Adolescent Varicocelectomy: Success at What Cost? Clinical Outcome and Cost Comparison of Surgical Ligation and Percutaneous Embolization

Introduction

Varicocele is dilatation of the testicular pampiniform venous plexus and the internal spermatic vein occurring predominantly on the left. It is one of the most common correctable causes of infertility. Varicoceles are present in about 15% of both the adult and adolescent populations. ¹ However, fertility is only affected in less than half of men with a clinical varicocele. ² In the adult population, infertility is the main indication for repair of a varicocele. In the adolescent population where infertility is uncertain, the indications for varicocelectomy are more contentious. There currently exists great discourse regarding the indications for varicocelectomy and optimal timing, or if varicoceles in adolescents should even be corrected at all.

Some currently accepted indications for intervention of varicoceles in adolescents include varicocele with ipsilateral testis hypotrophy or intolerable symptoms, including pain or sensation of heaviness. The intervention for varicocele can be broadly divided into two groups: surgical ligation and percutaneous embolization, each with their own advantages and disadvantages.

There is currently a paucity of studies that directly compare percutaneous embolization to surgical ligation. Our institution has utilized both for the treatment of adolescent varicocele. We hypothesize that surgical ligation and percutaneous embolization are similar in outcomes, complications, and cost.

Materials and Methods

Institutional Review Board approval was obtained from our institution (IRB #13020065). A retrospective study of adolescent males 18 years of age or younger, with the clinical diagnosis of unilateral varicocele who either underwent laparoscopic surgical ligation or percutaneous embolization between January 2006 and April 2016, was completed. Because this was a retrospective review, strict criteria for intervention were not standardized. Despite this, indications for varicocele treatment at our institution were consistent for all patients and included left testicular hypotrophy and/or symptoms. Symptoms were pain typically described as a chronic gnawing sensation or intolerable ache or heaviness. The choice of laparoscopic ligation versus embolization was based on surgeon/patient preference without any discerning criteria. The surgical approach was based on the laparoscopic technique described by Matsuma, which is an adaptation of the original open high spermatic cord ligation technique described by Palomo.^3,4

Briefly, laparoscopy is performed with primary umbilical port access for visualization. A right lower quadrant stab incision is made to accommodate a 3 mm instrument and a suprapubic stab incision with or without a 5 mm port is used to accommodate a clip applier. The left spermatic vessels are identified cephalad to the confluence with the vas deferens. The spermatic bundle (artery, veins, and lymphatics) is then clipped and transected. Artery and lymphatic sparing were used on occasion at the discretion of the surgeon and was not standardized.

Percutaneous embolization was performed similarly to the method described by Storm, modified as described. ⁵ Briefly, through a vascular sheath preferably in the right internal jugular or alternatively the right femoral vein, a catheter is advanced into the left renal vein where a venogram is performed. If reflux of contrast through the spermatic vein is seen to the level of the scrotum, a catheter is advanced into the inferior spermatic vein and fibered coils are placed to occlude the spermatic vein at the level of the internal inguinal ring. By venogram, if collaterals are visualized, additional coils are placed within these veins at their branch points. Sodium tetradecyl sulfate foam is then injected while the catheter is pulled back to the more superior portion of the gonadal vein, where additional coils are placed to obliterate the vein. A repeat venogram is performed to confirm occlusion of the spermatic vein and patency of the renal vein. The catheters are then removed, and a pressure dressing is applied.

All surgical ligations and percutaneous embolizations were performed under general anesthesia and patients discharged to home on the same day as the procedure.

Only patients with a palpable varicocele were included in the study. No patients with “subclinical” varicocele noted by ultrasound but nonpalpable by physical examination were included. Exclusion criteria included patients who had an intervention for a varicocele found incidentally during an unrelated operation, which included 2 patients who underwent laparoscopic varicocelectomy in this scenario. Those with bilateral varicocele were excluded a priori. No patients with recurrent varicocele or previous inguinal surgery were included in the study.

