Percutaneous varicocele embolization versus surgical ligation for the treatment of infertility: changes in seminal parameters and pregnancy outcomes

Varicoceles: Overview of Treatment from a Radiologic and Surgical Perspective

A testicular varicocele is the result of the expansion of the venous pampiniform plexus of the scrotum. Often painless, a significant number of patients experience orchialgia, swelling, testicular atrophy, and abnormalities in spermatic parameters. Treatment of symptomatic varicocele involves a radiologic or surgical intervention to obstruct the reflux of venous drainage. Testicular anatomy, diagnostic evaluation and imaging, options for surgical intervention, and a step-by-step description of retrograde embolization and antegrade scrotal sclerotherapy are discussed. Furthermore, included is an overview of postprocedural management and patient outcomes for radiological interventions, and the most up-to-date evidence on the efficacy of varicocele treatments as well as how they compare to each other.

Do sclero-embolization procedures have advantages over surgical ligature in treating varicocele in children, adolescents and adults? Results from a systematic review and meta-analysis

We aimed to systematically review complications, and recurrence rate of varicocele treatment by comparing the surgical ligature versus sclero-embolization techniques in children, adolescents and adults. The secondary outcomes were the evaluation of semen parameters and spontaneous pregnancy rate in adults. The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework. Continuous variables were pooled using the inverse variance of the mean difference (MD) with a fixed effect, and 95% confidence interval (CI). The incidences of complications were pooled using the Cochran-Mantel-Haenszel Method with the random effect model and reported as Odds Ratio (OR), and 95% CI. Statistical significance was set two-tail p-value < 0.05. Twenty studies were included. Incidence of postoperative hydrocele was significantly higher in the surgical ligation group (OR 3.06 95% CI 1.06-8.88, p = 0.04). Incidence of postoperative orchiepidydimitys was significantly higher in sclero-embolization group (OR 0.26 95% CI 0.08-0.85, p = 0.02). Presence of normal spermatozoa was significantly higher sclero-embolization group compared with the surgical ligature group (MD 2.54% 95% CI 0.43-4.65, p = 0.02). No difference was found in overall complications, wound infection, testis pain, surgical site hematoma, total sperm count, sperm motility, pregnancy and recurrence rate. This review confirms that current data does still not support the superiority of one type of treatment over other ones.

Improvement of semen parameters after coil embolization of varicoceles: a systematic review

This systematic review was conducted in accordance with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, including clinical studies in which one of the outcomes was semen parameter improvement after varicocele embolization using coils only. The objective of the review was to assess the evidence on the role of embolization using coils alone for semen parameter improvement in men with varicocele, since embolization using coils is the most cost-effective method of varicocele repair. Study quality was assessed using the methodological index for non-randomized studies (MINORS). Out of six retrospective and two prospective observational or comparative clinical studies involving 701 patients, semen concentration improved significantly in all five studies that assessed this parameter. Mean semen motility improved significantly in seven studies. The impact of embolization on semen density could not be analyzed.

[Recommendations of the Committee of Andrology and Sexual Medicine of the AFU concerning the management of Varicocele]

The diagnosis of varicocele is clinical, carried out in supine and standing position and in Valsalva maneuver. Only clinical varicoceles have to be treated. A scrotal ultrasound with Doppler is generally performed as part of the infertile man's evaluation or in case of examination difficulties. The main indication for varicocele treatment is the adult man with clinical varicocele and abnormalities of sperm parameters, in a context of infertility of couple, with a partner having a satisfactory ovarian reserve and no cause of female infertility or a curable infertility cause. The decision to treat varicocele must therefore be taken after evaluation of the two partners of the couple. Adults with symptomatic varicocele and those with spermogram abnormalities may also be offered a cure for their varicocele even in the absence of a paternity plan, as well as adolescents with reduced testicular growth, an ipsilateral decrease testicular volume, or a size gradient between the 2 testes. The cure of varicocele can be carried out by surgery or by percutaneous embolization. Microsurgery (inguinal or subinguinal) offers lower rates of recurrence and complications than high surgical approaches (laparoscopic or not) and surgeries without magnification. It is therefore the reference surgical technique. Percutaneous retrograde embolization is a minimally invasive alternative to microsurgery offering satisfactory outcomes with rare and often benign complications. The cure for varicocele results in an improvement in sperm parameters and recent data seem to confirm that it increases the natural pregnancy rate. These results appear after a delay of 3 to 9 months (at least 1 to 2 cycles of spermatogenesis). When the sperm involvement was severe (azoospermia, severe oligospermia), the improvement of the spermogram allow (1) to avoid surgery testicular sperm extraction or (2) perform intrauterine insemination rather than ICSI.

