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Kaltsas A, Markou E, Zachariou A, Dimitriadis F, Mamoulakis C, Andreadakis S, Giannakis I, Tsounapi P, Takenaka A, Sofikitis N. Varicoceles in Men With Non-obstructive Azoospermia: The Dilemma to Operate or Not. FRONTIERS IN REPRODUCTIVE HEALTH 2022; 4:811487. [PMID: 36303681 PMCID: PMC9580802 DOI: 10.3389/frph.2022.811487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 03/10/2022] [Indexed: 12/04/2022] Open
Abstract
The knowledge on male reproduction is constantly expanding, especially in treating infertility due to non-obstructive azoospermia (NOA). Varicocele is occasionally diagnosed in a subpopulation of males with NOA. Varicocele repair in NOA-men may contribute to the reappearance of spermatozoa in semen. However, spontaneous pregnancies are observed in only a small percentage of NOA-men post-varicocelectomy. Additionally, it has been reported that the repair of varicocele in NOA-men (before the performance of sperm retrieval techniques) may increase the testicular sperm recovery rate. In addition, it increases the pregnancy rate in intracytoplasmic sperm injection (ICSI) programs in NOA-men without spermatozoa in the semen post-varicocelectomy. In addition, to the improvement in Sertoli cellular secretory function, varicocelectomy may increase the secretory function of Leydig cells, which subsequently results in improved androgen production, raising the probability to negate the need for testosterone replacement therapy in cases of late-onset hypogonadism. On the other hand, the benefit of varicocelectomy in patients with NOA is still debatable. The current review study aims to provide a critical and extensive review of varicocele repair in males with NOA. This study additionally focuses on the impact of varicocele repair on sperm retrieval rates and its influence on the ICSI outcomes for those couples who remain negative for spermatozoa in their semen samples post-varicocelectomy.
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Affiliation(s)
- Aris Kaltsas
- Laboratory of Spermatology, Department of Urology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
- *Correspondence: Aris Kaltsas
| | - Eleftheria Markou
- Laboratory of Spermatology, Department of Urology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Athanasios Zachariou
- Laboratory of Spermatology, Department of Urology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Fotios Dimitriadis
- Department of Urology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Sotirios Andreadakis
- Laboratory of Spermatology, Department of Urology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Ioannis Giannakis
- Laboratory of Spermatology, Department of Urology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Panagiota Tsounapi
- Department of Urology, School of Medicine, Tottori University, Yonago, Japan
| | - Atsushi Takenaka
- Department of Urology, School of Medicine, Tottori University, Yonago, Japan
| | - Nikolaos Sofikitis
- Laboratory of Spermatology, Department of Urology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
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Makris GC, Efthymiou E, Little M, Boardman P, Anthony S, Uberoi R, Tapping C. Safety and effectiveness of the different types of embolic materials for the treatment of testicular varicoceles: a systematic review. Br J Radiol 2018; 91:20170445. [PMID: 29493263 DOI: 10.1259/bjr.20170445] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE The purpose of this study is to assess the current evidence regarding the safety and effectiveness of the various embolic materials used in varicoceles embolization. METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Databases were searched for clinical studies that investigated the clinical outcomes of embolization treatment for the management of testicular varicoceles. Study methodological quality was analyzed. RESULTS 23 retrospective and 7 prospective clinical studies were identified with a total of 3505 patients. Technical success rates appear to be above 90% for all embolic materials without any significant differences. In terms of recurrence rates, glue (N = 251) appeared to have the lowest and sclerosants alone (N = 728) the highest recurrence rates which were 4.2% (11-3.08%, SD: 5.9) and 11.03% (18.8-5.15%, SD: 6.06) within an average follow up (f/u) of 16.13 and 25.48 months respectively. Coils alone (N = 898) had an average recurrence rate of 9.1% (17.8-1.4%; SD: 5.79) and a mean f/u of 39.3 months. After an average of 12 months of f/u, the addition of sclerosants (N = 1628) as an adjunct to coils did not improve recurrence rates (8.44%, 16.5-5.1%; SD: 3.4). No differences were reported regarding the safety profile of the various embolic materials. CONCLUSION Despite the heterogeneity of the included studies, preliminary evidence supports the safe and effective use of the various embolic materials currently used for the management of varicoceles. At 1 year, glue appears to be the most effective in preventing recurrence with coils being the second most effective. The addition of sclerosants to the coil embolization did not appear to have an impact on recurrence rates. Further research is required to elucidate the cost-effectiveness of these approaches. Advances in knowledge: Varicocele embolization appears to be a safe and effective technique regardless of the embolic agent. Addition of a sclerosant agent to coil embolization does not appear to improve outcomes.