Variables considered were age at intervention, laterality, prior interventions, right and left testicular volumes with subsequent hypotrophy calculations, preoperative pain rating, procedure time, hospital charges, and complications. All patients received a preoperative ultrasound and testicular volumes were calculated in cubic centimeters using the Prolate Ellipsoid formula (L × W × H × 0.52).

We defined hypotrophy as a difference in testicular volume greater than 20% as measured by ultrasound using the equation, differential = ([right testis volume − left testis volume]/right testis volume) × 100. Others undergoing intervention without objective ultrasound assessment were subjectively identified to have had a grossly hypotrophic left testis by physical examination. Increase in testicular volume was defined by a decrease in the testicular volume differential after repair.

We defined success as absence of persistent or recurrent varicocele with differential size <20% in those patients that were operated on for size, and resolution of symptoms for those operated on for symptoms.

Statistical analysis was performed using IBM SPSS Statistics (IBM Corp, Armonk, NY). Baseline characteristics were obtained and comparison of the groups were done with Student's t-test and Mann–Whitney U test, where appropriate.

Results

Fifty-six consecutive adolescent males were identified that met inclusion criteria. All varicoceles were left sided. Mean age of the entire cohort was 14.35 years (range 10–18). Of these 56 patients, we identified 48 (86%) patients that underwent surgical ligation and 8 (14%) patients that underwent percutaneous embolization.

Thirty-three (59%) of the patients underwent intervention solely on the basis of testicular hypotrophy. Mean hypotrophy percentage differential from right was 33.2% in this group. Eleven (20%) were offered intervention solely based on pain symptomology. Twelve (21%) were operated on for both hypotrophy and symptoms, these patients had a mean hypotrophic differential percentage of 26.1%.

Of the 48 patients that underwent laparoscopic surgical ligation, 2 (4.2%) of these patients went on to develop a postoperative hydrocele noted by physical examination; one was asymptomatic and the patient and family uninterested in repair, the other underwent a subsequent hydrocelectomy. One patient (2%) developed new-onset testicular pain, which subsequently responded to percutaneous embolization. Additionally, 5 (10.4%) of the patients that underwent laparoscopic surgical ligation, artery-sparing approach, experienced a recurrence of their varicocele.

All patients in the surgical ligation cohort were treated using the laparoscopic Palomo technique. Variations of the Palomo technique performed include sparing of only the testicular artery, which was done in 23 patients and sparing of both the testicular artery and lymphatics in 10 patients, whereas the remaining underwent a mass ligation of the spermatic artery, veins, and lymphatics (Fig. 1).

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FIG. 1.

Descriptive flow chart of patient procedure and complications.

Within the group of 8 patients that underwent percutaneous embolization, we found no patients that developed a recurrence of their varicocele or postoperative hydrocele.

In all patients, postoperative ultrasound was recommended 6 months after repair. Of the 33 patients who underwent surgery solely based on hypotrophy (no pain), 16 underwent postoperative scrotal ultrasound, which demonstrated increase in testicular volume by a reduction in difference from testicular volume from a mean of 31.11% preoperatively to 18.24% postoperatively, (P < .001). Of the 11 patients who underwent intervention because of both hypotrophy and testicular pain, 8 had postoperative scrotal ultrasound, which demonstrated catch-up growth by a reduction in differential testicular volume from a mean of 25.55% preoperatively to 10.37% postoperatively, (P < .01). There were no cases of left testicular atrophy after any intervention.

Average duration of follow-up overall was 20.41 months. Average follow-up for surgical ligation group was 21.04 months. Average follow-up length for embolization group was 18 months. There were 6 patients that did not return after their initial postop visit at 1 month. These were included in the analysis, but if excluded, the mean follow-up would be: 22.65, 23.83, and 18 months for the entire cohort, surgical ligation, and embolization groups, respectively.

Mean operative time for surgical ligation was 41.3 minutes. Mean operative time for percutaneous embolization was 117.9 minutes. There was a significant difference in mean operative time between these groups (P < .0001).

