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Guideline Summary
Guideline Title
Varicocele in children and adolescents. In: Guidelines on paediatric urology.
Bibliographic Source(s)
Varicocele in children and adolescents. In: Tekgul S, Riedmiller H, Gerharz E, Hoebeke P, Kocvara R, Nijman R, Radmayr C, Stein R. Guidelines on paediatric urology. Arnhem, The Netherlands: European Association of Urology, European Society for Paediatric Urology; 2009 Mar. p. 23-5. [21 references]
Guideline Status

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Scope

Disease/Condition(s)

Varicocele

Guideline Category
Diagnosis
Treatment
Clinical Specialty
Pediatrics
Surgery
Urology
Intended Users
Physicians
Guideline Objective(s)
  • To outline a practical and preliminary approach to paediatric urological problems
  • To increase the quality of care for children with urological problems
Target Population

Children and adolescents with varicocele

Interventions and Practices Considered

Diagnosis

  1. Clinical examination of testicular veins
  2. Palpation during Valsalva maneuver
  3. Doppler color flow mapping to detect venous reflux
  4. Measurement of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) responses to the luteinizing hormone-releasing hormone (LHRH) stimulation test

Treatment

  1. Surgical ligation
    • Inguinal or subinguinal microsurgical ligation
    • Open or laparoscopic suprainguinal ligation
    • Use of optic magnification during surgery
  2. Lymphatic-sparing varicocelectomy
  3. Angiographic occlusion of the internal spermatic veins
Major Outcomes Considered
  • Rate of improvement in testicular growth and sperm production
  • Varicocele recurrence rate

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The guidelines were based on current literature following a systematic review using MEDLINE.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence

1a Evidence obtained from meta-analysis of randomized trials

1b Evidence obtained from at least one randomized trial

2a Evidence obtained from at least one well-designed controlled study without randomization

2b Evidence obtained from at least one other type of well-designed quasi-experimental study

3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports

4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities

Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence

Application of a structured analysis of the literature was not possible due to a lack of well-designed studies. Whenever possible, statements have been classified in terms of level of evidence and grade of recommendation. Due to the limited availability of large randomized controlled trials – influenced also by the fact that a considerable number of treatment options relate to surgical interventions on a large spectrum of different congenital problems – this document is therefore largely a consensus document.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
  • The first step in the European Association of Urology (EAU) guidelines procedure is to define the main topic.
  • The second step is to establish a working group. The working groups comprise about 4-8 members, from several countries. Most of the working group members are academic urologists with a special interest in the topic. In general, general practitioners or patient representatives are not part of the working groups. A chairman leads each group. A collaborative working group consisting of members representing the European Society for Paediatric Urology (ESPU) and the EAU has gathered in an effort to produce the current update of the paediatric urology guidelines.
  • The third step is to collect and evaluate the underlying evidence from the published literature.
  • The fourth step is to structure and present the information. The strength of the recommendation is clearly marked in three grades (A-C), depending on the evidence source upon which the recommendation is based. Every possible effort is made to make the linkage between the level of evidence and grade of recommendation as transparent as possible.
Rating Scheme for the Strength of the Recommendations

Grades of Recommendation

  1. Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial
  2. Based on well-conducted clinical studies, but without randomized clinical studies
  3. Made despite the absence of directly applicable clinical studies of good quality
Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

There is no formal external review prior to publication.

The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was used to analyse and assess a range of specific attributes contributing to the validity of a specific clinical guideline.

The AGREE instrument, to be used by two to four appraisers, was developed by the AGREE collaboration (www.agreecollaboration.org External Web Site Policy) using referenced sources for the evaluation of specific guidelines. (See the "Availability of Companion Documents" field for further methodology information).

Recommendations

Major Recommendations

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.

Note from the European Association of Urology (EAU) and the National Guideline Clearinghouse (NGC): The following recommendations were current as of the publication date. However, because EAU updates their guidelines frequently, users may wish to consult the EAU Web site External Web Site Policy for the most current version available.

Levels of evidence (1a-4) and grades of recommendation (A-C) are defined at the end of the "Major Recommendations" field.

Background

Varicocele is defined as an abnormal dilatation of testicular veins in the pampiniformis plexus caused by venous reflux. It is unusual in boys under 10 years of age and becomes more frequent at the beginning of puberty. It is found in 15%-20% of adolescents, with a similar incidence during adulthood. It appears mostly on the left side (78%-93% of cases). Right-sided varicoceles are least common; they are usually noted only when bilateral varicoceles are present and seldom occur as an isolated finding.