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Affiliation(s)
- Gregory C Makris
- 1 Department of Vascular and Interventional Radiology, Oxford University Hospitals, NHS Foundation Trust , Oxford , UK.,2 Department of Medicine, Alfa Institute of Biomedical Sciences , Athens , Greece
| | - Evgenia Efthymiou
- 1 Department of Vascular and Interventional Radiology, Oxford University Hospitals, NHS Foundation Trust , Oxford , UK
| | - Mark Little
- 1 Department of Vascular and Interventional Radiology, Oxford University Hospitals, NHS Foundation Trust , Oxford , UK
| | - Phillip Boardman
- 1 Department of Vascular and Interventional Radiology, Oxford University Hospitals, NHS Foundation Trust , Oxford , UK
| | - Susan Anthony
- 1 Department of Vascular and Interventional Radiology, Oxford University Hospitals, NHS Foundation Trust , Oxford , UK
| | - Raman Uberoi
- 1 Department of Vascular and Interventional Radiology, Oxford University Hospitals, NHS Foundation Trust , Oxford , UK
| | - Charles Tapping
- 1 Department of Vascular and Interventional Radiology, Oxford University Hospitals, NHS Foundation Trust , Oxford , UK
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Ali A, Wirth S, Treitl KM, Treitl M. Treatment of male varicoceles by transcatheter polidocanol foam sclerotherapy: evaluation of clinical success, complications, and patients' satisfaction with regard to alternative techniques. Eur Radiol 2015; 25:2889-97. [PMID: 25796582 DOI: 10.1007/s00330-015-3684-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Revised: 02/10/2015] [Accepted: 02/18/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVES We report our experience with polidocanol foam sclerotherapy with no additional coils, evaluating clinical success, patients' satisfaction, and complications. METHODS We conducted a retrospective study of 141 patients with 146 varicoceles (mean age: 29.3 years; range: 13 - 60 years) who underwent foam sclerotherapy with polidocanol 2% (range: 2 - 12 ml) in an outpatient setting between January 2007 and December 2013. For the follow-up, telephone interviews with the patients were conducted (mean follow-up time: 46.4 months, standard deviation: 20.17 months). RESULTS The technical success rate was 91.8%. There was a 55.8% response rate to the telephone interviews. Follow-up revealed a clinical success rate of 83.9% and a persistence or relapse rate of 16.1%. Of the patients, 81.9% were absolutely satisfied with the outcome. In 94.9% of cases, pain or discomfort resolution was reported, and in 97% of cases, aesthetic issues were no longer a problem. Of partners, 63.2% achieved pregnancy, and in 50% of patients with preprocedural testicular atrophy, catch-up growth was observed. One patient with pampiniform plexus phlebitis received inpatient treatment with no long-term damage recorded. CONCLUSIONS Polidocanol foam varicocele sclerotherapy is a safe and effective procedure, with a high rate of patients' satisfaction, clinical and technical success, and considerable catch-up growth and pregnancy achievement. KEY POINTS • Varicocele treatment using polidocanol foam sclerotherapy is a safe and effective procedure. • It is easily feasible in an outpatient setting. • The clinical and technical success rates are high. • It shows a high rate of patients' satisfaction and symptom resolution. • Postinterventional catch-up growth and pregnancy achievement are considerable.
