ABSTRACT
Objectives: To assess the efficacy of embolization of testicular vein for the treatment of recurrent varicocele.
Methods: Between January 2002 and December 2005, a total of 64 patients with a mean age of 28 (18 - 40 years) were treated by embolization of testicular vein for the treatment of recurrent varicocele at Prince Hussein Bin Abdullah II Center in King Hussein Medical Center. Indication for treatment was as either due to infertility or for treatment of dragging pain in the left testicle.
Results: Embolization was accomplished successfully in 53 patients (82.8%), where as it was difficult in eleven patients because of venous spasm and anomalous collaterals which could not be cannulated. One patient required transfusion of blood due to bleeding from the internal spermatic vein.
Conclusion: Embolization technique for internal spermatic vein for treatment of recurrent varicocele is a safe with low morbidity technique; it’s also minimally invasive, with high success rate.
Key words: Varicocele, Embolization, Fertility, Testicular vein.
JRMS April 2009; 16(1):22-25
Introduction
Varicocele is a meshwork of distended blood vessels of pampiniform plexus and the internal spermatic vein in the scrotum, usually in the left side due to dilatation of the spermatic vein.(1)
The internal spermatic vein together with external spermatic vein and vas deferens veins comprise the deep venous system of testicle, the veins form extensive network within the testicle. This includes the pampiniform plexus that is drained through the internal spermatic vein as well as the cremasteric plexus that discharge through the external iliac vein and also into the femoral vein. The vas deferens vein drains into the internal iliac vein. All the three deep veins pass through the inguinal canal.(2)
The right internal spermatic vein flows mostly into the inferior vena cava, the left internal spermatic vein flows in almost right angle into the left kidney.
Varicocele is etiologically based on the absence of confluence valves as well as collaterals that bypass the valve. This leads to the venous reflux through the internal spermatic vein into the plexus pampiniform. This causes different changes in the vein plexus that could be the cause for the disruption of spermatogenesis.
Patients with varicocele show frequently an oligo-teratoasthenozoospermia.(2)
The prevalence of varicocele in male population is 15% (55% are mild form, 35% moderate and 15% severe form). Men with infertility have a prevalence of about 40%. The highest incidence at 15 years, the left side is observed in about 80-98%, however, it is right sided in about 10% and bilateral in 10%.
Not all men with varicocele consult a doctor; however, the main reasons are pain in the testicle or groin, very big dilatation of spermatic cord vein, and infertility.(7)
Methods
Between January 2002 and December 2005, A total of 64 patients, mean age 28 (17-40) have been treated by embolization of the testicular vein for the treatment of varicocele at Prince Hussein Bin Abdullah II Center in King Hussein Medical Center.
Among these patients, 52 had a history of surgical high ligation varicocele under general anesthesia but varicocele recurred. Of the 64 patients, sixty patients had varicocele on the left side and four had bilateral varicocele.
The criteria of recurrence depended on clinical examination and ultrasound for all patients at least six months after the first surgery.
Indication of treatment was classified as either due to infertility or because of symptoms usually dragging pain in the left testicle. Amongst patients with sub fertility; semen analysis results before and at least 3 months after treatment were available in 46 patients. Differences in sperm analysis parameters were assessed and compared.
Embolization was carried out by an interventional radiologist under local anesthesia in an angiography suite.
The patient was positioned flat supine on the angiography operating table, using the seldinger technique, usually we use a vascular introducer sheath size 5fr but occasionally we use renal guiding catheter to have an extra support to the copra guide wire to negotiate the testicular vein, so a guidewire is inserted into the right femoral vein, over which a vascular catheter was advanced into the renal vein under fluoroscopic control using an image intensifier, intermittent screening with gonadal shielding and restricted field of view. The venous anatomy and reflux into the internal spermatic vein were delineated; the guidewire was steered into the internal spermatic vein and advanced retrogradely to the level of the inguinal ligament.
After ensuring correct positioning, individual coils were released from their cartridges and up to about five coils size 5x5mm followed by 4x3 mm to form a ball which is placed up to the level of the third lumber vertebra, interspersed with 1 ml of 3% sodium tetradecyl sulphate (STD) as a sclerosant to obliterate the lumen of the vein.
Venogram is done pre embolization to assess the anatomy of testicular vein as most of the recurrences are due to accessory veins or collaterals. If a single vein is found we usually embolize at the level of superficial inguinal ring, if multiple veins were found they usually form a common vein so we embolize at the site of communication.
