Recurrent varicocele: role of antegrade sclerotherapy as first choice treatment

Recurrent varicocele

Varicocele recurrence is one of the most common complications associated with varicocele repair. A systematic review was performed to evaluate varicocele recurrence rates, anatomic causes of recurrence, and methods of management of recurrent varicoceles. The PubMed database was evaluated using keywords “recurrent” and “varicocele” as well as MESH criteria “recurrent” and “varicocele.” Articles were not included that were not in English, represented single case reports, focused solely on subclinical varicocele, or focused solely on a pediatric population (age <18). Rates of recurrence vary with the technique of varicocele repair from 0% to 35%. Anatomy of recurrence can be defined by venography. Management of varicocele recurrence can be surgical or via embolization.

Intravenous methylene blue venography during laparoscopic paediatric varicocelectomy

INTRODUCTION

One of the challenges of varicocele surgery is to prevent hydrocele formation while still ensuring success. Methylene blue has been used to identify and preserve lymphatic vessels, and venography has been a standard component of sclerotherapy and percutaneous retrograde techniques. The authors have combined both approaches during laparoscopic varicocelectomy and report their experience.

METHODS

A prospective study was performed of adolescents with idiopathic varicocele and spontaneous venous reflux on Doppler ultrasound. A pampiniform plexus vein was cannulated via scrotal incision before creating the pneumoperitoneum. A mixture of methylene blue and Omnipaque™ was injected into the pampiniform plexus with fluoroscopic screening. Laparoscopic selective vein ligation was then performed using 5mm endoscopic clips or a bipolar vessel sealing device such as Plasmakinetic™ or Ligasure™. Venography was repeated to confirm complete ligation of the internal testicular veins. Patients were followed-up at 3, 6, and 9 months post-surgery with clinical examination and Doppler ultrasound. Data are presented as median (interquartile range).

RESULTS

Twenty-four patients underwent laparoscopic selective vein ligation with venography and methylene blue injection. The median age was 14.7 (14.6-15.7) years. The recurrence rate was 12%. No patients developed a hydrocele. The length of surgery was 120 (100-126) minutes.

CONCLUSION

Intra-operative intra-venous methylene blue injection and venography helps to identify venous duplications of the internal testicular veins and enhances the success rate of laparoscopic selective vein ligation. This approach prevents hydrocele formation but has a 12% recurrence rate, which appears to be higher than some techniques described in the literature.

Varicocele surgery: 10 years of experience in two pediatric surgical centers

AIM

The study was designed to compare recurrence rates and complications after laparoscopic versus open varicocele surgery in children.

SUBJECTS AND METHODS

A retrospective case-note review of all varicocele surgery over a 10-year period (April 1999-March 2009) in two pediatric surgical centers was performed. Multivariate analysis using logistic regression was performed using SPSS Statistics version 18 (SPSS Inc., Chicago, IL).

RESULTS

Thirty-seven patients had varicocele surgery during the study period. The median age at surgery was 14 years (range, 11-16 years). Most children had left-sided Grade 2 varicocele. Twenty-five (68%) primary procedures were laparoscopic (17 artery-sparing), and 12 (32%) procedures were open (9 artery-sparing). Six (16%) children had recurrence, and 6 (16%) had postoperative hydrocele. Recurrence rates after laparoscopic (16%) and open (17%) surgery were similar. Increasing age significantly decreased recurrence (odds ratio, 0.373; 95% confidence interval 0.161-0.862; P = .021). Although laparoscopy was associated with higher rates of postoperative hydrocele (odds ratio, 2.817; 95% confidence interval, 0.035-3.595; P = .380) and artery-sparing ligation was associated with higher rates of recurrence (odds ratio, 2.667; 95% confidence interval, 0.022-4.235; P = .787), these associations were not statistically significant.

CONCLUSIONS

The best results of varicocele surgery in terms of recurrence and postoperative hydrocele were achieved by open mass ligation; however, larger prospective studies are warranted.

Current management principles for adolescent varicocele

The authors review the current approach to management of the adolescent varicocele which has evolved over the past two decades. Principles of observational, surgical and adjunctive management are discussed relative to significant clinical findings. A selective approach to surgical intervention is advocated with the goal of preserving fertility potential.

Surgical outcomes after modified antegrade scrotal sclerotherapy: a prospective analysis of 700 consecutive patients with idiopathic varicocele

PURPOSE

We analyzed the surgical outcomes of antegrade scrotal sclerotherapy in a large, prospective, multisurgeon, consecutive series of patients treated for idiopathic varicocele.

MATERIALS AND METHODS

We prospectively collected data on 697 consecutive patients undergoing antegrade scrotal sclerotherapy between 1997 and 2005. For every patient we evaluated age, side, clinical and Doppler ultrasound grade, and seminal impairment. Perioperative complications were evaluated 1 month after surgery. At 12 months after antegrade scrotal sclerotherapy all patients underwent Doppler ultrasound. In those with seminal impairment semen analysis was also performed. Failure was defined as at least Doppler grade 1 varicocele.

RESULTS

Median age of the 697 analyzed patients was 28 years. Mean surgical time was 15 minutes. All surgeries were performed using local anesthesia and no intraoperative complications were observed. All patients were discharged home within 4 hours. Postoperatively complications developed in 35 patients (5%) and failure occurred in 63 (9%). Persistent reflux was observed in 6.5% of adolescents, in 9.4% of adults and in 7.5% of patients with recurrent varicocele. Failure rates were similar for different grades and sides. The failure rate was significantly higher in patients treated by surgeons during the learning curve (p = 0.007). In the 414 patients with seminal impairment median sperm count and the median percent of progressive motility and normal forms significantly improved after surgery (p <0.001).

CONCLUSIONS

Considering the low persistence and complication rates in all patient categories (adolescents, adults, first diagnosis, and bilateral and recurrent disease) antegrade scrotal sclerotherapy can be proposed as a safe and efficacious first choice treatment for varicocele. A specific learning curve is required to achieve the best outcome.