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

Efficacy and safety of antegrade sclerotherapy for varicocele in pediatric patients: A systematic review

OBJECTIVES

Antegrade sclerotherapy (Tauber's) procedure has been extensively used for the minimally-invasive treatment of varicocele; however, the results in the pediatric population are less defined. This systematic review evaluates the efficacy and safety of antegrade sclerotherapy for varicocele in the pediatric population.

EVIDENCE ACQUISITION

The review was conducted following the PRISMA guidelines. Systematic research of available literature in English language from 1980 until May 2022 was conducted through EMBASE, MEDLINE, Cochrane Library, and NIH Registry of Clinical Trials. For each study, information was gathered regarding the study design, the inclusion/exclusion criteria, the indications for treatment, the success rate and the complications. When available, the details about sperm analysis were reported.

EVIDENCE SYNTHESIS

The 10 studies were included in the final sample (564 patients). Median age of patients ranged 13.3-15.3 years. The indications for scleroembolization varied in the different studies, while most studies included patients with clinical G2-G3 varicocele and clinical symptoms or testicular asymmetry. The treatment was successful in 88%-98% of the patients, while the complication rate was <5%.

CONCLUSION

Tauber's sclerotherapy is a safe and effective treatment for varicocele also in the pediatric population. Further studies with standardized inclusion criteria are needed to provide higher level of evidence and compare the outcomes of antegrade sclerotherapy with the other available techniques.

Antegrade pampiniform plexus venography in recurrent varicocele: Case report and anatomy review

Varicoceles are often treated with percutaneous embolization, using fibered coils and sclerosing agents, with the latter targeted at occlusion of pre-existing collateral veins. While various methods of surgical and embolization treatment are available, varicoceles may still recur from venous collateralization. We present a case, where following demonstration of complete occlusion of the right and left gonadal veins, direct puncture of the pampiniform venous plexus under ultrasound guidance revealed recurrent varicoceles supplied by anastomoses from the ipsilateral saphenous and femoral veins to the pampiniform plexus. In doing so, we describe a technique of percutaneous pampiniform venography in a case where the pertinent anatomy was not easily demonstrated by other methods.

Management options of varicoceles

Varicocele is one of the most common causes of male infertility. Treatment options for varicoceles includes open varicocelectomy performed at various anatomical levels. Laparoscopic varicocelectomy has been established to be a safe and effective treatment for varicoceles. Robotic surgery has been introduced recently as an alternative surgical option for varicocelectomy. Microsurgical varicocelectomy has gained increasing popularity among experts in male reproductive medicine as the treatment of choice for varicocele because of its superior surgical outcomes. There is a growing volume of literature in the recent years on minimal invasive varicocele treatment with percutaneous retrograde and anterograde venous embolization/sclerotherapy. In this review, we will discuss the advantages and limitations associated with each treatment modality for varicoceles. Employment of these advanced techniques of varicocelectomy can provide a safe and effective approach aiming to eliminate varicocele, preserve testicular function and, in a substantial number of men, increase semen quality and the likelihood of pregnancy.

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.

Modified antegrade scrotal sclerotherapy in adolescent patients with varicocele

BACKGROUND/PURPOSE

The aim of this study is to evaluate the tolerability, safety, and efficacy of a modified antegrade scrotal sclerotherapy in the treatment of varicocele in adolescent patients.

METHODS

From 1998 to 2001, 45 consecutive adolescent patients (average age, 15.26 +/- 1.29; range, 13 to 17 years) underwent modified antegrade scrotal sclerotherapy for varicocele at the authors' department. All patients were evaluated pre- and postoperatively by physical examination and color Doppler ultrasonography of spermatic cords and testis. All treatments were performed under local anaesthesia by a single surgeon. Complication and reflux persistence rates were assessed 6 and 12 months after treatment.

RESULTS

The mean operating time was 15 minutes. No patient required general anaesthesia during the treatment. No intraoperative complication was recorded, and all patients were discharged within 4 hours. The patients returned to normal school activity within 48 hours. No complication was observed during the follow-up. Six and 12 months after surgery, only 1 patient had a reflux persistence (2.2%).