Varicocele and Testicular Pain: A Review

Varicocele is the dilatation of the scrotal portion of pampiniform plexus and the internal spermatic venous system. About 15% of men suffer from scrotal varicocele and 2% to 10% of them complain of pain. The probable mechanisms for pain include compression of the surrounding neural fibers by the dilated venous complex, elevated testicular temperature, increased venous pressure, hypoxia, oxidative stress, hormonal imbalances, and the reflux of toxic metabolites of adrenal or renal origin. Testicular pain associated with varicoceles is typically described as a dull, aching, or throbbing pain in the testicle, scrotum, or groin; rarely, it can be acute, sharp, or stabbing. The management of testicular pain associated with varicocele starts with a conservative, non-surgical approach and a period of observation. Varicocelectomy in carefully selected candidates with clinically palpable varicocele resolves nearly 80% of all cases of testicular pain. Microsurgical techniques for varicocelectomy have gained popularity with minimal complication rates and favorable outcomes. The grade of varicocele, the nature and duration of pain, body mass index, prior conservative management, and the type of surgical method used, are predictors for the success of varicocelectomy.

Varicocele management for infertility and pain: A systematic review

Despite being first described two thousand years ago, the varicocele remains a controversial multifaceted disease process with numerous biological consequences including infertility, hypogonadism, and chronic orchidalgia. The underlying mechanisms remain poorly understood and likely include hypoxia, oxidative stress, hyperthermia, anatomical aberrations, and genetics as primary components. Despite a high prevalence amongst asymptomatic fertile men, varicoceles paradoxically also represent the most common correctable cause for male infertility. In this systematic review we discuss the rich historical aspects of the varicocele and the contemporary data regarding its clinical manifestations. We performed a systematic literature review with the goal of comparing outcomes and complication rates of each of the major surgical approaches as they relate to infertility and pain. We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)-compliant systematic literature review for manuscripts focused on varicocele and its biological consequences. We identified 112 studies suitable for qualitative analysis and included 56 of these for quantitative analysis, with an emphasis on infertility and chronic pain outcomes. Taken together, the clinical work to date suggests that the highest fertility rates and the lowest complication rates are associated with the microsurgical subinguinal surgical approach to varicocelectomy. In all, 26-40% of patients undergoing varicocelectomy will successfully achieve short-term spontaneous pregnancy, and up to 90% of all patients undergoing varicocelectomy for pain will have improvement and/or resolution of their symptoms. Taken together, the data support an ongoing role for varicocelectomy in both of these clinical arenas.

Modified Inguinal Microscope-Assisted Varicocelectomy under Local Anesthesia: A Non-randomised Controlled Study of 3565 Cases

Varicocele is a common abnormality, but the conventional microsurgical subinguinal varicocelectomy (CMSV) has some disadvantages. We invented Modified Inguinal Microscope-Assisted Varicocelectomy (MIMV) under local anesthesia. This study aims to evaluate MIMV by comparing it to CMSV in operating duration, time to return to normal activity, postoperative complications, achievement of natural pregnancy and improvement of semen quality for patients with infertility, pain score for those with scrotal pain, and so on. We enrolled 3089 patients who underwent MIMV and 476 who underwent CMSV in our hospital. Both the operating duration and the time to return to normal activity of MIMV was shorter than that of CMSV (P < 0.001). The recurrence rate (P < 0.001) and injury rate of vas deferens (P = 0.011) after MIMV were lower than that after CMSV. Moreover, patients with MIMV showed higher degree of satisfaction with the surgery experience and outcome than those with CMSV (P < 0.001). However, no statistical difference was found between the two groups in scores of pain due to surgery, postoperative varicose veins diameters, reflux duration, and the postoperative complications of wound infection, hydrocele, atrophy of testis, epididymitis, and scrotal hematoma. In summary, MIMV is a promising varicocelectomy and could be applied more in clinical practice.

The significance of clinical practice guidelines on adult varicocele detection and management

Varicoceles are the most common correctable etiology of male factor infertility. However, the detection and management of varicoceles have not been standardized. This has led to decades of debate regarding the effect of varicocele on male infertility and subsequently whether repair leads to an improved fertility status. The current body of evidence investigating the role of varicocele and varicocelectomy is weak and conflicting. The stance taken by the AUA and ASRM suggests that there is insufficient outcomes data to support evidenced-based guidelines, citing evidence used to provide current recommendations are generally of a low quality level. On the other hand, the EAU Guidelines give a level 1a of evidence for management of varicoceles that are clinically palpable, associated with subnormal semen analyses and having otherwise unexplained fertility. Besides aiding with clinical varicocele detection and management, clinical practice opinion statements and guidelines aim to direct and strengthen the infrastructure of future studies. We review the current status of opinion statements and guidelines in varicocele and management detection with focus on their application in practice.

Varicocele: A Review

Varicoceles are relatively common clinical problem that are associated with pain, testicular atrophy, and reduced fertility rates. After a brief historical perspective is presented, this article reviews the anatomy, indications, treatment options, and potential complications related to varicoceles.

