Department of Pediatric Surgery, Children's Hospital, Lucerne, Switzerland.
Department of Pediatric Surgery, Children's Hospital, Lucerne, Switzerland.
J Pediatr Urol. 2018 Apr;14(2):152.e1-152.e6. doi: 10.1016/j.jpurol.2017.12.008. Epub 2018 Feb 8.
Varicocele is a common urologic anomaly in adolescent males; however, evidence-based treatment guidelines do not exist. Hydroceles are known to be a common complication after surgical therapy, with a wide variation in the reported incidence between 1 and 40%.
This study aimed to introduce a standardized indication-to-treat protocol and prove its efficacy by analyzing the outcome of patients. Secondly, it aimed to better define postoperative hydroceles because the wide variation of reported incidence is attributed to a lack of definition.
Our standardized treatment protocol included an initial assessment with clinical grading of varicoceles, ultrasound evaluation of testicular volume, and calculation of the atrophy index. Indications for surgical treatment were testicular volume asymmetry >20%, discomfort and pain, or bilateral varicocele. The Palomo procedure (laparoscopically since 2005) was the standard procedure. Postoperative hydroceles were graded according to clinical findings and symptoms: Grade I, sonographic chance finding without clinical correlate; Grade II, palpable but clinically insignificant; Grade III, symptomatic. All patients treated according to the defined protocol were prospectively monitored between January 2001 and December 2015.
A total of 129 patients with left varicocele were referred to our institution; 70 fulfilled the indication criteria for surgical treatment. Twenty-eight of these patients were treated for volume asymmetry, 26 of these showed catch-up growth. Forty-two patients were treated for discomfort and pain; the symptoms subsided in all of them. Postoperative hydroceles were detected in 36 patients (51%). In 29 patients this was a sonographic chance finding (Grade I). Three patients showed a palpable but clinically insignificant postoperative hydrocele (Grade II) and four patients (5.7%) showed symptomatic hydrocele (Grade III) where treatment was recommended.
The treatment protocol allowed judicious indication for surgery and postoperative outcomes similar to previous reports. The high rate of catch-up growth in operated cases represents a proxy for successful treatment in cases where more precise parameters, like semen quality or paternity rate, were not yet detectable. The introduced grading system for postoperative hydroceles provs to be a valid and appropriate instrument, and promises to be a standardized method for comparing outcomes in future studies.
The indication-to-treat protocol proved to be easily applicable, highly efficient, and have outcomes comparable to international literature. The necessity for a standardized grading of postoperative hydroceles was underscored in the data.
精索静脉曲张是青少年男性中常见的泌尿科异常；然而，目前并不存在基于循证的治疗指南。人们已知在手术后，鞘膜积液是一种常见的并发症，其报告发病率在 1%至 40%之间差异很大。
本研究旨在引入一种标准化的适应证治疗方案，并通过分析患者的结果来证明其疗效。其次，旨在更好地定义术后鞘膜积液，因为报告发病率的差异很大归因于缺乏定义。
我们的标准化治疗方案包括对精索静脉曲张进行临床分级评估、睾丸体积超声评估和萎缩指数计算。手术治疗的适应证为睾丸体积不对称>20%、不适和疼痛或双侧精索静脉曲张。Palomo 手术（自 2005 年起腹腔镜手术）是标准手术。根据临床发现和症状对术后鞘膜积液进行分级：I 级，超声偶然发现，无临床相关；II 级，可触及但无临床意义；III 级，有症状。所有根据既定方案治疗的患者均在 2001 年 1 月至 2015 年 12 月期间进行了前瞻性监测。
共有 129 例左侧精索静脉曲张患者被转介至我们的机构；70 例符合手术治疗的适应证标准。其中 28 例因体积不对称而接受治疗，其中 26 例出现追赶生长。42 例因不适和疼痛而接受治疗，所有这些症状均消退。36 例（51%）患者术后出现鞘膜积液。29 例为超声偶然发现（I 级）。3 例出现可触及但无临床意义的术后鞘膜积液（II 级），4 例（5.7%）出现有症状的鞘膜积液（III 级），建议对此进行治疗。
该治疗方案允许对手术进行明智的适应证，并取得与以往报告相似的术后结果。手术病例中出现的追赶生长率较高代表了治疗成功的标志，因为在这些病例中，更精确的参数，如精液质量或生育率，尚未可检测到。引入的术后鞘膜积液分级系统是一种有效且合适的工具，并有望成为未来研究中比较结果的标准化方法。
该适应证治疗方案被证明易于实施、高效，且结果与国际文献相当。数据强调了对术后鞘膜积液进行标准化分级的必要性。
