Surgical treatment of varicocele by a subinguinal approach combined with antegrade intraoperative sclerotherapy of venous vessels

OBJECTIVE: To evaluate the efficacy, in terms of recurrences, complications and operative duration, of a new technique for treating varicocele. PATIENTS AND METHODS: Between September 1999 and December 2002 we evaluated 307 men aged 17-51 years with varicocele. In all of the men the clinical diagnosis was confirmed by ultrasonography. The men were treated by a variant of the microsurgical technique described in 1994. A 2-3 cm distal subinguinal incision was made at the level of the superficial inguinal ring and the spermatic cord was exposed. The largest vein in the spermatic cord fat was cannulated. A 7-9 cm segment of the spermatic cord was clamped for 8-10 min; at the start of the ischaemia time, 1.5-3 mL of 3% atoxysclerol was injected into the cannulated vein. After sclerotherapy, the vein was ligated at the injection site, and the blood flow to the cord was restored. RESULTS: The mean operative duration was 25 min. Follow-up at 3 and 6 months after surgery, with objective examination and scrotal ultrasonography, revealed one case of clinical recurrence/persistence. The most common complication was penile lymphangitis (nine men) that regressed spontaneously; three men had temporary orchialgia. There were no cases of secondary hydrocele or testicular atrophy. CONCLUSIONS: The modified technique appears to be relatively easy and safe, and to of low cost. Given the promising results in terms of complications and persistence, the treatment appears to be a suitable first-line approach for the surgical treatment of varicocele.     

Recurrent varicocele: role of antegrade sclerotherapy as first choice treatment

OBJECTIVE: To underline the role of antegrade sclerotherapy as first choice treatment in recurrent varicocele. METHODS: In 53 patients, aged 11-38 years, observed over a 30-month period, antegrade sclerotherapy was carried out for the treatment of recurrent varicocele. In seven of these patients, varicocele was bilateral. The right varicocele, however, had not been previously detected and these patients were, therefore, submitted to simultaneous bilateral antegrade sclerotherapy. RESULTS: Antegrade sclerotherapy was feasible in all 53 patients (60 varicoceles) and no significant complications were observed. Unsuccessful results occurred in only two out of the 55 varicoceles observed over a minimum follow-up period of six months. CONCLUSIONS: Whilst antegrade sclerotherapy is recognized as a low-cost, safe and effective method in the management of varicocele, the success rate in recurrent varicocele is even greater than in primary varicocele. If, in the preceding treatment, the internal spermatic vein has presumably been occluded (percutaneous retrograde sclerotherapy, surgical or laparoscopic retroperitoneal ligation of the entire bundle), antegrade sclerotherapy should be considered the treatment of choice.     

Antegrade scrotal sclerotherapy and varicocele

Antegrade scrotal sclerotherapy is a simple and easy technique for the treatment of varicocele. The success rate varies between 87% and 95%. The initial reflux grade and the number of collateral vessels of the spermatic vein are the most important factors to predict the outcome of the technique. The postoperative complication rate is about 7% and the common ones are scrotal hematoma and epididymo-orchitis of slight severity. Testicular athrophy is a rare event (0.6%). This technique offers a considerable cost reduction compared to other therapeutic options currently available for varicocele.     

Antegrade scrotal sclerotherapy and varicocele

Antegrade scrotal sclerotherapy is a simple and easy technique for the treatment of varicocele.The success rate varies between87%and95%,The initlal reflux grade and the number of collateral vessels of the spermatic vein are the most important factors to predict the outcome of the technique.The postoperative complica-tion rate is about7%and the common ones are scrotal hematoma and epididymo-orchitis of slight severity.Testicular athrophy is a rare event(0.6%).This technique offers a considerable cost eduction compared to other therapeutic optione currently available for varicocele.     

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.     

