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  • Writer's pictureFrancesco Bruno Tagliaferro

What is varicocele embolization?

Updated: Jan 20

Varicolcele embolization is a minimally invasive procedure, performed under local anesthesia, which selectively closes the veins responsible for the varicocele. It guarantees the same results as traditional surgery but with less invasiveness and faster post-surgery recovery. The patient is discharged on the day of the procedure, without the need to stay overnight in hospital.



WHAT IS MALE VARICOCELE?


Male varicocele is varicose dilatation of the testicular veins secondary to blood reflux into the spermatic vein. It is a very common condition affecting 10-15% of the general male population and 30-40% of men who undergo tests for infertility. It is located on the left in most cases. In 15% of cases it is bilateral. Isolated right varicocele is rare.



WHAT ARE THE SYMPTOMS?


Varicoceles can be asymptomatic. If symptomatic, it can cause:

  • Scrotal mass or swelling of the scrotum

  • Scrotal pain

  • Testicular atrophy

  • Infertility/reduced fertility


ULTRASOUND DIAGNOSIS


The scrotal echo-color-doppler is the reference diagnostic imaging exam for varicocele, as it allows both to confirm the diagnosis and to determine the severity of the pathology. On ultrasound, the varicocele appears as a serpiginous dilatation of the veins of the pampiniform plexus (>2 mm diameter), with reflux during the Valsalva maneuver (even at rest in the most serious cases).


Reflusso di sangue nel plesso pampiniforme ectasico
Reflux in the pampiniform plexus
Ecografia che mostra ectasia del plesso pampiniforme
Pampiniform plexus ectasia

VARICOCELE GRADING ACCORDING TO SARTESCHI Grade I

  • Veins not dilated

  • Reflux in the inguinal canal during valsalva

Grade II

  • Dilated veins at the upper pole of the testicle

  • The reflux extends to the testicle during valsalva

Grade III

  • Veins dilated to any height, visible only when standing

  • Reflux extending to the lower pole of the testicle

Grade IV

  • Veins dilated even in supine position

  • Reflux extending to the lower pole of the testicle

Grade V

  • Dilated veins with reflux even at rest



VARICOCELE EMBOLIZATION


INDICATIONS


Varicocele embolization is indicated in one or more of the following cases

  • Chronic groin/scrotal pain

  • nfertility with sperm abnormalities detected by spermiogram

  • Recurrence of varicocele after surgery

  • Testicular atrophy in pediatric patients


CONTRAINDICATIONS


The varicocele embolization is contraindicated in case of

  • Severe coagulopathy

  • Previous severe allergic reaction to contrast medium

  • Kidney failure


WHAT TO DO BEFORE THE INTERVENTION? Before surgery, it is necessary to perform a scrotal doppler ultrasound and a spermiogram. If necessary, the Interventional Radiologist will request further tests before recommending the procedure. Before the procedure it is necessary to fast for 12 hours, i.e. from the evening before admission.

HOW VARICOCELE EMBOLIZATION IS PERFORMED? Varicocele embolization is a minimally invasive procedure that is performed in day surgery, with no need to stay overnight in the hospital: the patient is admitted in the morning and discharged in the evening. In the operating room, in strictly sterile conditions, after hthe local anesthesia, the Interventional Radiologist performs an ultrasound-guided venous access in the right (or left) basilic vein, using a common needle cannula (1.). After that, a metal guide (2.) is inserted and on this a 4F vascular introducer (about 3 mm in diameter) (3. – 4.), a small plastic tube with a valve that prevents blood from leaking.



Using the X-rays guidance and without further cuts, the Interventional Radiologist navigates inside the venous system with a vascular catheter (a small tube with a diameter of a couple of mm) and a guide wire until he reaches the spermatic vein of the pathological side (both , if necessary).







In the spermatic vein, by injecting a few cc of contrast medium, the Interventional Radiologist confirms the presence of the varicocele.




Once this is done, we proceed to the external compression of the spermatic cord in correspondence with the pubic branch (in the groin) to prevent the embolizing drug from reaching the testicle. The embolizing drug is then injected, generally a 3% ATOSSISCLEROL foam.


The catheter and introducer are then removed and the venous access is closed by manual compression for a few minutes, without stitches, only with a sterile dressing.



AFTER THE PROCEDURE The procedure is performed in Day-Surgery regime: the patient can be discharged the same day of the procedure. Physical and sexual activity should be avoided for at least five days. Pregnancies should be avoided for at least two months.

FOLLOW-UP 3-6 months after surgery, it is necessary to repeat the spermiogram and the scrotal doppler ultrasound.

RESULTS

The results of traditional surgical treatment and embolization are the same

  • Technical success: 93% first treatment

  • 100% post-surgical recurrence treatment

  • 35% of infertile couples will become pregnant after treatment (if no other infertility factors coexist)


COMPLICATIONS


They are modest. Phlebitis (inflammation of the veins) may develop if the embolization drug gets into the pampiniform plexus. This is generally self-limiting, treatable with anti-inflammatory drugs and rest.


  • In 10% of cases there is a modest pain in the lumbar region that lasts 24-48 hours; treatable with anti-inflammatory drugs.

  • 10% of patients report scrotal swelling and discomfort, generally lasting up to 24-48 hours, treatable with anti-inflammatory drugs.



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