles were repaired using a subinguinal
ligation of intrafunicular and extrafunicular dilated veins,
without the use of optical magnification. Deferential vein
was left untreated except interoperative dilatation >2 mm
was detected. The tunica vaginalis was at the beginning
left untouched, whereas it was everted or resected to prevent post-operative hydrocele in the last period.
Group B includes 65 patients treated with open surgery
from January 2001 to January 2011. All received a preoperative CDUS evaluation, to assess varicocoele haemodynamic pattern and testicular volume. Performing
CDUS, patients were evaluated by scrotal and inguinal
investigation, while supine and upright position. We used
a linear multifrequency 7 to 13-MHz transducer connected to an Aloka Prosound SSV500 (ALOKA, Tokyo,
Japan). Maximum vein diameter (MVD) of dilated veins
was detected (MVD >3 mm, suggestive for surgical indication) and reflux was defined as a retrograde flow at rest
or enduring more than 2 sec after Valsalvas manoeuver.
For CDUS pulse repetition, the frequency was set at
1.5 kHz. The haemodynamic pattern was evaluated using
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Up-to-date management of pediatric varicocele

the described technique (Cimador et al., 2006, 2008), and

testicular volume was calculated in millilitres with the formula V = 0.71 LDW of the testicular ellipsoid (Sakamoto
et al., 2007).All patients received microsurgical subinguinal selective ligation of refluxing veins detected by
pre-operative CDUS. In all surgical procedures, the use of
2.5 optical magnification was provided (Cimador et al.,
2003). When the iliac-deferential reflux was detected at
CDUS the interruption of deferential vein was carried
out. In all patients tunica vaginalis was everted to prevent
post-operative hydrocele.
Group C includes 167 patients treated in our institution by laparoscopy from January 2001 to March 2011.
All patients underwent a pre-operative CDUS evaluation.
Type I varicocoele was treated by transperitoneal laparoscopic Palomo; in type II or III varicocoele, Palomo ligation was associated with laparoscopic interruption of
deferential vein as previously reported (Cimador et al.,
2003). When the deferential vein showed a more evident
dilatation underneath the left iliac vessels, it was
approached in the deep pelvis.
For all groups post-operative follow-up consisted of
CDUS evaluation performed 1, 3,6 , 12 months after surgical treatment, than every year. Persistence recurrence of
varicocoele, testicular volume and presence of hydrocele
were evaluated.
A Chi-squared (or Fishers exact) test was used to compare frequencies between groups and a p value of 0.05
was considered significant.
Results
From January 1994 to January 2011, 374 patients had surgery for varicocoele at our institution; according to findings, 301 (80.4%) showed a grade 3 left varicocoele, 72
(19.3%) had a grade 2 varicocoele. Only 1 (0.02%) bilateral varicocoele (grade 3 on left side, grade 2 on the
right) was observed. Among grade 2 varicocoeles, 31
(43%) had scrotal discomfort or pain, and 41 (57%) had
testicular hypotrophy. Mean presentation age at time of
surgery was 12, 3 years (range 7.116.0 years). Out of 232
patients, undergoing a pre-operative CDUS evaluation,
197 (84.9%) patients had an internal spermatic vein
(ISV) reflux (Coolsaet type I), 34 (14.6%) had both ISV
and deferential vein (DV) reflux (Coolsaet type III); only
1 patient (0,5%) had isolated DV reflux (Coolsaet type
II). According to literature (Franco et al., 1999), no cases
of cremasteric reflux were detected.
Group A: In all group A patients (142 boys) an open
treatment was performed without a pre-operative CDUS
evaluation. One-hundred-six (74.6%) cases were grade 3
varicocoele, whereas 36 (25.4%) were grade 2. Twentynine (20.4%) had testicular hypotrophy at diagnosis.
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All patients received an open subinguinal repair. Tunica