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Affiliation(s)
- Alma Ali
- Institute for Clinical Radiology, Hospital of the Ludwig-Maximilians University of Munich, Nussbaumstr. 20, 80336, Munich, Germany,
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Jargiello T, Drelich-Zbroja A, Falkowski A, Sojka M, Pyra K, Szczerbo-Trojanowska M. Endovascular transcatheter embolization of recurrent postsurgical varicocele: anatomic reasons for surgical failure. Acta Radiol 2015; 56:63-9. [PMID: 24413222 DOI: 10.1177/0284185113519624] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Formation or pre-existence of collateral gonadal veins in varicocele patients has been reported as the main cause of surgical treatment failure. PURPOSE To describe venographic findings in patients with postsurgical recurrent varicoceles and to assess the efficacy of the following minimally invasive endovascular treatment. MATERIAL AND METHODS Thirty-three men with failed surgical treatment of left-sided varicocele were examined between 2006 and 2013, using retrograde venography to assess the anatomy of varicocele draining veins before the attempted transcatheter embolization. Anatomic variants of gonadal veins were categorized according to the classification modified for the purpose of the present study. 3% polidocanol was used as an embolic agent together with pushable fibered coils. RESULTS In 31 (93%) out of 33 patients venography demonstrated incompetence of the gonadal vein or veins draining varicoceles after failed surgical treatment. The most frequent venographic finding was gonadal vein duplication - 66% of cases (39% in its mid-portion). Technical success of embolization was achieved in all 31 patients. No major complications were observed. CONCLUSION Retrograde varicocele embolization may be superior to surgery because of its ability to detect gonadal vein variants. In our study group, transcatheter embolization with 3% polidocanol and fibered coils allowed successful, minimally invasive treatment of postsurgical varicoceles.
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Affiliation(s)
- Tomasz Jargiello
- Department of Interventional Radiology, Medical University of Lublin, Lublin, Poland
| | - Anna Drelich-Zbroja
- Department of Interventional Radiology, Medical University of Lublin, Lublin, Poland
| | - Aleksander Falkowski
- Department of Interventional Radiology, Medical University of Lublin, Lublin, Poland
| | - Michal Sojka
- Department of Interventional Radiology, Medical University of Lublin, Lublin, Poland
| | - Krzysztof Pyra
- Department of Interventional Radiology, Medical University of Lublin, Lublin, Poland
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Verstandig AG, Shamieh B, Shraibman V, Raveh D. Radiation dose reduction in fluoroscopic procedures: left varicocele embolization as a model. Eur Radiol 2014; 25:1639-45. [DOI: 10.1007/s00330-014-3556-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 11/23/2014] [Accepted: 12/04/2014] [Indexed: 10/24/2022]
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Abstract
Varicocele is a common treatable cause of testicular pain, male infertility, and Leydig cell dysfunction. Scrotal ultrasonography has become the modality of choice in the diagnosis and post-treatment follow-up of varicocele. Visualization of dilated veins and reflux into the pampiniform plexus enables accurate diagnosis. Although the pathophysiology of varicocele in testicular dysfunction remains unclear, numerous studies have established significant improvement in the seminal parameters and pregnancy rates after varicocele repair. Interventional therapy is a minimally invasive effective treatment option for primary and salvage varicocele repair. This review discusses sonographic criteria used in the pre- and post-procedural evaluation of varicocele and various interventional techniques for varicocele treatment.
