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Commentary on “Clinical outcome of pediatric and young adult subclinical varicoceles: a single-institution experience”

 ASST Fatebenefratelli-Sacco, Luigi Sacco University Hospital, Department of Urology, Milan 20157, Italy

Date of Submission22-Feb-2021
Date of Acceptance15-Mar-2021
Date of Web Publication27-Apr-2021

Correspondence Address:
Franco Palmisano,
ASST Fatebenefratelli-Sacco, Luigi Sacco University Hospital, Department of Urology, Milan 20157

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aja.aja_34_21

PMID: 33904507

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How to cite this URL:
Palmisano F, Talso M, Granata AM, Gregori A. Commentary on “Clinical outcome of pediatric and young adult subclinical varicoceles: a single-institution experience”. Asian J Androl [Epub ahead of print] [cited 2021 Jun 12]. Available from:

We read with interest the study by Cho et al.[1] regarding the features of subclinical varicocele in a pediatric and young adult single-center population. Out of 98 patients identified, the majority had a right-sided subclinical varicocele (69%, n = 25), usually with a contralateral clinical varicocele. Testicular asymmetry (>20% volume difference of the affected side by testicular atrophy index formula) was assessed in nine patients with unilateral subclinical varicocele without contralateral varicocele, either clinical or subclinical. Interestingly, of 17 patients with a mean follow-up of 32 months, 3 (17.6%) progressed to clinical varicocele without asymmetric testicular volume, as most remained subclinical or had subsequent resolution by ultrasound. The authors concluded that subclinical varicoceles appeared unlikely to progress to a clinical disease, to affect testicular volume, or to lead to surgery.

We believe that the authors should be commended for the innovation of their preliminary data, which focused on a very specific topic that is still a matter of debate today. However, the significance of their findings should be considered in the context of the study limitations, in particular, the small cohort, the limited follow-up, and the lack of data regarding semen analysis.

At present, the clinical management of varicocele is still mainly based on physical examination, whereas scrotal color Doppler ultrasound is useful in assessing venous reflux and diameter, when palpation is unreliable, and/or in detecting recurrence/persistence after surgery.[2],[3] In this context, guidelines from the most important societies, including the American Urological Association (AUA), European Academy of Andrology (EAA), and European Association of Urology (EAU), suggest monitoring for subclinical disease.[2],[4] Although the boundary between clinical and subclinical varicocele remains elusive and no surgical recommendation has been given for the treatment of subclinical varicocele, several studies suggest a role in male infertility.[5]

The role of ultrasonography remains controversial because subclinical varicoceles have a poor concordance with those detected on physical examination.[6] In light of this, subclinical varicocele represents a gray area, which relies on the diagnostic criteria employed. Obviously, the degree of varicocele by palpation is subjective, but this dilemma apparently cannot be overcome by ultrasound, whose main characteristic is being operator-dependent. In addition, the heterogeneity and nonstandardization of the various scores and ultrasound classifications complicate the topic.

Despite this, the article by Cho et al.[1] suggests interesting findings on the lack of progression of subclinical varicocele in a clinical setting, justifying its conservative management. Therefore, the article to be commented is highly recommended to readers and we encourage the authors to provide in the future further data on a larger cohort with a longer follow-up, also including speculation about semen analysis and follicle-stimulating hormone levels of patients affected by subclinical varicocele.

  Author Contributions Top

FP contributed to the concept of the study, prepared the materials, collected and/or processed the data, performed literature search, and wrote the manuscript. AMG and AG supervised the study and critically reviewed the manuscript. FP and MT designed the study, were responsible for the resources, analyzed and interpreted the results, and did other works. All authors read and approved the final manuscript.

  Competing Interests Top

All authors declare no competing interests.

  References Top

Cho PS, Yu RN, Paltiel HJ, Migliozzi MA, Li X, et al. Clinical outcome of pediatric and young adult subclinical varicoceles: a single-institution experience. Asian J Androl 2021. Doi: 10.4103/aja.aja_22_21. [Epub ahead of print].  Back to cited text no. 1
Salonia A, Bettocchi C, Carvalho J, Corona G, Jones TH, et al. European association of urology guidelines on sexual and reproductive health. In: Presented at the EAU Annual Congress Amsterdam 2020. Arnhem: EAU Guidelines Office; 2020.  Back to cited text no. 2
American Urological Association. The Optimal Evaluation of the Infertile Male: AUA Best Practice Statement. Linthicum: American Urological Association Education and Research Inc.; 2010.  Back to cited text no. 3
Colpi GM, Francavilla S, Haidl G, Link K, Behre HM, et al. European Academy of Andrology guideline management of oligo-astheno-teratozoospermia. Andrology 2018; 6: 513–24.  Back to cited text no. 4
Palmisano F, Moreno-Mendoza D, Ievoli R, Veber-Moisés-Da Silva G, Gasanz-Serrano C, et al. Clinical factors affecting semen improvement after microsurgical subinguinal varicocelectomy: which subfertile patients benefit from surgery? Ther Adv Urol 2019; 11: 1756287219887656.  Back to cited text no. 5
Petros JA, Andriole GL, Middleton WD, Picus DA. Correlation of testicular color Doppler ultrasonography, physical examination and venography in the detection of left varicoceles in men with infertility. J Urol 1991; 145: 785–8.  Back to cited text no. 6


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