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

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

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

All authors declare no competing interests.