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

Challenging cases of adherent periarterial vein during subinguinal Fisch technique and subinguinal micro-varicocelecotmy and sclerotherapy: a prospective comparative study

BACKGROUND

To the best of our knowledge, there is a gap in the review of literature about the most suitable varicocelectomy technique in isolating and ligating adherent periarterial vein(s). Consequently, leaving the artery intact or ligating it together with the adherent vein may pose a challenge. We conducted a comparative prospective study to assess the outcomes of the three techniques namely Fisch, sclerotherapy and microvaricoclectomy (MSV).

RESULTS

The patients who underwent MSV showed the longest operative time (66.29 ± 2.78 min), followed by Fisch technique (56.94 ± 3.07 min) then sclerotherapy (55.45 ± 1.99). Thus, the difference in the operative time between the three techniques was statistically significant (P < 0.001). Regarding the postoperative right vein diameter, MSV group showed the largest diameter (2.14 ± 0.15 mm), followed by Fisch technique (2.13 ± 0.15 mm) then sclerotherapy (1.75 ± 0.42 mm). Regarding the postoperative left vein diameter, MSV group showed again the largest diameter (2.17 ± 0.21 mm), followed by Fisch technique (2.14 ± 0.15 mm) then sclerotherapy (1.75 ± 0.42 mm). Moreover, the patients who underwent sclerotherapy showed the highest postoperative progressive sperm motility percent (25.27 ± 4.00%), followed by Fisch technique (21.56 ± 7.30%) then MSV group (19.85 ± 6.33%). Post hoc pair wise comparisons revealed that sclerotherapy and Fisch technique had a significantly higher effectiveness in reducing operative time than MSV. Additionally, it revealed that sclerotherapy technique had a significantly higher effectiveness in reducing postoperative vein diameters measurement than MSV and Fisch technique. Post hoc pair wise comparisons revealed that sclerotherapy technique had a significantly higher effectiveness in improving the postoperative progressive sperm motility percent than MSV. Patients who underwent the 3 techniques demonstrated statistically significant differences between baseline and post-operative vein diameter, reflux duration, sperm concentration, progressive sperm motility, progressive motile count/ejaculate and sperm abnormal forms.

CONCLUSION

The 3 techniques showed significant improvement in the semen parameters after 3 months in the studied patients. However, sclerotherapy technique showed a significantly higher effectiveness in improving the postoperative progressive sperm motility percent compared to MSV.

Comparing the efficacy of different embolisation materials in improving pain and fertility outcomes in patients with varicoceles: A systematic review

Radiological embolisation has emerged as a safe and effective alternative to surgery for varicocele treatment. While systematic reviews have compared embolisation to surgery, attempts to compare different embolisation materials have been limited. The objective was to conduct a systematic review assessing the potential benefits of combining coils with sclerosants for varicocele embolisation on fertility, pain, recurrence and complication rates in male patients, as compared to using coils alone. The search was conducted through MEDLINE, Embase and CENTRAL databases from inception to May 2023. Comparative studies that reported male varicocele patients treated with embolisation using either coils or coils with sclerosants were included, with primary outcomes of either fertility, pain or recurrence. Pearling of reference lists was also performed to identify additional articles. Risk of bias for each study was assessed using the Downs and Black Checklist. Overall, 21 studies (2236 patients) were included. Patients were treated with coils in 14 studies, and nine studies used coils with sclerosants. An improvement in sperm concentration and motility was identified post-embolisation in most studies that reported these outcomes. Pregnancy and recurrence rates were comparable between the two materials. All four studies that reported pain outcomes following embolisation noted improvement in pain scores. Only one comparative study was included, for recurrence. This review has identified improvements in pain and fertility following varicocele embolisation. However, it could not be determined which material was superior due to the lack of high-quality comparative studies in the literature.