Inguinal and subinguinal micro-varicocelectomy, the optimal surgical management of varicocele: a meta-analysis

Conventional meta-analyses have shown inconsistent results for the efficacy of various treatments of varicoceles. Therefore, we performed a multiple-treatment meta-analysis to assess the effectiveness and safety of 10 methods of varicocelectomy and embolization/sclerotherapy. We systematically reviewed 35 randomized controlled trials and observational studies, from 1966 to August 5, 2013, which compared any of the following treatments for varococeles: laparoscopic, retroperitoneal, open inguinal and subinguinal varicocelectomy, microsurgical subinguinal and inguinal varicocelectomy, percutaneous venous embolization, Tauber antegrade sclerotherapy, retrograde sclerotherapy and expectant therapy (no treatment). Inguinal and subinguinal microsurgery, open inguinal, laparoscopic varicocelectomy showed a significant advantage over expectant therapy in terms of pregnancy rates (odds ratio (OR): 3.48, 2.68, 2.92 and 2.90, respectively). Compared with retroperitoneal open surgery, inguinal microsurgery showed an improvement of sperm density (mean difference (MD): 10.60, 95% confidence interval (CI): 1.92–19.60) and sperm motility (MD: 9.09, 95% CI: 4.88–13.30). Subinguinal and inguinal microsurgery outperformed retroperitoneal open surgery in terms of recurrence (OR: 0.05, 0.06 respectively). Tauber antegrade sclerotherapy and subinguinal microsurgery were associated with the lowest risk of hydrocele formation. The odds of overall complication, compared with retroperitoneal open varicocelectomy, were lowest for inguinal microsurgery (OR = 0.07, 95% CI: 0.02–0.19), followed by subinguinal microsurgery (OR = 0.09, 95% CI: 0.02–0.19). Inguinal and subinguinal micro-varicocelectomy had the highest pregnancy rates, significant increases in sperm parameters, with low odds of complication. These results warrant additional properly conducted randomized controlled clinical studies with larger sample sizes.

Surgical management of male infertility: an update

Male factor infertility is common, affecting 7% of the total population and up to half of couples who are trying to conceive. Various surgical and reconstructive options allow biological paternity depending on the etiology of the male factor issues. This article describes historical treatments and newer approaches, discussing the role for traditional open surgery, microsurgery and robotic surgery, as well as interventional radiologic procedures in the management of male infertility.

Imaging and interventional therapy for varicoceles

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.

Cost-effectiveness analysis reveals microsurgical varicocele repair is superior to percutaneous embolization in the treatment of male infertility

INTRODUCTION

Varicoceles are a common cause of male infertility; repair can be accomplished using either surgical or radiological means. We compare the cost-effectiveness of the gold standard, the microsurgical varicocele repair (MV), to the options of a nonmicrosurgical approach (NMV) and percutaneous embolization (PE) to manage varicocele-associated infertility.

METHODS

A Markov decision-analysis model was developed to estimate costs and pregnancy rates. Within the model, recurrences following MV and NMV were re-treated with PE and recurrences following PE were treated with repeat PE, MV or NMV. Pregnancy and recurrence rates were based on the literature, while costs were obtained from institutional and government supplied data. Univariate and probabilistic sensitivity-analyses were performed to determine the effects of the various parameters on model outcomes.

RESULTS

Primary treatment with MV was the most cost-effective strategy at $5402 CAD (Canadian)/pregnancy. Primary treatment with NMV was the least costly approach, but it also yielded the fewest pregnancies. Primary treatment with PE was the least cost-effective strategy costing about $7300 CAD/pregnancy. Probabilistic sensitivity analysis reinforced MV as the most cost-effective strategy at a willingness-to-pay threshold of >$4100 CAD/pregnancy.

CONCLUSIONS

MV yielded the most pregnancies at acceptable levels of incremental costs. As such, it is the preferred primary treatment strategy for varicocele-associated infertility. Treatment with PE was the least cost-effective approach and, as such, is best used only in cases of surgical failure.

Primary treatment of painful varicocoele through percutaneous retrograde embolization with fibred coils

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.

Left-sided grade 3 varicocele may affect the biological function of the epididymis

OBJECTIVE

Varicocele is present in approximately 30-40% of men evaluated for infertility and in 10-20% of the general male population, but the association between varicocele, compromised semen quality and male infertility remains unclear. This indicates that varicocele may impair spermatogenesis or in some other way mitigate sperm quality. Better understanding of criteria for the selection of men who will benefit from varicocele repair would improve the clinical management of men with impaired semen quality and varicocele.

MATERIAL AND METHODS

To further understand the effect of varicocele repair by embolization in men with grade 3 varicocele, 50 men referred for infertility with varicocele were evaluated before and after embolization.

