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Meta-Analysis
. 2021 Apr 23;4(4):CD000479.
doi: 10.1002/14651858.CD000479.pub6.

Surgical or radiological treatment for varicoceles in subfertile men

Emma Persad  1   2 , Clare Aa O'Loughlin  3 , Simi Kaur  4 , Gernot Wagner  1 , Nina Matyas  1 , Melanie Rosalia Hassler-Di Fratta  5 , Barbara Nussbaumer-Streit  1
Affiliations
Meta-Analysis

Surgical or radiological treatment for varicoceles in subfertile men

Emma Persad et al. Cochrane Database Syst Rev. .

Abstract

Background: Varicoceles are associated with male subfertility; however, the mechanisms by which varicoceles affect fertility have yet to be satisfactorily explained. Several treatment options exist, including surgical or radiological treatment, however the safest and most efficient treatment remains unclear. OBJECTIVES: To evaluate the effectiveness and safety of surgical and radiological treatment of varicoceles on live birth rate, adverse events, pregnancy rate, varicocele recurrence, and quality of life amongst couples where the adult male has a varicocele, and the female partner of childbearing age has no fertility problems.

Search methods: We searched the following databases on 4 April 2020: the Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL. We also searched the trial registries and reference lists of articles.

Selection criteria: We included randomised controlled trials (RCTs) if they were relevant to the clinical question posed and compared different forms of surgical ligation, different forms of radiological treatments, surgical treatment compared to radiological treatment, or one of these aforementioned treatment forms compared to non-surgical methods, delayed treatment, or no treatment. We extracted data if the studies reported on live birth, adverse events, pregnancy, varicocele recurrence, and quality of life.

Data collection and analysis: Screening of abstracts and full-text publications, alongside data extraction and 'Risk of bias' assessment, were done dually using the Covidence software. When we had sufficient data, we calculated random-effects (Mantel-Haenszel) meta-analyses; otherwise, we reported results narratively. We used the I2 statistic to analyse statistical heterogeneity. We planned to use funnel plots to assess publication bias in meta-analyses with at least 10 included studies. We dually rated the risk of bias of studies using the Cochrane 'Risk of bias' tool, and the certainty of evidence for each outcome using the GRADE approach.

Main results: We identified 1897 citations after de-duplicating the search results. We excluded 1773 during title and abstract screening. From the 113 new full texts assessed in addition to the 10 studies (11 references) included in the previous version of this review, we included 38 new studies, resulting in a total of 48 studies (59 references) in the review providing data for 5384 participants. Two studies (three references) are ongoing studies and two studies are awaiting classification. Treatment versus non-surgical, non-radiological, delayed, or no treatment Two studies comparing surgical or radiological treatment versus no treatment reported on live birth with differing directions of effect. As a result, we are uncertain whether surgical or radiological treatment improves live birth rates when compared to no treatment (risk ratio (RR) 2.27, 95% confidence interval (CI) 0.19 to 26.93; 2 RCTs, N = 204; I2 = 74%, very low-certainty evidence). Treatment may improve pregnancy rates compared to delayed or no treatment (RR 1.55, 95% CI 1.06 to 2.26; 13 RCTs, N = 1193; I2 = 65%, low-certainty evidence). This suggests that couples with no or delayed treatment have a 21% chance of pregnancy, whilst the pregnancy rate after surgical or radiological treatment is between 22% and 48%. We identified no evidence on adverse events, varicocele recurrence, or quality of life for this comparison. Surgical versus radiological treatment We are uncertain about the effect of surgical versus radiological treatment on live birth and on the following adverse events: hydrocele formation, pain, epididymitis, haematoma, and suture granuloma. We are uncertain about the effect of surgical versus radiological treatment on pregnancy rate (RR 1.13, 95% CI 0.75 to 1.70; 5 RCTs, N = 456, low-certainty evidence) and varicocele recurrence (RR 1.31, 95% CI 0.82 to 2.08; 3 RCTs, N = 380, low-certainty evidence). We identified no evidence on quality of life for this comparison. Surgery versus other surgical treatment We identified 19 studies comparing microscopic subinguinal surgical treatment to any other surgical treatment. Microscopic subinguinal surgical treatment probably improves pregnancy rates slightly compared to other surgical treatments (RR 1.18, 95% CI 1.02 to 1.36; 12 RCTs, N = 1473, moderate-certainty evidence). This suggests that couples with microscopic subinguinal surgical treatment have a 10% to 14% chance of pregnancy after treatment, whilst the pregnancy rate in couples after other surgical treatments is 10%. This procedure also probably reduces the risk of varicocele recurrence (RR 0.48, 95% CI 0.29, 0.79; 14 RCTs, N = 1565, moderate-certainty evidence). This suggests that 0.4% to 1.1% of men undergoing microscopic subinguinal surgical treatment experience recurrent varicocele, whilst 1.4% of men undergoing other surgical treatments do. Results for the following adverse events were inconclusive: hydrocele formation, haematoma, abdominal distension, testicular atrophy, wound infection, scrotal pain, and oedema. We identified no evidence on live birth or quality of life for this comparison. Nine studies compared open inguinal surgical treatment to retroperitoneal surgical treatment. Due to small sample sizes and methodological limitations, we identified neither treatment type as superior or inferior to the other regarding adverse events, pregnancy rates, or varicocele recurrence. We identified no evidence on live birth or quality of life for this comparison. Radiological versus other radiological treatment One study compared two types of radiological treatment (sclerotherapy versus embolisation) and reported 13% varicocele recurrence in both groups. Due to the broad confidence interval, no valid conclusion could be drawn (RR 1.00, 95% CI 0.16 to 6.20; 1 RCT, N = 30, very low-certainty evidence). We identified no evidence on live birth, adverse events, pregnancy, or quality of life for this comparison.

