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Clinical and radiological features of imported chikungunya fever in Japan: a study of six cases at the National Center for Global Health and Medicine

Mizuno Y, Kato Y, Takeshita N, Ujiie M, Kobayashi T, Kanagawa S, et al.

J Infect Chemother, 2011 Jun;17(3):419-23.
PMID: 20862507 DOI: 10.1007/s10156-010-0124-y

Chikungunya fever (CHIKF) is currently distributed in Africa and in South and Southeast Asia; outbreaks have occurred periodically in the region over the past 50 years. After a large outbreak had occurred in countries in the western Indian Ocean region in 2005, several countries reported cases of CHIKF from travelers who had visited affected areas. In Japan, there have been only 15 cases of CHIKF patients so far, according to the National Institute of Infectious Diseases. Therefore, to evaluate the clinical and radiological features associated with the disease, we describe 6 imported cases of CHIKF. All of the patients had had prolonged arthralgia on admission to our hospital, and diagnosis was confirmed with specific antibodies by using an IgM-capture enzyme-linked immunoassay and a plaque reduction neutralizing antibody assay. Magnetic resonance imaging (MRI) of one patient revealed erosive arthritis and tenosynovitis during the convalescence stage. Clinicians should be aware of the late consequences of infection by the chikungunya virus (CHIKV) and recognize the possible association of subacute and chronic arthritis features. In addition, competent vectors of CHIKV, Aedes aegypti, can now be found in many temperate areas of the eastern and western hemispheres, including Japan. This fact raises concern that the virus could be introduced and become established in these areas. This necessitates an increased awareness of the disease, because imported cases are likely to contribute to the spread of CHIKV infection wherever the competent mosquito vectors are distributed.
Multimodality Techniques in Microsurgical Clipping as the Gold Standard Treatment in the Management of Basilar Tip Aneurysm: A Case Series

Seng LB, Yamada Y, Rajagopal N, Mohammad AA, Teranishi T, Miyatani K, et al.

Asian J Neurosurg, 2018 11 22;13(4):1148-1157.
PMID: 30459884 DOI: 10.4103/ajns.AJNS_159_18

Introduction: Basilar aneurysms represent 5%-7% of all intracranial aneurysms. The main goal of open surgery is to achieve complete obliteration of the aneurysmal sac using minimal invasive technique while emphasizing on avoidance of complication.
Materials and Methods: We performed a retrospective cohort study of nine cases of unruptured basilar tip aneurysm referred to the Fujita Health University Banbuntane-Hotokukai Hospital, Japan. The objective of the study was to analyze the surgical outcomes of unruptured basilar tip aneurysm.
Results: Nine patients with unruptured basilar tip aneurysm were referred to our hospital between 2015 and 2017. The median size of the aneurysm and age were 4.00 mm (interquartile range [IQR] = 3.25-6.75 mm) and 58 years (IQR = 54-70 years), respectively. Five patients (55.6%) were presented with multiple intracranial aneurysms. Surgical adjuncts such as intraoperative neuromonitoring, intraoperative indocyanine green (ICG) angiography with dual-image videoangiography (DIVA), and neuroendoscope were used. Two patients developed transient postoperative oculomotor nerve palsy which resolved spontaneously. The median duration of surgery and days of hospitalization were 292 min (IQR = 237.5-350.5 min) and 12 days (IQR = 12-25 days), respectively. There was no mortality recorded in this case series.
Conclusion: Microsurgical clipping of basilar tip aneurysm is safe in unruptured basilar tip aneurysm with a low risk of postoperative mortality or morbidity. All complications reported in this case series were transient with no long-term sequalae. The improved safety profile of microsurgical technique is due to the availability of intraoperative neuromonitoring, neuroendoscope, ICG, and DIVA. The application of multimodality technique in neurovascular surgery has also helped to achieve complication avoidance. The obliteration of the aneurysmal sac helps to restore the laminar blood flow in the bifurcation and distal blood vessels and improves the brain perfusion.
Fulltext Loss of Contralateral Upper Limb Motor Evoked Potential Due to Occlusion of the Internal Carotid Artery in Microsurgical Clipping of Basilar Tip Aneurysm

Seng LB, Yasuhiro Y, Rajagopal N, Mohammad AA, Takao T, Kyosuke M, et al.

