Antonio Savanelli “Federico II” University Napltaly Chair of Pediatric Surgery Dipartimento di Scienze Mediche Traslazionali Federico II Università di

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<ul><li> Slide 1 </li> <li> Antonio Savanelli Federico II University Napltaly Chair of Pediatric Surgery Dipartimento di Scienze Mediche Traslazionali Federico II Universit di Napoli Indicazioni e trattamento del varicocele in et pediatrica Confronti in Pediatria: Ospedale, Territorio, Universit Secondo Incontro. Pozzuoli 14 Novembre 2014 </li> <li> Slide 2 </li> <li> NO CLINICAL EVIDENCE Varicocele a dilemma ! Conflicting reports in the literature </li> <li> Slide 3 </li> <li> Quale classificazione ??? La classificazione del varicocele primitivo, su base clinica, pi utilizzata quella proposta da Dubin e Amelar (1970). Essa suddivide il varicocele in gradi: Varicocele subclinico: non visibile n palpabile, evidenziabile solo su base strumentale. Varicocele di I grado: varicocele evidenziabile alla palpazione soltanto durante una manovra di Valsalva. Varicocele di II grado: varicocele evidenziabile alla palpazione (palpabile). Varicocele di III grado: varicocele evidenziabile all'ispezione (visibile) </li> <li> Slide 4 </li> <li> Clino Orto Valsalva </li> <li> Slide 5 </li> <li> Varicocele implicato come un fattore nel 3550% degli uomini con infertilita primaria e fino al 81% degli uomini con infertilita secondaria. La pi alta incidenza nellinfertilita secondaria potrebbe indicare il varicocele come responsabile del determinare un progressivo danno della funzione testicolare nel tempo. VARICOCELE E INFERTILITA </li> <li> Slide 6 </li> <li> Vari meccanismi sono stati proposti per linfertilit nel maschio con varicocele: IPERTERMIA IPOSSIA E STASI REFLUSSO SURRENALICO E PERIRENALE INGORGO E IPERTENSIONE VENOSA DISFUNZIONE ORMONALE INCREMENTO STRESS OSSIDATIVO Gat et al Hum Reprod 2004 Srini e Veerachari Int J Endocrinol 2011 Patogenesi Tuttavia lesatta causa non ancora conosciuta. </li> <li> Slide 7 </li> <li> Large numbers of studies have suggested that varicocele repair can improve sperm count, motility, morphology and have reported significant improvements in one or more semen parameters in 65% of men and pregnancy rates of 40% in couples. Schlesinger MH, et al. Treatment outcome after varicocelectomy a critical analysis. Urol Clin North Am, 1994;21(3):51729. VARICOCELE AND MALE INFERTILITY Efficacy of varicocelectomy in improving semen parameters: new meta- analytical approach. Agarwal A Agarwal A 1, Deepinder F, Cocuzza M, Agarwal R, Short RA, Sabanegh E, Marmar JLDeepinder FCocuzza MAgarwal RShort RASabanegh EMarmar JL Urology.Urology. 2007;70(3):532-8. Men with grade III varicocele show a greater relative improvement in semen quality after varicocelectomy than those with grades I and II varicoceles. Steckel J, Dicker AP, Goldstein M, Relationship between varicocele size and response to varicocelectomy,J Urol, 1993;149(4):76971. </li> <li> Slide 8 </li> <li> Diversi studi hanno mostrato che il miglioramento dei parametri del seme solo temporaneo. Pasqualotto Ff,Lucon Am Induction of spermatogenesis in azoospermic men after varicocele repair. Hum Reprod, 2003; 18: 108. Tuttavia gli effetti della correzione chirurgica del varicocele in termini di miglioramento della fertilita controverso in letteratura.. Surgery or embolization for varicoceles in subfertile men (Review): There is evidence suggesting that treatment of a varicocele in men from couples with otherwise unexplained subfertility may improve a couples chance of pregnancy. However, findings are inconclusive as the quality of the available evidence is very low and more research is needed with live birth or pregnancy rate as the primary outcome. 2012 The Cochrane Collaboration. Published by JohnWiley &amp; Sons, Ltd. </li> <li> Slide 9 </li> <li> MANAGING VARICOCELE IN ADOLESCENTS The decision of when to treat adolescents with varicocele is controversial, since 80% of adults with varicocele are fertile.The decision of when to treat adolescents with varicocele is controversial, since 80% of adults with varicocele are fertile. Routine surgery is inappropriate for all adolescents since fertility will not necessarily be affected by the varicocele.Routine surgery is inappropriate for all adolescents since fertility will not necessarily be affected by the varicocele. There is no beneficial effect of pubertal screening and treatment for varicocele regarding chance of paternity later in life. On the other hand, waiting until patients present as adult with potential irreversible infertility can be unacceptable.On the other hand, waiting until patients present as adult with potential irreversible infertility can be unacceptable. </li> <li> Slide 10 </li> <li> Display Settings: Abstract Send to: See comment in PubMed Commons below Pediatr Endocrinol Rev. Pediatr Endocrinol Rev. 2014 Feb;11 Suppl 2:274-83. Varicocele: a