Challenging the role of cremasteric reflux in the pathogenesis of varicocele using a new venographic approach

PURPOSE: Cremasteric or extrafunicular reflux is considered by many a major cause of primary and recurrent varicocele. Therefore, surgical techniques that allow ligation of the intrafunicular and extrafunicular veins are often performed. We evaluated the incidence of cremasteric reflux in patients with primary or recurrent varicocele with a new and simple venographic technique. MATERIALS AND METHODS: A series of 73 patients with primary (54) or recurrent (19) varicocele underwent venography of the left iliac vein while standing and performing Valsalva's maneuver to reveal the possible presence of reflux in cremasteric or other extrafunicular veins. In patients with recurrent varicocele antegrade transcrotal spermatic venography was also performed immediately before surgery. RESULTS: None of the patients presented with reflux of contrast material from the left iliac vein to the left pampiniform plexus via the extrafunicular veins. Cremasteric veins, in particular, were always continent at the confluence with the epigastric vein even when grossly dilated at spermatic antegrade venography in recurrent cases. CONCLUSIONS: Cremasteric reflux seems to have a limited role if any in the pathogenesis of primary and even recurrent varicocele. Dilatation of the extrafunicular veins is not necessarily a sign of reflux but may represent only a consequence of venous overflow due to insufficiency of the internal spermatic vein and possibly partial obstruction of the left iliac vein. The rationale of surgical treatments aimed at ligation of the extrafunicular veins should be questioned.     

Treatment of varicoceles in childhood and adolescence with Tauber's antegrade scrotal sclerotherapy

PURPOSE: The aim of this study was to evaluate surgical complications and the outcome of grade II and III varicoceles treated with Tauber's antegrade scrotal sclerotherapy. METHODS: A total of 21 patients with a median age of 13 (range, 10 to 21) years and left-sided grade II and III varicoceles were treated with Tauber's antegrade scrotal sclerotherapy and underwent follow-up over a median period of 23 months (range, 9 to 35). RESULTS: One grade II varicocele persisted after antegrade sclerotherapy for 6 months. After a second sclerotherapy 6 months later, no further recurrence was detected. One patient with a grade II to III varicocele had a grade I varicocele recurrence 14 months after operation. Three patients showed a slight hydrocele postoperatively. CONCLUSION: This limited series indicates that Tauber's antegrade scrotal sclerotherapy is a safe and effective treatment for grade II and III varicoceles in children and adolescents.     

Induction of spermatogenesis in men with azoospermia or severe oligoteratoasthenospermia after antegrade internal spermatic vein sclerotherapy for the treatment of varicocele

Aim:To evaluate the treatment outcome of antegrade internal spermatic vein sclerotherapy in men with non-obstruc-tive azoospermia or severe oligoteratoasthenospermia(OTA)as a result of varicocele.Methods:Between September1995 and January 2004,47 patients(mean age 33.8±6.3 years)underwent antegrade internal spermatic vein sclero-therapy for the treatment of varicocele with azoospermia(14 patients)or severe OTA(33 patients).Testicular corebiopsy was also performed in complete azoospermic patients who provided informed consent.The outcome wasassessed in terms of improvement in semen parameters and conception rate.Results:Forty-two(89.4%)of 47patients had bilateral varicocele,Serum follicle stimulating hormone(FSH)did not differ between patients withazoospermia and severe OTA.After the follow-up of 24.8±9.2 months,significant improvement was noted in meansperm concentration,motility and morphology in 35 patients(74.5%).Comparison between groups during thefollow-up revealed significantly higher values of sperm concentration,motility and normal morphology in the severeOTA group.Pregnancy was achieved in 14 cases(29.8%).Testicular histopathology of the azoospermic patientswith postoperative induction of spermatogenesis revealed maturation arrest at spermatid stage,Sertoli-cell-only(SCO)with focal spermatogenesis or hypospermatogenesis.None of the patients with pure SCO pattern or maturation arrestat spermatocyte stage achieved spermatogenesis after the treatment.Preoperative serum FSH levels didn't relate totreatment outcome.Conclusion:Antegrade internal spermatic vein sclerotherapy is an easy and effective treatmentfor symptomatic varicocele.It can significantly reverse testicular dysfunction and improve spermatogenesis in menwith severe OTA,as well as induce sperm production in men with azoospermia,improving pregnancy rates insubfertile couples.(Asian J Androl 2006 Sep;8:613-619)     

The role of Doppler ultrasonography in determining the proper surgical approach to the management of varicocele in children and adolescents