RESULTS

There was a significant improvement in total sperm count (25.5 ± 4.7 million to 78 ± 11 million, p < 0.001) and sperm motility (slowly and rapidly progressive) (31.5 ± 2.9% to 45 ± 2.5%, p < 0.001) after spermatic vein embolization, comparing baseline to 3 month post-treatment follow-up data. Furthermore, alpha-glucosidase (specific epididymis-derived protein) increased from 61.7 ± 5.7 U to 84.7 ± 7.0 U (p < 0.05) and sperm droplets decreased from 14.2 ± 1.5% to 11.0 ± 1.0% (p < 0.05).

CONCLUSION

The results indicate improved epididymal function and suggest that left-sided grade 3 varicocele may affect the epididymis in addition to effects on the testis.

Surgical management of adolescent varicocele: Systematic review of the world literature

Historically, idiopathic varicocele is the most commonly diagnosed pre-pubertal andrological condition. The clinical presentation of varicocele may vary from dull and dragging unilateral or bilateral testicular pain to visible varicose veins lying over the hemiscrotum. Over the last decade, significant strides were made in managing symptomatic varicoceles, particularly minimal invasive procedures and surgeries. We sought to review the published literature in a systematic manner to gain an overview and streamline the presentations and main treatment modalities.

Varicocelectomy in the treatment of testicular pain: a review

PURPOSE OF REVIEW

Varicoceles are a common finding in adolescent boys and men. Most are asymptomatic, although up to 10% may cause testicular pain. This study will review the use of varicocelectomy in the treatment of testicular pain in men with clinical varicoceles, as well as provide prognostic indicators for successful outcome.

RECENT FINDINGS

Recent studies that examined the impact of varix ligation on preoperative testicular pain were reviewed. Most studies are retrospective and uncontrolled; although objective outcome measures were used in the majority. Varicocele grade, duration of discomfort, and the quality of pain tended to predict outcome but have not been universally supported.

SUMMARY

On the basis of the majority of the recently published studies, varicocelectomy, in the properly chosen patients, results in significant improvement or resolution of testicular pain.

A critical appraisal on the role of varicocele in male infertility

Varicocele is a major cause of male infertility, as it may impair spermatogenesis through several distinct physiopathological mechanisms. With the recent advances in biomolecular techniques and the development of novel sperm functional tests, it has been possible to better understand the mechanisms involved in testicular damage provoked by varicocele and, therefore, propose optimized ways to prevent and/or reverse them. Up to now, there is still controversy involving the true benefit of varicocele repair in subfertile men as well as in certain specific situations such as concomitant contralateral subclinical varicocele or associated nonobstructive azoospermia. Also, with the continued development of assisted reproductive technology new issues and questions are emerging regarding the role of varicocelectomy in this context. This paper reviews the most recent data available on the pathogenesis, diagnosis, and management of varicocele with regard to male infertility.

Antegrade pampiniform plexus venography in recurrent varicocele: Case report and anatomy review

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.

Review of current varicocelectomy techniques and their outcomes

OBJECTIVES

• To review all the various techniques and their results and efficiencies to provide practicing urologists with some guidance for choice of technique • To discuss improvements of varicocelectomy techniques in the last 15 years and their impact on results of surgery.

PATIENTS AND METHODS

• A PubMed English literature review of literature from 1995 to present.

RESULTS

• Pregnancy rates were highest with microsurgical subinguinal technique • Varicocele recurrence rates were lowest with microsurgical subinguinal technique • Hydrocele formation rates were lowest with microsurgical inguinal technique • Surgical complications were highest in the laparoscopic technique • Varicocelectomy by itself or in conjunction with IVF is cost effective

CONCLUSIONS

• Microsurgical subinguinal or microsurgical inguinal techniques offer best outcomes • Varicocelectomy is a cost effective treatment modality for infertility • Further research is needed to explore new developments in varicocelectomy.

Initial experience with percutaneous selective embolization: A truly minimally invasive treatment of the adolescent varicocele with no risk of hydrocele development

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.

Percutaneous treatment of varicocele with microcoil embolization: comparison of treatment outcome with laparoscopic varicocelectomy

