Antegrade scrotal sclerotherapy and varicocele

Asian J Androl 2002 Sep; 4: 213-219 

Keywords: antegrade scrotal sclerotherapy; varicocele; reflux; complications

Abstract 

Antegrade scrotal sclerotherapy is a simple and easy technique for the treatment of varicocele. The success rate varies between 87 % and 95 %. The initial reflux grade and the number of collateral vessels of the spermatic vein are the most important factors to predict the outcome of the technique. The postoperative complication rate is about 7 % and the common ones are scrotal hematoma and epididymo-orchitis of slight severity. Testicular athrophy is a rare event (0.6 %). This technique offers a considerable cost reduction compared to other therapeutic options currently available for varicocele.

1 Introduction

The traditional surgical treatment for varicocele was the ligation of spermatic vein at the subinguinal or retroperitoneal level [1,2]. The microsurgical ligation techniques, the laparoscopic ligation of spermatic vein and the scleroembolization procedures were presently the main alternative therapeutic options. The antegrade scrotal sclerotherapy of spermatic vein was described for the first time in 1988 by Tauber et al [3]. It is an easy technique, rapid to perform, effective and with a low complication rate [4]. Our experience with antegrade scrotal sclerotherapy started in 1997 and it was characterized by the introduction of a few technical modifications of the cannulation and sclerotization steps [5]. This paper reviewed the literature data regarding the varicocele treatment by antegrade scrotal sclerotherapy and introduced our modifications.

Before surgery 0.5 mg atropine and 10 mg diazepam were given through im injection as well as an antibiotic prophylaxis with ciprofloxacin. The patient was placed supine in a slight anti-Trendelenburg position. During the treatment the saline solution was administered iv.

The deferens were palpated and digitally separated from the other spermatic cord structures. This manoeuvre, in our opinion, reduced the risk of vagal stimulation during the spermatic cord traction. 7-10 mL of 2 % mepivacaine was administered under the root of the involved emiscrotum. The anaesthetic was injected superficially into the site of the incision and deeply into the area surrounding the spermatic cord. The spermatic cord was isolated and suspended using a Penrose drain (Figure 1). Once the spermatic cord vaginal fascia is opened, a vein of the anterior pampiniform plexus was isolated and cannulated with a particular 24 G - venous catheter. The venous catheter was equipped distally with a 4cm butterfly cannula, a 7cm long flexible and trans-parent intermediate portion and a proximal portion with a two-way adapter to permit the remotion of the mandrel, and the infusion of contrast medium and sclerosing agent separately. The vein was cannulated directly without performing a phlebotomy; the proximal part of the cannula was kept closed by forceps.

Figure 1. The spermatic cord is isolated and suspended using a Penrose drain.

After a phlebography of the spermatic district, the sclerotization was carried out with the air-block technique. The flexible portion of the venous catheter allowed to direct the syringe tip upward, so that 1 mL of air followed by 4 mL of 3 % ethoxysclerol was introduced simul-taneously (Figure 2). During the sclerosing step, the patient performs a Valsalva manoeuvre in order to permit an optimal distribution of the sclerosing agent through the spermatic vein. To prevent ethoxysclerol reflux toward the testis, during the whole sclerosing phase and for the following 5 min, the spermatic cord was clamped by the Penrose drain. Once the venous catheter was removed, the isolated vein was ligated below and over the point of injection. The spermatic cord vaginal fascia and skin suture ended the procedure.

Figure 2. Sclerosing step with air-block technique. The spermatic cord is clamped by the Penrose drain.

Up to July 2002, 9 different series analysing 765 patients who underwent antegrade scrotal sclerotherapy had been published in the literature [4-12]. The reflux persistence rate was between 5 % and 13 % with a mean rate of 8 % (Table 1). The success rate depended significantly on the preoperative reflux grade. The treatment was decisive in 100 % of grade 1 (light) reflux patients, in 87 %-100 % of grade 2 (moderate) reflux patients and in 85 %-89 % of grade 3 (severe) reflux patients [4,5,12]. Most patients with a persistent reflux after antegrade scrotal sclerotherapy presented a lower grade reflux than the original one. This had been observed in 58 % of cases in our series [5]. The lack of a complete spermatic vein occlusion could depend on the use of an insufficient amount of sclerosing agent [4, 6]. The high success rate reported in persistent reflux treatment by a repeated antegrade scrotal sclerotherapy supported this hypothesis indirectly. In our experience, the injection into the spermatic venous district of a larger amount of 3% ethoxysclerol (4 mL) had probably improved the success rate in moderate reflux patients (100 % success rate) but it did not show any significant advantage in severe reflux patients (88 % success rate) [5].

