[New techniques for embolisation of the internal spermatic vein: intravenous tissue adhesive (author's transl)]

CIRSE Standards of Practice on Varicocele Embolisation

BACKGROUND

Percutaneous embolisation is an effective, minimally invasive means of treating a variety of benign and malignant lesions and has been successfully used to treat varicoceles since the late 1970s, with refined and expanded techniques and tools currently offering excellent outcomes for varicocele embolisation.

PURPOSE

This document will presume that the indication for treatment is clear and approved by the multidisciplinary team (MDT) and will define the standards required for the performance of each modality, as well as their advantages and limitations. CIRSE Standards of Practice documents are not intended to impose a standard of clinical patient care, but recommend a reasonable approach to, and best practices for, the performance of percutaneous varicocele embolisation.

METHODS

The writing group was established by the CIRSE Standards of Practice Committee and consisted of five clinicians with internationally recognised expertise in embolisation of male varicoceles. The writing group reviewed the existing literature on varicocele embolisation, performing a pragmatic evidence search using PubMed to search for publications in English and relating to human subjects published from 2006 to 2021. The final recommendations were formulated through consensus.

CONCLUSION

Embolisation has an established role in the successful management of male varicoceles. This Standards of Practice document provides up-to-date recommendations for the safe performance of varicocele embolisation.

Embolization in Pediatric Patients: A Comprehensive Review of Indications, Procedures, and Clinical Outcomes

Embolization in pediatric patients encompasses a large spectrum of indications, ranging from the elective treatment of congenital diseases of the cardiovascular system to the urgent management of acute hemorrhagic conditions. In particular, the endovascular treatment of central and peripheral vascular malformations and hypervascular tumors represents a wide chapter for both congenital and acquired situations. Thanks to the progressive availability of low-profile endovascular devices and new embolic materials, the mini-invasive approach has gradually overtaken surgery. In this review, the main embolization procedures will be illustrated and discussed, with a focus on clinical indications and expected outcomes. The most recent mini-invasive techniques will be described, with hints on the cutting-edge devices and embolic materials.

Relevant Biological Effects of Varicocele Embolization with N-Butyl Cyanoacrylate Glue on Semen Parameters in Infertile Men

Surgical treatment or varicocele embolization (VE) with sclerosing or mechanical embolic agents have been shown to improve the semen parameters of infertile men. The aim of this study was to evaluate the impact of VE using N-butyl cyanoacrylate (NBCA) glue on semen parameters in infertile men. From January 2014 to June 2018, infertile adult patients with stage 3 varicocele and an initial semen analysis showing at least one abnormal semen parameter, and who were successfully embolized with NBCA Glubran^®2 glue, were retrospectively recruited. The availability of a second semen analysis after VE was mandatory for patient inclusion. The primary endpoint was the change in total sperm number (TSN) after VE. The other parameters of interest were progressive and total sperm motilities (Smot) at 1 h (H1), sperm vitality (SV) and morphology (SMor). One hundred and two patients were included. Eight patients presented null TSN before and after VE. Among the remaining 94 patients, a significant improvement in the median TSN after VE was shown (31.79 × 10⁶/ejaculate [IQR: 11.10-127.40 × 10⁶/ejaculate] versus 62.24 × 10⁶/ejaculate [IQR: 17.90-201.60 × 10⁶/ejaculate], p = 0.0295). Significant improvement in TSN was found for the 60 oligo- or azoospermic patients (p = 0.0007), whereas no significant change was found for the 42 patients with normal initial TSN (p = 0.49). Other parameters, such as progressive and total SMot, SV and SMor, also significantly improved after VE (p = 0.0003, 0.0013, 0.0356 and 0.007, respectively). The use of NBCA glue as an embolic agent for VE in infertile men with stage 3 varicocele significantly improves the semen parameters.

Liquid and Solid Embolic Agents in Gonadal Veins

Male varicocele and pelvic congestion syndrome (PCS) are common pathologies with high predominance in young patients, having a high impact on the quality of life and infertility. Lately, the use of different endovascular embolization techniques, with various embolizing agents, shows good technical results and clinical outcomes. With the aim of presenting the “state of the art” of endovascular techniques for the treatment of male varicocele and PCS, and to discuss the performance of the different embolic agents proposed, we conducted an extensive analysis of the relevant literature and we reported and discussed the results of original studies and previous meta-analyses, providing an updated guide on this topic to clinicians and interventional radiologists. We have also underlined the technical aspects for the benefit of those who approach this type of interventional treatment. Our review suggests promising results in both the endovascular embolic treatment of male varicocele and PCS; for varicocele, a success rate of between 70% and 100% and a recurrence rate of up to 16% is reported, while for PCS it has been found that technical success is achieved in almost all cases of endovascular treatment, with a highly variable recurrence rate based on reports. Complications are overall rather rare and are represented by periprocedural pain, migration of embolic media and vascular perforations: severe adverse events have been reported very rarely.