Successful treatment of a testicular varicocele, which can result in scrotal pain and swelling as well as male subfertility, can be accomplished via operative ligation of the varicocele or interventional treatment with coil embolization of the testicular vein. This study compared the treatment outcome of percutaneous embolization treatment versus laparoscopic varicocelectomy in patients with symptomatic varicoceles. Patients with varicoceles undergoing either laparoscopic varicocelectomy or percutaneous coil embolization of the testicular vein during a recent 5-year period were analyzed. Treatment outcome and hospital costs of these two minimally invasive treatment modalities were compared. Forty-one patients underwent percutaneous coil embolization of the testicular vein, which were compared with a cohort of 43 patients who underwent laparoscopic varicocelectomy. Technical success in interventional and laparoscopic treatment was 95% and 100%, respectively. The mean operative time or procedural time was 63 +/- 13 minutes and 52 +/- 25 minutes for interventional and laparoscopic cohorts (not significant), respectively. Embolization treatment resulted in two recurrent varicoceles (4.8%) compared to one patient following laparoscopic repair (2.3%, not significant). Embolization treatment was associated with a lower complication rate than laparoscopic repair (9.7% vs 16.3%, p = .03). Regarding cost analysis, no significant difference in hospital cost was noted between the interventional or laparoscopic treatment strategies. Both laparoscopic varicocelectomy and coil embolization are effective treatment modalities for varicoceles. With lower treatment complication rates in the interventional treatment group, coil embolization of the testicular vein offers treatment advantage compared with laparoscopic repair in patients with varicoceles.

Gonadal vein embolization: treatment of varicocele and pelvic congestion syndrome

Therapeutic embolization of the gonadal veins is performed on male and female patients for different clinical situations using similar techniques. The testicular varicocele is a common clinical problem associated with pain and reduced fertility rates. In women, chronic pelvic pain can be attributed to pelvic congestion syndrome, which is said to result from retrograde flow in incompetent ovarian veins. Both of these clinical problems respond well to gonadal vein embolization. In this article, we review the clinical evaluation, diagnostic workup, and technical aspects of percutaneous intervention of gonadal vein embolization. The supporting literature is also reviewed.

Embolization of varicocles: pretreatment sperm motility predicts later pregnancy in partners of infertile men

PURPOSE

To identify predictors of future pregnancy in partners of infertile men undergoing embolization of varicoceles.

MATERIALS AND METHODS

This study was conducted within local institutional review board guidelines, and written informed consent was obtained. In 223 clinically infertile men (age range, 18-50 years) with varicoceles and associated oligoteratoasthenospermia, endovascular embolization of the spermatic veins was performed with distal coil embolization and sclerotherapy. Additional anti-inflammatory treatment was initiated if required. Baseline clinical examination, semen specimen, and hormone level findings were compared to follow-up data. Posttreatment pregnancy rate of their healthy female partners was assessed with a standardized questionnaire. Unconditioned logistic regression was used to identify factors among all available clinical and laboratory data predicting treatment success (sired pregnancy during follow-up).

RESULTS

A total of 226 of 228 varicoceles in 223 patients were successfully treated. Resolution of varicoceles at clinical examination and ultrasonography (US) was observed in 206 patients (92.4%). Three-month follow-up semen analysis in these patients showed significant improvement in sperm motility (P < .001) and sperm count (P < .001); however, average values remained in the abnormal range (World Health Organization guidelines). In 173 patients, follow-up data were successfully obtained, with pregnancy reported in 45 (26%). Baseline sperm motility was identified as the only significant pretreatment factor (standardized regression coefficient beta = 3.285, t = 7.560, P = .006) predicting sired pregnancy. Hormone levels, clinical grading of varicoceles, Doppler US findings, and other semen parameters did not reach statistical significance.

CONCLUSION

Sperm motility prior to varicocele treatment in infertile men is an important predictor of later pregnancy.

Male varicocele: transcatheter foam sclerotherapy with sodium tetradecyl sulfate--outcome in 244 patients

PURPOSE

To retrospectively evaluate the recurrence rate, resolution of pain, improvement of semen parameters, and achievement of pregnancy after transcatheter foam sclerotherapy (TCFS) in varicocele by using sodium tetradecyl sulfate (STS) foam.

MATERIALS AND METHODS

The institutional review board approved the study; informed consent was waived. A retrospective study was conducted in 244 consecutive male patients (mean age, 28.2 years; range, 17-42 years) with 280 varicoceles treated with TCFS between January 2000 and January 2004. The gonadal vein was selectively catheterized by using left antecubital transbrachial venous access; a foam of 3% STS and air was injected. Follow-up was performed with physical and Doppler ultrasonographic examinations and by using a questionnaire-based assessment of pain and pregnancy. Semen analysis was performed according to World Health Organization guidelines. Significant differences in semen parameters before and after treatment were determined by using the Wilcoxon signed rank test.

RESULTS

Technical success rate was 97.1% (272 varicoceles). Complete follow-up results (mean, 40.3 months +/- 19.46 [standard deviation]) in 225 varicoceles (80.4%) revealed eight (3.6%) grade II-III recurrent varicoceles and resolution of pain in 164 (96.5%) of 170 cases. Statistically significant improvement of all semen parameters was achieved in infertile patients after treatment (P < .001). Of 59 patients with pretreatment sperm alterations who desired pregnancy, 23 (39.0%) achieved pregnancy (mean follow-up, 28.6 months +/- 7.77).

