Richter F, Stock J A, LaSalle M, Sadeghi-Nejad H, Hanna M K
Section of Urology, University of Medicine and Dentistry New Jersey Medical School, Newark, New Jersey, USA.
Urology. 2001 Jul;58(1):98-102. doi: 10.1016/s0090-4295(01)01118-9.
Varicoceles are a common condition affecting male fertility seen by urologists. However, prepubertal varicoceles are much less common and their management is controversial. We designed a questionnaire to assess the practice patterns among urologists (pediatric urologists/urologists with infertility training) with regard to prepubertal varicocele management.
A 15-point questionnaire pertaining to management issues of prepubertal varicoceles was sent to 150 pediatric urologists and 150 urologists with infertility training. Two clinical scenarios referring to treatment algorithms of prepubertal varicoceles were included.
Of the 300 questionnaires mailed, 174 urologists (58%) responded. Seventy-five of the respondents were urologists with an interest in infertility, and 99 were pediatric urologists. Of the 174 respondents, 86.2% treated prepubertal varicoceles and 13.8% referred patients to interventional radiologists for embolization. The ratio of varicocelectomy to expectant management was about equal between urologists with infertility training and pediatric urologists (46% versus 54%). A difference in testicular size was the most common indication for varicocelectomy (80.5%), followed by pain (51.1%) and potential fertility problems (24.7%). About one third of all urologists would perform varicocelectomy on patients of any age and seven (4%) would not operate before puberty. In 136 responses (78.2%), follow-up information was not available. Among the 35 respondents with follow-up information (21.8%), 21 reported infertility occurring after varicocelectomy and 16 after expectant management. If varicocelectomy was performed, most urologists (47.2%) used magnification loupes, 29.3% used microscopes, and 29% used no magnification. The preferred approach was inguinal (Ivanissevich) in 35.6% followed by subinguinal in 30%; 21% performed retroperitoneal varicocelectomy (Palomo) and 9.8% used a laparoscopic approach. Of the 300 complications reported, postoperative hydroceles were the most common (40.4%), followed by recurrence (20.8%) and hematomas (17.4%).
The management of prepubertal varicoceles is controversial among different urologic subspecialties (pediatric urology/infertility). Differences include indications, timing, and techniques used for varicocelectomy. Accurate follow-up information for children with prepubertal varicoceles is rare. A prospective randomized study comparing varicocelectomy versus expectant management of prepubertal varicoceles is needed to assess the outcomes and define uniform treatment criteria.
精索静脉曲张是泌尿外科医生常见的影响男性生育能力的病症。然而，青春期前精索静脉曲张则较为少见，其治疗存在争议。我们设计了一份问卷，以评估泌尿外科医生（小儿泌尿外科医生/接受过不育症培训的泌尿外科医生）对青春期前精索静脉曲张治疗的实践模式。
向150名小儿泌尿外科医生和150名接受过不育症培训的泌尿外科医生发送了一份关于青春期前精索静脉曲张管理问题的15分问卷。问卷包含两个涉及青春期前精索静脉曲张治疗算法的临床病例。
在寄出的300份问卷中，174名泌尿外科医生（58%）回复。其中75名回复者是对不育症感兴趣的泌尿外科医生，99名是小儿泌尿外科医生。在174名回复者中，86.2%治疗青春期前精索静脉曲张，13.8%将患者转诊给介入放射科医生进行栓塞治疗。接受过不育症培训的泌尿外科医生和小儿泌尿外科医生在精索静脉高位结扎术与观察等待治疗的比例上大致相同（46%对54%）。患侧睾丸大小差异是精索静脉高位结扎术最常见的指征（80.5%），其次是疼痛（51.1%）和潜在的生育问题（24.7%）。约三分之一的泌尿外科医生会对任何年龄的患者进行精索静脉高位结扎术，7名（4%）医生不会在青春期前进行手术。在136份回复（78.2%）中，没有随访信息。在有随访信息的35名回复者（21.8%）中，21名报告在精索静脉高位结扎术后出现不育，16名在观察等待治疗后出现不育。如果进行精索静脉高位结扎术，大多数泌尿外科医生（47.2%）使用放大放大镜，29.3%使用显微镜，29%不使用放大设备。首选的手术方式是腹股沟（伊瓦尼斯维奇）入路，占35.6%，其次是腹股沟下入路，占30%；21%进行腹膜后精索静脉高位结扎术（帕洛莫），9.8%采用腹腔镜手术方式。在报告的300例并发症中，术后鞘膜积液最为常见（40.4%），其次是复发（20.8%）和血肿（17.4%）。
青春期前精索静脉曲张的治疗在不同的泌尿外科亚专业（小儿泌尿外科/不育症）中存在争议。差异包括精索静脉高位结扎术的指征、时机和技术。青春期前精索静脉曲张患儿的准确随访信息很少见。需要进行一项前瞻性随机研究，比较青春期前精索静脉曲张的精索静脉高位结扎术与观察等待治疗，以评估治疗效果并确定统一的治疗标准。
