Percutaneous venography and embolization of the internal spermatic vein by spring coil for treatment of the left varicocele in children

Postvaricocele Embolization Pain Syndrome: A Case Series Report and Review of Current Treatment Strategies

BACKGROUND

Orchialgia is not an uncommon complaint among men with varicocele, but postvaricocele embolization-related testicular pain has not been widely investigated. This study evaluates the phenomenon of postvaricocele embolization pain (PVEP) syndrome and examines the current strategies to treat this unusual complication.

METHODS AND MATERIALS

A prospectively collected database of patients with PVEP who presented to a tertiary center was analyzed between January 2011 and January 2020 following internal ethics approval. Patient demographics, including other complications related to embolization, analgesic requirements, and pain scores (on a 10-point visual analog score), treatment strategies, Patient Global Impression of Improvement (PGI-I) score and overall satisfaction score (on a 5-point scale), were reviewed. All patients were reviewed for a minimum of 12 months.

RESULTS

A total of 20 men with a mean age of 33.8 (18-45) years old, presented with PVEP over 10 years. Most men received embolization on an average of 26.6 (18-48) months. The reasons for varicocele embolization include either isolated or combined orchialgia (15 men), subfertility (5 men), and cosmesis (6 men). Eighteen (90%) men underwent microscopic spermatic cord denervation (MSCD) and 2 patients elected for conservative measures. The average pain scores pre-MSCD and post-MSCD were 6.9 (4-9) and 1.4 (0-4) (p<0.001) with a significant reduction in analgesia requirements. Immediate improvement in pain score was reported in all the patients and this persisted at the 12 months review. Most men reported a high satisfaction score (of 4/5) and only one patient reported no change in symptoms after MSCD.

CONCLUSION

PVEP is a unique complication and patients should be counseled on the potential risk of persistent orchialgia following embolization for varicocele. The MSCD appears to be an effective treatment option with high success and satisfaction rates.

Safety and effectiveness of the different types of embolic materials for the treatment of testicular varicoceles: a systematic review

OBJECTIVE

The purpose of this study is to assess the current evidence regarding the safety and effectiveness of the various embolic materials used in varicoceles embolization.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Databases were searched for clinical studies that investigated the clinical outcomes of embolization treatment for the management of testicular varicoceles. Study methodological quality was analyzed.

RESULTS

23 retrospective and 7 prospective clinical studies were identified with a total of 3505 patients. Technical success rates appear to be above 90% for all embolic materials without any significant differences. In terms of recurrence rates, glue (N = 251) appeared to have the lowest and sclerosants alone (N = 728) the highest recurrence rates which were 4.2% (11-3.08%, SD: 5.9) and 11.03% (18.8-5.15%, SD: 6.06) within an average follow up (f/u) of 16.13 and 25.48 months respectively. Coils alone (N = 898) had an average recurrence rate of 9.1% (17.8-1.4%; SD: 5.79) and a mean f/u of 39.3 months. After an average of 12 months of f/u, the addition of sclerosants (N = 1628) as an adjunct to coils did not improve recurrence rates (8.44%, 16.5-5.1%; SD: 3.4). No differences were reported regarding the safety profile of the various embolic materials.

CONCLUSION

Despite the heterogeneity of the included studies, preliminary evidence supports the safe and effective use of the various embolic materials currently used for the management of varicoceles. At 1 year, glue appears to be the most effective in preventing recurrence with coils being the second most effective. The addition of sclerosants to the coil embolization did not appear to have an impact on recurrence rates. Further research is required to elucidate the cost-effectiveness of these approaches. Advances in knowledge: Varicocele embolization appears to be a safe and effective technique regardless of the embolic agent. Addition of a sclerosant agent to coil embolization does not appear to improve outcomes.

