Adolescent varicocele: a surgical conundrum

Adolescent varicocele is a common yet clinically complex condition, affecting up to 15% of postpubertal boys. The natural history and long-term reproductive implications in adolescents are not as well understood as the association of varicocele with infertility in the adult population. As such, the primary challenge in the management of adolescent varicocele lies in identifying the subset of boys at risk for impaired spermatogenesis while avoiding unnecessary intervention in those who may normalize testicular development as puberty progresses. The pathophysiology of varicocele-related testicular dysfunction is thought to be multifactorial, involving increased scrotal temperature, oxidative stress, and associated germ cell apoptosis. There is also an element of genetic factors that may have implications in the development of varicocele and susceptibility to spermatogenic injury. Regardless of history, we have taken an institutional algorithmic approach whereby boys are evaluated at the time of initial presentation using a longitudinal, biologically informed process incorporating physical exam, serial assessment of total and relative testicular volume, scrotal ultrasound, endocrine evaluation, and semen analysis in appropriate Tanner V patients. Indications for surgical intervention in adolescents are guided by surrogate markers of testicular dysfunction such as persistent testicular volume asymmetry, abnormal semen parameters, and hormonal abnormalities. The preferred technique for intervention when indicated is a subinguinal microsurgical varicocele repair because this is associated with low recurrence and few complications. Surgical repair has been shown to improve testicular growth and semen parameters. However, the long-term impact of surgical repair on paternity is particularly challenging to assess in the adolescent population and requires continued long-term study. An algorithmic, longitudinal approach to the evaluation and management of adolescent varicocele that allows for the early identification of at-risk patients and avoidance of overtreatment is presented. Ultimately, management should be individualized, with the goal of preserving testicular function and optimizing future reproductive potential.