Endovascular Sclerotherapy for Male Varicoceles: A Retrospective Analysis of 1619 Patients

Special Article - Minimally Invasive Surgery: Current & Future Developments

Austin J Surg. 2015;2(2): 1051.

Endovascular Sclerotherapy for Male Varicoceles: A Retrospective Analysis of 1619 Patients

Grosso M1, Balderi A1*, Antonietti A1, Pedrazzini F1, Sortino D1, Vinay C1, Giovinazzo G1, Caridi J2 and Manenti M3

1Department of Radiology, Hospital S. Croce and Carle, Italy

2Department of Radiology, Shands at the University of Florida, USA

3Department of Gynecology Endocrinology Hospital, University of Turin, Italy

*Corresponding author: Balderi A, Dipartimento Radiologico - S.C. Radiodiagnostica Azienda Ospedaliera “S.Croce e Carle” via M.Coppino 26 - 12100 Cuneo, Italy

Received: November 25, 2014; Accepted: January 05, 2015; Published: January 07, 2015


Purpose: To retrospectively evaluate safety and efficacy (resolution of pain, recurrence rate, improvement in sperm counts and motility) after transcatheter sclerotherapy using Lauromacrogrol 400 in 1619 consecutive patients.

Material and Methods: The institutional review board approved the study and informed consent was obtained.

A retrospective analysis was conducted on 1646 procedures using sclerotherapy performed on 1619 male patients (mean age 29.4 years; range 12.3−65.5 years) with varicoceles during twelve years (from 1998 to 2010). Suspicious testicular veins were catheterized via a right femoral vein approach. Sclerosis of affected veins was induced by a slow injection of a liquid sclerosing agent (Lauromacrogol 400; Kreussler Pharma, Wiesbaden, Germany). Patients were discharged after 6 hours of observation. Follow-up was performed with ultrasound (US)-Doppler 30 days after the procedure. Post-procedure semen analysis was available for 56.4 % of patients.

Results: Catheterisation and sclerotherapy were possible in 1613 of 1646 procedures (98%). No major periprocedural complications occurred. Recurrence was found on US-Doppler follow-up in 30 patients (1.9%). All were retreated: 27 (90%) by using the same percutaneous technique and three by surgery. Post-sclerotherapy semen analysis (available for 56.4% of patients) showed significant improvements in sperm counts (mean 7.9 +/- 3.8 million sperm/mL; p<0.005) and motility (7.2 +/- 2.1%; p<0,005).

Conclusion: Percutaneous sclerotherapy is a safe and minimally invasive technique treating for varicoceles in men.

Keywords: Varicocele; Endovascular sclerotherapy


Varicoceles are abnormal dilatations of the spermatic veins. The primary variety develops before puberty (around 12−15 years old), rarely during childhood and adulthood [1]. Primary varicoceles, resulting from reflux into testicular veins, are common (up to 18%) in paediatric subjects [2]. Secondary varicoceles, which are rarer, are caused by external compression of the renal and/or spermatic veins (pelvic or abdominal malignancy, “nutcracker syndrome”), resulting in an increase in hydrostatic pressure.

In 95% of cases varicoceles involve the left spermatic venous plexus (pampiniform) and are attributable to vascular anatomic factors, congenital weakness of the venous walls or incontinent valves. In 4% of cases varicoceles are bilateral, and in 1% are isolated to the right side [3]. Varicoceles are almost always asymptomatic: only a few patients report mild testicular discomfort that is worse on standing or during prolonged effort.

Up until adolescence, normal development of the left testis can be altered by compression by the dilated veins [4]. Furthermore, blood stagnation around the epididymis increases the local temperature from 35° to 37°C, interfering with normal maturation of sperm.

In addition, it has been suggested that reflux of adrenal metabolites, with consequent vasoconstriction, hypo-oxygenation and testicular damage can occur [5]. As a result of these factors, varicoceles are the commonest identifiable cause of infertility in men, being present in 8−22% of the general population and 21−39% of men attending infertility clinics [6]. Commonly associated seminal alterations include oligospermia, asthenospermia, teratospermia and increased numbers of spermatogenetic cells [7].