dilemma in adolescent males. Haddad NG Haddad NG, Houk CP, Lee PA.Houk CPLee PA Abstract Varicoceles are the most common cause of infertility in men. Despite the high prevalence of varicoceles, only a small percentage of men with varicoceles have subfertility or infertility. In adolescents, the prevalence of varicoceles increases dramatically during puberty to reach adult prevalence rates. The development of varicoceles during puberty can impair testicular growth and function. Data on hormonal and semen parameters in adolescents with varicoceles are limited, making it harder to determine which varicoceles are associated with infertility and which may benefit from surgery. The main indications for varicocelectomy in adolescents with varicoceles include a volume differential between unaffected and affected testes or abnormality in semen analysis Display Settings: Abstract Send to: See comment in PubMed Commons below Pediatr Endocrinol Rev. Pediatr Endocrinol Rev. 2014 Feb;11 Suppl 2:274-83. Varicocele: a dilemma in adolescent males. Haddad NG Haddad NG, Houk CP, Lee PA.Houk CPLee PA Abstract Varicoceles are the most common cause of infertility in men. Despite the high prevalence of varicoceles, only a small percentage of men with varicoceles have subfertility or infertility. In adolescents, the prevalence of varicoceles increases dramatically during puberty to reach adult prevalence rates. The development of varicoceles during puberty can impair testicular growth and function. Data on hormonal and semen parameters in adolescents with varicoceles are limited, making it harder to determine which varicoceles are associated with infertility and which may benefit from surgery. The main indications for varicocelectomy in adolescents with varicoceles include a volume differential between unaffected and affected testes or abnormality in semen analysis Pediatr Endocrinol Rev.Pediatr Endocrinol Rev. 2014 Feb;11 Suppl 2:274-83. Varicocele: a dilemma in adolescent males. Haddad NGHaddad NG, Houk CP, Lee PA.Houk CPLee PA Abstract Varicoceles are the most common cause of infertility in men. Despite the high prevalence of varicoceles, only a small percentage of men with varicoceles have subfertility or infertility. In adolescents, the prevalence of varicoceles increases dramatically during puberty to reach adult prevalence rates. The development of varicoceles during puberty can impair testicular growth and function. Data on hormonal and semen parameters in adolescents with varicoceles are limited, making it harder to determine which varicoceles are associated with infertility and which may benefit from surgery. The main indications for varicocelectomy in adolescents with varicoceles include a volume differential between unaffected and affected testes or abnormality in semen analysis. Il dilemma ancora oggi se e come possibile prevedere quali di quegli adolescenti con varicocele potrebbero da adulti avere problemi di infertilit e, quindi, beneficiare di un intervento precoce di varicocelectomia </li> <li> Slide 11 </li> <li> Does earlier varicocelectomy prevent loss of testicular function and allow normal spermatogenesis during puberty?? Bong GW, et al. The adolescent varicocele: to treat or not to treat. Urol Clin North Am, 2004;31(3):50915. Paduch DA, et al. Repair versus observation in adolescent varicocele: a prospective study. J Urol, 1997;158(3 Pt 2):112832. EARLY VARICOCELECTOMY ???? </li> <li> Slide 12 </li> <li> Algorithm of indications and benefits of varicocele repair ART: assisted reproduction technology Cocuzza M., et al. Varicocele A Dilemma for the Urologist Current Concepts. European Urological Review, 2007:54-9 </li> <li> Slide 13 </li> <li> Guidelines on PaediatricUrology(ESPU) affecting fertility 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 </li> <li> Slide 14 </li> <li> Slide 15 </li> <li> A rapid catch-up growth of the affected testis after varicocelectomy has been consistently reported in 5080% of adolescents and suggests that early intervention is effective as well as defensible. In addition, semen quality improvement and high paternity rates among men who underwent a varicocele repair during adolescence have been demonstrated. Laven JS, et al., Effects of varicocele treatment in adolescents: a randomized study. Fertil Steril, 1992;58(4):75662. Salzhauer EW, et al. Paternity after adolescent varicocele repair. Pediatrics, 2004;114;(6):16313. Lenzi A, et al. Sperm parameters after early left varicocele treatment. Fertil Steril. 