Authors' conclusions: Based on the limited evidence, it remains uncertain whether any treatment (surgical or radiological) compared to no treatment in subfertile men may be of benefit on live birth rates; however, treatment may improve the chances for pregnancy. The evidence was also insufficient to determine whether surgical treatment was superior to radiological treatment. However, microscopic subinguinal surgical treatment probably improves pregnancy rates and reduces the risk of varicocele recurrence compared to other surgical treatments. High-quality, head-to-head comparative RCTs focusing on live birth rate and also assessing adverse events and quality of life are warranted.

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Conflict of interest statement

EP, COL, SK, NM, GW, MH, and BNS have no conflicts of interest to declare.

Figures

1
1
Study flow diagram.
2
2
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
3
3
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
4
4
Forest plot of comparison: 1 Varicocele treatment versus non‐surgical, non‐radiological, delayed, or no treatment, outcome: 1.1 Live birth.
5
5
Forest plot of comparison: 1 Varicocele treatment versus non‐surgical, non‐radiological, delayed, or no treatment, outcome: 1.2 Pregnancy.
6
6
Forest plot of comparison: 3 Microscopic subinguinal surgical treatment versus other surgical treatment, outcome: 3.1 Pregnancy.
7
7
Forest plot of comparison: 3 Microscopic subinguinal surgical treatment versus other surgical treatment, outcome: 3.9 Varicocele recurrence.
8
8
Web of Knowledge search strategy (searched 4 April 2020).
1.1
1.1. Analysis
Comparison 1: Varicocele treatment versus non‐surgical, non‐radiological, delayed, or no treatment, Outcome 1: Live birth
1.2
1.2. Analysis
Comparison 1: Varicocele treatment versus non‐surgical, non‐radiological, delayed, or no treatment, Outcome 2: Pregnancy
2.1
2.1. Analysis
Comparison 2: Surgical treatment versus radiological treatment, Outcome 1: Live birth
2.2
2.2. Analysis
Comparison 2: Surgical treatment versus radiological treatment, Outcome 2: Adverse event: hydrocele formation
2.3
2.3. Analysis
Comparison 2: Surgical treatment versus radiological treatment, Outcome 3: Adverse event: pain
2.4
2.4. Analysis
Comparison 2: Surgical treatment versus radiological treatment, Outcome 4: Adverse event: epididymitis
2.5
2.5. Analysis
Comparison 2: Surgical treatment versus radiological treatment, Outcome 5: Adverse event: haematoma
2.6
2.6. Analysis
Comparison 2: Surgical treatment versus radiological treatment, Outcome 6: Adverse event: suture granuloma
2.7
2.7. Analysis
Comparison 2: Surgical treatment versus radiological treatment, Outcome 7: Pregnancy
2.8
2.8. Analysis
Comparison 2: Surgical treatment versus radiological treatment, Outcome 8: Varicocele recurrence
3.1
3.1. Analysis
Comparison 3: Microscopic subinguinal surgical treatment versus other surgical treatment, Outcome 1: Pregnancy
3.2
3.2. Analysis
Comparison 3: Microscopic subinguinal surgical treatment versus other surgical treatment, Outcome 2: Adverse event: hydrocele formation
3.3
3.3. Analysis
Comparison 3: Microscopic subinguinal surgical treatment versus other surgical treatment, Outcome 3: Adverse event: testicular atrophy
3.4
3.4. Analysis