CONCLUSIONS

Modified antegrade scrotal sclerotherapy was well tolerated in our adolescent patients under local anesthesia. The procedure is simple, rapid, safe, and effective. The possibility to perform this treatment under local anesthesia decreases the hospitalization time and allows the rapid return to school activity in this particular category of patients.

Percutaneous retrograde varicocele embolisation using tungsten embolisation coils: a five year audit

OBJECTIVE

To assess the efficacy of percutaneous retrograde varicocele embolisation using Spirale tungsten coils over a period of five years.

PATIENTS AND METHODS

Fifty consecutive patients underwent local anaesthetic day case varicocele embolisation via a right femoral approach. Venous anatomy was identified and classified. Morbidity and recurrence were recorded at three month clinical follow up.

RESULTS

The procedurewas technically successful in 94% of the patients. The varicocele recurred in 16%, the majority of whom had complex venous anatomy. 8% of the patients complained of discomfort at follow up.

CONCLUSIONS

Although the coils used in this study have been withdrawn, a high technical success rate is described with failure being predominantly due to complex venous anatomy.

Antegrade scrotal sclerotherapy in the treatment of varicocele: a prospective study

OBJECTIVE

To assess the results of our experience in correcting primary varicocele using a modified technique of antegrade scrotal sclerotherapy.

PATIENTS AND METHODS

From December 1997 to February 2000, 201 patients with primary varicocele underwent antegrade scrotal sclerotherapy. Before treatment all patients were evaluated by a physical examination, colour Doppler ultrasonography of the spermatic cord, and abdominal and scrotal ultrasonography. Sperm samples were analysed only in patients aged > 18 years. The treatment was administered using a special venous catheter system with a Y-adapter. Complications after treatment and the rate of persistence of reflux were assessed 3 and 6 months after the antegrade scrotal treatment, by clinical examination and colour-Doppler ultrasonography of the spermatic cord.

RESULTS

The mean operative duration was 15 min; there were no significant complications during treatment and all patients were discharged within 4 h. Complications after treatment occurred in 10 of the 201 patients (5%); four patients had epididymo-orchitis, three a scrotal haematoma, one a surgical wound infection, one persistent scrotal pain and one persistent flank pain on the same side as the surgery. Reflux was persistent in 12 patients (6%).

CONCLUSIONS

Antegrade scrotal sclerotherapy is a simple, minimally invasive and highly effective technique for blocking spermatic vein reflux, with a low rate of complications. The technical changes simplified the cannulation of the spermatic vein and facilitated antegrade phlebography and sclerotherapy using the air-block technique.

Adolescent varicocele: treatment by antegrade sclerotherapy

BACKGROUND/PURPOSE

The most effective treatment for adolescent varicocele is still debated, although the same treatment methods used for adults have also been used in children. Since 1991 at the Pediatric Surgery Operative Unit of "S. Camillo" Hospital in Rome a multidisciplinary protocol has been established according to which percutaneous retrograde scleroembolization was suggested as the first therapeutic option. Surgery (retroperitoneal ligation) was reserved for select cases. The author now presents his personal experience with alternative-approach antegrade sclerotherapy.

METHODS

Since February 1998, as an alternative to percutaneous retrograde sclerosis and surgical ligation, antegrade sclerotherapy has been performed in 92 varicocele patients, 65 of whom were 11 to 19 years of age. In this group, the indication for treatment was grade III varicocele with spontaneous continual reflux, which worsened with the Valsalva maneuver. Twenty patients had recurrent varicocele after other treatments.

RESULTS

At a mean follow-up of 9 months, the clinical recovery rate was 92.6%.

CONCLUSIONS

Antegrade sclerotherapy is an intermediate treatment because of its invasive nature and success rate compared with more commonly used percutaneous retrograde sclerosis and Palomo procedures in adolescents. In particular, this method is highly effective and well-accepted by patients with recurrent varicocele.