Asian J Neurosurg, 2019 4 3;14(1):295-299.
PMID: 30937059 DOI: 10.4103/ajns.AJNS_157_18

The motor evoked potential (MEP) monitoring is routinely used as an adjunct in the microsurgical clipping of anterior circulation. We describe a case of unruptured basilar tip aneurysm treated with microsurgical clipping developed loss in MEP recording of the left abductor pollicis brevis (APB) following clipping of basilar tip aneurysm. A 58-year-old man was referred to the Fujita Health University Banbuntane-Hotokukai Hospital, Nagoya, Aichi, Japan, with incidental finding of unruptured 6.5 mm basilar tip saccular aneurysm. He underwent right anterior temporal approach of basilar tip aneurysm clipping. The internal carotid artery (ICA) was mobilized laterally to allow direct visualization of the neck of the basilar tip aneurysm. Following the application of temporary clip and subsequently permanent clip at the neck of the aneurysm, the MEP signal was lost in the left APB. The temporary clip was immediately removed. Dual-image videoangiography (DIVA) showed a filling defect in the right ICA and a branch of middle cerebral artery (MCA). The MEP was absent for about 23 minutes and the amplitude improved to only 75% of the baseline recording at 38 minutes till the end of the surgery. A repeat DIVA showed good flow within the right ICA and MCA. Glasgow coma score was 15/15 on postoperative day 1 and there was no gross motor or sensory deficit except right oculomotor nerve palsy with complete recovery at 6 months follow-up. This is the first reported ICA occlusion due to its mobilization in microsurgical clipping of basilar tip aneurysm. The use of neuromonitoring especially MEP is essential even in the posterior circulation aneurysm surgery especially when excessive manipulation of the ICA is unavoidable. When performing intraoperative angiography for aneurysm surgery, it is prudent to detect any filling defect within the surrounding vessels.
Fulltext Timing of Surgery and Surgical Strategies in Symptomatic Brainstem Cavernomas: Review of the Literature

Rajagopal N, Kawase T, Mohammad AA, Seng LB, Yamada Y, Kato Y

Asian J Neurosurg, 2019 4 3;14(1):15-27.
PMID: 30937003 DOI: 10.4103/ajns.AJNS_158_18

Brainstem cavernomas (BSCs) are angiographically occult, benign low flow vascular malformations that pose a significant surgical challenge due to their eloquent location. The present study includes an extensive review of the literature and three illustrative cases of BSC with emphasis on the timing of surgery: surgical approaches, usage of intraoperative monitoring, and complication avoidance. A systematic search was performed using the PubMed database was from January 1, 1999, to June 2018. The relevant articles were reviewed with particular attention to hemorrhage rates, timing of surgery, indications for surgery, surgical approaches, and outcome. Along with this, a retrospective analysis of three cases of symptomatic BSC, who were operated for the same, during the year 2018 in our institute was conducted. All the three patients presented with at least 1 episode of hemorrhage before surgery. Of these, one patient was operated immediately due to altered sensorium whereas the other two were operated after at least 4 weeks of the hemorrhagic episode. The patients who were operated in the subacute phase of bleed were seen to have liquefaction of hematoma, thus providing a good surgical demarcation and thereby reduced surgery-related trauma to the surrounding eloquent structures. Two patients improved neurologically during the immediate postoperative period, whereas one had transient worsening of neurological deficits during the immediate postoperative period in the form of additional cranial nerve palsies which completely improved on follow-up after 2 months. Radical resection is recommended in all patients with symptomatic BSCs. Surgery should be considered after the first or the second episode of hemorrhage as multiple rebleeds can cause exacerbation of deficits and sometimes mortality as well. Considering surgical timing, anywhere between 4 and 6 weeks or the subacute phase of the hemorrhage is considered appropriate. The aims of surgical intervention must be to improve preoperative function, minimize surgical morbidity and to reduce hemorrhagic rates. In spite of the significant surgical morbidity associated with BSCs, appropriate patient selection, meticulous surgical planning with adjuncts such as intraoperative monitoring and neuronavigation will go a long way in avoidance of major postoperative complications.
Fulltext Current Updates on Idiopathic Normal Pressure Hydrocephalus

Liew BS, Takagi K, Kato Y, Duvuru S, Thanapal S, Mangaleswaran B

Asian J Neurosurg, 2019 9 10;14(3):648-656.
PMID: 31497081 DOI: 10.4103/ajns.AJNS_14_19

Idiopathic normal pressure hydrocephalus (iNPH) is one of the neurodegenerative diseases which can be treated surgically with favorable outcome. The gait disturbance, cognitive, and urinary symptoms are known as the clinical triad of iNPH. In this review, we have addressed the comorbidities, differential diagnoses, clinical presentations, and pathology of iNPH. We have also summarized the imaging studies and clinical procedures used for the diagnosis of iNPH. The treatment modality, outcomes, and prognosis were also discussed.
Historical occurrences of polybrominated diphenyl ethers and polychlorinated biphenyls in Manila Bay, Philippines, and in the upper Gulf of Thailand

Kwan CS, Takada H, Boonyatumanond R, Kato Y, Mizukawa K, Ito M, et al.