CONCLUSION

TCFS in male varicocele with 3% STS foam was associated with a low recurrence rate, a high rate of pain resolution, and a significant improvement of pretreatment sperm parameter alterations; a substantial increase in pregnancy achievement was obtained for patients with pretreatment sperm alterations who desired pregnancy.

Reassessing the value of varicocelectomy as a treatment for male subfertility with a new meta-analysis

OBJECTIVE

To determine the efficacy of varicocelectomy as a treatment for male factor infertility by improving the chance of spontaneous pregnancy.

DESIGN

Meta-analysis.

SETTING

Cleveland Clinic's Glickman Urological Institute.

PATIENT(S)

Infertile men with abnormal results on semen analyses and a palpable varicocele.

INTERVENTION(S)

Surgical varicocelectomy.

MAIN OUTCOME MEASURE(S)

Spontaneous pregnancy outcome.

RESULT(S)

The odds of spontaneous pregnancy after surgical varicocelectomy, compared with no or medical treatment for palpable varicocele, were 2.87 (95% confidence interval [CI], 1.33-6.20) with use of a random-effects model or 2.63 (95% CI, 1.60-4.33) with use of a fixed-effects model. The number needed to treat was 5.7 (95% CI, 4.4-9.5).

CONCLUSION(S)

Surgical varicocelectomy in infertile men with palpable lesions and at least one abnormal semen parameter improves the odds of spontaneous pregnancy in their female partners. Five studies were included (two randomized, three observational). All were scored for bias. Our study suggests that varicocelectomy in selected patients does indeed have beneficial effects on fertility status.

Varicocele sclerotherapy improves serum inhibin B levels and seminal parameters

The usefulness of treating varicocele in order to improve fertility is still a matter of debate. The aim of this study was to evaluate variations in seminal parameters and inhibin B concentrations in a group of males affected by varicocele and treated by percutaneous retrograde sclerotherapy in comparison with a group of patients who did not undergo varicocele treatment. Thirty-eight patients with left varicocele underwent spermatic vein phlebography and percutaneous retrograde sclerotherapy with hydroxy-polyaethoxy-dodecanol. Serum inhibin B, follicle-stimulating hormone (FSH), testosterone levels and seminal parameters (sperm concentration, motility and morphology) were performed before and 6 months after sclerotherapy. Forty patients with left varicocele who did not undergo sclerotherapy were studied as controls. A significant increase (p < 0.01) in serum inhibin B levels and a significant decrease (p < 0.05) in FSH levels were observed 6 months after treatment. Semen analysis showed a significant improvement in sperm concentration (p < 0.05) and progressive motility (p < 0.01) after treatment. In control group no significant variations in hormonal and seminal parameters were observed 6 months after the basal examination. Six months after the basal evaluation, inhibin B levels were significantly higher in treated subjects than in controls (p < 0.05) whereas FSH levels were significantly lower (p < 0.05). Sperm concentration and progressive motility were significantly increased (p < 0.05 and p < 0.001, respectively) in treated subjects in comparison with controls. In conclusion, varicocele sclerotherapy improves inhibin B levels and seminal parameters, confirming the positive effect of this treatment on spermatogenesis and Sertoli cell function.

Minimal invasiveness and effectivity of subinguinal microscopic varicocelectomy: a comparative study with retroperitoneal high and laparoscopic approaches

AIM

The standard management of varicocele repair is the subject of ongoing controversy. We retrospectively evaluated three surgical methods of varicocele treatment to determine the minimally invasive and most effective procedure.

METHODS

We performed 144 varicocelectomies on infertile patients with left clinical varicocele. Of the patients, 50 were treated with retroperitoneal high ligation under lumbar anesthesia, 33 with laparoscopic ligation under general anesthesia, and 61 with subinguinal microscopic ligation under local anesthesia. Operative time, hospital days, and clinical outcomes were compared between these techniques.

RESULTS

The operating time and hospitalization period required for subinguinal microscopic ligation was signi fi cantly shorter compared to those for the other procedures. All patients treated with subinguinal microscopic ligation could achieve normal activity as soon as they returned to their rooms. Postoperative complications were observed in fi ve (10.0%) cases treated with high ligation and three (9.1%) laparoscopic cases, but were not observed after the subinguinal procedure. There were six cases (12.0%) of recurrence in the high ligation group and six (6.1%) in the laparoscopic group, but none in the subinguinal group. Sperm density was signi fi cantly improved in all procedures postoperatively, but sperm motility was not improved. The two-year pregnancy rate calculated by the Kaplan-Meier method was 35.8% for high ligation, 40.4% for laparoscopic ligation and 50.9% for subinguinal microscopic ligation, although there were no statistical differences between the three groups.

CONCLUSION

We concluded that subinguinal microscopic varicocelectomy could be a minimally invasive procedure compared to the other two techniques and a worthy method for treating male infertility due to clinical varicocele.