A cost outcome study of varicocoele embolisation and future pregnancy in an Australian public hospital setting

INTRODUCTION

Varicocoele is commonly encountered in males with infertility. Studies have shown that varicocoele repair (surgery or embolisation) can improve the rate of subsequent pregnancy. In Australia, there have been no studies assessing the cost of varicocoele embolisation and current practice is based on international data. This study aimed to assess the cost of varicocoele embolisation and estimate the treatment cost per pregnancy.

METHODS

Retrospective cost-outcome study of patients treated by embolisation between January 2018 and 2023. A bottom-up approach was used to calculate procedure costs whereas a top-down approach was used to calculate costs for all other patient services, including direct and indirect costs. To calculate cost per pregnancy, costs were adjusted according to existing published data on the rate of pregnancy after embolisation.

RESULTS

Costing data from 18 patients were included, of median age 33.5 years (range 26-60) and median varicocoele grade 2.5 (range 1-3). All patients had unilateral treatment, most commonly via right internal jugular (16 patients, 89%) and using a 0.035″ system (17 patients, 94%). The median cost for the entire treatment including procedural, non-procedural, ward and peri-procedural costs was AUD$2208.10 (USD$1405 or EUR€1314), range AUD$1691-7051. The projected cost to the healthcare system per pregnancy was AUD$5387 (USD$3429 or EUR€3207).

CONCLUSION

Total varicocoele embolisation cost and the cost per-pregnancy were lower than for both embolisation and surgical repair in existing international studies. Patients undergoing varicocoele treatment should have the option to access an interventional radiologist to realise the benefits of this low-cost pinhole procedure.

Case report of testicular failure and azoospermia after antegrade embolization of varicocele: A rare complication

INTRODUCTION

Varicocele is a common condition affecting males of reproductive age and accounting for the most frequent cause of secondary infertility in males.

PRESENTATION

A young male presented with second infertility and bilateral varicoceles and underwent antegrade angioembolization. He developed testicular ischemia and testicular failure with new onset hypogonadism and cryptozoospermia.

CONCLUSION

Antegrade embolization is a valid option in patients with varicoceles but has its own unique risks of complications.

Radiation Exposure and Surgical Outcomes after Antegrade Sclerotherapy for the Treatment of Varicocele in the Paediatric Population: A Single Centre Experience

INTRODUCTION

Antegrade sclerotherapy (Tauber) effectively treats varicocele. However, fluoroscopy exposes young males to ionizing radiation. We aimed to evaluate radiation exposure and surgical outcomes after the Tauber procedure.

MATERIALS AND METHODS

We retrospectively analysed data from 251 patients. Dose area product (DAP) and fluoroscopy time were recorded. The effective dose was calculated with the PCXMC software. Descriptive statistics and linear regression tested the association between clinical predictors and radiation exposure.

RESULTS

Median (IQR) age and body mass index (BMI) were 14 (13-16) years and 20.1 (17.9-21.6) kg/m². Five (2.1%) patients developed clinical recurrence and two (0.81%) developed complications. Median fluoroscopy time and DAP were 38.5 (27.7-54.0) s and 89.6 (62.5-143.9) cGy*cm². The effective dose was 0.19 (0.14-0.31) mSv. Fluoroscopy time was higher in patients with collateral veins (41 (26-49) s vs. 36 (31-61) s, p = 0.02). The median amount of sclerosing agent (SA) used was 3 (3-4) ml. DAP was higher when SA > 3 mL was used (101.4 (65-183) cGy*cm² vs. 80.5 (59-119) cGy*cm²; p < 0.01). At univariable linear regression, age, BMI, operative time and SA > 3 mL were associated with higher DAP (all p < 0.01). At multivariable linear regression, only BMI (beta 12.9, p < 0.001) and operative time (beta 1.9, p < 0.01) emerged as predictors of higher DAP, after accounting for age and SA > 3 mL.

CONCLUSIONS

The Tauber procedure is safe and associated with low effective doses. Operative time and the patient's BMI independently predict a higher radiation dose.