Comparison 3: Microscopic subinguinal surgical treatment versus other surgical treatment, Outcome 4: Adverse event: haematoma
3.5
3.5. Analysis
Comparison 3: Microscopic subinguinal surgical treatment versus other surgical treatment, Outcome 5: Adverse event: pain
3.6
3.6. Analysis
Comparison 3: Microscopic subinguinal surgical treatment versus other surgical treatment, Outcome 6: Adverse event: wound infection
3.7
3.7. Analysis
Comparison 3: Microscopic subinguinal surgical treatment versus other surgical treatment, Outcome 7: Adverse event: oedema
3.8
3.8. Analysis
Comparison 3: Microscopic subinguinal surgical treatment versus other surgical treatment, Outcome 8: Adverse event: abdominal distention
3.9
3.9. Analysis
Comparison 3: Microscopic subinguinal surgical treatment versus other surgical treatment, Outcome 9: Varicocele recurrence
4.1
4.1. Analysis
Comparison 4: Open inguinal surgical treatment versus retroperitoneal surgical treatment, Outcome 1: Pregnancy
4.2
4.2. Analysis
Comparison 4: Open inguinal surgical treatment versus retroperitoneal surgical treatment, Outcome 2: Adverse event: hydrocele formation
4.3
4.3. Analysis
Comparison 4: Open inguinal surgical treatment versus retroperitoneal surgical treatment, Outcome 3: Adverse event: testicular atrophy
4.4
4.4. Analysis
Comparison 4: Open inguinal surgical treatment versus retroperitoneal surgical treatment, Outcome 4: Adverse event: haematoma
4.5
4.5. Analysis
Comparison 4: Open inguinal surgical treatment versus retroperitoneal surgical treatment, Outcome 5: Adverse event: pain
4.6
4.6. Analysis
Comparison 4: Open inguinal surgical treatment versus retroperitoneal surgical treatment, Outcome 6: Adverse event: wound infection
4.7
4.7. Analysis
Comparison 4: Open inguinal surgical treatment versus retroperitoneal surgical treatment, Outcome 7: Adverse event: oedema
4.8
4.8. Analysis
Comparison 4: Open inguinal surgical treatment versus retroperitoneal surgical treatment, Outcome 8: Adverse event: epididymitis
4.9
4.9. Analysis
Comparison 4: Open inguinal surgical treatment versus retroperitoneal surgical treatment, Outcome 9: Adverse event: epididymo‐orchitis
4.10
4.10. Analysis
Comparison 4: Open inguinal surgical treatment versus retroperitoneal surgical treatment, Outcome 10: Adverse event: pneumoscrotum
4.11
4.11. Analysis
Comparison 4: Open inguinal surgical treatment versus retroperitoneal surgical treatment, Outcome 11: Adverse event: subcutaneous emphysema
4.12
4.12. Analysis
Comparison 4: Open inguinal surgical treatment versus retroperitoneal surgical treatment, Outcome 12: Adverse event: inferior epigastric bleeding
4.13
4.13. Analysis
Comparison 4: Open inguinal surgical treatment versus retroperitoneal surgical treatment, Outcome 13: Adverse event: persistence of dilated veins
4.14
4.14. Analysis
Comparison 4: Open inguinal surgical treatment versus retroperitoneal surgical treatment, Outcome 14: Adverse event: wound erythema
4.15
4.15. Analysis
Comparison 4: Open inguinal surgical treatment versus retroperitoneal surgical treatment, Outcome 15: Varicocele recurrence
5.1
5.1. Analysis
Comparison 5: Radiological treatment (sclerotherapy) versus radiological treatment (embolisation), Outcome 1: Varicocele recurrence
See this image and copyright information in PMC