Sci Total Environ, 2014 Feb 1;470-471:427-37.
PMID: 24140702 DOI: 10.1016/j.scitotenv.2013.09.076

Historical trends of the accumulation of polybrominated diphenyl ethers (PBDEs) and polychlorinated biphenyls (PCBs) in a typical tropical Asian environment were investigated using radio-dated sediment cores from Manila Bay, the Philippines and from the upper Gulf of Thailand. Vertical profiles indicated earlier usage of PCBs than of PBDEs which coincided with their industrial production. The increasing concentrations of total PBDEs and PCBs toward the surface suggested an increased consumption of PBDEs; and possible leakage of PCBs from old machineries into the aquatic environment in recent years. Current input of PCBs to the catchment of Manila Bay was supported by the analyses of air samples and plastic resin pellets. The vertical profiles of total PBDEs in the cores (i.e., rapidly increasing concentrations corresponding to the mid-1980s until mid-1990s, followed by a decrease until the early 2000s, and increasing again toward the surface) likely corresponded to the rapid economic growth in Asia in the 1990s, the Asian financial crisis in 1997, and the economic recovery since early 2000s. BDE-209 was predominant especially on the surface layers. BDEs 47 and 99 generally decreased toward the surface, reflecting the phase-out of the technical penta-PBDE products and the regulation by the Stockholm Convention in recent years. Increasing ratios of BDE-202/209, 206/209, 207/209 and decreasing % of BDE-209 down the core layers may provide evidence for the anaerobic debromination of BDE-209 in the sediment cores. Inventories in ng/cm(2) of total PCBs were higher than total PBDEs (92 vs. 34 and 47 vs. 11 in the Philippines; 47 vs. 33 in Thailand). However, the doubling times indicated faster accumulation of total PBDEs (6-7 years) and BDE-209 (6-7.5 years) than of PCBs (8-11 years). Furthermore, the temporal increase in BDE-209 was comparable to or faster than those reported in other water bodies around the world.
Fulltext First case of Plasmodium knowlesi infection in a Japanese traveller returning from Malaysia

Tanizaki R, Ujiie M, Kato Y, Iwagami M, Hashimoto A, Kutsuna S, et al.

Malar J, 2013;12:128.
PMID: 23587117 DOI: 10.1186/1475-2875-12-128

This is the first case of Plasmodium knowlesi infection in a Japanese traveller returning from Malaysia. In September 2012, a previously healthy 35-year-old Japanese man presented to National Center for Global Health and Medicine in Tokyo with a two-day history of daily fever, mild headaches and mild arthralgia. Malaria parasites were found in the Giemsa-stained thin blood smear, which showed band forms similar to Plasmodium malariae. Although a nested PCR showed the amplification of the primer of Plasmodium vivax and Plasmodium knowlesi, he was finally diagnosed with P. knowlesi mono-infection by DNA sequencing. He was treated with mefloquine, and recovered without any complications. DNA sequencing of the PCR products is indispensable to confirm P. knowlesi infection, however there is limited access to DNA sequencing procedures in endemic areas. The extent of P. knowlesi transmission in Asia has not been clearly defined. There is limited availability of diagnostic tests and routine surveillance system for reporting an accurate diagnosis in the Asian endemic regions. Thus, reporting accurately diagnosed cases of P. knowlesi infection in travellers would be important for assessing the true nature of this emerging human infection.
Fulltext Modulation of P2Y6R expression exacerbates pressure overload-induced cardiac remodeling in mice

Shimoda K, Nishimura A, Sunggip C, Ito T, Nishiyama K, Kato Y, et al.

