Endovascular management for Varicocele
Varicocele, characterized by enlarged and twisted veins within the spermatic cord’s pampiniform plexus, is prevalent in around 15% of men, more so in those with infertility issues. Despite often being asymptomatic, varicocele can lead to declining testicular function, impacting semen parameters and testosterone levels. Treatment can halt this decline, improving testicular function, semen quality, and even testosterone levels. Surgical and nonsurgical methods exist, including traditional surgical ligation, laparoscopic approaches, and radiographic interventions. Recurrence rates vary, with percutaneous embolization emerging as the least invasive option, using venography for precise identification and minimal risk to the testicular artery. Unlike surgical methods, percutaneous approaches require less extensive anesthesia, providing potential benefits for both infertility and scrotal pain treatment.
| Anesthesia | Local anesthesia and intravenous sedation |
| Vascular access | 1. Right Common femoral vein 2. Internal Jugular vein 3. Basilic vein |
| Anatomy | 1. Right internal spermatic vein - is typically located at an acute angle on the right anterolateral inferior vena cava just below the right renal vein. 2. Left internal spermatic vein - typically drainage into Left renal vein |
| Venography | 1. Catheter tip - junction of the distal internal spermatic vein and the pampiniform plexus 2. Patient in reverse Trendelenburg position or ask the patient to perform the Valsalva maneuver - helps in diagnosis and mapping of the venous collaterals (presence of collaterals can lead to unsuccessful embolization with resultant persistence or recurrence of varicocele) |
| Embolic Agent | 1. Solid embolic - coils and vascular plugs 2. Liquid embolic - Sclerosant sodium tetradecyl sulfate (STS) and adhesive polymers like NBCA (glue) |
| Technical success | Cessation of flow as demonstrated by intra-operative imaging |
| Failure rates | 1. Right side - 19.3% and Left side - 3.2% (results similar to surgery) 2. Overall 13.05% Embolization was inferior to microsurgical varicocelectomy with regard to natural pregnancy rates |
| Recurrent varicocele following surgical therapy | Success results 93% to 100% |
| Fertility | Significant increases in - median sperm concentration - sperm motility, - vitality, - percentage of normal sperm, and - sperm head morphology No improvement in - postoperative serum testosterone, - FSH or - inhibin B levels |
| Scrotal pain | Surgery may exacerbate pain due to post operative inflammation and scarring. percutaneous approach should be preferred. |
| Complications | 1. Peri-procedural pain - 5-7 days, 2. Fever, epididymo-orchitis, testicular or groin swelling or hydrocele 3. Venous injury and hematoma formation 4. Coil migration |
- Halpern, Joshua et al. “Percutaneous embolization of varicocele: technique, indications, relative contraindications, and complications.” Asian journal of andrology vol. 18,2 (2016): 234-8. doi:10.4103/1008-682X.169985
- Cayan S, Shavakhabov S, Kadioglu A. Treatment of palpable varicocele in infertile men: a meta-analysis to define the best technique. J Androl. 2009;30:33–40.
- Kim J, Shin JH, Yoon HK, Ko GY, Gwon DI, et al. Persistent or recurrent varicocoele after failed varicocoelectomy: outcome in patients treated using percutaneous transcatheter embolization. Clin Radiol. 2012;67:359–65.
- Jargiello T, Drelich-Zbroja A, Falkowski A, Sojka M, Pyra K, et al. Endovascular transcatheter embolization of recurrent postsurgical varicocele: anatomic reasons for surgical failure. Acta Radiol. 2015;56:63–9.
- Ramasamy R. Percutaneous embolization: a viable treatment option for varicocele. Basic Clin Androl. 2014;24:10.
- Prasivoravong J, Marcelli F, Lemaitre L, Pigny P, Ramdane N, et al. Beneficial effects of varicocele embolization on semen parameters. Basic Clin Androl. 2014;24:9.
- Tanahatoe SJ, Maas WM, Hompes PG, Lambalk CB. Influence of varicocele embolization on the choice of infertility treatment. Fertil Steril. 2004;81:1679–83.