Update of

References

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Zhang 2015a {published data only}
    1. Zhang Z. Analysis of the effect of microscopy and laparoscopic surgery on varicocele [Xiǎnwéijìng yǔ fùqiāng jìng shǒushù zhìliáo jīng suǒ jìngmài qūzhāng de liáoxiào fēnxī]. Henan Medical Research 2015;24(11):117-8.
Zheng 2012 {published data only}
    1. Zheng C, Shenmin Y. Comparative study of effect of low-approach microscopic and laparoscopic varicocelectomy in treatment of varicocele. Chinese Journal of Andrology 2012;26(3):49-51. [DOI: 10.3969/j.issn.1008-0848.2012.03.013] - DOI

References to studies excluded from this review

Abdel Maguid 2010 {published data only}
    1. Abdel-Maguid AF, Othman I. Microsurgical and nonmagnified subinguinal varicocelectomy for infertile men: a comparative study. Fertility and Sterility 2010;94(7):2600-3. - PubMed
Abdel Meguid 2011b {published data only}
    1. Abdel-Meguid AT, Al-Sayyad A, Tayib A, Farsi HM. Re: Does varicocele repair improve male infertility? An evidence-based perspective from a randomized, controlled trial. Journal of Urology 2011;186(5):1993-4. [DOI: 10.1016/j.juro.2011.08.071] - DOI - PubMed
Abdelsalam 2017 {published data only}
    1. Abdelsalam YM, Saeed WM, Moeen AM, Elganainy EO, Ahmed AI. Retroperitoneal varix ligation with sclerotherapy: a prospective randomized comparative study. Central European Journal of Urology 2017;70(3):296-300. [DOI: 10.5173/ceju.2017.1297] - DOI - PMC - PubMed
Abrol 2014 {published data only}
    1. Abrol N, Panda A, Kekre NS. Painful varicoceles: role of varicocelectomy. Indian Journal of Urology 2014;30(4):369-73. [DOI: 10.4103/0970-1591.128497] - DOI - PMC - PubMed
ACTRN12612001169831 {published data only}
    1. ACTRN12612001169831. The comparison of laparoscopic and microsurgical varicocelectomy on paternity rate 12 months after surgery: a prospective randomized controlled trial. www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=363221 (first received 31 October 2012).
Adams 1983 {published data only}
    1. Adams PE. Treatment of varicoceles with detachable balloon embolization. Radiologic Technology 1983;55(2):611-4. - PubMed
Akin 2014 {published data only}
    1. Akin Y, Ate M, Yücel S, Barsara I, Çelik O, Bozkurt A, et al. Comparison of different ligation techniques in laparoscopic varicocelectomy. Turkish Journal of Medical Sciences 2014;44(2):273-8. - PubMed
Allameh 2018a {published data only}
    1. Allameh F, Hasanzadeh HA, Abedi A, Ranjbar A, Qashqai H, Fadavi B, et al. Varicocelectomy with primary gubernaculum veins closure: a randomised clinical trial [2009 Feb 23 [Epub ahead of print]]. Andrologia 2018;50(4):e12991. [DOI: 10.1111/and.12991] - DOI - PubMed
Allameh 2018b {published data only}
    1. Allameh F, Hasanzadeh HA, Abedi A, Ranjbar A, Qashqai H, Fadavi B, et al. Varicocelectomy with primary gubernaculum veins closure: a randomised clinical trial. Andrologia 2018;50(4):e12991. - PubMed
Arafa 2017 {published data only}
    1. Arafa MM, Elbardisi H, Majzoub A, Alsaid SS. Outcome of microsurgical subinguinal varicocelectomy in men with nonobstructive azoospermia. Fertility and Sterility 2017;108(3):E135. [DOI: 10.1016/j.fertnstert.2017.07.408] - DOI
Atmaja 2016 {published data only}
    1. Atmaja GY, Birowo P, Rasyid N. Effectiveness of surgery in infertile patients caused by varicocele. BJU International 2016;117:21-2.
Aziz 2018 {published data only}
    1. Aziz WA, Rafi A, Ali M, Biyabani R. Factors predicting paternity after varicocele surgery. Journal of Sexual Medicine 2018;15(7):S342. [DOI: 10.1016/j.jsxm.2018.04.485] - DOI
Baazeem 2011 {published data only}