vaginalis was left untouched in 46 (32.3%) children, but
it was reversed in 42 (29.5%) and resected in 54 (38%) to
prevent post-operative hydrocele. In 126 cases (88.7%)
varicocoele was successfully treated by surgery, but in 16
boys a mild residual vein dilatation persisted with a postoperative venous reflux. Thus, our recurrence rate has
been 11, 2% (16 over 142 patients) in this series. Average
post-operative follow-up was 2.3 years (range 15 years).
No testicular atrophy was observed. Based on our last series, at 1 year follow-up control, mean testicular volume,
assessed by ultrasound, increased not significantly after
surgery from ml 4.69 (SD 1.46) pre-operative volume
to ml 5.19 (SD 1.36) post-operative (p = 0.2). Postoperative hydrocele was detected in 14 cases (9.8%): 10
over 46 who had left untouched the vaginalis (13%) and
in 4 over 96 who received resection eversion of the vaginalis (4.2%) (p = 0.005). All these boys underwent surgical correction of hydrocele.
Group B: This group includes 65 patients in which a
grade 3 varicocoele was investigated using CDUS as previously reported (Cimador et al., 2006). Fifty-six patients
(86.1%) presented with type I varicocoele, whereas nine
patients (13.9%) presented with type III varicocoele.
At diagnosis testicular hypotrophy was observed in 21%
(14 65). No cases of type II varicocoele nor cremasteric
reflux were detected in this group. All patients were treated with microurgical subinguinal varicolectomy. According to our past experience, the tunica vaginalis was always
everted to prevent post-operative hydrocele. The mean
follow-up period was 3.6 years (range 6 months-5 years).
During this period no cases of persistence recurrence and
no cases of testicular atrophy were observed. By date,
only two cases (3%), of post-operative hydrocele were
observed both resolved spontaneously in a few months.
Testicular catch-up growth was observed in 73% (10 14)
of cases at 1-year follow-up.
Group C: Group C patients (167 boys) received laparoscopic surgery for left varicocoele and only 1 for a bilateral
varicocoele. This latter boy showed, in upright position and
in the upper scrotum, visible dilated veins in the left-side
and palpable only dilated veins in the right-side. Valsalvas
manoeuver enhanced venous dilatation on both sides. At
CDUS, bilateral reflux was confirmed in upright and supine
position either at the rest and after Valsalvas in the leftside, whereas on the right-side, reflux was only detected
after Valsalvas manoeuver. Everyone had pre-operative
CDUS evaluation. One-hundred-thirtyone (78.4%) presented with grade 3 varicocoele, while 36 (21.6%) presented
with grade 2 associated with scrotal discomfort pain (16
cases). Testicular hypotrophy was detected in 52 (31.1%)
patients. Type I varicocoele was diagnosed in 143 boys
(85.6%) patients; isolated type II in 1 (0.5%); type III in 23
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M. Cimador et al.

(13.7%). In 143 patients with isolated ISV reflux a classic

laparoscopic Palomo was performed; in the remaining 24
patients, Coolsaet type II and III varicocoeles, all had a laparoscopic varicocelectomy modified, as previously
described, with the interruption of deferential vein
(Cimador et al., 2009). The follow-up was performed using
the same CDUS procedure as in pre-operative assessment.
The median follow-up period was 2 years (0.53 years). No
cases of recurrence persistence were detected. No cases of
testicular atrophy were observed. Testicular catch-up
growth was observed in 77% (40 52) of cases at 1-year
follow-up.
In 12 (7.1%) patients a post-operative hydrocele was
observed during follow-up. In 6 of 12 cases hydrocele
resolved spontaneously; in four boys percutaneous drainage was necessary, but in two cases a surgical hydrolecectomy was required. In two patients presenting with type
III varicocoele, the deferential vein was approached in the
deep pelvis. In one case a post-operative pain in left thigh
spontaneously resolving in a few days was recorded.
Overall, in terms of recurrences, results were statistical
significant (A vs. B p = 0.003; A vs. C p = 0.000;),
whereas there is no significance in terms of post-operative
hydrocele (A vs. B p = 0.09; A vs. C p = 0.4)
Discussion
This study describes the evolution in management of
childhood varicocoele at our institution in the past
18 years. During this time we reached some key-points
on varicocoele surgery: (i) we opted for a progressive less
invasive approach: laparoscopic surgery and open surgery
results are similar, but the first-one, less invasive, should
be preferred, (ii) optimization of surgical results need the
detection and the interruption of all refluxing systems,
and (iii) CDUS revealed a safe, effective and non-invasive
tool for understanding varicocoele haemodynamic pathophysiology.
Varicocoele can be approached with various surgical
strategies: open surgery (inguinal or sub-inguinal), laparoscopic or retroperitoneoscopic surgery, percutaneous
sclerosis or embolization. Nevertheless, varicocoele treatment is complicated by a certain rate of persistence recurrence. In these cases the failure of first-time
surgery is because of the presence of refluxing venous
system undetected at the time of first pre-operative evaluation. The deferential refluxing vein (DV) is considered
the main cause of varicocoele persistence recurrence
(Franco et al., 1999; Esposito et al., 2000; Niedzielski &
Paduch, 2001). Thus, we consider as the surgical goal
the mandatory interruption of all refluxing venous
systems, and to do that, the exact identification of all
refluxing venous systems (renal-internal spermatic and or
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M. Cimador et al.

