Outcome following the surgical management of varicocele in children and adolescents: a systematic review and meta-analysis

BACKGROUND: The ideal surgical approach for the management of varicocele in children and adolescents remains controversial. Several techniques are available including artery- or lymphatic-sparing with optical magnification (via open inguinal or sub-inguinal approach), laparoscopic, antegrade and retrograde embolization/sclerotherapy. OBJECTIVES: We aimed to appraise the clinical outcomes of these techniques in children and adolescents. DATA SOURCES AND METHODS: A systematic review was conducted (1997–2023). Meta-analysis or proportional meta-analysis for non-comparative studies (Freeman-Tukey transformation) using the random effects model was conducted. Results are expressed as overall proportion % and 95% confidence interval (CI). RESULTS: We identified 1910 studies; 632 duplicates were removed, 1278 were screened, 203 were reviewed and 56 were included, with 12 reporting on 2 different techniques (total of 68 data sets). Optical magnification via inguinal approach (498 cases): recurrence 2.5% (0.6–5.6), hydrocele 1.6% (0.47–3.4), testicular atrophy 1% (0.3–2.0), complications 1.1% (0.2–2.6); optical magnification via sub-inguinal approach (592 cases): recurrence 2.1% (0.7–4.4), hydrocele 1.26% (0.5–2.3), testicular atrophy 0.5% (0.1–1.3), complications 4% (1.0–8.8). Laparoscopic with mass-ligation/division (1943 cases): recurrence 2.9% (1.5–4.6), hydrocele 11.4% (8.3–14.9); complications 1.5% (0.6–2.9); laparoscopic with lymphatic-sparing (974 cases): recurrence 2.4% (1.5–3.5), hydrocele 1.2% (0.45–3.36), complications 1.2% (0.05–3.9); laparoscopic with artery-sparing (228 cases): recurrence 6.6% (2.3–12.9), hydrocele 6.5% (2.6–12.0). Antegrade embolization/sclerotherapy (403 cases): recurrence 7.6% (5.2–10.4), hydrocele 0.8% (0.17–1.9), technical failure 0.6% (0.1–1.6), complications 4.0% (2.3–6.1); retrograde embolization/sclerotherapy (509 cases): recurrence 6.9% (4.6–9.5), hydrocele 0.8% (0.05–2.5), technical failure 10.2% (4.6–17.6), and complications 4.8% (1.0–11.2). CONCLUSION: The recurrence rate varies between 2.1% and 7.6% and is higher with the embolization/sclerotherapy techniques. Post-operative hydrocele rate varies between 0.8% and 11.4% and is higher with the laparoscopic mass-ligation/division technique. Testicular atrophy has not been reported with the laparoscopic and embolization/sclerotherapy techniques. The retrograde embolization technique is associated with 10% technical failure (inability to complete the procedure). The laparoscopic lymphatic-sparing technique is characterized by the lowest recurrence rate, incidence of hydrocele and other complications, and no reports of testicular atrophy.