In a study from Italy, colour-Doppler ultrasonography was a reliable diagnostic tool in the preoperative assessment of patients with varicocele. The authors also found that it helped to distinguish those who could be treated laparoscopically from those who should be treated by microsurgical subinguinal ligature. OBJECTIVE: To investigate whether colour Doppler ultrasonography (CDUS) is a reliable diagnostic tool for selecting patients with varicocele to undergo either laparoscopy or open microsurgical subinguinal ligation. PATIENTS AND METHODS: In a 3-year period, 42 boys affected by left varicocele were evaluated before surgery by inguinal and scrotal CDUS. Using this method it was possible to distinguish Coolsaet type-1 varicocele (due to isolated renal-internal spermatic vein reflux) and Coolsaet type-3 varicocele (due to associated renal-internal spermatic reflux and iliac-deferential reflux). Boys with Coolsaet type-1 varicocele were treated by a laparoscopic transperitoneal Palomo procedure, whereas those with Coolsaet type-3 varicoceles were treated by lymphatic-sparing microsurgical subinguinal ligation. RESULTS: The varicocele was Coolsaet type-3 in six patients (14%), who had microsurgical open surgery, and the remaining 36 (86%) had Coolsaet type-1 and had laparoscopic surgery. At the follow-up there was no venous scrotal reflux. In two patients in the laparoscopic group a hydrocele developed after surgery, which resolved spontaneously. CONCLUSIONS: This study showed that CDUS was a reliable diagnostic tool for assessing boys with varicocele. It clearly distinguished Coolsaet-type 1 varicoceles that can be treated laparoscopically, from Coolsaet type-3 varicoceles that should be treated with microsurgical subinguinal ligature.     

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.     

Antegrade scrotal sclerotherapy for treating primary varicocele in children

OBJECTIVE: To evaluate the effectiveness and limitations of antegrade sclerotherapy (AS) for the treatment of primary varicocele in childhood. PATIENTS AND METHODS: From December 1996 to December 2004, 88 patients (mean age 13.3 years, range 9-18) with primary varicocele underwent AS (91 varicocele ablations in all). The indications for surgery were testicular pain (16 boys, 18%), a large varicocele with cosmetic implications, testicular hypotrophy (one) and in 71 (81%) the varicocele was detected incidentally during a routine physical examination; all were left-sided. According to the classification used by Tauber, 46 (52%) varicoceles were grade II and 42 (48%) grade III. The clinical and ultrasonography (US) results were evaluated over a median (range) follow-up of 11 (3-60) months, and the operative duration, X-ray exposure time, persistence rate of varicoceles and complications were compared with those using other techniques. RESULTS: In 11 patients there was a palpable difference in size between the testicles, but in only five (6%) was testicular hypotrophy (testicular volume (<75% testicular volume vs the normal side) confirmed by US. The mean (sem) operative duration for AS was 33.2 (2.14) min. In 16 (18%) patients it was necessary to expose a second or third vein because the first vein chosen was unsuitable for sclerotherapy. The mean operative radiation exposure was 2.18 (0.21) s. One patient (1%) was treated with a high ligature of the testicular vein (Palomo procedure) after initial unsuccessful AS, and was excluded from the analysis. Eighty-four (97%) patients were eligible for follow-up: six (7%) had a persistent varicocele (four grade II, two grade III), four of whom had repeat sclerotherapy successfully (no recurrence at follow-up). Fourteen (15%) patients had enlarged testicular veins only on US (varicocele grade 0). No patient developed a hydrocele after AS, There were complications after surgery in three (3%) patients (two superficial wound infections, one scrotal haematoma together with focal testicular necrosis). CONCLUSIONS: AS is an efficient minimally invasive surgical method for correcting varicoceles in older children, although the operative duration is sometimes longer than in adults, and surgery can be more difficult because of the smaller veins. Partial testicular necrosis, despite correct AS, is a very rare but serious complication.     

Comparative hemodynamic evaluations of varicocele by bidirectional ultrasonic Doppler sonography and phlebography of the internal spermatic vein

Clinical studies (degree of severity) and bidirectional ultrasonic Doppler sonography (Pressure-type, Shunt-type) of varicocele were compared with the phlebography of the internal spermatic vein (degree of spermatic incompetence, diameter of the int. spermatic v.). Doppler probe and phlebography are equivalent methods to demonstrate the venous reflux in palpable varicocele and for follow-up examination after sclerotherapy. The subclinical varicocele is discussed. The slight degree of spermatic incompetence (reflux by Valsalva's manoeuvre) is responsible for the small varicocele (grade I) and the Pressure-type. The severe degree of spermatic incompetence (spontaneous reflux) causes the Shunt-type and the large varicocele (grade III) as well as a dilatation of the internal spermatic vein.     