    1. Baazeem A, Belzile E, Ciampi A, Dohle G, Jarvi K, Salonia A, et al. Varicocele and male factor infertility treatment: a new meta-analysis and review of the role of varicocele repair. European Urology 2011;60(4):796-808. - PubMed
Badur 2015 {published data only}
    1. Badur N, Karakeci A, Cayan S, Orhan I. The effect of microsurgery inguinal varicocelectomy by secondary infertile male patients with clinical varicocele. Human Reproduction 2015;30:145.
Bebars 2000 {published data only}
    1. Bebars GA, Zaki A, Dawood AR, El-Gohary MA. Laparoscopic versus open high ligation of the testicular veins for the treatment of varicocele. Journal of the Society of Laparoendoscopic Surgeons 2000;4(3):209-13. - PMC - PubMed
Boxin 2012 {published data only}
    1. Boxin X, Yuxi S, Jian W. Laparoendoscopic single-site surgery by single port technique versus conventional transperitoneal laparoscopic varicocele ligation: a prospective randomized study. International Journal of Urology 2012;19:264. [DOI: 10.1111/j.1442-2042.2012.03167.x] - DOI
Broe 2016 {published data only}
    1. Broe MP, Ryan E, Forde JC, Murphy DJ, Lennon GM, Galvin DJ, et al. Spermatic vein embolisation as a treatment for symptomatic varicocoele. BJU International 2016;118:22-3.
Cadeddu 2012 {published data only}
    1. Cadeddu JA. Re: Laparoendoscopic single-site surgery versus conventional laparoscopic varicocele ligation in men with palpable varicocele: a randomized, clinical study: editorial comment. Journal of Urology 2012;188(6):2318. [DOI: 10.1016/j.juro.2012.08.072] - DOI - PubMed
Cantoro 2015 {published data only}
    1. Cantoro U, Polito M, Muzzonigro G. Reassessing the role of subclinical varicocele in infertile men with impaired semen quality: a prospective study. Urology 2015;85(4):826-30. - PubMed
Cayan 2017 {published data only}
    1. Cayan S, Akbay E. Fate of recurrent or persistent varicocele in the era of assisted reproduction technology: microsurgical subinguinal redo varicocelectomy versus observation. Journal of Urology 2017;197(4):E1343. [DOI: 10.1016/j.juro.2017.02.3139] - DOI - PubMed
Chen 2010 {published data only}
    1. Chen GQ, Jiang DF, Chen C, Tang XQ, Liu XB, Bai WJ. Spermatic vein and artery ligation for varicocele. National Journal of Andrology 2010;16(2):154-7. - PubMed
Chiba 2016 {published data only}
    1. Chiba K, Ramasamy R, Lamb D, Lipshultz L. The varicocele: diagnostic dilemmas, therapeutic challenges and future perspectives. Asian Journal of Andrology 2016;18(2):276-81. [DOI: 10.4103/1008-682x.167724] - DOI - PMC - PubMed
Eisenberg 2011 {published data only}
    1. Eisenberg M, Lipshultz L. Re: Does varicocele repair improve male infertility? An evidence-based perspective from a randomized, controlled trial. European Urology 2011;60(2):395. - PubMed
Fandella 1991 {published data only}
    1. Fandella A, Faggiano L, Frasson F, Di Toma F, Merlo F, Maccatrozzo L, et al. Scleroembolization in the treatment of varicocele: results of a randomized comparative study with surgical correction. Acta Urologica Italica 1991;5(4):263-5.
Feneley 1997 {published data only}
    1. Feneley MR, Pal MK, Nockler IB, Hendry WF. Retrograde embolization and causes of failure in the primary treatment of varicocele. British Journal of Urology 1997;80(4):642-6. - PubMed
Gargouri 2015 {published data only}
    1. Gargouri MM, Ouanes Y, Ben Chehida MA, Sellami A, Chelif M, Ben Rhouma S, et al. Varicocele open surgery or laparoscopy or embolization: which is better? Journal of Sexual Medicine 2015;12:262.
Ghanem 2004 {published data only}
    1. Ghanem H, Anis T, El-Nashar A, Shamloul R. Subinguinal microvaricocelectomy versus retroperitoneal varicocelectomy: comparative study of complications and surgical outcome. Urology 2004;64(5):1005-9. - PubMed