Contribution to the Pathophysiology and Treatment of Varicoceles

Anatomical differences between adults and adolescents and between left and right varicoceles were shown in this work. We designed a standardized and reproducible method for pressure measurement in the inguinal internal spermatic vein (ISV). We demonstrated that the mean absolute pressure in the ISV in the upright position is higher than the veno-capillary pressure in the testicle, and hence could impair spermatogenesis prompting the need for treatment in varicoceles.

Histoacryl transparent and Glubran2, the current commercially available adhesives for the treatment of varicoceles, do not differ with regard to efficiency, safety and tolerance during and after embolization. Both adhesives cause a mild pain in 30% of the patients in the week after embolization. The radiation exposure is low during embolizations of varicoceles with highly viscous liquid products. Therefore, the endovascular treatment with glue is an efficient, safe and tolerable method of treatment for varicoceles when applicable.

The evolution and refinements of varicocele surgery

Varicoceles had been recognized in clinical practice for over a century. Originally, these procedures were utilized for the management of pain but, since 1952, the repairs had been mostly for the treatment of male infertility. However, the diagnosis and treatment of varicoceles were controversial, because the pathophysiology was not clear, the entry criteria of the studies varied among centers, and there were few randomized clinical trials. Nevertheless, clinicians continued developing techniques for the correction of varicoceles, basic scientists continued investigations on the pathophysiology of varicoceles, and new outcome data from prospective randomized trials have appeared in the world's literature. Therefore, this special edition of the Asian Journal of Andrology was proposed to report much of the new information related to varicoceles and, as a specific part of this project, the present article was developed as a comprehensive review of the evolution and refinements of the corrective procedures.

Treatment of male varicoceles by transcatheter polidocanol foam sclerotherapy: evaluation of clinical success, complications, and patients' satisfaction with regard to alternative techniques

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.

Tolerance of glue embolization under local anesthesia in varicoceles: a comparative study of two different cyanoacrylates

PURPOSE

To find out whether in varicocele embolization the copolymer cyanoacrylate glue (NBCA-MS) has a better patient tolerance compared to the monomer n-butyl-2-cyanoacrylate (NBCA).

MATERIALS AND METHODS

N=112 insufficient spermatic veins (left sided N=84, right sided N=28) diagnosed in N=83 adult males were prospectively randomized for blinded embolization with either NBCA N=54 (Histoacryl) or with NBCA-MS N=58 (Glubran2). Before, during and up to one week after embolization, patient discomfort was assessed by a standardized pain scale. Type, location and side of discomfort were noted. Statistical analysis was performed with the Mann-Whitney U-test, the McNemar test and the Fisher's exact test.

RESULTS

Embolization caused discomfort in N=48/112 (43%) spermatic veins, comprising N=26/54 (48%) in the NBCA group and N=22/58 (38%) in the NBCA-MS group. During the week after embolization, the overall number of discomfort reports rose to N=62/106 (59%), with an increase to N=30/53 (57%) in the NBCA group and to N=32/53 (60%) in the NBCA-MS group. The number of immediate grade 2 to 4 pain reactions was N=22/112 (20%), and rose to N=37/106 (35%) after one week. No difference in discomfort during embolization and at 1 week after treatment was noted. Characteristics, severity grading, and location of discomfort were similar in both NBCA groups, regardless the time point of observation.

CONCLUSION

Discomfort after glue embolization of varicocele is a common side effect, which might evolve to pain. The assumed lower inflammatory reaction on NBCA-MS was not translated in an improved tolerance.

Endovascular embolization of varicoceles using n-butyl cyanoacrylate (NBCA) glue

Background:

Varicoceles are abnormally dilated veins within the pampiniform plexus. They are caused by reflux of blood in the internal spermatic vein. The incidence of varicoceles is approximately 10–15% of the adolescent male population. The etiology of varicoceles is probably multifactorial. The diagnosis is based on Doppler US. Treatment could be endovascular or surgical.

