Current Management of Varicoceles

Treatment of bleeding varicose veins of the scrotum with percutaneous coil embolization of the left spermatic vein: a case report

Percutaneous coil embolization of the spermatic vein offers a minimally invasive method for treating symptomatic varicose veins of the scrotum. We describe the case of a 63-year-old man with multiple comorbidities and persistent bleeding from scrotal varicosities. Venography revealed significant left spermatic vein reflux and a large left varicocele. Percutaneous coil embolization of the left spermatic vein completely resolved the bleeding from the left side of the patient's scrotum. Although many vascular specialists possess the technical skills to perform this procedure, they may not be familiar with its use in the treatment of scrotal varicosities and varicoceles.

Testicular varicoceles

A testicular varicocele represents an abnormal degree of venous dilatation of the pampiniform plexus. It is a relatively common condition and may present at scrotal pain and swelling. An association with male subfertility is an area of debate. This article describes the present day radiological criteria and imaging techniques to aid accurate diagnosis of varicoceles. In addition, the role of the interventional radiologist in treating this condition is discussed.

Improvement in the fertility rate after placement of microsurgical shunts in men with recurrent varicocele

OBJECTIVE

To evaluate the effectiveness of microsurgical shunts for secondary varicocele repair after ligation-like procedures, focusing on long-term functional outcomes.

DESIGN

Long-term survey (mean follow-up, 8.5 years) of infertile men after secondary microsurgical reconstructive varicocelectomy.

SETTING

University-based medical center.

PATIENT(S)

Thirty-four infertile men (group A, <30 years of age; and group B, >30 years) with recurrent palpable varicocele after varicocelectomy, according to Ivanissevich (n = 28), or after angiographic vein occlusion (n = 6). Ten patients presented bilateral recurrence.

INTERVENTION(S)

Microsurgical shunts between spermatic vein and inferior epigastric vein.

MAIN OUTCOME MEASURE(S)

Sperm count, pregnancy rate, and ultrasound evaluation of varicosity.

RESULT(S)

Complete disappearance of varicosity was achieved in 97.06% of patients, while in 2.94%, a consistent reduction in size was observed. In patients with severe infertility, a significant postoperative increase in seminal parameters was observed. Pregnancy rates were 43.75% in group A and 22.22% in group B.

CONCLUSION(S)

Microsurgical drainage in patients with recurrent varicocele after ligation-like procedures was shown to be an effective minimally invasive treatment, with immediate hemodynamic recovery of testicular venous outflow and excellent long-term results in patients with left or bilateral recurrences.

Clinical assessment after varicocelectomy

The present study, conducted in Hong Kong, was designed to evaluate the clinical assessment and interobserver variation between doctors with different levels of training in the assessment of recurrent varicoceles, and to compare their findings with those made by ultrasound. Fifteen patients, previously operated for left varicocele testis, were evaluated clinically by four observers. The mean age was 12.9 years (range 8-15 years) at surgery. The testicular texture, size and flow with and without the Valsalva manoeuvre were determined by colour Doppler sonography. The follow-up time was 6-48 months after surgery. The echotexture of the testes was normal in all patients. The mean volumes of the left and right testes were equal after surgery (left 9.0 ml [range 2.4-15.2 ml and right 8.7 ml [range 3.4-15.6 ml]). There was large variation between observers in the predictability of both positive and negative clinical findings of varicocele testis when compared with ultrasound. Objective assessment in grading varicocele testis and testicular volume using ultrasound is required for both clinical management and scientific research.