We were able to access the financial hospital charges for only nine encounters due to institutional data retention policies. Of these nine encounters, five of the encounters were for surgical ligation while the remaining four were for percutaneous embolization. The mean hospital charge for surgical ligation was $3982.70 (range $2749.75–6459.15). The mean hospital charge for percutaneous embolization was $18,164.54 (range 17,594.58–20,424.87). There was a significant difference in the mean charges between the two interventions (P < .001).

Discussion

Varicocele is one of the more controversial topics in pediatric urology. In adults, the indication for intervention to treat varicocele is most commonly based on abnormal semen parameters in the setting of infertility. In adolescents, fertility is nearly universally unknown and surrogate parameters reflecting who may benefit from repair are often employed to discriminate pathologic from asymptomatic varicoceles. Symptoms such as pain or an intolerable sensation of heaviness are commonly accepted indications for intervention. In the absence of symptoms, a difference in testicular size with the affected side smaller than the contralateral unaffected “control” side has been most commonly utilized but data supporting the efficacy of this approach or a definitive cutoff for size differential are lacking. Add to this that adolescents are progressing through puberty, so dynamic, asynchronous testicular growth adds an additional confounding variable. In our study, the Prolate Ellipsoid Formula was utilized. Although controversy exists regarding the ideal formula, the other most commonly used Lambert Formula differs only by a constant (0.52 versus 0.71, respectively) in the equation. Because ratios are utilized to compare left and right testicular volume, these constants are factored out and removed such that the differential size assessment is the same.

If one can move beyond the question of “who would benefit from intervention?” the next conundrum is “What is the optimal intervention?” Both open and minimally invasive surgical techniques have been employed in the management of adult varicocele, with a minority of the literature extended to the adolescent population. Several surgical approaches have been described and remain popular. The laparoscopic Palomo technique has appealed to our group given its simplicity, minimally invasive nature, and high success rate paired with a low rate of complication (hydrocele) or subsequent testicular atrophy. Feber and Kass ⁶ reported a high success rate of 97% (207 out of 213) that showed at least a 20% increase in the left testicular volume. A low rate of left hydrocele of 5% that required hydrocelectomy was noted of all patients who underwent a varicocelectomy.

Our results for success and development of postoperative hydrocele are in line with that of other studies.^6,7 Mass ligation of the entire spermatic cord is associated with higher success but also higher rates of resulting hydrocele. Others have noted as efforts are made to spare the spermatic artery or lymphatics, the incidence of hydrocele decreases but at the expense of increasing recurrence rates. This is attributed to small veins traveling with the spermatic artery or veins mistaken as lymphatics. It is notable in our study that all recurrences were associated with some variation of “sparing” technique. Techniques to facilitate lymphatic recognition have been described involving testicular injection of isosulfan blue. ⁸ This injection technique was not employed in our study.

Percutaneous embolization is inherently appealing, as the venous drainage of the testis can be visualized and discretely controlled. It has been shown to be safe with relatively low rates of recurrence (10%–15%), largely related to collateral circulation. ⁹ This comes with the addition of fluoroscopic radiation exposure, and in the adolescent arena, has similar general anesthetic requirements as surgical treatment. Although highly successful in our study, others have described significant failure rates and complications of hydrocele formation associated with percutaneous embolization.

The measurement of success of any approach, even in adults, rarely considers paternity, but more commonly utilizes semen analysis parameters as a surrogate. In adolescent studies, paternity data are nonexistent, and semen analysis has only relatively recently come into the conversation as a common modality for assessment. Although gaining in popularity, it is still often met with resistance from families and patients.

Our study supports that both surgical varicocelectomy and percutaneous embolization are viable options for management of adolescent varicoceles. Both resulted in substantial increase in testicular volume after treatment. A criticism of our study is that the study arms were not balanced. There were relatively few percutaneous embolization patients and although this approach had a seemingly lower rate of recurrence and complications, this study was underpowered for statistical relevance.

