Peak retrograde flow: a novel predictor of persistent, progressive and new onset asymmetry in adolescent varicocele.

PURPOSE: The major indication for adolescent left varicocelectomy is testicular asymmetry. However, a period of observation is often recommended preoperatively to determine if the asymmetry resolves, persists or progresses. We investigated whether varicocele grade or the duplex Doppler ultrasound measurements of peak retrograde flow and mean vein diameter could be used as predictors of persistent, progressive or new onset asymmetry. MATERIALS AND METHODS: Only patients with left varicoceles who had undergone at least 2 duplex Doppler ultrasounds without intervening surgery were included in the study. Grade of varicocele, peak retrograde flow and mean vein diameter were analyzed as possible determinants of catch-up growth, or persistent or new onset asymmetry. RESULTS: A total of 77 patients (mean age 14.3 years, range 9 to 20) were identified with a mean observation period of 13.2 months. Of the patients 50 (65%) had 10% or greater asymmetry at the first measurement. Of patients with initial 20% or greater asymmetry 71% had persistent or worsening asymmetry on followup evaluation. All 14 patients with the combination of an initial peak retrograde flow 38 cm per second or greater and 20% or greater asymmetry had progressive asymmetry on followup examination. Peak retrograde flow was the only significant parameter of predictive value for persistent or worsening asymmetry (p = 0.032). CONCLUSIONS: Peak retrograde flow can serve as a valuable tool in predicting persistent, progressive and new onset asymmetry. Varicoceles associated with a peak retrograde flow of 38 cm per second or greater and 20% or greater asymmetry should be considered for varicocelectomy at initial presentation. Patients with peak retrograde flow greater than 30 cm per second need to be monitored carefully. Those with peak retrograde flow less than 30 cm per second are less likely to require surgery.

Evaluation and management of the persistent/recurrent varicocele.

OBJECTIVE: To review outcomes in adolescent patients following redo varicocelectomy surgery. METHODS: The composite varicocele registry of a single surgeon was queried to identify patients who had undergone redo varicocelectomy. Variables of testicular asymmetry, testicular volume, presence and degree of retrograde venous flow, and incidence of postoperative hydrocele were evaluated. RESULTS: Nineteen boys were identified as having had a redo varicocelectomy (16 open, 1 laparoscopic, 2 radiographic embolization) with a minimum postoperative follow-up of 6 months (mean: 23.4; range: 6-53 months). No varicocele was palpable postoperatively among the 17 surgical redoes; one patient's testicle was significantly smaller after surgery, and 3 developed a hydrocele requiring repair. One of two boys who underwent radiographic embolization had a persistent varicocele. Eight of the nine boys who had asymmetry of 10% or greater before redo demonstrated catch-up growth after repair. The consistent intraoperative finding in all redo patients was the presence of large veins within the cord, just proximal to the junction with the vas and in continuity with the dilated veins distal to the internal ring. Post-redo retrograde venous flow was not identifiable in 16 and minimal in three. CONCLUSIONS: Redo varicocelectomy can be accomplished successfully and has a similar chance of achieving catch-up growth as does an initial repair. Postoperatively, there exists a small risk of testicular volume compromise and a significant risk of hydrocele development. Distal collateral veins may have a smaller role in varicocele formation and recurrence than previously thought.