Evaluation of the role of varicocelectomy including external spermatic vein ligation in patients with scrotal pain

OBJECTIVES: The aim of the present study was to assess and compare pre- and postoperative scrotal pain in patients with varicocele who underwent varicocelectomy with different approaches. METHODS: The study included 144 consecutive patients with left-sided varicocele who had left scrotal pain for more than 3 months. All patients underwent varicocele ligation using either a subinguinal or inguinal approach with or without external spermatic vein ligation. We asked the patients to complete an 'Assessment Questionnaire for Scrotal Pain' both before and after the surgery. RESULTS: The surgery was successful in 101 (83.4%) of the 121 patients available for follow up. Seventy-four (61.1%) patients reported the complete resolution of pain while 27 patients (22.3%) reported partial resolution. Symptoms worsened in a single case and pain persisted postoperatively in 19 cases (15.7%). There were no statistically significant differences in the characteristics of the pain and grade of varicocele between postoperative groups. A significant difference was observed in postoperative success between patients who had external spermatic vein ligation and those who did not, regardless of the surgical approach (inguinal or subinguinal). All patients who reported complete or partial resolution of pain stated that they would recommend surgery to relatives with the same problem. CONCLUSIONS: Varicocelectomy using either inguinal or subinguinal approaches is an effective and reasonable treatment option in this patient group and should include external spermatic vein ligation for a satisfactory outcome.     

The role of varicocele sclerotherapy in men with severe oligo-astheno-teratozoospermia

The aim of this study was to verify the role of antegrade scrotal sclerotherapy for the treatment of varicoceles in infertile men with severe oligo-astheno-teratozoospermia (OAT). The 59 patients with severe OAT in this study underwent antegrade scrotal sclerotherapy for the treatment of varicoceles. The outcome was assessed in terms of improvement in semen parameters and spontaneous conception rate. Semen parameters and reproductive hormones were evaluated before antegrade sclerotherapy (AS) and 6 months after AS. After an average follow-up time of 34.8±3.2 months, significant improvement was noted in the mean sperm concentration, motility and morphology in 36 patients (61%). Spontaneous pregnancy occurred in nine couples (15%). Six months after treatment, inhibin B levels were significantly higher (P<0.04), whereas follicle-stimulating hormone (FSH) levels were significantly lower (P<0.001) than before treatment. Antegrade internal spermatic vein sclerotherapy can significantly improve seminal parameters and hormonal parameters in men with severe OAT and may even result in spontaneous pregnancy in couples who would otherwise be candidates for intracytoplasmic sperm injection (ICSI).     

Simultaneous microsurgical spermatic vein ligation and sclerotherapy. a combined procedure for the treatment of recurrent or persistent varicocele.

OBJECTIVES: Microsurgical ligation as well as antegrade sclerotherapy have been established in varicocele treatment. The aim of this study was to evaluate whether a combination of microsurgery and sclerotherapy can provide a safe and effective treatment of varicocele recurrence or persistence. METHODS: Nine patients with recurrent or persistent varicoceles were operated by means of the combination method. Under microscopic control varix veins were ligated selectively preserving lymphatics and arteries. Ectopic veins as a possible source for varicocele persistence or recurrence were also ligated. Finally, an intraoperative venography with subsequent sclerotherapy was performed through one of the dissected veins. RESULTS: Despite difficult anatomical situations after previous surgical interventions, the operations were performed successfully without any complications. Clinical controls showed varicocele disappearance without damage of the testis. No varicocele recurrence or persistence was observed. CONCLUSIONS: This method combines the advantages of both methods. Precision of the microsurgical technique is combined with velocity of sclerotherapy. Thus, it may represent an interesting alternative to conventional operation methods especially in the treatment of recurrent or persistent varicoceles.     

Sonographic quantitative evaluation of scrotal veins in healthy subjects: normative values and implications for the diagnosis of varicocele

OBJECTIVES: To define the normative values of scrotal vein diameters, investigate the eventual presence and characteristics of scrotal reflux in healthy subjects, and describe its implication for the diagnosis of scrotal varicocele. METHODS: Color-Doppler ultrasonography was performed on a population of 145 healthy, symptomless subjects, with clinical examinations and semen analyses within normal limits. RESULTS: The upper limit of the scrotal veins diameter (3.7-3.8mm) exceeds values presently employed for a diagnosis of varicocele. Furthermore, a high percentage of healthy subjects (53%) were found to have reflux in the scrotal veins, currently considered one of the criteria for diagnosing varicocele, especially in its subclinical form. CONCLUSIONS: To reduce the risk of misinterpretations between the various specialists involved in Color-Doppler ultrasonography and urologists, quantitative data of the scrotal veins (i.e., maximum diameter and the presence, velocity, and duration of reflux) should be described in reports of sonographic examinations performed for scrotal varicocele.     