Varicocele develops during accelerated body growth by a mechanism that is not clearly understood. Varicocele can induce apoptotic pathways because of heat stress, androgen deprivation and accumulation of toxic materials. Severe damage is found in 20% of adolescents affected, with abnormal findings in 46% of affected adolescents. Histological findings are similar in children or adolescents and in infertile men. In 70% of patients with grade II and III varicocele, left testicular volume loss was found. However, studies correlating a hypoplastic testicle with poor sperm quality have reported controversial results.

Several authors reported on reversal of testicular growth after varicocelectomy in adolescents (Level of evidence: 2). However, this may partly be attributable to testicular oedema associated with the division of lymphatic vessels (Level of evidence: 2).

In about 20% of adolescents with varicocele, fertility problems will arise. The adverse influence of varicocele increases with time. Improvement in sperm parameters has been demonstrated after adolescent varicocelectomy (Level of evidence: 1).

Diagnosis

Varicocele is mostly asymptomatic, rarely causing pain at this age. It may be noticed by the patient or parents, or discovered by the paediatrician at a routine visit. The diagnosis depends upon the clinical finding of a collection of dilated and tortuous veins in the upright posture; the veins are more pronounced when the patient performs the Valsalva manoeuvre.

Varicocele is classified into 3 grades: Grade I - Valsalva positive (palpable at Valsalva manoeuvre only); Grade II - palpable (palpable without the Valsalva manoeuvre); Grade III - visible (visible at distance). The size of both testicles should be evaluated during palpation to detect a smaller testis.

Venous reflux into the plexus pampiniformis is diagnosed using Doppler colour flow mapping in the supine and upright position. Venous reflux detected on ultrasound only is classified as subclinical varicocele. The ultrasound examination includes assessment of the testicular volume to discriminate testicular hypoplasia. In adolescents, a testis that is smaller by more than 2 mL compared to the other testis is considered to be hypoplastic (Level of evidence: 4).

In order to assess testicular injury in adolescents with varicocele, supranormal follicle-stimulating hormone (FSH) and luteinizing hormone (LH) responses to the luteinizing hormone-releasing hormone (LHRH) stimulation test are considered reliable, as histopathological testicular changes have been found in these patients.

Therapy

Surgical intervention is based on ligation or occlusion of the internal spermatic veins. Ligation is performed at different levels:

  • Inguinal (or subinguinal) microsurgical ligation
  • Suprainguinal ligation, using open or laparoscopic techniques

The advantage of the former is the lower invasiveness of the procedure, while the advantage of the latter is a considerably lower number of veins to be ligated and safety of the incidental division of the internal spermatic artery at the suprainguinal level.

For surgical ligation, some form of optical magnification (microscopic or laparoscopic magnification) should be used because the internal spermatic artery is 0.5 mm in diameter at the level of the internal ring. The recurrence rate is usually less than 10%. Angiographic occlusion is based on retrograde or antegrade sclerotization of the internal spermatic veins.

Lymphatic-sparing varicocelectomy is preferred to prevent hydrocele formation and testicular hypertrophy development and to achieve a better testicular function according to the LHRH stimulation test (Level of evidence: 2; Grade of recommendation: A). The methods of choice are subinguinal or inguinal microsurgical (microscopic) repairs, or suprainguinal open or laparoscopic lymphatic-sparing repairs.

Angiographic occlusion of the internal spermatic veins also meets these requirements. However, although this method is less invasive, it appears to have a higher failure rate (Level of evidence: 2; Grade of recommendation: B).

There is no evidence that treatment of varicocele at paediatric age will offer a better andrological outcome than an operation performed later. The recommended indication criteria for varicocelectomy in children and adolescents are:

  • Varicocele associated with a small testis
  • Additional testicular condition affecting fertility
  • Bilateral palpable varicocele
  • Pathological sperm quality (in older adolescents)
  • Varicocele associated with a supranormal response to LHRH stimulation test
  • Symptomatic varicocele

Repair of a large varicocele physically or psychologically causing discomfort may be also considered. Other varicoceles should be followed-up until a reliable sperm analysis can be performed (Level of evidence: 4; Grade of recommendation: C).