Retrograde percutaneous sclerotherapy of left idiopathic varicocele in children: results and follow-up

Treatment of pediatric patients with varicocele is based on the desire to prevent testicular dysfunction and possible infertility that may become irreversible in adults. The authors reviewed their experience with retrograde percutaneous sclerotherapy (RPS) via a trans-femoral approach to assess its results in children. A retrospective study was conducted, including all the children admitted between 2000 and 2004 who underwent RPS with at least 24 months follow-up (FU). The indication for treatment was grade II and III varicocele (Dubin-Amelar classification), confirmed by Doppler US. Three per cent sodium tetradecyl sulfate was the sclerosing agent. FU included Doppler US 1 month after the procedure and then yearly for at least 2 years. Eighty-six children (mean age 13.8 years) underwent phlebography and, when feasible, RPS. Varicocele was grade II in 49 cases and grade III in 37. RPS was feasible in 72 (84%) children because of unfavourable anatomic features of the left spermatic vein. RPS was successful in 66 (92%) out of 72 treated children. Median FU was 29 months. During FU, five (8%) patients relapsed. RPS of varicocele is a simple and effective treatment. A minimum of 2 years FU is recommended, as a few cured cases may relapse during this period.

Percutaneous embolization of varicocele in children: A Canadian experience

BACKGROUND/PURPOSE

The importance of early treatment of varicocele, to prevent testicular damage is widely accepted. Surgical treatment of varicocele has been the standard method of therapy, but recently a less invasive procedure was introduced and utilized mostly in Europe. The authors reviewed their experience with percutaneous embolization and sclerotherapy to assess the feasibility and outcome of this approach in children.

METHODS

The authors conducted a retrospective study including all patients who underwent percutaneous embolization and sclerotherapy for varicocele in the authors' institutions for the last 10 years. Clinical data, investigation, pre and postintervention management, and the technique of the procedure, including sedation and anesthesia when needed, were collected from the charts. Follow-up was obtained from the chart or by phone.

RESULTS

Between 1991 and 2001, 41 patients underwent 43 percutaneous interventions. The median age was 14 years (range, 10 to 20 years). All but 2 were injected with a sclerosing agent; in 26 cases coils were added. All procedures except one were done under local anesthesia with sedation. Only 2 patients were admitted overnight, and 5 patients had minor complications. The average procedure time was 55 minutes. Follow-up data were obtained in 39 patients (95%), with a mean follow-up of 22 months. A total of 89.1% of those who were injected have satisfactory results (cured or improved) without the need for further procedures. Six patients required surgery post-percutaneous procedure, 4 because of persistent or recurrent varicocele and 2 because of technical failure.

CONCLUSIONS

Percutaneous embolization is a safe and effective treatment of varicocele in children with technical success in 95% and therapeutic success in 89%. It now is the authors' first treatment modality for this disease.

Adolescent varicocele: Tauber antegrade sclerotherapy versus Palomo repair

PURPOSE

There is general agreement on treatment for varicocele in pediatric patients. Randomized prospective studies have shown that anatomical and functional lesions may be corrected. Due to the impossibility of seminal examination patients with moderate to large varicocele or ipsilateral testicular hypertrophy, characterized by a change in testicular consistency or symptoms, should undergo surgical correction. The best therapeutic approach is still under discussion.

MATERIALS AND METHODS

At 2 centers 2 therapeutic approaches to varicocele treatment in pediatric patients were compared, namely the Palomo repair and antegrade sclerotherapy according to Tauber. The 89 patients from the same geographical area elected 1 procedure after an explanation. From the medical records we retrospectively evaluated operative time, postoperative analgesics, postoperative fever onset, complications, convalescence, recurrence and postoperative hydrocele.

RESULTS

After Palomo repair in 45 patients there were 2 recurrences (4.4%) and 2 postoperative hydroceles (4.4%). Of 44 antegrade sclerotherapy cases 1 was converted to Palomo repair, there was no hydrocele formation and recurrence developed in 2 (4.5%). Testicular atrophy was not observed in any patient regardless of the method used. The cost of the procedure was lower in the sclerotherapy group.

CONCLUSIONS

These data suggest that the failure rate was similar in both groups. The principal advantages of sclerotherapy are simplicity, decreased cost and lack of hydrocele formation.