ABSTRACT
BACKGROUND: Varicocele is a condition characterized by dilated, tortuous veins within the pampiniform venous plexus of the scrotal sac. Presence of varicocele is associated with an increased risk of alteration of semen parameters. The objective of this study was to compare the current standard in varicocele treatment procedures: sub-inguinal microscopic ligation to percutaneous embolization in terms of semen parameters improvement, fertility, and morbidity at the university hospital of Toulouse (France). Seventy six patients with clinical varicocele, alteration of semen parameters and infertility, underwent either procedure (microsurgery in 49 case performed by a single surgeon and embolization in 27 cases) and were prospectively analyzed. Outcome measures were: semen parameters, spontaneous pregnancies, pain, side effects, recovery time and overall satisfaction. All patients were contacted in January 2015 in order to determine reproductive events. RESULTS: Preoperatively, there was no difference in clinical and biological items between the two groups. Postoperatively, on the overall population, there was a significant improvement of sperm concentration at 3, 6, 9 and 12 months (p = <0.001, <0.001, 0.012, 0.018) and sperm motility at 6 months (p = 0.002). The sperm concentration was higher at 6 months in the percutaneous embolization group (13.42, vs. 8.1×106/ml; p = 0.043). With a median follow-up of 4 years, 27 pregnancies occurred (spontaneous pregnancy rate of 35.5%). There was no significant difference between procedures on the sperm quality, pregnancy rate, and the overall satisfaction. Patients undergoing percutaneous embolization reported a faster recovery time (p = 0.002) and less postoperative pain (p = 0.007). CONCLUSION: Our study shows that percutaneous embolization seems to be an equivalent alternative to sub-inguinal microscopic ligation in term of sperm quality improvement, pregnancy rate, and overall satisfaction with a slight advantage on post-operative morbidity.
CONTEXTE: La varicocèle est une affection caractérisée par une dilatation et tortuosité des veines du plexus veineux pampiniforme du sac scrotal. La présence de varicocèle est associée à un risque accru d'altération des paramètres du sperme. Cette étude vise à comparer la norme actuelle des procédures de traitement par varicocèle: la ligature microscopique sous-inguinale à l'embolisation percutanée en termes d'amélioration des paramètres spermatiques, de fertilité et de morbidité dans l'hôpital universitaire de Toulouse(France). Soixante-seize patients atteints de varicocèle clinique, d'altération des paramètres spermatiques et d'infertilité ont subi une intervention (microchirurgie dans 49 cas réalisées par un seul urologue et embolisation dans 27 cas) et ont fait l'objet d'une analyse prospective. Les données étudiées sont les suivantes: paramètres du sperme, grossesses spontanées, douleur, effets secondaires, temps de récupération et satisfaction globale. Tous les patients ont été contactés en janvier 2015 afin de déterminer les grossesses spontanées. RÉSULTATS: En préopératoire, il n'existait aucune différence sur les items cliniques et biologiques entre les deux groupes. Sur la population globale, on observe une amélioration significative de la concentration spermatique à 3, 6, 9 et 12 mois (p = <0,001, <0,001, 0,012, 0,018) et de la motilité à 6 mois (p = 0,002). La concentration de spermatozoïdes était plus élevée à 6 mois dans le groupe d'embolisation percutané (13,42 vs 8,09; p = 0,043). Avec un suivi médian de 4 ans, 27 grossesses sont survenues (taux de grossesse spontanée de 35.5%). Il n'y avait pas de différence significative entre les procédures sur la qualité du sperme, le taux de grossesse et la satisfaction globale. Les patients traités par embolisation percutanée ont rapporté un temps de récupération plus rapide (p = 0,002) et moins de douleur postopératoire (p = 0,007). CONCLUSION: Notre étude montre que l'embolisation percutanée semble être une alternative équivalente à la ligature microscopique sous-inguinale en terme d'amélioration de la qualité du sperme, du taux de grossesse et de la satisfaction globale avec un léger avantage sur la morbidité post-opératoire.
ABSTRACT
OBJECTIVE: To compare the performance of the main methods used to estimate stone burden in order to improve and standardize preoperative evaluation of stone disease. METHODS: From January 2012 to June 2013, a series of consecutive retrograde intrarenal stone surgery was prospectively evaluated at a single institute. All patients had a pre- and postoperative CT scan. The stone burden was estimated using 3 methods: the cumulative stone diameter (M1), Ackermann's formula (M2), and the sphere formula (M3). The predictive value of the postoperative stone-free status of these methods was then compared. RESULTS: Overall (n = 142), the stone-free rate was 64%. The three methods (M1, M2, and M3) were all predictive of stone-free status for stones <20 mm (P = .0076, .018, and .016, respectively). However, only M2 and M3 were significant for stones >20 mm (P = .0024 and .023). Using receiver operating characteristic curves, we found that areas under the curve were 0.73, 0.70, and 0.71 for stones below 20 mm and 0.53, 0.74, and 0.74 for stones above 20 mm for M1, M2, and M3, respectively. In multivariate analysis, M1 and M3 were both found to be independently associated with the stone-free status in the whole series (P <.001 and .011, respectively). However, for stones above 20 mm, only M3 was significant (P = .020). CONCLUSION: Evaluation of the stone burden is an important predictor of the outcome of retrograde intrarenal stone surgery. For stones below 20 mm, all the three methods approximate stone burden correctly; however, for the stones above 20 mm, calculation of volume is recommended.