Definitions:

Levels of Evidence

1a Evidence obtained from meta-analysis of randomized trials

1b Evidence obtained from at least one randomized trial

2a Evidence obtained from at least one well-designed controlled study without randomization

2b Evidence obtained from at least one other type of well-designed quasi-experimental study

3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports

4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities

Grades of Recommendation

  1. Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial
  2. Based on well-conducted clinical studies, but without randomized clinical studies
  3. Made despite the absence of directly applicable clinical studies of good quality
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for some of the recommendations (see "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Appropriate diagnosis and treatment of varicocele in children and adolescents
  • Normal sexual function
  • Preservation of fertility
Potential Harms

Angiographic occlusion of the internal spermatic veins is a less invasive surgery, but it appears to have a higher failure rate.

Qualifying Statements

Qualifying Statements

The purpose of these texts is not to be proscriptive in the way a clinician should treat a patient but rather to provide access to the best contemporaneous consensus view on the most appropriate management currently available. European Association of Urology (EAU) guidelines are not meant to be legal documents but are produced with the ultimate aim to help urologists with their day-to-day practice.

Implementation of the Guideline

Description of Implementation Strategy

The European Association of Urology (EAU) Guidelines long version (containing all 19 guidelines) is reprinted annually in one book. Each text is dated. This means that if the latest edition of the book is read, one will know that this is the most updated version available. The same text is also made available on a CD (with hyperlinks to PubMed for most references) and posted on the EAU websites Uroweb and Urosource (http://www.uroweb.org/guidelines/online-guidelines/ External Web Site Policy & http://www.urosource.com/diseases/ External Web Site Policy).

Condensed pocket versions, containing mainly flow-charts and summaries, are also printed annually. All these publications are distributed free of charge to all (more than 10,000) members of the Association. Abridged versions of the guidelines are published in European Urology as original papers. Furthermore, many important websites list links to the relevant EAU guidelines sections on the association websites and all, or individual, guidelines have been translated to some 15 languages.

Implementation Tools
Pocket Guide/Reference Cards
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
IOM Domain
Effectiveness

Identifying Information and Availability

Bibliographic Source(s)
Varicocele in children and adolescents. In: Tekgul S, Riedmiller H, Gerharz E, Hoebeke P, Kocvara R, Nijman R, Radmayr C, Stein R. Guidelines on paediatric urology. Arnhem, The Netherlands: European Association of Urology, European Society for Paediatric Urology; 2009 Mar. p. 23-5. [21 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2008 Mar (republished 2009 Mar)
Guideline Developer(s)
European Association of Urology - Medical Specialty Society
European Society for Paediatric Urology - Medical Specialty Society
Source(s) of Funding

European Association of Urology

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Primary Authors: S. Tekgül; H. Riedmiller; E. Gerharz; P. Hoebeke; R. Kocvara; R. Nijman; Chr. Radmayr; R. Stein

Financial Disclosures/Conflicts of Interest

All members of the working group submit a conflict of interest form. The information is kept on file in the European Association of Urology (EAU) Central Office database. This guidelines document was developed with the financial support of the EAU. No external sources of funding and support have been involved. The EAU is a non-profit organisation and funding is limited to administrative assistance, travel, and meeting expenses. No honoraria or other reimbursements have been provided.

Guideline Status

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Guideline Availability

Electronic copies of the updated guideline: Available in Portable Document Format (PDF) from the European Association of Urology Web site External Web Site Policy.

Print copies: Available from the European Association of Urology, PO Box 30016, NL-6803, AA ARNHEM, The Netherlands.

Availability of Companion Documents

The following are available:

  • Guidelines on paediatric urology. Pocket guideline. Arnhem, The Netherlands: European Association of Urology (EAU); 2009 Mar. 13 p. Electronic copies: Available in Portable Document Format (PDF) from the European Association of Urology Web site External Web Site Policy. Also available as an e-book form the European Association of Urology Web site External Web Site Policy.
  • EAU guidelines office template. Arnhem, The Netherlands: European Association of Urology (EAU); 2007. 4 p.
  • The European Association of Urology (EAU) guidelines methodology: a critical evaluation. Arnhem, The Netherlands: European Association of Urology (EAU); 18 p.

Print copies: Available from the European Association of Urology, PO Box 30016, NL-6803, AA ARNHEM, The Netherlands.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on November 14, 2008. The information was verified by the guideline developer on December 19, 2008.

Copyright Statement

This summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Downloads are restricted to one download and print per user, no commercial usage or dissemination by third parties is allowed.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouseâ„¢ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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