In Italy, compulsory military service used to permit evaluation of young men: clinical examinations revealed that approximately 15% of recruits had varicoceles. Because this useful screening no longer occurs, military conscription having been abolished, evaluation of teenagers is recommended. In fact, several studies have demonstrated the importance of early management of varicoceles during adolescence to prevent development of adult infertility [8,9].

Traditional therapy for varicoceles includes surgical ligation and exclusion of the spermatic vein in the inguinal region [10]. This can be performed with or without local injection of sclerosing agents. Interventional radiology offers a minimally invasive alternative, potential benefits including, according to comparative studies, lower complication rates [11,12] and quicker recovery of full activity [13], with no statistically significant differences in seminal values or pregnancies achieved. The aim of this study was to assess and report on our twelve year experience of male varicocele sclerotherapy in 1619 patients.

Materials and Methods

During the twelve years from January 1999 to June 2011, 1646 varicocele percutaneous sclerotherapy procedures were performed in our centre on 1619 patients whose ages ranged from 12.3 to 65.5 years (mean ± sd: 29.4 ± 7.7 years). The procedure was the first therapy for 1565 patients (173 of them had symptoms such as scrotal pain) and the second treatment for 54 patients in whom surgical treatment had failed.

In 1587 patients (98%) we performed unilateral left-side treatment instead of in 32 patients we performed a bilateral treatment.

The main indications for treatment were infertility, sub fertility or symptomatic varicoceles. In paediatric patients, the indications were enormous symptomatic varicoceles with the potential to cause testicular atrophy [13].

All patients admitted to our department with varicoceles underwent clinical examination (according to the Dubin and Amelar classification [13]) and scrotal ultrasound (US)-Doppler evaluation during which the veins were studied both at rest and during Valsalva manoeuvres.

Reflux was classified according to the Sarteschi Doppler classification [14-18]:

Grade 1: Prolonged reflux in the vessels of the inguinal canal only during the Valsalva manoeuvre, while scrotal varicosity is not evident in the grey-scale study.

Grade 2: Small posterior varicosities reach the upper pole of the testicle and increase in diameter during the Valsava manoeuvre. Doppler demonstrates evident venous reflux in the supratesticular region only during the Valsalva manoeuvre

Grade 3: Vessels appear enlarged to the inferior pole of the testis when the patient is standing, whereas no dilatation is evident with the patient in the supine position. Colour Doppler demonstrates evident reflux only during the valsalva manoeuvre.

Grade 4: Venous dilatation identifiable with the patient both standing and supine. The dilatation increases with the patient standing and during the Valsalva manoeuvre

Grade 5: Presence of patent venous dilatation in both the prone and supine position. Colour Doppler shows significant baseline venous reflux which does not increase after the Valsalva manoeuvre.

In our study, US-Doppler showed grade I−II varicoceles in 49 patients (3%) grade III in 701 (43.3%) and grade IV−V in 869 (53.7%).

Semen analysis was performed in all patients except for prepubescent children (57 patients were aged < 14 years).

The institutional review board approved the study. Before starting the procedure, an informed consent was obtained from all subjects or both of their parents in the case of minors.

The percutaneous interventions were performed in an angiography suite as day patients (routinely 8 hour same day hospitalization). Atropine (0.5 mg intramuscularly) was administered to minimise the risk of bradycardia during the Valsalva manoeuvre. Steroids/ antihistamines were administered to all reportedly allergic patients.

Following induction of local anaesthesia, the right femoral vein was accessed percutaneously and a 5 Fr sheath inserted through which a catheter with a curve specifically shaped for spermatic vein catheterisation was introduced (VSC catheter; Cook Medical, Bjaeverskov, Denmark). Next, the left renal vein was cannulated, using a spermatic (VSC 1, 2 or 3, Cook) or Cobra catheter (Terumo Europe, Leuven, Belgium) while right spermatic vein was catheterized using Simmons right catheter (Terumo Europe, Leuven, Belgium) under fluoroscopic guidance (MultiDiagnost 3; Philips, Best, The Netherlands). With the patient performing the Valsalva manoeuvre, a renal vein venogram was then obtained (Figure 1 a−d).