Angiographic findings of primary versus salvage varicoceles treated with selective gonadal vein embolization: an explanation for surgical treatment failure

Clinical efficacy comparison of sclerosing embolization with 3% polidocanol and the microsurgical subinguinal varicocelectomy in primary varicocele patients

Varicocele is a more common male genitourinary system disease with sperm quality dysfunction or discomfort. This study was aimed to compare the clinical efficacy of sclerosing embolization with 3% polidocanol and the microsurgical subinguinal varicocelectomy in treating primary varicocele. Total of 59 patients with primary varicocele receiving a 3-month postoperative follow-up were included to analyse their biochemical parameters and clinical outcomes, including the operative time, hospitalization time, postoperative recurrence rates, and complication rate. Nineteen patients were treated with sclerosing embolization with 3% polidocanol (SE group), while 40 patients were treated with microsurgical subinguinal varicocelectomy (MSV group). For the SE group, 17 patients were treated on the left side, and two patients have treated on both without recurrences and complications during the follow-up period. For the MSV group, three patients were treated bilaterally, and 36 patients were treated separately on the left side with a total 5% recurrence rate and 10% complication rate. The duration of surgery and the hospitalization time of the SE group (46.2 ± 9.79 min and 2.53 ± 0.90 days, respectively) are significantly lower than MSV group (100.5 ± 13.76 min and 3.6 ± 1.58 days, respectively), p < 0.05. The total sperm count at 3 months was significantly higher in the SE group than in the MSV group (p < 0.05). In summary, sclerosing embolization is more effective for varicocele in improving sperm quality, shortening recovery time, and reducing recurrence rates and complications.

Potential role of imaging in assessing harmful effects on spermatogenesis in adult testes with varicocele

Varicocele is characterized by an abnormal dilatation and retrograde blood flow in the spermatic veins. Varicocele is the leading correctable cause of male infertility. Although it is highly prevalent in infertile men, it is also observed in individuals with normal fertility. Determining which men are negatively affected by varicocele would enable clinicians to better select those men who will benefit from treatment. To assess the functional status of the testes in men with varicocele, color Doppler sonographic parameters were evaluated. Testicular arterial blood flow was significantly reduced in men with varicocele, reflecting an impairment of spermatogenesis. An improvement in the testicular blood supply was found after varicocelectomy on spectral Doppler analysis. Testicular contrast harmonic imaging and elastography might improve our knowledge about the influence of varicocele on intratesticular microcirculation and tissue stiffness, respectively, providing possible information on the early damage of testicular structure by varicocele. Magnetic resonance imaging (MRI), with measurement of apparent diffusion coefficient has been used to assess the degree of testicular dysfunction and to evaluate the effectiveness of varicocele repair. Large prospective studies are needed to validate the possible role of functional sonography and MRI in the assessment of early defects of spermatogenesis in testes with varicocele.

Diagnosis of clinical and subclinical varicocele: how has it evolved?

In this review, we examine the evolution and application of various diagnostic modalities for varicoceles starting with venography, scintigraphy, and thermography and their role in the evaluation of a varicocele patient. Some of these methods have been supplanted by less invasive and more easily performed diagnostic modalities, especially ultrasound and Doppler examination of the scrotum. Advances in ultrasound and magnetic resonance imaging hold the potential to expand the role of imaging beyond that of visual confirmation and characterization of varicoceles. The ability to identify the early indicators of testicular dysfunction based on imaging findings may have implications for the management of varicoceles in the future.

Percutaneous embolization of varicocele: technique, indications, relative contraindications, and complications

There are several options for the treatment of varicocele, including surgical repair either by open or microsurgical approach, laparoscopy, or through percutaneous embolization of the internal spermatic vein. The ultimate goal of varicocele treatment relies on the occlusion of the dilated veins that drain the testis. Percutaneous embolization offers a rapid recovery and can be successfully accomplished in approximately 90% of attempts. However, the technique demands interventional radiologic expertise and has potential serious complications, including vascular perforation, coil migration, and thrombosis of pampiniform plexus. This review discusses the common indications, relative contraindications, technical details, and risks associated with percutaneous embolization of varicocele.

A Rare Anatomical Variant of Spermatic Vein as Cause of Recurrence After Surgical Correction of Varicocele

Varicocele may be treated with many different modalities, including radiologic and surgical approaches, but what is the best treatment remains controversial. The recurrence rate following varicocele repair ranges from 0.6% to 35% depending upon the technique used. We describe in detail a rare anatomical variant of the left internal spermatic veins and the appropriate treatment of recurrent varicocele with percutaneous scleroembolization. In case of recurrent varicocele after surgical repair, knowledge of anatomical variability of internal spermatic veins is essential for treatment planning.

Treatment of male varicoceles by transcatheter polidocanol foam sclerotherapy: evaluation of clinical success, complications, and patients' satisfaction with regard to alternative techniques

OBJECTIVES

We report our experience with polidocanol foam sclerotherapy with no additional coils, evaluating clinical success, patients' satisfaction, and complications.