Sci Rep, 2020 08 18;10(1):13926.
PMID: 32811872 DOI: 10.1038/s41598-020-70956-5

Cardiac tissue remodeling caused by hemodynamic overload is a major clinical outcome of heart failure. Uridine-responsive purinergic P2Y6 receptor (P2Y6R) contributes to the progression of cardiovascular remodeling in rodents, but it is not known whether inhibition of P2Y6R prevents or promotes heart failure. We demonstrate that inhibition of P2Y6R promotes pressure overload-induced sudden death and heart failure in mice. In neonatal cardiomyocytes, knockdown of P2Y6R significantly attenuated hypertrophic growth and cell death caused by hypotonic stimulation, indicating the involvement of P2Y6R in mechanical stress-induced myocardial dysfunction. Unexpectedly, compared with wild-type mice, deletion of P2Y6R promoted pressure overload-induced sudden death, as well as cardiac remodeling and dysfunction. Mice with cardiomyocyte-specific overexpression of P2Y6R also exhibited cardiac dysfunction and severe fibrosis. In contrast, P2Y6R deletion had little impact on oxidative stress-mediated cardiac dysfunction induced by doxorubicin treatment. These findings provide overwhelming evidence that systemic inhibition of P2Y6R exacerbates pressure overload-induced heart failure in mice, although P2Y6R in cardiomyocytes contributes to the progression of cardiac fibrosis.
Women in Neurosurgery (WIN): Barriers to Progress, World WIN Directory and the Way Forward

Balasubramanian SC, Palanisamy D, Bakhti S, El Abbadi N, Collange NZ, Karekezi C, et al.

Asian J Neurosurg, 2020 10 19;15(4):828-832.
PMID: 33708650 DOI: 10.4103/ajns.AJNS_108_20

Women in Neurosurgery (WIN) have come a long way and are making inroads in every neurosurgical subspecialty. There has been a worldwide increase in the number of female neurosurgeons both in the training and practice. Although this is a welcome trend, gender equality at work in terms of opportunities, promotions, and pay scales are yet to be attained. This is more apparent in the developing and underdeveloped nations. Barriers for a female neurosurgeon exist in every phase before entering residency, during training, and at workplace. In the neurosurgical specialty, only a few women are in chief academic and leadership positions, and this situation needs to improve. WIN should be motivated to pursue fellowships, sub-specialty training, research, and academic activities. Furthermore, men should come forward to mentor women, only then the gender debates will disappear and true excellence in neurosurgery can be attained. This article reviews the issues that are relevant in the present era focusing on the barriers faced by female neurosurgeons in the developing and underdeveloped countries and the possible solutions to achieve gender equality in neurosurgery. The authors also present the data from the World WIN Directory collected as a part of Asian Congress of Neurological Surgeons-WINS project 2019. These numbers are expected to grow as the WIN progress and add value to the neurosurgical community at large.
Fulltext Anterior Temporal Approach and Clipping of a High-Riding Basilar Tip Aneurysm: Case Report and Review of the Surgical Technique

Musara A, Yamada Y, Takizawa K, Seng LB, Kawase T, Miyatani K, et al.

Asian J Neurosurg, 2019 11 25;14(4):1283-1287.
PMID: 31903379 DOI: 10.4103/ajns.AJNS_121_19

Basilar apex aneurysms constitute 5%-8% of all intracranial aneurysms. Microsurgical clipping of basilar tip aneurysms is still advocated for as it is safe, especially for unruptured basilar tip aneurysms which have a low risk of postoperative mortality or morbidity. Careful patient preparation is needed preoperatively because the risk of intraoperative rupture is significant. Good surgical techniques should be applied. The skill will need to be preserved as endovascular surgery becomes more popular. This is a case of basilar tip aneurysm managed by clipping through the anterior temporal approach, followed by a review of the literature.
Fulltext Report on the international Primary Neurosurgical Life Support course in the eighth Asian Congress of Neurological Surgeons in Kuala Lumpur, Malaysia

Nakamura T, Ajimi Y, Okudera H, Yamada M, Toyoda I, Itoh K, et al.

Asian J Neurosurg, 2011 Jan;6(1):2-5.
PMID: 22059097 DOI: 10.4103/1793-5482.85625

On November 22, 2010, a simulation-based hands-on education course for medical staff in the neurosurgical fields was held in 8(th) Asian Congress of Neurological Surgeons (ACNS) in Kuala Lumpur, Malaysia. The present education course called Primary Neurosurgical Life Support (PNLS) course had been started by the Japan Society of Neurosurgical Emergency since 2008. This report summarizes the international version of PNLS course in 8(th) ACNS.
Fulltext International expert consensus statement about methods and indications for keyhole microneurosurgery from International Society on Minimally Invasive Neurosurgery

Lan Q, Sughrue M, Hopf NJ, Mori K, Park J, Andrade-Barazarte H, et al.

