100th Anniversary of Nagoya J Med Sci: Comments to the Highly Cited Articles
Nagoya J. Med. Sci. 85. 10–12, 2023
doi:10.18999/nagjms.85.1.10

Comment to our article; Effects of varicocelectomy ontestis volume and semen parameters in adolescents:a randomized prospective study
Hatsuki Hibi
Department of Urology, Kyoritsu General Hospital, Nagoya, Japan

This is an Open Access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International
License. To view the details of this license, please visit (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Yamamoto M, Hibi H, Katsuno S, Miyake K. Effects of varicocelectomy on testis volumeand semen parameters in adolescents: a randomized prospective study. Nagoya J Med
Sci. 1995;58(3–4):127–132.
Because the treatment of a varicocele in adolescents remains controversial, we undertook aprospective study in 51 male adolescents, aged 15–21 years, who were referred for a varicocele. Twenty-nine patients were treated with high retroperitoneal ligation of the left spermaticvein, and 22 were untreated. Eighteen healthy adolescent volunteers without a varicocele werealso assessed. Testicular volume was measured using an orchiometer, and semen analyses
were carried out at referral and after 1 year of follow-up. In addition, serum luteinizing
hormone (LH), follicle-stimulating hormone (FSH) and testosterone levels were estimatedby radioimmunoassay. Both patient groups had significantly smaller testis volumes than thecontrols at the outset. In the follow-up, the treated patients had testis volumes similar to thoseof the controls. Both testes increased significantly in volume after treatment. Although semen
parameters were comparable in all groups initially, sperm concentration increased significantly
after treatment of the varicocele. We concluded that varicocele treatment in adolescents leads
to increased testis volume and a higher sperm concentration; however, whether early treatment
will improve testicular function remains to be elucidated.
Keywords: Adolescents, Preventive treatment, Semen quality, Testis volumes
Varicocele is common in young men and boys. It affects up to 15% of the general malepopulation. A varicocele is caused by excessive venous distension of the pampiniform plexus due
to incompetent venous valves along the spermatic cord. Although most adult varicoceles cases
are discovered during infertility investigations, they are frequent in adolescent populations due
to asymptomatic left hemiscrotal swelling.

Received: July 8, 2022; accepted: August 10, 2022
Corresponding Author: Hatsuki Hibi, MD
Department of Urology, Kyoritsu General Hospital, 4-33 Goban-cho, Atsuta-ku, Nagoya 456-8611, Japan
Tel: +81-52-654-2211, Fax: +81-52-651-7210, E-mail: hibih@quartz.ocn.ne.jp
10Hatsuki Hibi

Surgical treatment of varicocele ultimately aims to improve and preserve the potential for
future fertility of an individual. The treatment goal in adolescents is to avoid testicular injury
and prevent testicular damage, which can be achieved through varicocelectomy.
Several academic societies have recently published guidelines for surgical indications. According to the American Society for Reproductive Medicine (ASRM), American Urological Association(AUA), and European Association of Urology (EAU) guidelines, adolescent males with unilateralor bilateral varicocele and considerable testicular hypotrophy ipsilateral to the varicocele may
be considered candidates for varicocelectomy. Furthermore, the European Society of PediatricUrology (ESPU) believes that older adolescent with poor semen quality are potential candidates
for varicocelectomy.
In 1995 we conducted a random prospective trial to assess the effects of varicocele inadolescents.1 When compared to the control group, our results demonstrated that varicocelectomy
resulted in significant testicular growth. Several authors have confirmed similar results aftervaricocelectomy. Although sperm concentration increased in the treated group, other parameters
did not change in the treated, untreated, or control groups. Our research showed that a varicocelectomy resulted in either the cessation of a progressive effect or reversal of an establishedeffect. Our control research findings appeared to be consistent with those of others who havereported progressive deterioration of semen parameters in patients with untreated varicocele.2,3There are various varicocelectomy techniques. The ASRM and AUA guidelines concur thatboth surgery and percutaneous embolization may be conducted when considering varicocele repair.
The surgical methods include laparoscopy or open retroperitoneal, inguinal, and subinguinal
approaches. Percutaneous embolization treatment of varicocele is achieved through percutaneous
embolization of the refluxing internal spermatic vein. These recommendations acknowledge that
there are variations in the recurrence rates among the techniques, and state that few of thesemethods has been demonstrated to be more effective than others in terms of boosting fertility.4 However, the type of intervention selected largely depends on the therapist’s experience.
Laparoscopic varicocelectomy is technically possible, but it must also be justified financially.
Recent evidence indicates that microsurgical varicocelectomy is the most efficient and least
morbid method among the various varicocelectomy techniques. We used the retroperitoneal
approach to operate at the time of this article in 1995. To avoid scrotal lymphatic hydrocele,
microscopic lymphatic sparing varicocelectomy is now common, and low ligation technique iswidely accepted. However, I have conducted high ligation microscopic lymphatic sparing underan operating microscope, because low ligation may cause spermatic arterial injury.
The recommendations acknowledge the lack of information on the future fertility impact oftreatment. However, the recent EAU/ESPU meta-analysis reports that there is moderate evidence
regarding the advantages of varicocele treatment in children and adolescents concerning testicularvolume and sperm concentration increase.5 One of the most persistent issues in pediatric urology
is how to manage varicocele in children and adolescents. As the majority of boys present withan asymptomatic varicocele leading to unknown future fertility issues, it is difficult to determine
whether surgical intervention is required and beneficial and whether it can be managed withcontinued observation. Different techniques and modalities may be used to access adolescentvaricocele. As not all adolescents with a varicocele experience testicular growth arrest or subfertility, active surveillance has emerged as a useful strategy.
Our article was published over 25 years ago and was based on one of the few prospectivestudies.1 I hope that this article will aid in future research.

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doi:10.18999/nagjms.85.1.10

Hatsuki Hibi

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Yamamoto M, Hibi H, Katsuno S, Miyake K. Effects of varicocelectomy on testis volume and semen
parameters in adolescents: a randomized prospective study. Nagoya J Med Sci. 1995;58:127–132.
Gorelick JI, Goldstein M. Loss of fertility in men with varicocele. Fertil Steril. 1993;59(3):613–616.
doi:10.1016/s0015-0282(16)55809-9.
Yamamoto M, Tsuji Y, Hibi H, Miyake K. Progressive decline in semen characteristics and testis volume
over time in seven cases of untreated varicocele [in Japanese]. Jpn J Fertil Steril. 1993;38,714–717.
Ding H, Tian J, Du W, Zhang L, Wang H, Wang Z. Open non-microsurgical, laparoscopic or open
microsurgical varicocelectomy for male infertility: a meta-analysis of randomized controlled trials. BJU Int.
2012;110(10):1536–1542. doi:10.1111/j.1464-410X.2012.1193.x.
Roque M, Esteves SC. A systematic review of clinical practice guidelines and best practice statements forthe diagnosis and management of varicocele in children and adlescents. Asian J Androl. 2016;18(2):262–268.
doi:10.4103/1008-682X.169559.

References EndNagoya J. Med. Sci. 85. 10–12, 2023

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