METHODS

We conducted a retrospective study of 141 patients with 146 varicoceles (mean age: 29.3 years; range: 13 - 60 years) who underwent foam sclerotherapy with polidocanol 2% (range: 2 - 12 ml) in an outpatient setting between January 2007 and December 2013. For the follow-up, telephone interviews with the patients were conducted (mean follow-up time: 46.4 months, standard deviation: 20.17 months).

RESULTS

The technical success rate was 91.8%. There was a 55.8% response rate to the telephone interviews. Follow-up revealed a clinical success rate of 83.9% and a persistence or relapse rate of 16.1%. Of the patients, 81.9% were absolutely satisfied with the outcome. In 94.9% of cases, pain or discomfort resolution was reported, and in 97% of cases, aesthetic issues were no longer a problem. Of partners, 63.2% achieved pregnancy, and in 50% of patients with preprocedural testicular atrophy, catch-up growth was observed. One patient with pampiniform plexus phlebitis received inpatient treatment with no long-term damage recorded.

CONCLUSIONS

Polidocanol foam varicocele sclerotherapy is a safe and effective procedure, with a high rate of patients' satisfaction, clinical and technical success, and considerable catch-up growth and pregnancy achievement.

KEY POINTS

• Varicocele treatment using polidocanol foam sclerotherapy is a safe and effective procedure. • It is easily feasible in an outpatient setting. • The clinical and technical success rates are high. • It shows a high rate of patients' satisfaction and symptom resolution. • Postinterventional catch-up growth and pregnancy achievement are considerable.

Microsurgical varicocelectomy with transfixing of the difficult-to-isolate periarterial vein using microsutures

OBJECTIVE

To address difficulty in isolating the adhered periarterial vein in microsurgical subinguinal varicocelectomy, we introduced the transfixing microsuture method as well as to evaluate the impact of this technical modification on the surgical success of varicocele repair.

MATERIALS AND METHODS

We retrospectively evaluated 4 patients with a mean age of 31.5 years who underwent subinguinal varicocelectomy with transfixion of the difficult-to-isolate periarterial vein (a 9-0 transfixing microsuture was placed transversely through the periarterial vein as near to the adjacent border between the testicular artery and adherent vein as possible; then, it was knotted to nick or completely ligate the lumen.) The incidence of recurrence or persistence, postoperative hydrocele formation, sperm improvement, and symptom release was analyzed.

RESULTS

In 4 cases, the periarterial vein transfixing procedures were performed with a mean follow-up of 6 months. No postoperative recurrence or hydrocele was identified postoperatively. One patient reported no symptom improvement, but there was significant improvement in the symptoms and/or semen parameters in the other 3 patients. Postoperative ultrasonography evaluation revealed that there was no postoperative varicocele recurrence or persistence, no hydrocele formation, and no testicular atrophy.

CONCLUSION

When the adhered periarterial vein is difficult to isolate and ligate, transfixing the vein with a microsuture in microsurgical subinguinal varicocelectomy is a viable compromise that reduces the incidence of postoperative recurrence or persistence without serious complications.

Imaging and interventional therapy for varicoceles

Varicocele is a common treatable cause of testicular pain, male infertility, and Leydig cell dysfunction. Scrotal ultrasonography has become the modality of choice in the diagnosis and post-treatment follow-up of varicocele. Visualization of dilated veins and reflux into the pampiniform plexus enables accurate diagnosis. Although the pathophysiology of varicocele in testicular dysfunction remains unclear, numerous studies have established significant improvement in the seminal parameters and pregnancy rates after varicocele repair. Interventional therapy is a minimally invasive effective treatment option for primary and salvage varicocele repair. This review discusses sonographic criteria used in the pre- and post-procedural evaluation of varicocele and various interventional techniques for varicocele treatment.

Recurrent varicoceles: causes and treatment using angiography and magnification assisted subinguinal varicocelectomy

PURPOSE

To investigate the causes of varicocele recurrence and assess the use of embolization and subinguinal varicocelectomy in its treatment in patients with angiography and subinguinal varicocelectomy.

MATERIALS AND METHODS

The present study involved 15 patients with recurrent varicoceles. The mean patient age was 21.2 years (range: 12-42 years). Preoperative angiography was performed in 11 patients. Embolization was used in patients with patent internal spermatic veins (ISVs). Patients without patent ISVs or preoperative angiography underwent magnification-assisted subinguinal varicocelectomy which included testicular retrieval and ligation of all collateral veins except arteries and deferential veins.

RESULTS

Seven among 11 patients (64%) which had preoperative angiography had patent ISVs and underwent embolization and 8 patients underwent subinguinal varicocelectomy. Of those 8 patients, 6 had dilated ISVs and external spermatic veins (ESVs), one had dilated ISVs and gubernacular veins, and one had dilated ISVs, ESVs and gubernacular veins. No patient experienced recurrence or testis atrophy.

CONCLUSION

Patent ISVs or collateral veins may be the cause of recurrence after varicocelectomy. Angiographic embolization was successful in 64% of recurrent varicoceles patients with patent ISVs. However, microscope-assisted subinguinal varicocelectomy may be the best overall treatment for patients with recurrent varicoceles.