Neurosurg Rev, 2021 02;44(1):1-17.
PMID: 31754934 DOI: 10.1007/s10143-019-01188-z
Fulltext Expert Consensus on the Management of Brain Arteriovenous Malformations

Kato Y, Dong VH, Chaddad F, Takizawa K, Izumo T, Fukuda H, et al.

Asian J Neurosurg, 2019 11 25;14(4):1074-1081.
PMID: 31903343 DOI: 10.4103/ajns.AJNS_234_19

Brain arteriovenous malformations (bAVMs) are complex, heterogeneous, and uncommon intracranial lesions. They can be treated by one or a combination of the following treatment modalities, namely embolization, radiosurgery, or microsurgical resection. In Spetzler-Martin Grade 4 and 5 arteriovenous malformations (AVMs), conservative management may be the best option. A group of experts in the management of AVMs of different disciplines gathered in January 2019 in Hanoi to compile the "Expert Consensus on the Management of Brain Arteriovenous Malformations".
Fulltext International survey on the implementation of the European and American guidelines on disorders of consciousness

Farisco M, Formisano R, Gosseries O, Kato Y, Koboyashi S, Laureys S, et al.

J Neurol, 2024 Jan;271(1):395-407.
PMID: 37740739 DOI: 10.1007/s00415-023-11956-z

Diagnostic, prognostic, and therapeutic procedures for patients with prolonged disorders of consciousness (pDoCs) vary significantly across countries and clinical settings, likely due to organizational factors (e.g., research vs. non-academic hospitals), expertise and availability of resources (e.g., financial and human). Two international guidelines, one from the European Academy of Neurology (EAN) and one from the American Academy of Neurology (AAN) in collaboration with the American Congress of Rehabilitation Medicine (ACRM) and the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR), were developed to facilitate consistent practice among professionals working with this challenging patient population. While the recommendations of both guidelines agree in principle, it remains an open issue how to implement them into clinical practice in the care pathway for patients with pDoCs. We conducted an online survey to explore health professional clinical practices related to the management of patients with pDoCs, and compare said practices with selected recommendations from both the guidelines. The survey revealed that while some recommendations are being followed, others are not and/or may require more honing/specificity to enhance their clinical utility. Particular attention should be given to the implementation of a multimodal assessment of residual consciousness, to the detection and treatment of pain, and to the impact of restrictions imposed by COVID-19 pandemics on the involvement of patients' families/representatives.
Fulltext Correction to: International survey on the implementation of the European and American guidelines on disorders of consciousness

Farisco M, Formisano R, Gosseries O, Kato Y, Koboyashi S, Laureys S, et al.

J Neurol, 2024 Jan;271(1):408-409.
PMID: 37991607 DOI: 10.1007/s00415-023-12083-5
Fulltext Review of global neurosurgery education: Horizon of Neurosurgery in the Developing Countries

Kato Y, Liew BS, Sufianov AA, Rasulic L, Arnautovic KI, Dong VH, et al.

Chinese neurosurgical journal, 2020;6:19.
PMID: 32922948 DOI: 10.1186/s41016-020-00194-1

Globally, the discipline of neurosurgery has evolved remarkably fast. Despite being one of the latest medical specialties, which appeared only around hundred years ago, it has witnessed innovations in the aspects of diagnostics methods, macro and micro surgical techniques, and treatment modalities. Unfortunately, this development is not evenly distributed between developed and developing countries. The same is the case with neurosurgical education and training, which developed from only traditional apprentice programs in the past to more structured, competence-based programs with various teaching methods being utilized, in recent times. A similar gap can be observed between developed and developing counties when it comes to neurosurgical education. Fortunately, most of the scholars working in this field do understand the coherent relationship between neurosurgical education and neurosurgical practice. In context to this understanding, a symposium was organized during the World Federation of Neurological Surgeons (WFNS) Special World Congress Beijing 2019. This symposium was the brain child of Prof. Yoko Kato-one of the eminent leaders in neurosurgery and an inspiration for female neurosurgeons. Invited speakers from different continents presented the stages of development of neurosurgical education in their respective countries. This paper summarizes the outcome of these presentations, with particular emphasis on and the challenges faced by developing countries in terms of neurosurgical education and strategies to cope with these challenges.
Fulltext Correction to: Review of global neurosurgery education: Horizon of Neurosurgery in the Developing Countries

Kato Y, Liew BS, Sufianov AA, Rasulic L, Arnautovic KI, Dong VH, et al.