Radiological anatomy of the internal spermatic vein(s) in 200 retrograde venograms.

The radiological anatomy of the internal spermatic vein(s) was studied in 200 retrograde venograms performed as part of presurgical evaluation in patients with variocele. A large range of anatomical variations was found at the left side. Bilateral reflux occurs in one out of four patients with unilateral varicocele at palpation. Bilateral treatment is therefore necessary in as much as one fourth of cases with 'unilateral' left side varicocele. In right side varicocele the spermatic vein generally enters the right renal vein. Varicocele ligation should be performed near the internal inguinal ring in order to interrupt reflux most securely. Non-surgical treatment of varicocele by means of sclerosis or embolization of the internal spermatic vein, will remain restricted to those cases in which reflux passes through only one spermatic vein. Insufficient knowledge of the anatomy of the internal spermatic vein(s), and the resulting incomplete interruption of reflux in this (or these) vessel(s) may be the cause of poor treatment results reported by some authors.     

导管引导下泡沫硬化剂治疗精索静脉曲张的疗效分析

目的：探讨泡沫硬化剂栓塞治疗精索静脉曲张（varecocle,VC）的疗效。方法：选择VC患者58例,采用经导管泡沫硬化剂栓塞治疗,对比分析栓塞前后精索静脉主干内径、精液质量的变化,分析其疗效。结果：术后5～30d阴囊坠胀不适等症状消失18例（31．0％）,术后3个月曲张的静脉内径小于1．8mm者48例（82．8％）,大于1．8mm者10例（17．2％）,术后6个月与术前相比,患者精子密度、a＋b级精子活力、精子活动率显著升高,精子畸形率明显降低,两组间差异有统计学意义（P〈0．05）。结论：导管引导下泡沫硬化剂治疗VC疗效确切,能够显著改善VC患者疼痛等不适,提高VC患者精液质量,是一种值得推荐的方法。     

Spermatic vein embolization as a treatment for symptomatic varicocele

IntroductionVaricocele is a relatively common condition in men that causes pain in approximately 10% of cases. There have been few studies to date assessing the improvements in both pain and quality of life parameters associated with spermatic vein embolization (SVE) as a treatment for patients with symptomatic varicocele, so we aimed to assess this.MethodsA review was carried out of consecutive SVE procedures performed at our institution from 2013–2019. Only patients with painful varicocele were included after other causes of testicular pain were excluded. The technique employed was a combination of distal coil embolization of the spermatic vein with 4–6 mm coils at the level of the inguinal canal, as well as sclerotherapy to prevent reflux of sclerosant. Furthermore, a prospective validated Pain Impact Questionnaire-6 (PIQ-6) was performed to assess for improvement in quality of life. A matched pair Student two-tailed t-test was used to compare mean scores pre- and post-treatment, with 95% confidence intervals presented as T scores and their associated p-values.ResultsOver six years, 62 SVE procedures were performed for symptomatic varicocele. Success rate was 95%, with a median followup of nine months. Two patients had a failed procedure on two occasions requiring subsequent surgical ligation. There was one clinically significant recurrence. All components of PIQ-6 score showed a statistically significant reduction post-SVE, most noticeably pain severity and impact on leisure activities.ConclusionsSVE is a safe, effective, and well-tolerated treatment for symptomatic varicocele, improving pain and quality of life.     

A case of non-traumatic rupture of varicocele

We report a case of a non-traumatic rupture of varicocele. A 28-year-old man visited our hospital complaining of left scrotal swelling with severe spontaneous pain of sudden onset after straining for defecation. MRI revealed a dilated spermatic cord with scrotal hematoma surrounding the left testis, which leads to the diagnosis of varicocele rupture. Conservative treatment with oral analgesics for a couple of weeks relieved the swelling and pain. Subinguinal microscopic ligation of left spermatic veins was performed 4 months later.