at what testicular volume would you do a varicocelectomy?

[lost777]

pt is 31 yrs old with left varicocele. present for >10yrs according to him.

testicular US:
right testicle: 3.9 x 3.1 x 3.4cm

left testicle: 4.0 x 3.1 x 2.3cm


is the left testicle small enough to refer to recommend a varicocelectomy?

more info:
pt has no pain. unable to evaluate fertility as pt has not tried to have kids. (is a fertility/sperm test an appropriate part of the workup?)

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[DoctwoB]

pt is 31 yrs old with left varicocele. present for >10yrs according to him.

testicular US:
right testicle: 3.9 x 3.1 x 3.4cm

left testicle: 4.0 x 3.1 x 2.3cm


is the left testicle small enough to refer to recommend a varicocelectomy?

more info:
pt has no pain. unable to evaluate fertility as pt has not tried to have kids. (is a fertility/sperm test an appropriate part of the workup?)

Short answer: it's complicated and controversial.

Long answer: It will depend very much on the Urologist and institutional practice. Some would offer repair based on size differential. I would get a semen analysis to check semen parameters and see where he is at. If his semen analysis is relatively normal I would leave him alone and only repair if having trouble with conception in future. There is evidence that varicocelectomy will improve semen parameters and paternity rates, but we have no evidence that either of those are a problem right now. The counter argument to my plan is that in theory earlier repair could prevent further damage and reduced paternity rates in the future even if delayed surgery is undertaken. Definitive data is lacking.

With regards to testicular volume differential, i generally find that to be a more useful data point in adolescents when a semen analysis is unreliable. At that point the book answer is 20% differential to consider repair, but I would want to see a trend over multiple ultrasounds as assymetric growth over puberty Is not abnormal and the testicle could have catch up growth given time.

 

[cpants]

Agree with @DoctwoB. It is controversial and there is not a definite right answer.

In my opinion size differential is only really a valid indication in the pediatric population.

Does he have children? If no fertility issues, I would leave him alone. If unknown fertility potential, I would probably still leave him alone. If he is very concerned about it, consider a semen analysis, but unless very abnormal, I would probably leave him alone. Most people with varicoceles have normal fertility potential.