Chinese neurosurgical journal, 2020;6:30.
PMID: 32925985 DOI: 10.1186/s41016-020-00209-x

[This corrects the article DOI: 10.1186/s41016-020-00194-1.].
Fulltext Post-Vasectomy Semen Analysis: Optimizing Laboratory Procedures and Test Interpretation through a Clinical Audit and Global Survey of Practices

Agarwal A, Gupta S, Sharma RK, Finelli R, Kuroda S, Vij SC, et al.

World J Mens Health, 2022 Jan 02.
PMID: 35021311 DOI: 10.5534/wjmh.210191

PURPOSE: The success of vasectomy is determined by the outcome of a post-vasectomy semen analysis (PVSA). This article describes a step-by-step procedure to perform PVSA accurately, report data from patients who underwent post vasectomy semen analysis between 2015 and 2021 experience, along with results from an international online survey on clinical practice.
MATERIALS AND METHODS: We present a detailed step-by-step protocol for performing and interpretating PVSA testing, along with recommendations for proficiency testing, competency assessment for performing PVSA, and clinical and laboratory scenarios. Moreover, we conducted an analysis of 1,114 PVSA performed at the Cleveland Clinic's Andrology Laboratory and an online survey to understand clinician responses to the PVSA results in various countries.
RESULTS: Results from our clinical experience showed that 92.1% of patients passed PVSA, with 7.9% being further tested. A total of 78 experts from 19 countries participated in the survey, and the majority reported to use time from vasectomy rather than the number of ejaculations as criterion to request PVSA. A high percentage of responders reported permitting unprotected intercourse only if PVSA samples show azoospermia while, in the presence of few non-motile sperm, the majority of responders suggested using alternative contraception, followed by another PVSA. In the presence of motile sperm, the majority of participants asked for further PVSA testing. Repeat vasectomy was mainly recommended if motile sperm were observed after multiple PVSA's. A large percentage reported to recommend a second PVSA due to the possibility of legal actions.
CONCLUSIONS: Our results highlighted varying clinical practices around the globe, with controversy over the significance of non-motile sperm in the PVSA sample. Our data suggest that less stringent AUA guidelines would help improve test compliance. A large longitudinal multi-center study would clarify various doubts related to timing and interpretation of PVSA and would also help us to understand, and perhaps predict, recanalization and the potential for future failure of a vasectomy.
Fulltext Consensus and Diversity in the Management of Varicocele for Male Infertility: Results of a Global Practice Survey and Comparison with Guidelines and Recommendations

Shah R, Agarwal A, Kavoussi P, Rambhatla A, Saleh R, Cannarella R, et al.

World J Mens Health, 2023 Jan;41(1):164-197.
PMID: 35791302 DOI: 10.5534/wjmh.220048

PURPOSE: Varicocele is a common problem among infertile men. Varicocele repair (VR) is frequently performed to improve semen parameters and the chances of pregnancy. However, there is a lack of consensus about the diagnosis, indications for VR and its outcomes. The aim of this study was to explore global practice patterns on the management of varicocele in the context of male infertility.
MATERIALS AND METHODS: Sixty practicing urologists/andrologists from 23 countries contributed 382 multiple-choice-questions pertaining to varicocele management. These were condensed into an online questionnaire that was forwarded to clinicians involved in male infertility management through direct invitation. The results were analyzed for disagreement and agreement in practice patterns and, compared with the latest guidelines of international professional societies (American Urological Association [AUA], American Society for Reproductive Medicine [ASRM], and European Association of Urology [EAU]), and with evidence emerging from recent systematic reviews and meta-analyses. Additionally, an expert opinion on each topic was provided based on the consensus of 16 experts in the field.
RESULTS: The questionnaire was answered by 574 clinicians from 59 countries. The majority of respondents were urologists/uro-andrologists. A wide diversity of opinion was seen in every aspect of varicocele diagnosis, indications for repair, choice of technique, management of sub-clinical varicocele and the role of VR in azoospermia. A significant proportion of the responses were at odds with the recommendations of AUA, ASRM, and EAU. A large number of clinical situations were identified where no guidelines are available.
CONCLUSIONS: This study is the largest global survey performed to date on the clinical management of varicocele for male infertility. It demonstrates: 1) a wide disagreement in the approach to varicocele management, 2) large gaps in the clinical practice guidelines from professional societies, and 3) the need for further studies on several aspects of varicocele management in infertile men.

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