1998;69(2):347-9 Indicazioni al trattamento del varicocele:testicolo ipotrofico </li> <li> Slide 16 </li> <li> La questione rimane se il cosidetto catch-up growth dovuto alledema postoperatorio o rappresenta un reale incremento del tessuto testicolare. Parte della crescita pu essere attribuito alledema interstiziale secondario alla divisione dei vasi linfatici. Kocvara R, DolezalJ et al: Division of lymphatic vessels at varicocelectomy leads to testicular oedema and decline in testicular function according to the Lh-Rh analogue stimulation test. Eur Urol 2003;43:430.La Il 71% della differenza di volume dei testicoli nei ragazzi con varicocele pu risolversi spontaneamente. Kolon Tf, Clement MR et al Transient asynchronous testicular growth in adolescent males with a varicocele. J Urol 2008;180:1111 Indicazioni al trattamento del varicocele:testicolo ipotrofico </li> <li> Slide 17 </li> <li> Indicazioni al trattamento del varicocele: :testicolo ipotrofico Preston et alt.supportano la teoria affermante che i testicoli durante ladolescenza si sviluppino a fasi di crescita differenti tra essi (il 50% )e di conseguenza che la riparazione profilattica del varicocele potrebbe esporre molti ragazzi a rischi chirurgici non necessari. Preston MA, Carnat T, Flood T, Gaboury I, Leonard MP: Conservative Management Of Adolescent Varicoceles: A Retrospective Review. Urology 2008 Jul;72(1):77-80. La incidenza di un piccolo testicolo sinistro (pi di 2 cm) era comparabile in entrambi i gruppi (trattati e no) e non hanno influenzato la chance di paternit. Bogaert G,Orye c, De win G Pubertal screening and treatment for varicocele do not improve chance of paternity as adult. J urol, 2013,189,2298-2304. </li> <li> Slide 18 </li> <li> Indicazioni allintervento volume testicolare Testicular volume is more predictive of total motile count (TMC) than is testicular volume differential. Total testicular volume can predict TMC at the end of adolescence but not throughout puberty. Active Surveillance of the Adolescent with Varicocele: Predicting Semen Outcomes from Ultrasound Matthew S. Christman, Stephen A. Zderic, Douglas A. Canning and Thomas F. Kolon THE JOURNAL OF UROLOGY 2014 Vol. 191, 1401-1406 </li> <li> Slide 19 </li> <li> E presente una significativa differenza nei volumi testicolari di soggetti fertili ed infertili indipendentemente dalla presenza di varicocele. Non esistono evidenze che confermino una progressione della ipotrofia testicolare in adolescenti in long-term follow-up per varicocele. Nessuna correlazione volume testicolare-grado del varicocele. Diamond DA, Zurakowski D, Atala A, Bauer SB, Borer JG, Cilento BG Jr, Paltiel H, Peters CA, Retik AB: Is adolescent varicocele a progressive disease process? J Urol 2004; 172: 17461748. Alukal JP, Zurakowski D, Atala A, et al: Testicular hypotrophy does not correlate with grade of adolescent varicocele. J Urol 2005;174: 23672370. VARICOCELE E RIDUZIONE DEL VOLUME TESTICOLARE </li> <li> Slide 20 </li> <li> VIDEOSURGERY TRATTAMENTO - Chirurgia Open - Chirurgia mininvasiva Sclero-embolizazione (ante e retrograda) Laparoscopia (retro o transaddominale) Beutner S, et al. Treatment of varicocele with reference to age: a retrospective comparison of three minimally invasive procedures. Surg Endosc. 2007 Jan; 21(1):61-5. </li> <li> Slide 21 </li> <li> CHIRURGIA OPEN 1 3 2 Legatura vena sperm. interna : Ivanissevitch Legatura vene sp. iint. e arteria: Palomo APPROCCIO: retroperitoneale, inguinale e subinguinale microchirurgica La tecnica pi popolare in et pediatrica lapproccio retroperitoneale. Recidive: 14% </li> <li> Slide 22 </li> <li> CHIRURGIA OPEN ; Ivanissevitch modificata: legatura spermatica interna ed esterna Recidive: 7-9% V SE VSIVSI </li> <li> Slide 23 </li> <li> Sclerotizzazione retrograda Si pratica dopo lincanulamento della vena renale linfusione di mdc (Transfemorale,Transbrachiale,Transgiugulare) Si inietta sostanza sclerosante Sclero-Embolizzazione Anterograda sec. Tauber </li> <li> Slide 24 </li> <li> SCLERO-EMBOLIZAZIONE Questo tipo di approccio, per definizione, elimina il rischio di interrompere il flusso arterioso ed il drenaggio linfatico. Nelladulto, inoltre, questi trattamenti possono essere fatti in anestesia locale il che, ovviamente, e un vantaggio. Tuttavia anche con questa tecnica il rischio di recidiva e compreso tra il 5-15% Inoltre c una esposizione alle radiazioni, piu breve nella tecnica anterograda. </li> <li> Slide 25 </li> <li> Can Urol Assoc J.Can Urol Assoc J. 2014 Large bowel infarct following antegrade scrotal sclerotherapy for varicocele: A case report. Vicini P Vicini P 1, Di Pierro GB 2, Grande P 2, Voria G 3, Antonini G 2, De Marco F 1, Di Nicola S 1, Gentile V 2.Di Pierro GBGrande PVoria GAntonini GDe Marco FDi Nicola SGentile V SCLERO EMBOLIZAZZIONE: anterograda sec Tauber </li> <li> Slide 26 </li> <li> La laparoscopia rappresenta un valido approccio comparato ad altre procedure chirurgiche. La tecnica di Palomo e preferibile alla procedura di Ivanissevitch Recidiva: Palomo 2-5 % Ivanissevitch: 5-12 % Very few medical conditions benefit from surgical disruption of an organs arterial blood supply,particularly when the ultimate goal is to improve growth and function. Pastuszak A Diagnostic and managment approaches to pediatric and adolescent varicocele: a...</li></ul>

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