Biomechanical properties of normal and varicose internal spermatic veins

To investigate possible differences in biomechanical properties between varicose spermatic veins and controls. During surgery on 12 patients for grade 3 left-sided varicocele testis, 2 cm of the vein was obtained for comparison with: (i) samples of the left internal spermatic vein taken from the same anatomical localization from 8 patients without scrotal disease, and (ii) samples from the right internal spermatic vein from 7 other patients also without scrotal disease. The biomechanical properties of ring-shaped venous specimens were investigated by loading the specimen at a constant deformation rate until rupture. The relative amounts of collagen in the specimens were determined as the contents of hydroxyproline. There was a significant difference between varicocele testis/right spermatic vein in UC (unit collagen), F-max (maximum strength), Strain (ultimate extensibility) and E-fail (relative failure energy), but not in LD (diameter) and Tan-a (stiffness of the specimen). There were no significant differences between left and right spermatic vein in LD, UC, F-max, Strain, Tan-a and E-fail. There was a significant difference in LD between varicocele testis/left spermatic vein, but no relationship in UC, F-max, Strain, Tan-a and E-fail. Biomechanical analyses of the spermatic veins from patients operated for varicocele seem to support the hypothesis that a difference in biomechanical properties plays a part in the development of varicocele because a significant increase in extensibility of varicocele samples was found compared with normal right spermatic vein samples.

Percutaneous varicocele embolization versus surgical ligation for the treatment of infertility: changes in seminal parameters and pregnancy outcomes

PURPOSE

To compare the success of percutaneous varicocele embolization to surgical ligation with regard to changes in semen characteristics and pregnancy outcome.

MATERIALS AND METHODS

Infertility records from 346 men who underwent correction of their varicocele for infertility (surgical ligation 149; embolization 197) were reviewed retrospectively. Preprocedural and postprocedural semen analyses and pregnancy outcomes were obtained with use of chart and telephone follow-up.

RESULTS

In men who successfully impregnated their partners, there were significant improvements in sperm density, percent total improvement, motility, and progression. Postprocedural (embolization vs surgery) percentage increases in seminal parameters were density, 156.8% versus 138.5%; total, 168.8% versus 157.91%; and motility, 2.7% versus 3.2%. The percent of individuals who had a change in sperm progression was 31% versus 41%. There was no statistical difference between the techniques based on t tests. The pregnancy rates were similar for the two groups, 39% and 34% for embolization and surgery, respectively.

CONCLUSION

There is no significant statistical difference in seminal values or pregnancy outcome between the two techniques.

Antegrade scrotal sclerotherapy for the treatment of varicocele in childhood and adolescence

OBJECTIVE

To test the efficacy of antegrade scrotal sclerotherapy (ASS) for the treatment of varicocele in teenagers.

PATIENTS AND METHODS

The study included 38 patients (mean age 14.9 years, range 12-18) with left-sided varicocele. Three patients had a grade 1 varicocele, 22 were grade 2 and 13 were grade 3. ASS was performed under local anaesthesia on an out-patient basis.

RESULTS

ASS was accepted by all patients except one. There were no peri-operative problems and only one patient developed post-operative epididymitis. During 9 to 15 months of follow-up (mean 11 months), only two patients developed persistence of a lower grade of varicocele.

CONCLUSION

This study illustrates that ASS is a safe and successful out-patient procedure for the treatment of varicocele in teenagers.

Incidence of external spermatic veins in patients undergoing inguinal varicocelectomy

OBJECTIVES

To determine the incidence of external spermatic veins at inguinal varicocelectomy.

METHODS

A prospective study was performed by making intraoperative observations on 78 varicocelectomies (47 patients) performed by a single surgeon. All patients were referred for evaluation of male infertility and had a palpable varicocele present when examined while performing a Valsalva maneuver in the upright position. Varicocelectomies were performed via the inguinal approach using x 2.5 loupe magnification. Presence of external spermatic veins was defined as visualization (with x 2.5 loupe magnification) of veins on the floor of the inguinal canal traveling posterolateral to the spermatic cord that then subsequently exited the spermatic cord before passing through the internal inguinal ring. Age, anesthetic technique, and need for incision of the external inguinal ring were also recorded for each patient.