iliac-deferential) is mandatory to better plan the surgical

treatment.
Indications for surgery became progressively imagingrelated in the presented work. At the beginning, main
indications for surgery were the venous dilatation (grade
3 varicocoele according to Dubin-Amelar) and the testicular hypotrophy, both clinically detected.
Venous reflux and venous ectasies, clinically indistinguishable, are not always different aspects of the same
pathology: in fact, unrefluxing dilated testicular veins are
described, and venous reflux, causing testicular damage, is
not always related with venous dilatation adequate to
reflux. For this reason the sole clinical detection of dilated
veins is not considered, nowadays, a surgical indication.
The CDUS is a valid and objective tool to measure
entity and duration of the reflux. In the presented series
of patients with a pre-operative CDUS evaluation (group
B + group C) a deferential reflux was detected in 33 cases
and always surgically treated (in 24 cases a laparoscopic
procedure was performed; nine patients had an open
procedure). It is interesting to note that no one case of
recurrence persistence of varicocoele was observed in
both groups, suggesting that in all cases, every refluxing
vein was detected and interrupted. On the contrary, in
patients without a pre-operative CDUS evaluation (group
A) 16 (11.2%) cases of recurrence persistence of reflux
were observed. This high-rate of failure could be
explained either with the lack of a pre-operative CDUS
(which misdiagnosed type-3 varicocoele because of deferential reflux), either with the surgical technique which
was unable to interrupt all refluxing veins, while try to
spare lymphatic vessels. Testicular hypotrophy is expression of organ-damage because of varicocoele (Kass et al.,
1987; Cozzolino & Lipshultz, 2001). Accurate measurement by US is mandatory especially in small testicles.
Treatment
In this paper, is presented the evolution of varicocoele
surgery at our institution during 3 different periods. In
the first period (group A) all patients underwent open
surgery without CDUS and without optical magnification.
The main advantage of open surgery is the simultaneous
exposition of all venous systems allowing an intraoperative evaluation of every system, but results are influenced
by empirical intraoperative observation of venous dilatation and difficulty to distinguish lymphatic vessels. The
main complication occurred in this group, as in the
others, was hydrocele with an overall incidence of 9.8%
but with a significant difference if the tunica vaginalis was
resected and everted at surgery than if it was left
untouched (4.2% and 13% respectively). Thus, approaching subinguinal varicocelectomy with a no-lymphatic
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sparing surgery highly increases the risk of post-operative