The aim of the study was to describe and evaluate a novel method of endovascular embolization of varicoceles using n-butyl cyanoacrylate (NBCA) glue.

Material/Methods:

17 patients were subjected to endovascular treatment of varicoceles using NBCA. A 2.8 Fr microcatheter and a 1:1 mixture of NBCA and lipiodol were used for embolization of the spermatic vein.

Results:

All 17 procedures were successful. There were no complications.

Discussion:

Embolization of varicoceles using NBCA glue is efficient and safe for all patients. The method should be considered as a method of choice in all patients. Phlebography and Valsalva maneuver are crucial for technical success and avoidance of complications.

Conclusions:

Endovascular treatment of varicoceles using NBCA glue is very effective and safe.

Efficacy and safety of two different n-butyl-2-cyanoacrylates for the embolization of varicoceles: a prospective, randomized, blinded study

PURPOSE

This was a prospective, randomized, blinded comparative study of the efficacy and safety of two different n-butyl-2-cyanoacrylates (NBCAs) for embolization of varicoceles.

METHODS

A total of 112 insufficient spermatic veins (left-sided, n=84; right-sided, n=28) that were diagnosed in 83 adult males were prospectively randomized for blinded embolization with NBCA (n=54; Histoacryl, Braun, Germany) or NBCA-MS (n=58; Glubran2, General Enterprise Marketing, Viareggio, Lucca, Italy). Handling, embolic efficacy, and safety of both NBCAs were compared according the fulfillment of a standardized embolization plan, the occlusive effect on the spermatic vein, and the sticking to the microcatheter. Statistical analysis was performed with the Mann-Whitney U test and the Fisher's exact test.

RESULTS

Patients of both study arms were comparable for age and clinical indication. Spermatic vein characteristics were comparable for varicocele classification and embolization side. Both NBCAs were equally efficient in occluding the spermatic vein and blocking reflux (NBCA, n=54/54, 100% vs. NBCA-MS, n=54/57, 94.7%; P=0.244). The embolization plan could be accomplished in an equal number of veins for both groups (NBCA, n=45/54, 83.3% vs. NBCA-MS, n=41/58, 70.7%; P=0.124). Adhesiveness of the glue to the microcatheter was the same in both NBCA groups (NBCA, n=25/54, 46.3% vs. NBCA-MS, n=29/58, 50%; P=0.71). No glue-related complications were noted.

CONCLUSIONS

NBCA and NBCA-MS are equally efficient and safe glues for embolization of varicoceles.

Azoospermia and maturation arrest: malfunction of valves in erect poster of humans leads to hypoxia in sperm production site

Maturation arrest (MA) of spermatogenesis is diagnosed on histology as interruption of spermatogenesis before the final stage without impairment of Sertoli or Leydig cells. It is considered a condition of irreversible or absolute infertility. Varicocele, which represents impairment in the testicular venous drainage system, has been shown to be a bilateral disease. Malfunction of the valves increase the hydrostatic pressure in the testicular venous system that exceeds the pressure in the arterial system leading to hypoxia in the testicular microcirculation and in the seminiferous tubules, the sperm production site. Sperm production deteriorates, and ultimately progresses to azoospermia. Our prediction was that MA, if genetic factors are excluded, is the final stage of long standing hypoxia. This would indicate that MA is not always an independent disease entity, but may represent progressive process of deterioration of the testicular parenchyma beyond azoospermia. By histology and electron microscopy, our prediction confirmed, at least partially, that MA is associated with degenerative ischaemic changes in the seminiferous tubules. Adequate treatment of bilateral varicocele by microsurgery or super-selective sclerotherapy of the internal spermatic veins including associated network of venous bypasses, vertically oriented, may resume the flow of oxygenated blood. If irreversible damages did not occur and ischaemia is not too long standing, limited sperm production may be restored, at least partially.

A Proposed Anatomic Typing of the Right Internal Spermatic Vein: Importance for Percutaneous Sclerotherapy of Varicocele

PURPOSE

To classify the anatomic types of the right internal spermatic vein (ISV).

METHODS

We evaluated venograms obtained in 150 consecutive patients with idiopathic varicocele referred for transfemoral sclerotherapy.

RESULTS

Six anatomic types of the right internal spermatic vein (ISV) were recognized. These were classified by the location of their orifices and the tributary venous patterns. In roughly half the patients (53%), the ISV appeared as a simple vein with no remarkable retroperitoneal interconnections. In the remainder, complex retroperitoneal anastomoses were encountered.