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Affiliation(s)
- No Kwak
- Department of Radiology, North Shore-LIJ Health System, Manhasset, NY, USA,
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Puche-Sanz I, Flores-Martín JF, Vázquez-Alonso F, Pardo-Moreno PL, Cózar-Olmo JM. Primary treatment of painful varicocoele through percutaneous retrograde embolization with fibred coils. Andrology 2014; 2:716-20. [PMID: 25073877 DOI: 10.1111/j.2047-2927.2014.00253.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 06/30/2014] [Accepted: 07/09/2014] [Indexed: 11/28/2022]
Abstract
The literature on the treatment of painful varicocoele is limited, likely because of the short period since it was recognized as a clinical entity and the limitations posed by the subjectivity of pain. Our aim was to systematically analyse the results of percutaneous embolization as the chosen treatment for this condition. We conducted a retrospective study of patients undergoing percutaneous embolization as primary treatment for painful varicocoele from January 2007 to November 2013. Radiologic and ultrasonographic successes were evaluated according to the existence or absence of venous reflux on venography after embolization and on Echo Doppler control at 3-6 months. Clinical success was assessed by Visual Analog Scale pain questionnaires before surgery and at 3-6 months; in addition, at the time of the study, telephone interviews were conducted to update the clinical situation and development. A total of 154 patients received operations. The median pain before surgery, at 3-6 months and at the time of interview was 7, 1 and 0 points respectively (p < 0.001). The ultrasonographic success rate at 3-6 months was 68.6%. With a median follow-up of 39 months, the success and relapse/clinical persistence rates were 86.9 and 13.1% respectively. By studying the degree of agreement between clinical success and ultrasonographic success, a kappa index = 0.443 was obtained. Patients with success recounted greater pre-operative pain scores than those who relapsed or persisted (7.5 vs. 5.0; p = 0.004). In patients with painful varicocoele, the ultrasonographic recurrence of venous reflux does not imply the recurrence of pain; hence, the proper assessment of success in these patients should include a systematic assessment of their pain and grade of reflux. Percutaneous retrograde embolization as a primary treatment for painful varicocoele is a clinically effective option with a high success rate that can be maintained in the long term, especially in patients with high pre-operative pain.
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Affiliation(s)
- I Puche-Sanz
- Department of Urology, Virgen de las Nieves University Hospital, Granada, Spain
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Urbano J, Cabrera M, Alonso-Burgos A. Sclerosis and varicocele embolization with N-butyl cyanoacrylate: experience in 41 patients. Acta Radiol 2014; 55:179-85. [PMID: 23888063 DOI: 10.1177/0284185113493774] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Embolization is an established treatment for varicocele. Coils are most frequently used in the procedure. Liquid embolic and sclerosing agents seem to have a number of advantages over coils. PURPOSE To report our experience and explain the technique of using N-2-butyl-cyanoacrylate (N2BCA) in varicocele treatment. MATERIAL AND METHODS From January 2010 to July 2011, 42 gonadal veins in 41 consecutive patients (age range, 11-41 years; mean, 18 years) with a diagnosis of varicocele were treated with N2BCA as an embolic agent. The clinical diagnosis was confirmed by Doppler ultrasound in all patients. Institutional review board approval was obtained, and all the patients signed informed consent for this retrospective review. In all cases, a 4-F hydrophilic catheter was used to catheterize the distal portion of the gonadal vein through which N2BCA, emulsified with lipiodol, was injected. RESULTS The technical success was 100%. No complications or non-targeted embolizations were reported. Seven patients reported moderate post-embolization pain that required oral analgesic treatment for 7-10 days. After 12-month follow-up, all patients exhibited varicocele resolution in the Doppler ultrasound examination as well as relief of all previous symptoms. We have no fertility-related data for patients treated for this condition. CONCLUSION N2BCA as an embolic agent is a therapeutic alternative for the endovascular treatment of varicocele. This technique is uncomplicated, inexpensive, efficient, and safe.
