Radiological treatment of male varicocele: technical, clinical, seminal and dosimetric aspects

Abstract

Purpose: The purpose of this study was to present our experience with percutaneous treatment of male varicocele considering technical, clinical, seminal and dosimetric aspects.

Materials and methods: At baseline and at 6 months' follow-up, 290 male patients aged between 18 and 37 (average age 27.3 years) with left (266 cases) or bilateral (24 cases) varicocele underwent clinical assessment, Doppler ultrasonography (US), laboratory testing of free and total serum testosterone, leutenising hormone (LH) and follicle stimulating hormone (FSH) gonadotropins, inhibin B and spermiogram. In 223 cases, selective catheterisation of the spermatic vein was performed with a right transfemoral approach. Two hundred and six out of 223 underwent radiological treatment of varicocele; in 194, hydroxy-poliethoxydocanol (Aetoxysclerol) was used only whereas in 12 cases (5.8%), 5 ml of absolute alcohol and a Gianturco coil (0.038-in. Cook coil, 10 mmx50 mm) were also used. In 17/223 patients (7.6%), sclerotherapy was contraindicated or not technically feasible. Sixty-seven patients refused radiological treatment and were used as a control group. In 20 patients, the following parameters were measured: dose area product, entrance surface dose, effective dose and gonad dose.

Results: Technical success was achieved in 206/223 cases; two phlebographic examinations (immediately following administration of the sclerosing agent and after 15-20 min) showed prethrombotic endoluminal alterations of the internal spermatic vein. At 6 months' follow-up, 172/206 patients (83.49%) showed complete resolution of the varicocele whereas 34/206 (16.5%) had only partial disengorgement of the pampiniform plexus. In these 206 patients, the spermogram showed a significant increase in sperm concentration (52.1+/-4.1 vs. 44.2+/-3.6 million/ml, p=0.002) and motility (40.5+/-2.2 vs. 33.3+/-2.0%, p=0.0001), with negligible morphological changes. In the control group and in the other 17 untreated patients, no variations in seminal parameters were observed. The following minor procedural complications were recorded: two cases of acute abdominal pain, three of vagal crisis during administration of sclerosing agent that resolved spontaneously and two of spermatic cord inflammation that resolved within days after medical therapy. We recorded no statistically significant differences with regard to testicular volume or serum hormone levels between the treated and untreated groups. Maximum effective dose and maximum gonad dose equivalent were 6.9 mSv and 0.69 mSv, respectively.

Discussion and conclusions: Percutaneous radiological treatment of varicocele is a minimally invasive technique, which is well tolerated by patients and able to significantly improve seminal parameters. The principal technical limitation to percutaneous treatment is related to difficult selective catheterisation of the spermatic vein due to anatomic alterations, spasms and intimal dissection of the vein. Moreover, when the cremasteric vein is incontinent, inguinal surgical ligation provides better results. In the majority of cases, administration of at least 3 ml sclerosing agent at 3% ensures occlusion of the gonadic vein above the abdominal collaterals, which are responsible for long-term recurrence if not treated. In the remaining cases, absolute alcohol and metallic coils can be used to complete the treatment. The positive results in seminal parameters do not, however, allow for reliable assessment of patients' fertility. Finally, we believe that radiological procedures are not indicated or justified when prolonged catheterisation with elevated gonadic irradiation is needed.