CONCLUSION

By understanding these anatomic variations, the angiographer can approach treatment of right-sided varicocele with foreknowledge of the nature of these types and the presence of valves and collaterals.

Pain experience during internal spermatic vein embolization for varicocele: comparison of two cyanoacrylate glues

The purpose of this study was to evaluate possible pain sensation differences in patients after retrograde varicocele embolization either with n-butyl-(2)-cyanoacrylate (NBCA) or with n-butyl-(2)-cyanoacrylate + methacryloxysulfolane (NBCA-MS). Transcatheter varicocele embolization was performed in 64 consecutive patients (62 left, two bilateral). Embolization was done with NBCA (n=32) or NBCA-MS (n=32). Immediately after the procedure, patients were asked to evaluate pain during embolization using a visual analog scale (VAS). Statistical analysis was done with Student's t test. Mean pain score on VAS was 3.23 (range: 0-8) for NBCA and 3.28 (range 0-9) for NBCA-MS. This difference was not significant (P=0.932). Independently of the type of glue, no difference in pain sensation (P value 0.421) was found between patients younger than 18 (n=29) and patients older than 18 years of age (n=35) (younger than18, mean 3.52; older than 18, mean 3.05). No difference in mean pain experience level (P=0.323) was seen in 11 patients with vessel wall perforation (23.4%) during the procedure (3.89; range: 0-8.5) in comparison with those without perforation (mean pain sensation level: 3.13; range: 0-9). No difference in pain experience was found after transcatheter varicocele embolization either with NBCA or NBCA-MS. Age and vessel wall perforation have no influence on pain sensation independently of the type of glue.

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.

Surgical ligation vs. angiographic embolization of the vena spermatica: a prospective randomized study for the treatment of varicocele-related infertility

Varicoceles as a common cause of male infertility are treated either by surgical ligation or, more recently, by angiographic occlusion of the spermatic vein. In the present prospective randomized study 38 patients were treated by surgical ligation and 33 by angiographic embolization. During the 12-month follow-up period a significant increase in sperm number (at 3 and 12 months) and sperm motility (at 12 months) occurred in both groups while sperm morphology remained unaffected. Altogether, 22 pregnancies (31%) were reported within the year following treatment, of which 11/38 (29%) occurred in the ligation group and 11/33 (33%) in the embolization group. Thus both treatment modalities appear equivalent, whereby embolization has the advantage that it can be performed on an outpatient basis.

Reassessment of the accuracy of traditional sperm characteristics and adenosine triphosphate (ATP) in estimating the fertilizing potential of human semen in vivo

Receiver operating characteristic curves and accuracy parameters were computed for traditional sperm characteristics (concentration, motility, morphology) and the number of peroxidase negative cells, and the concentration of adenosine triphosphate (ATP) in semen from populations of fertile and infertile men, and men who achieved a pregnancy after varicocele treatment. The percentage and concentration per millilitre of spermatozoa with rapid linear progressive motility, and the ATP concentration, provided the best discrimination between fertile and treated fertile from infertile men. The misclassification rate was higher for sperm morphology, total progressive motility and viability, whereas sperm concentration and the total sperm count per ejaculate had the worst discriminating power. The number of peroxidase negative cells per 100 spermatozoa was highly specific in identifying men who achieved pregnancy after varicocele treatment. The lower limit of normality of sperm characteristics was remarkably different between fertile men and men achieving pregnancy after treatment or during infertility work-up.

Testicular arterial perfusion in varicocele: the role of rapid sequence scintigraphy with technetium in varicocele evaluation

Rapid sequence scintigraphy was used to study testicular arterial perfusion and venous stasis in 53 patients with varicocele-associated infertility, 17 with idiopathic testicular failure and 9 treated for varicocele. Arterial blood supply to the diseased testicle was decreased in 63 per cent of the patients with subclinical or low grade varicocele compared to 18 per cent with idiopathic testicular failure. In the majority of cases the disturbance of perfusion disappeared immediately after interruption of retrograde blood flow in the internal spermatic vein by transcatheter embolization, whereas persistently impaired perfusion was found in a few cases with no improvement of semen quality after treatment. Venous stasis was found in only 18 per cent of the patients with low grade varicocele compared to 88 per cent with large varicoceles. It is suggested that impaired arterial blood supply rather than venous stasis is the pathogenic factor in epididymo-testicular dysfunction associated with low grade varicocele.