Venogram is done again after completion of procedure to ensure complete obliteration of veins. The technique duration is about 35 minutes including a total screening time of 3-4 minutes. After the procedure, patients were laid flat for 3 hours before mobilizing and going home. Precautions should be taken to prevent bleeding at the puncture femoral site and at the site of the coiling.
No specific precautions to be taken from the patient after procedure and he can regain his activity second day.
The patients were followed in the out patient clinic for six months, they were examined two weeks after surgery and three months later when they were examined again and seminal fluid analysis were done, some times ultrasound if indicated.
Results
Embolization was accomplished successfully in 53 patients (82.8%), including four men with bilateral varicocele. Four attempts were necessary in 3 patients early in series because there were technical difficulties. Bilateral varicocele was treated successfully in these patients. One patient who had a successful embolization subsequently underwent venography to evaluate recurrence; further embolization was not technically possible as the internal spermatic vein was shown to be occluded.
Embolization was difficult in 4 patients including one with bilateral varicocele. Among these, two failures were caused by venous spasm and the procedure was not repeated. Three were associated with anomalous collateral veins at the renal hilum; one was associated with lumbar collaterals, and one with small collateral that could not be cannulated and one were abounded because of a vasovagal attack during the procedure.
After embolization sperm count and motility were improved.
Patients undergoing embolization had lower absenteeism (3-10 days, median 7 days) compared to ligation (14-30 days, median 21 days). The analgesic requirements varied from nil to 7 days.
All patients who underwent the technique were back to work within 10 days except one patient who experienced significant bleeding from the internal spermatic vein injury which required blood transfusion.
Discussion
Embolization of the internal spermatic vein offers several advantages over surgical ligation for the treatment of varicocele.(4) It is carried out under local anesthesia as an out-patient procedure, whereas ligation involves brief hospital admission for a short period of time and requires general anesthesia. Laparoscopic ligation offers no advantage with respect to this requirement, although post operative discomfort may be reduced compared with surgical ligation. In contrast, percutaneous embolization is considered less invasive.(5) Both morbidity and analgesic need are less in embolization compared with other treatment modalities, and patient returned to work earlier.
Varicocele is characterized by retrograde flow of blood in the internal spermatic vein mainly due to valvular incompetence, however, venous reflux can occur despite competent valves by collaterals retrograde reflux, these collaterals can easily be identified by venography and ensure their embolization to prevent reflux.(6)
Venography offers the opportunity to define the venous anatomy and evaluate reflux into spermatic vein before treatment. Multiple contributing vessels may be identified and occluded. Embolization technique is an established, highly effective and minimally invasive procedure. Coils and sclerosant are used to occlude the vein which are usually used in combination; also detachable balloons have been used. It is known now that if the varicocele arises due to incompetent valves, embolization will be highly effective in treatment, but if varicocele is due to collaterals, recurrence may occur because it is not always easy to identify all the collaterals or to embolize them.(3)
Recurrence of varicocele may occur in up to 10% of the cases whether treated by embolization or ligation technique. Late failure may occur and it is usually due to opening of persistent small venous collaterals draining into the internal spermatic vein which is not always easily to be detected during operation.
Successful embolization depends on experience and venous anatomy. The present success rate compared with that reported, at 82.8% for the treatment of recurrent varicocele post high ligation.
The success rate in other studies was reported by Wunch R, et al to be 87%,(2) while Mickevicus R, et al. reported recurrence rate of 21.9%(5) and Punekar S, et al reported 85% success rate.(4) We encountered one major complication which was bleeding due to internal spermatic vein injury which was managed conservatively.
Patients should be warned that they may experience a testicular swelling post embolization which is usually transient; also they may experience testicular pain which is usually transient and can be managed with mild analgesic drugs.(8)
Other complications include infection at the site of puncture and hematoma at the groin access. Hydrocele may develop with any of the available techniques for varicocele treatment.
Radiological complication related to contrast media, migration of coils may occur but it is so rare.
Conclusion
Embolization technique for internal spermatic vein for treatment of recurrent varicocele is a safe and low morbidity technique; it’s also minimally invasive, with high success rate.
References
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3.Tay KH, Martin ML, Mayer AL, et al. Selective spermatic venography and varicocele embolization in men with circumaortic left renal veins. J Vasc Interv Radiol 2002; 13: 739-742.
4.Punekar SV, Prem AR, Ridhopkar VR, et al. Post-surgical recurrent varicocele: Efficacy of internal spermatic venography and steel-coil embolization. Br J Urol 1996; 77: 124-128.
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