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Multicenter analysis of percutaneous embolization, laparoscopic and open varicocelectomy for adolescent patients
Robert Lurvey, MD1, Blythe Durbin-Johnson, PhD2, Eric Kurzrock, MD, FAAP1.
1University of California Davis, Sacramento, CA, USA, 2University of California Davis, Davis, CA, USA.

BACKGROUND: The literature on treatment of adolescent varicocele is limited to high-volume single institution case series and meta-analyses of these same studies. We utilize a large hospital consortium database to determine the rates of varicocele persistence and hydrocele occurrence after open or laparoscopic varicocelectomy or percutaneous embolization (PE). METHODS: The Faculty Practice Solutions Center database was queried to identify male subjects under age 19 years with a diagnosis of varicocele (based upon ICD-9) between January 2009 and December 2012. We then determined which of these patients underwent open or laparoscopic varicocelectomy or PE prior to 2013 based upon CPT coding. Patients were followed until Dec. 31, 2013 (1 to 5 years of follow-up) to determine if they had occurrence of outcome variables: retreatment, diagnosis of hydrocele and/or treatment of hydrocele. The association of variables: age at primary surgery, race, insurance type, geographical region and surgical approach with outcome variables was analyzed using a mixed-effects Cox proportional hazard model including random effects for surgeon and institution.
RESULTS: Of 6,729 patients with a diagnosis of varicocele, 1,036 (15%) underwent treatment, open (405), laparoscopic (530) and PE (101). Neither race, region, insurance type or age was independently associated with outcomes. Retreatment rates after open, laparoscopic and PE treatments were 1.5%, 3.4% and 9.9%, respectively. Controlling for all variables, PE was independently associated with a nearly 6-fold higher hazard ratio of retreatment than open surgery (P = 0.010). PE was the most common retreatment modality following failure of primary open varicocelectomy and PE, whereas open varicocelectomy was the most common secondary treatment following primary lap varicocelectomy. The incidence of hydrocele diagnosis after open, laparoscopic and PE treatments was 4.9%, 8.1% and 5%, respectively. Yet, no treatment approach was independently associated with surgical treatment of hydrocele.
CONCLUSIONS: Percutaneous embolization of adolescent varicocele has a significantly higher retreatment rate compared to open varicocelectomy and trended towards significance compared to laparoscopic varicocelectomy. This may be due to a higher failure rate or a lower threshold to retreat by interventional radiologists. Despite a higher rate of hydrocele following the laparoscopic approach, it was not associated with a higher hydrocele treatment rate. This may reflect a smaller size of hydrocele after laparoscopic varicocelectomy or a higher threshold to treat by these surgeons.

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