Grasso 1995 {published data only}
    1. Grasso M, Lania C, Castelli M, Galli L, Rigatti P. Bilateral varicocele: impact of right spermatic vein ligation on fertility. Journal of Urology 1995;153(6):1847-8. - PubMed
Ha 2011 {published data only}
    1. Ha US, Kim SH, Koh JS, Cho YH, Lee SW, Moon HS, et al. Laparoendoscopic single-site surgery versus conventional laparoscopic varicocele ligation: a randomized clinical study. European Urology, Supplements 2011;10(2):221-2. [DOI: 10.1016/S1569-9056(11)60679-9] - DOI
Hinev 2009 {published data only}
    1. Hinev A, Chankov P, Paunov S, Anakievski D, Dyakov S, Raikov R. Prospective comparative study with two microsurgical techniques of varicocele repair. Urology 2009;74(4 Suppl S):S188. [DOI: 10.1016/j.urology.2009.07.506] - DOI
Iqbal 2004 {published data only}
    1. Iqbal M, Aslam M, Hussain S, Avais S, Akhtar M, Rashid M. Varicocele - laparoscopic versus open ligation. Annals of King Edward Medical University 2004;10(4):314-7.
IRCT201409299014N43 {unpublished data only}
    1. IRCT201409299014N43. Effect of laparoscopy versus open surgery on the size and function of testis in patients with varicocele [Effect of laparoscopy versus open surgery on the size and function of testis in patients with varicocele: a double blinded randomized clinical trial]. en.irct.ir/trial/9482 (first received 7 October 2014).
IRCT2016092524166N2 {unpublished data only}
    1. IRCT2016092524166N2. Comparative assessment of varicocelectomy outcomes with and without gubernacular veins closure [Comparative assessment of varicocelectomy outcomes with gubernacular veins closure]. en.irct.ir/trial/20474?revision=20474 (first received 29 November 2016).
Johnson 2017 {published data only}
    1. Johnson D, Sandlow J. Treatment of varicoceles: techniques and outcomes. Fertility and Sterility 2017;108(3):378-84. [DOI: 10.1016/j.fertnstert.2017.07.020] - DOI - PubMed
JPRN C000000377 {published data only}
    1. JPRN-C000000377. Treatment of varicocele: randomized prospective study on surgery [Sei saku seimyakuryū ni taisuru shujutsu ryōhō no yūkōsei ni kansuru shiken]. upload.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?function=brows&action=bro... (first received 1 April 2006).
Kalkan 2011 {published data only}
    1. Kalkan M, Yalcinkaya S, Etlik O, Sahin C. Is microsurgery necessary in grade 3 varicocele? Urology Journal 2011;8(4):298-301. - PubMed
Kang 2013 {published data only}
    1. Kang DH, Lee JY, Chung JH, Jo JK, Lee SH, Ham WS, et al. Laparoendoscopic single site varicocele ligation: comparison of testicular artery and lymphatic preservation versus complete testicular vessel ligation. Journal of Urology 2013;189(1):243-9. - PubMed
Khan 2003 {published data only}
    1. Khan M, Khan S, Pervez A, Nawaz H, Ahmed S, Tareen S. Evaluation of low ligation and high ligation procedures for varicocele. Journal of the College of Physicians and Surgeons Pakistan: JCPSP 2003;13(5):280-3. - PubMed
Khan 2016 {published data only}
    1. Khan M, Papa N, Lukies M, Buraundi S, Ranatunga D, Bolton D, et al. Recurrence rates of radiological embolization for the treatment of varicocele are comparable to surgical intervention: a decade long study. Journal of Urology 2016;195(4):E212. [DOI: 10.1016/j.juro.2016.02.2768] - DOI
Laven 1992 {published data only}
    1. Laven JS, Haans LC, Mali WP, Te Velde ER, Wensing CJ, Eimers JM. Effects of varicocele treatment in adolescents: a randomized study. Fertility and Sterility 1992;58:756-62. - PubMed
Matsuda 1993 {published data only}
    1. Matsuda T, Horii Y, Yoshida O. Should the testicular artery be preserved at varicocelectomy? Journal of Urology 1993;149:1357-60. - PubMed
Moursy 2014 {published data only}