Pediatric varicocele embolization

Varicocele is a very common condition. Although some patients may have pain, it is usually asymptomatic. Treatment of adolescent and pediatric patients is based on the desire to prevent testicular dysfunction and infertility that may be irreversible in adulthood. Venous embolization of the spermatic vein is an effective and minimally invasive method to occlude the varicocele and is known to improve testicular size and function. Embolization can be optimized by use of sclerosant, such as sodium tetradecyl sulfate (STS) foam or ethanol to permanently occlude the internal spermatic vein. About 10 to 15% of patients have recurrent varicocele after embolization. This is usually due to collateral vessels, such as from the right spermatic vein or the splanchnic veins. Embolizing as low as possible, while preventing pampiniform phlebitis by externally compressing the external inguinal ring, and empiric bilateral embolization appear to have the best outcome for preventing recanalization. Complications of varicocele embolization are uncommon. They include pampiniform phlebitis and venous thromboembolism into the renal vein or pulmonary artery.

Follow-up of varicocele treated with percutaneous retrograde sclerotherapy: technical, clinical and seminal aspects

Varicocele is a common cause of male infertility; it can be treated by percutaneous retrograde embolization of the internal spermatic vein in order to improve sperm parameters and male fertility. The aim of this study was to verify the improvement of semen parameters after varicocele retrograde sclerotherapy. We evaluated 223 patients with left (206) or bilateral (17) varicocele (mean age +/- SD, 27.3 +/- 4.7 yr, range 18-37) by clinical, Doppler and seminal examinations; all the patients underwent phlebography, using 5F Cobra catheter from the right femoral vein access to the internal spermatic vein and varicocele sclerosing with Hydroxy-polyaethoxydodecanol. Doppler and seminal examinations 6 months after sclerotherapy were requested for the follow-up. Sixty-seven patients with left or bilateral varicocele who did not undergo sclerotherapy were studied as controls. Six months after sclerotherapy, a complete resolution of left varicocele was present in 172 patients (77.1%), while a partial improvement was obtained in 34 patients (15.3%). In these 206 patients seminal examination showed a significant improvement of sperm concentration (mean +/- SEM, 52.1 +/- 4.1 vs 44.2 +/- 3.6 million/ml, p = 0.002) and progressive motility (40.5 +/- 2.2 vs 33.3 +/- 2.0%, p = 0.0001), but not of normal sperm morphology (38.9 +/- 2.3 vs 37.4 +/- 2.1%, ns). In the control group no significant variations of seminal parameters were observed 6 months after the basal examination. In conclusion, varicocele retrograde sclerotherapy is a well-tolerated technique with a low cost-benefit ratio, able to improve semen parameters.

Percutaneous retrograde varicocele embolisation using tungsten embolisation coils: a five year audit

OBJECTIVE

To assess the efficacy of percutaneous retrograde varicocele embolisation using Spirale tungsten coils over a period of five years.

PATIENTS AND METHODS

Fifty consecutive patients underwent local anaesthetic day case varicocele embolisation via a right femoral approach. Venous anatomy was identified and classified. Morbidity and recurrence were recorded at three month clinical follow up.

RESULTS

The procedurewas technically successful in 94% of the patients. The varicocele recurred in 16%, the majority of whom had complex venous anatomy. 8% of the patients complained of discomfort at follow up.

CONCLUSIONS

Although the coils used in this study have been withdrawn, a high technical success rate is described with failure being predominantly due to complex venous anatomy.

Management strategies for male factor infertility

Although modern assisted reproduction techniques contribute a lot to overcoming severe male factor infertility, application of these methods in every infertile couple would represent an over-treatment. Therefore, conventional treatment modalities are still the first approach to male fertility disorders. Apart from assisted reproduction techniques, these include surgical procedures and the administration of drugs. Causal treatment regimens of proven effectiveness are only available for patients with infertility resulting from hypogonadotrophic hypogonadism. Drug treatment of retrograde ejaculation is also effective. Inconsistent results have been obtained with empirical treatment including antiestrogens, androgens, aromatase-inhibitors, mast cell blockers, zinc and pentoxifylline. Anti-inflammatory and immunosuppressive therapy as well as treatment with antioxidants in the presence of reactive oxygen species has not yet been demonstrated to be effective by controlled studies but represent at least a rational approach which should be investigated more thoroughly. High dosage administration of follicle stimulating hormone aimed particularly at improving disturbed sperm structures, and the combination of tamoxifen with androgens, may be promising developments. A careful diagnostic work-up is necessary before any andrological treatment is commenced so that adequate treatment options can be selected for individual patients.