hydrocele and resection eversion of tunica vaginalis is
recommended.
In the subsequent period (group B) in all patients a
pre-operative CDUS was performed before open surgery.
With CDUS we obtained a comprehensive haemodynamic
evaluation in the pre-operative period involving a better
comprehension of all venous patterns and allowing the
use of functional tests as the Valsalva manoeuvre. Moreover, considering our past experience, in all patients the
tunica vaginalis was resected and everted. These solutions
in diagnostic and surgical treatment allowed us to reset to
zero the recurrence rate and reduce to 3% post-operative
hydrocele rate. Although microsurgical approach to spermatic cord can reduce post-operative hydrocele rate while
performing a LSV, on our knowledge any study reported
no cases of this sequela. In this scenario, microsurgical
skill is required and operative time is strongly influenced
by surgical technique. Moreover, increase of post-operative
morbidity, due to testicular manipulation, could occur.
In the last 15 years, laparoscopic surgery gained popularity demonstrating a safe and effective approach, with
good results in term of complications rates (Esposito
et al., 2000). Laparoscopy has some advantages: shorter
operative time, no testicular manipulation, low post-operative morbidity, lower incidence of hydrocele with lymphatic sparing technique. For this reasons, in the last
period (group C) all patients received a laparoscopic
Palomo procedure for left varicocoele.
The pre-operative CDUS evaluation allowed us to
better plan the surgical laparoscopic procedure. In all
patients presenting with type I varicocoele, a classic
laparoscopic Palomo procedure was performed. Boys
with type II-III varicocoele, was approached also with a
laparoscopic Palomo procedure, but with the concurrent interruption of deferential vein (Cimador et al.,
2009). No cases of recurrence persistence of varicocoele
were detected, and the post-operative hydrocele rate
was 7.1%. Overall, the use of pre-operative CDUS
strongly influenced results, in terms of recurrences (A
vs. B p = 0.003; A vs. C p = 0.000), whereas there was
no significance in terms of post-operative hydrocele (A
vs. B p = 0.09; A vs. C p = 0.4). As reported in literature (Borruto et al., 2010), only a LSV is able to
reduce hydroceles.
Despite the encouraging results, according to literature,
the use of laparoscopic vs. open surgery in treatment of
varicocoele is still a matter of debate.
If laparoscopic surgery is performed, an attempt dissection of veins from fat could reduce the incidence of postoperative hydrocele; results, anyway, strictly depend on
surgeons laparoscopic learning curve. To this point,
others authors reported that the scrotal injection of vital
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Up-to-date management of pediatric varicocele

colourant to perform an intraoperative testicular lymphography is an helpful tool to better distinguish lymphatics from veins during surgery; the authors, anyway
suggest that a standardized method could be helpful to
optimize the technique (Chiarenza et al., 2006). Nevertheless, another study shows that the use of intra-testicular
vital colourant for lymphography caused pathological
changes in testicular histology in rats. The authors suggest
carefulness in the use of vital colourant for lymphography
(Makari et al., 2007).
The evaluation of testicular function in children is
committed to testicular volume only, detected with US.
From this point of view, several studies investigated the
role of testicular volume in pre-operative management of
varicocoele with different results (Poon et al., 2010;
Spinelli et al., 2010; Van Batavia et al., 2010). With
regards to post-operative testicular volume, the testis
catch-up growth after varicocelectomy is still an unclear
phenomenon: it is classically considered as the results of
functional improvement of testicular function after varicocelectomy (Decastro et al., 2009); in a recent paper
(Kocvara et al., 2003) has been reported the intratesticular
interstitial oedema as the cause of an apparent catch-up
growth in non lymphatic-sparing varicocelectomy. The
authors, at last, suggest that only with LSV the testicular
catch-up growth could be reliably measured; LSV,
anyway, hardly weights on operative time.
Conclusions
In conclusion, open and laparoscopic surgery offers
similar results. In our opinion, the key-point in paediatric and adolescent varicocoele is not the surgical
approach to use, but the exact diagnosis. The detection
of every refluxing system, is in fact, essential to plan
the best surgical treatment, open or laparoscopic Careful CDUS evaluation is, in our opinion, a valid, safe,
cost-effective and immediate tool to accurately detect
all refluxing venous system and for achieving a comprehensive evaluation of the vascular anatomy of varicocoele in paediatric and adolescent age. Laparoscopic
Palomo or open subinguinal microsurgical varicocelectomy offer similar results in terms of recurrence; meanwhile the use of a lymphatic sparing surgery with or
without blue-dye is recommended to reduce post-operative hydroceles.
Authorship
MC performed surgery, designed the study, analysed data and
revised the text; MP wrote the paper; MS and AMC collected
and follow-up the cases; EDG performed surgery and supervised
the study. No conflict of interest exists for all Authors.
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