    1. Moursy E, El Dahshoury M, Hussein M, Badawy A. Dilemma of adolescent varicocele: long-term outcome in patients managed surgically and in patients managed expectantly. Journal of Urology 2014;191(4):E253. [DOI: 10.1016/j.juro.2014.02.895] - DOI - PubMed
NCT00767338 {unpublished data only}
    1. NCT00767338. Microsurgical varicocelectomy versus no surgery in men with a palpable varicocele and an abnormal semen analysis. clinicaltrials.gov/ct2/show/NCT00767338 (first received 7 October 2008).
NCT03281915 {published data only}
    1. NCT03281915. The effect of different modialites of varicocelectomy on semen parameters in patient with normal semen analysis. clinicaltrials.gov/ct2/show/NCT03281915 (first received 13 September 2017).
NCT03341897 {published data only}
    1. NCT03341897. Varicocele treatment by endovasculer embolization. clinicaltrials.gov/ct2/show/NCT03341897 (first received 14 November 2017).
Paduch 1997 {published data only}
    1. Paduch DA, Niedzielski J. Repair versus observation in adolescent varicocele: a prospective study. Journal of Urology 1997;158:1128-32. - PubMed
Park 2011 {published data only}
    1. Park SW, Kim TN, Lee W, Park HJ, Lee SD, Park NC. Umbilical laparoendoscopic single site surgery versus inguinal varicocelectomy for bilateral varicocele: a comparative study. International Journal of Urology 2011;18(3):250-4. [DOI: 10.1111/j.1442-2042.2010.02701.x] - DOI - PubMed
Podkamenev 2002 {published data only}
    1. Podkamenev VV, Stalmakhovich VN, Urkov PS, Solovjev AA, Iljin VP. Laparoscopic surgery for pediatric varicoceles: randomized controlled trial. Journal of Pediatric Surgery 2002;37(5):727-9. - PubMed
Sayfan 1992 {published data only}
    1. Sayfan J, Soffer Y, Orda R. Varicocele treatment: prospective randomized trial of 3 methods. Journal of Urology 1992;148(5 I):1447-9. - PubMed
Shamsa 2009 {published data only}
    1. Shamsa A, Mohamadi L, Abolbashari M, Shakeri M, Shamsa S. Comparison of open, local and laparoscopic varicocelectomy according to operation time, cost, spermogram and complications. Journal of Endourology 2009;23(Suppl 1):A262.
Shioshvili 2003 {published data only}
    1. Shioshvili TI, Shishvili AS. Comparative evaluation of a current method of treating varicocele. Urologiia 2003;3:31-6. - PubMed
Siu 2016 {published data only}
    1. Siu JJY, Huang CP. Laparoscopic and open varicocelectomy: a comparison of efficacy in an Asian scenario. International Journal of Urology 2016;1:3.
Sun 2018 {published data only}
    1. Sun Xl, Wang Jl, Peng YP, Gao QQ, Song T, Yu W, et al. Bilateral is superior to unilateral varicocelectomy in infertile males with left clinical and right subclinical varicocele: a prospective randomized controlled study. International Urology and Nephrology 2018;50(2):205-10. - PubMed
Takeuchi 2014 {published data only}
    1. Takeuchi T, Nagao K, Aono N, Mori Y, Nakajo Y, Okuda T, et al. Beneficial effect of microsurgical varicocelectomy on semen parameters and clinical outcome in severe male factor infertility. Fertility and Sterility 2014;102(3):E191. [DOI: 10.1016/j.fertnstert.2014.07.644] - DOI
Tamhankar 2017 {published data only}
    1. Tamhankar A, Sawant A, Kulkarni V, Pawar P, Mundhe S, Patil S. Study to analyse the fertility potential of varicocelectomy in non-obstructive azoospermia (noa), virtual azoospermia (va) and severe oligospermia (so). Journal of Urology 2017;197(4):E1343-4. [DOI: 10.1016/j.juro.2017.02.3140] - DOI
Vanlangenhove 2012 {published data only}
    1. Vanlangenhove P, De Keukeleire K, Everaert K, Van Maele G, Defreyne L. Efficacy and safety of two different n-butyl-2-cyanoacrylates for the embolization of varicoceles: a prospective, randomized, blinded study. Cardiovascular and Interventional Radiology 2012;35(3):598-606. [DOI: 10.1007/s00270-011-0188-9] - DOI - PubMed