Selective spermatic venography and varicocele embolization in men with circumaortic left renal veins

The presence of variant venous anatomy may increase the technical difficulty of percutaneous varicocele embolization. The authors review their experience performing venography of the left spermatic vein and varicocele embolization in 18 men with circumaortic left renal veins. Selective catheterization of the left spermatic vein was achieved in all but one patient, and all patients with positive venographic results underwent successful embolization. The site of the confluence of the left spermatic vein and the renal vein was variable and it was necessary to use jugular and femoral venous approaches to achieve selective left spermatic vein catheterization. Familiarity with anatomic variations associated with circumaortic renal veins and with embolization techniques from jugular and femoral venous routes facilitates percutaneous varicocele embolization in patients with this variant.

Percutaneous embolization of varicocele in children: A Canadian experience

BACKGROUND/PURPOSE

The importance of early treatment of varicocele, to prevent testicular damage is widely accepted. Surgical treatment of varicocele has been the standard method of therapy, but recently a less invasive procedure was introduced and utilized mostly in Europe. The authors reviewed their experience with percutaneous embolization and sclerotherapy to assess the feasibility and outcome of this approach in children.

METHODS

The authors conducted a retrospective study including all patients who underwent percutaneous embolization and sclerotherapy for varicocele in the authors' institutions for the last 10 years. Clinical data, investigation, pre and postintervention management, and the technique of the procedure, including sedation and anesthesia when needed, were collected from the charts. Follow-up was obtained from the chart or by phone.

RESULTS

Between 1991 and 2001, 41 patients underwent 43 percutaneous interventions. The median age was 14 years (range, 10 to 20 years). All but 2 were injected with a sclerosing agent; in 26 cases coils were added. All procedures except one were done under local anesthesia with sedation. Only 2 patients were admitted overnight, and 5 patients had minor complications. The average procedure time was 55 minutes. Follow-up data were obtained in 39 patients (95%), with a mean follow-up of 22 months. A total of 89.1% of those who were injected have satisfactory results (cured or improved) without the need for further procedures. Six patients required surgery post-percutaneous procedure, 4 because of persistent or recurrent varicocele and 2 because of technical failure.

CONCLUSIONS

Percutaneous embolization is a safe and effective treatment of varicocele in children with technical success in 95% and therapeutic success in 89%. It now is the authors' first treatment modality for this disease.

Anatomical variations in the human testicular blood vessels

The testis is an important organ upon which the survival of the human species depends. The testicular arteries and veins play major roles in the thermo-regulation that is essential for the efficient functioning of this organ. However, very little is found in the literature about the veins and their anatomical variations. Therefore the testicular veins and arteries in 150 dissection room cadavers at the University of the Witwatersrand, Johannesburg and University of Zimbabwe, Harare were examined for anatomical variations from the usual descriptions in textbooks of Anatomy. Variations were found more frequently in the testicular veins than in the accompanying arteries. The variations, which were more common on the left side, were seen in 32 (21.3%) of the cadavers. In 6 (18.8%) of these cases, the variations were present bilaterally. The veins were either completely or partially duplicated, with or without beading. The duplicated veins terminated in the corresponding renal veins either separately or after combining into one vein. In two cases, the right testicular vein terminated in the right renal vein, rather than in the inferior vena cava. Anatomical variations of the testicular artery were present in 4.7% of cases and were associated with their origin, which were either from unusually high levels of the abdominal aorta or from the renal artery.

The nitinol vascular occlusion plug: preliminary experimental evaluation in peripheral veins

PURPOSE

To compare the nitinol occlusion plug with standard stainless steel coils for the occlusion of moderate-size peripheral veins.

MATERIALS AND METHODS

The nitinol plug is a braided multilayered vascular occlusion device filled with thrombogenic polyester fibers. It is self-expanding and can be recaptured into its 6-F introducing sheath for repositioning prior to detachment. Ten occlusion procedures were performed in five dogs from a retrograde transjugular venous approach. Five nitinol plugs (diameter: 7.4 mm +/- 0.5) were deployed in five femoropopliteal veins (diameter: 6.5 mm +/- 0.7; mean oversizing 14.6%). Two sequential Gianturco coils (diameter: 7.4 mm +/- 0.9) were deployed in the corresponding contralateral veins (diameter: 6.2 mm +/- 0.8; mean oversizing 19.6%). Follow-up venography was performed at 1 month, following which the animals were killed and the vessels were explanted.

RESULTS

Time-to-occlusion was significantly shorter with the nitinol plug as compared to two Gianturco coils (4.2 minutes +/- 3.4 vs 25.6 minutes +/- 14.1, respectively [P < .03]). At 1 month all but one coil-doublet (80%) had recanalized or migrated, compared to only one nitinol occluder (20%, P < .04). Histopathologic examination of plug-occluded veins showed a uniform organized matrix and underlying intimal proliferative response.

CONCLUSION

A single nitinol occluder resulted in significantly faster occlusion time and significantly lower recanalization or migration rate than two Gianturco coils, in moderate-size peripheral veins.