Varicolcele embolization is a minimally invasive procedure, performed under local anesthesia, which selectively closes the veins responsible for the varicocele. It guarantees the same results as traditional surgery but with less invasiveness and faster post-surgery recovery. The patient is discharged on the day of the procedure, without the need to stay overnight in hospital.
WHAT IS MALE VARICOCELE?
Male varicocele is varicose dilatation of the testicular veins secondary to blood reflux into the spermatic vein. It is a very common condition affecting 10-15% of the general male population and 30-40% of men who undergo tests for infertility. It is located on the left in most cases. In 15% of cases it is bilateral. Isolated right varicocele is rare.
WHAT ARE THE SYMPTOMS?
Varicoceles can be asymptomatic. If symptomatic, it can cause:
Scrotal mass or swelling of the scrotum
Scrotal pain
Testicular atrophy
Infertility/reduced fertility
ULTRASOUND DIAGNOSIS
The scrotal echo-color-doppler is the reference diagnostic imaging exam for varicocele, as it allows both to confirm the diagnosis and to determine the severity of the pathology. On ultrasound, the varicocele appears as a serpiginous dilatation of the veins of the pampiniform plexus (>2 mm diameter), with reflux during the Valsalva maneuver (even at rest in the most serious cases).
VARICOCELE GRADING ACCORDING TO SARTESCHI Grade I
Veins not dilated
Reflux in the inguinal canal during valsalva
Grade II
Dilated veins at the upper pole of the testicle
The reflux extends to the testicle during valsalva
Grade III
Veins dilated to any height, visible only when standing
Reflux extending to the lower pole of the testicle
Grade IV
Veins dilated even in supine position
Reflux extending to the lower pole of the testicle
Grade V
Dilated veins with reflux even at rest
VARICOCELE EMBOLIZATION
INDICATIONS
Varicocele embolization is indicated in one or more of the following cases
Chronic groin/scrotal pain
nfertility with sperm abnormalities detected by spermiogram
Recurrence of varicocele after surgery
Testicular atrophy in pediatric patients
CONTRAINDICATIONS
The varicocele embolization is contraindicated in case of
Severe coagulopathy
Previous severe allergic reaction to contrast medium
Kidney failure
WHAT TO DO BEFORE THE INTERVENTION? Before surgery, it is necessary to perform a scrotal doppler ultrasound and a spermiogram. If necessary, the Interventional Radiologist will request further tests before recommending the procedure. Before the procedure it is necessary to fast for 12 hours, i.e. from the evening before admission.
HOW VARICOCELE EMBOLIZATION IS PERFORMED? Varicocele embolization is a minimally invasive procedure that is performed in day surgery, with no need to stay overnight in the hospital: the patient is admitted in the morning and discharged in the evening. In the operating room, in strictly sterile conditions, after hthe local anesthesia, the Interventional Radiologist performs an ultrasound-guided venous access in the right (or left) basilic vein, using a common needle cannula (1.). After that, a metal guide (2.) is inserted and on this a 4F vascular introducer (about 3 mm in diameter) (3. – 4.), a small plastic tube with a valve that prevents blood from leaking.
Using the X-rays guidance and without further cuts, the Interventional Radiologist navigates inside the venous system with a vascular catheter (a small tube with a diameter of a couple of mm) and a guide wire until he reaches the spermatic vein of the pathological side (both , if necessary).
In the spermatic vein, by injecting a few cc of contrast medium, the Interventional Radiologist confirms the presence of the varicocele.
Once this is done, we proceed to the external compression of the spermatic cord in correspondence with the pubic branch (in the groin) to prevent the embolizing drug from reaching the testicle. The embolizing drug is then injected, generally a 3% ATOSSISCLEROL foam.
The catheter and introducer are then removed and the venous access is closed by manual compression for a few minutes, without stitches, only with a sterile dressing.
AFTER THE PROCEDURE The procedure is performed in Day-Surgery regime: the patient can be discharged the same day of the procedure. Physical and sexual activity should be avoided for at least five days. Pregnancies should be avoided for at least two months.
FOLLOW-UP 3-6 months after surgery, it is necessary to repeat the spermiogram and the scrotal doppler ultrasound.
RESULTS
The results of traditional surgical treatment and embolization are the same
Technical success: 93% first treatment
100% post-surgical recurrence treatment
35% of infertile couples will become pregnant after treatment (if no other infertility factors coexist)
COMPLICATIONS
They are modest. Phlebitis (inflammation of the veins) may develop if the embolization drug gets into the pampiniform plexus. This is generally self-limiting, treatable with anti-inflammatory drugs and rest.
In 10% of cases there is a modest pain in the lumbar region that lasts 24-48 hours; treatable with anti-inflammatory drugs.
10% of patients report scrotal swelling and discomfort, generally lasting up to 24-48 hours, treatable with anti-inflammatory drugs.
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