Vyas 2017 {published data only}
    1. Vyas H, Bhandari V, Kumar A, Nanda B, Singh H, Bhowmick S. A prospective randomized comparative trial between open subinguinal and loupe assisted subinguinal varicocelectomy: a single center experience. Urology Annals 2017;9(1):13-7. - PMC - PubMed
Wang 2015 {published data only}
    1. Wang J, Xia SJ, Liu ZH, Tao L, Ge JF, Xu CM, et al. Inguinal and subinguinal micro-varicocelectomy, the optimal surgical management of varicocele: a meta-analysis. Asian Journal of Andrology 2015;17(1):74-80. - PMC - PubMed
Wang 2016 {published data only}
    1. Wang YM, Change DH, Zhang B. The research on microscopic vs self-made laparoscopic varicocelectomy: therapeutic effects and complications. International Journal of Urology 2016;1:7.
Yamamoto 1995a {published data only}
    1. Yamamoto M, Hibi H, Katsuno S, Miyake K. Effects of varicocelectomy on testis volume and semen parameters in adolescents: a randomized prospective study. Nagoya Journal of Medical Sciences 1995;58:127-32. - PubMed
Yamamoto 1995b {published data only}
    1. Yamamoto M, Tsuji Y, Ohmura M, Hibi H, Miyake K. Comparison of artery-ligating and artery-preserving varicocelectomy: effect on postoperative spermatogenesis. Andrologia 1995;27:37-40. - PubMed
Yamamoto 1995c {published data only}
    1. Yamamoto M, Tsuji Y, Ohmura M, Hibi H, Miyake K. Comparison of artery-ligating and artery-preserving varicocelectomy: effect on post-operative spermatogenesis. Andrologia 1995;27(1):37-40. - PubMed
Youssef 2015 {published data only}
    1. Youssef T, Abdalla E. Corrigendum to 'Single incision transumbilical laparoscopic varicocelectomy versus the conventional laparoscopic technique: a randomized clinical study'. International Journal of Surgery 2015;20:170. [DOI: 10.1016/j.ijsu.2015.07.001] - DOI - PubMed
Zhang 2015b {published data only}
    1. Zhang H, Li H, Hou Y, Jin J, Gu X, Zhang M, et al. Microscopic retroperitoneal varicocelectomy with artery and lymphatic sparing: an alternative treatment for varicocele in infertile men. Urology 2015;86(3):511-5. [DOI: 10.1016/j.urology.2015.06.033] - DOI - PubMed
Zheng 2009 {published data only}
    1. Zheng YQ, Gao X, Li ZJ, Yu YL, Zhang ZG, Li W. Efficacy of bilateral and left varicocelectomy in infertile men with left clinical and right subclinical varicoceles: a comparative study. Urology 2009;73(6):1236-40. - PubMed

References to studies awaiting assessment

Cavallini 2003 {published data only}
    1. Cavallini G, Biagiotti G, Ferraretti AP, Gianaroli L, Vitali G. Medical therapy of oligoasthenospermia associated with left varicocele. British Journal of Urology 2003;91:513-8. - PubMed
Feng 2017 {published data only}
    1. Feng Q, Qiu MX. Microscopic spermatic vein ligation for the treatment of varicocele. Zhong Hua Nan Ke Xue 2017;23(12):1080-4. - PubMed

References to ongoing studies

NCT02695199 {published data only}
    1. NCT02695199. Doppler ultrasound assisted varicocelectomy improve sperm qualities. clinicaltrials.gov/ct2/show/NCT02695199 (first received 1 March 2016).
    1. NCT02695199. Doppler ultrasound assisted varicocelectomy improve sperm qualities [Comparison between laparoscopic doppler ultrasound assisted laparoscopic varicocelectomy and microscopic subinguinal varicocelectomy]. clinicaltrials.gov/ct2/show/NCT02695199 (first received 1 March 2016).
NCT02722187 {published data only}
    1. NCT02722187. The role of microsurgery in surgical treatment of varicocele. clinicaltrials.gov/ct2/show/NCT02722187 (first received 24 March 2016).

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