The concept of an increase in testicular volume as an indicator of improved fertility potential remains poorly supported. Whether this truly represents growth or is a reflection of venous congestion is arguable. Despite this controversy, in the absence of semen analysis, this is the most commonly used parameter to assess success in the absence of recurrence.

Our hypothesis that both approaches would be equivalent was generally true for success and complication rates. However, the hypothesis was false in that hospital charges were 3–4 times higher for percutaneous embolization. This reflects nearly three times the duration of the procedure resulting in increased costs, but also an associated increase to exposure to general anesthesia.

There are several limitations to our study. The overall number of patients was not large and as mentioned, within the cohort, the percutaneous embolization group was disproportionally smaller than the surgical ligation group. Storm et al., described a series of 21 adolescents undergoing varicocele embolization. In that series, there were two failures due to aberrant vasculature with regard to the number of veins and tortuosity. No hydroceles developed in the 19 patients considered successful. ⁵ It is possible that with more patients within our embolization groups, different rates of postoperative success and recurrence may have been realized. No patients in the embolization group of our study were unable to be embolized. Additionally, follow-up for the embolization group was 18 months, nearly 6 months shorter on average than the surgical group, and longer follow-up may have revealed more recurrence or complications. ⁷ Hydroceles may develop late after repair as other's have reported mean time to development of hydrocele at 14 months. ⁶

Another limitation was the limited financial hospital charge data that we were able to obtain. While our cost analysis was done on a fraction of our total patients, the subset of patients analyzed had a relatively narrow range of charges and we speculate this provides a reasonable representation of our cohort as a whole. We acknowledge that total hospital charges are not a true measurement of cost, and that this likely correlates with total operative/procedure time. As a result, it may be possible that the procedure time for percutaneous embolization may decrease as the interventional radiologists' familiarity increases with this procedure.

The majority of patients underwent a laparoscopic Palomo approach. As this was a retrospective study, the technique was not standardized regarding the decision on whether to do a mass ligation, artery sparing, and/or lymphatic-sparing approach. In most cases, efforts were made to preserve the testicular artery, but this was not always possible with a large varicocele. A criticism of most retrospective studies, a more uniform technique may have led to different outcomes with regard to success, complication, and recurrence making our findings less generalizable.

The lack of a reliable marker of success is a criticism of this study and most studies of adolescent varicocele in the literature. It is unknown how the addition of semen analysis, and the presence of abnormal semen parameters with or without testicular hypotrophy will affect the indications and potential benefits of intervention. In the era of this study, none of the patients underwent semen analysis pre- or postoperatively. We began to use semen analysis as a criterion for surgical intervention and outcome parameter starting in 2017, with variable enthusiasm from families and patients. We have found little correlation in findings with size differential and now emphasize a semen analysis as part of our routine varicocele evaluation when appropriate.

In the current environment of health care delivery, clinicians and hospitals strive to provide the most cost-effective and efficient care to patients. If deemed necessary, the optimal approach to repair of adolescent varicocele remains debatable. A prospective, randomized study would better answer this question, but would be challenging due to the relative infrequency of the condition and the effect on enrollment of the multiple controversies aforementioned. This study was conceived as a pilot for eventual randomized, prospective trial; however, it became apparent that standardization and efforts for cost containment related to embolization are prerequisites to argue equipoise to justify such a study.

Based on our findings of a relatively high success rate with a substantially lower cost, surgical ligation is the most logical first choice when offering intervention at our institution. Given that percutaneous embolization requires much greater resource allocation and eventual financial burden on the patient, it may be a better choice as a salvage procedure when surgical ligation has failed. We acknowledge that costs are unique to different institutions and may limit generalization.

Conclusion

Percutaneous embolization has a trend toward lower rates of postoperative hydrocele and varicocele recurrence in comparison to surgical ligation but with three times the exposure to general anesthesia and at four times the price. Given these findings, embolization may be better reserved for failures of surgical repair.