RESULTS

One third of patients had undergone left-sided varicocelectomies, while two thirds had undergone bilateral procedures. External spermatic veins were identified in 15% of left-sided varicoceles and 19% of right-sided ones. Of 31 patients undergoing bilateral varicocelectomies, 19% had at least 1 external spermatic vein. Of these patients, only 2 (7%) had a unilateral right external spermatic vein, none had a unilateral left external spermatic vein, and 4 (13%) had bilateral external spermatic veins. Overall, of all patients studied, 16% had at least 1 external spermatic vein. Follow-up at 1 year showed no evidence of clinical recurrence in any patient.

CONCLUSIONS

These results emphasize the importance of distal gonadal venous anatomy in the surgeon's choice of the proper approach to varicocele repair, since external spermatic veins are only accessible via an inguinal approach.

Subinguinal microsurgical varicocelectomy: a technical critique and statistical analysis of semen and pregnancy data

A total of 606 modified subinguinal microscopic varicocelectomies was performed on 466 outpatients using local anesthesia and sedation. The patients selected for these procedures were infertile for at least 12 months and had at least 1 semen parameter below threshold level: less than 20 million per ml., less than 50% motility or less than 40% normal morphological forms. The lymphatics, spermatic artery and vas were preserved, whereas all refluxive veins were transected or obliterated. Postoperative complications were limited to transient epididymal discomfort in 5.5% of the patients, ecchymosis at the wound site in 3.4% and wound inflammation in 2.4%. There was only 1 permanent hydrocele. The palpable recurrence rate was 0.82% per procedure. The median values for each semen parameter were compared preoperatively and postoperatively by the Wilcoxon signed rank test. The differences in the median values were significant for all parameters. As an alternative statistical model, the average preoperative semen value was subtracted from the average postoperative semen value for each parameter. The median differences were 10.8 million sperm per ml. for sperm density, 13.9% for motility and 3.8% for normal morphological forms. These differences were significantly greater than zero by the Wilcoxon signed rank test. The intra-quartile ranges for these differences suggested that postoperatively more than 75% of the patients had a difference of greater than zero for sperm density and per cent motility, and 63% had a difference of greater than zero for normal morphology. The 1-year pregnancy rate was 35.6% for 186 varicocelectomy patients compared to 15.8% for 19 medically treated men with varicocele. The difference between the true 1-year pregnancy rates was 19.8% and the 95% confidence intervals estimated bounds of 1.91 to 37.5%. These data suggest that outpatient subinguinal microscopic varicocelectomy has minimal morbidity and recurrence, and may be beneficial for select patients.

Laparoscopic ligature of the spermatic veins. A comparison between outpatient and hospitalised treatment

The preferable operation for varicocele is ligation of all venous trunks of the spermatic vein above the internal orifice of the inguinal canal, traditionally performed by a retroperitoneal approach. An alternative method is laparoscopic ligature of the spermatic veins. To evaluate this procedure and to see if it can be done on an outpatient basis, 24 patients were operated upon laparoscopically. The patients were allocated to two series, one scheduled to be operated upon on an outpatient basis and one hospitalised. In 22 out of 24 patients the varicocele had disappeared completely at follow-up 1-3 months after the operation. Three of the patients operated upon late during the day in the outpatient group had to stay overnight. No complications occurred. The costs were more than 50% lower in the outpatient group. Laparoscopic ligature of the spermatic veins seems to be an attractive way to treat varicoceles, with good postoperative results and, if performed on an outpatient basis, with a substantial reduction of costs.

Surgical ligation vs. angiographic embolization of the vena spermatica: a prospective randomized study for the treatment of varicocele-related infertility

Varicoceles as a common cause of male infertility are treated either by surgical ligation or, more recently, by angiographic occlusion of the spermatic vein. In the present prospective randomized study 38 patients were treated by surgical ligation and 33 by angiographic embolization. During the 12-month follow-up period a significant increase in sperm number (at 3 and 12 months) and sperm motility (at 12 months) occurred in both groups while sperm morphology remained unaffected. Altogether, 22 pregnancies (31%) were reported within the year following treatment, of which 11/38 (29%) occurred in the ligation group and 11/33 (33%) in the embolization group. Thus both treatment modalities appear equivalent, whereby embolization has the advantage that it can be performed on an outpatient basis.