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Affiliation(s)
- José Urbano
- Vascular & Interventional Service, Jiménez Díaz Foundation University Hospital, Madrid, Spain
| | - Manuel Cabrera
- Vascular & Interventional Service, Jiménez Díaz Foundation University Hospital, Madrid, Spain
| | - Alberto Alonso-Burgos
- Vascular & Interventional Service, Jiménez Díaz Foundation University Hospital, Madrid, Spain
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Hawkins CM, Racadio JM, McKinney DN, Racadio JM, Vu DN. Varicocele Retrograde Embolization with Boiling Contrast Medium and Gelatin Sponges in Adolescent Subjects: A Clinically Effective Therapeutic Alternative. J Vasc Interv Radiol 2012; 23:206-10. [DOI: 10.1016/j.jvir.2011.10.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2011] [Revised: 10/22/2011] [Accepted: 10/24/2011] [Indexed: 10/14/2022] Open
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Nees SN, Glassberg KI. Observations on hydroceles following adolescent varicocelectomy. J Urol 2011; 186:2402-7. [PMID: 22019156 DOI: 10.1016/j.juro.2011.07.116] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Indexed: 10/16/2022]
Abstract
PURPOSE There is wide variation in the reported incidence of hydrocele after varicocelectomy (0% to 29%). We determined the incidence of hydroceles and hydrocelectomy following adolescent varicocelectomy, the time it took for them to manifest, and the results of aspiration and surgical correction. MATERIALS AND METHODS Our adolescent varicocele registry was reviewed to identify patients with a post-varicocelectomy hydrocele. We evaluated physical examination and ultrasound findings, postoperative interval to development and treatment results. RESULTS A total of 400 patients with at least 6 months of postoperative followup underwent 521 varicocelectomies (16 redo, 1 right, 104 bilateral) from 1987 to 2010. Mean followup was 32 months (range 6 to 182). Hydrocele was detected in 80 of 521 (15.4%) at a mean of 2 years after surgery. The incidence of hydrocele was higher in open vs laparoscopic (p <0.001), bilateral vs unilateral (p = 0.013), nonlymphatic sparing vs lymphatic sparing (p = 0.043) and Palomo vs laparoscopic nonlymphatic sparing (p = 0.001) procedures. Eight patients underwent aspiration for a large postoperative hydrocele. In all 8 patients fluid returned to pre-aspiration status. There were 29 patients (5.6%) who underwent Jaboulay bottleneck hydrocelectomy and none had recurrence. CONCLUSIONS Hydroceles are a common sequela of varicocelectomy, with the fewest hydroceles occurring after laparoscopic lymphatic sparing varicocelectomy. Patients should be followed for at least 2 years after varicocelectomy to examine for the presence of hydroceles. Although there have been reports on the use of aspiration for post-varicocelectomy hydrocele, we have not had success in those with a single aspiration. Jaboulay bottleneck hydrocelectomy had a 100% success rate in this select group.
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Affiliation(s)
- Shannon N Nees
- Division of Pediatric Urology, Morgan Stanley Children's Hospital of New York-Presbyterian, Department of Urology, Columbia University, College of Physicians and Surgeons, New York, New York 10032, USA
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Gendel V, Haddadin I, Nosher JL. Antegrade pampiniform plexus venography in recurrent varicocele: Case report and anatomy review. World J Radiol 2011; 3:194-8. [PMID: 21860716 PMCID: PMC3158898 DOI: 10.4329/wjr.v3.i7.194] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Revised: 05/20/2011] [Accepted: 05/27/2011] [Indexed: 02/06/2023] Open
Abstract
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.
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Initial experience with percutaneous selective embolization: A truly minimally invasive treatment of the adolescent varicocele with no risk of hydrocele development. J Pediatr Urol 2010; 6:567-71. [PMID: 20149980 DOI: 10.1016/j.jpurol.2010.01.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2009] [Accepted: 01/06/2010] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Postoperative hydrocele development is a frustrating complication of varicocele surgical repair. To avoid this complication, we began to offer percutaneous embolization as a treatment option. We present our initial experience with this technique. METHODS A retrospective review of all patients who underwent percutaneous embolization and sclerotherapy of a varicocele at our institution was performed. RESULTS There were 27 patients with a mean age of 16 years (range 13-19 years). Indications included pain (48%), varicocele size (30%) and persistent testicular asymmetry (22%). Four patients had experienced failure of a previous surgical repair. Follow-up data were available for 21 patients (mean 9 months). The varicocele resolved in 19 patients (91%) with no evidence of hydrocele formation in any of the boys. There was resolution of pain in all patients for whom this was the indication for the procedure. In the two failures, access to the lower spermatic vein was not possible owing to the number and tortuosity of the vessels. CONCLUSIONS Percutaneous embolization and sclerotherapy represent a truly minimally invasive treatment with low morbidity, minimal pain and rapid recovery. In our early experience, since lymphatic channels are completely avoided, there appears to be no risk of hydrocele formation.
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Digital Subtraction Angiography–Guided Foam Sclerotherapy of Peripheral Venous Malformations. AJR Am J Roentgenol 2010; 194:W439-44. [PMID: 20410391 DOI: 10.2214/ajr.09.3416] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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