Table 1. Clinical efficacy and morbidity of antegrade scrotal sclerotherapy: literature analysis.

Other anatomical aspects predictive of failure of antegrade sclerotization are the presence of a high number of collateral vessels of inner spermatic vein and a bilateral varicocele [6, 9].

In our experience, the only data related to reflux persistence were the initial severe reflux grade and the presence of a high number of collateral vessels (un-published data). But we had not observed the reflux persistence in patients with bilateral varicocele.

For patients with cross-communications between the left and right districts, we prefered bilateral sclero-tization.

The complication rate was between 0% and 14% [4-12]. The common complications were scrotal haematoma (1.5 %-2.2 %) and epididymo-orchitis (0.5 %- 2 %). The occurrence of pampiniform plexus throm-bophlebitis, erythemas, persistent flank pain, surgical wound infections and contrast medium allergic reactions was rarely described. Hydrocele is not a common compli-cation reported only by Fette et al [10]. Testicular atrophy was the most relevant complication reported. It has occured less than 1 % of cases and it could be followed by an injurious effect of the sclerosing agent on the testis, a lesion of arterial testicular district or a massive occlusion of the venous testicular plexus with a complete inter-ruption of the venous flow [4,13]. Clamping spermatic cord during sclerosing step could be an effectivemethod to avoid sclerosing agent reflux towards the testis.

The complication rate showed a relationship to sur-geon's knowledge and skill. In one of our experiences, most complications were observed in the first 30 treated patients. According to what Tauber and Johnsen reported in 1994, we also agreed that antegrade sclerotherapy need a particular care and should be performed by surgeons that have already completed a specific training. The kind of anaesthesia, the short length of the procedure and the stay in hospital could be valued as indirect parameters of the invasivity for this technique [14].

Antegrade scrotal sclerotherapy was usually per-formed under local anaesthesia. Fette et al reported the only treatment undertaken general anaesthesia [10]. We justified their choice with the adolescent patients and with a possible lack of compliance with surgical procedure under local anaesthesia. In Frangis series, general anaesthesia had been used in 53 % of patients and it was related to the Center's practical experience [9]. The need of general anaesthesia in adolescent patients is probably overestimated according to the results recently reported by Mazzoni et al[11].

In our experience, local anaesthesia was enough in 12-18 years old patients. In no case it needed sedation or general anaesthesia. Moreover, we believe that undertaking the sclerosing step under local anaesthesia allows patients to perform a Valsalva manoeuvre in order to improve the diffusion of sclerosing agent through the venous spermatic district.

The mean operating time is between 12 min and 30 min. Surgeons who are in the course of learning this technique generally need a longer operating time.

Antegrade scrotal sclerotherapy was a "one day surgery" technique. The in-hospital stay was between 2 and 4 h in most series [4-6, 8, 11]. A further advantage of antegrade scrotal sclerotherapy compared to other therapeutic options for varicocele was the lower cost of materials and articles necessary to perform the surgery [12, 14, 15].

References

[1] Ivanissevitch O, Gregoriani H.:A new operation for the cure of the varicocele. Semana Med 1918; 61: 17.
[2] Palomo A. Radical cure of varicocele by a new technique: preliminary report. J Urol 1949; 61: 604.
[3] Tauber R, Weizert P, Pfeiffer KJ, Huber R.Die antegrade Sklerosierung der Vena spermatica zur Therapie der Varkozele. Verhand Dtsch Gesell Urol 1988. 239-40.
[4] Tauber R, Johnsen N. Antegrade scrotal sclerotherapy for the treatment of varicocele: technique and late results. J Urol 1994; 151: 386-90.
[5] Ficarra V, Porcaro AB, Righetti R, Cerruto MA, Pilloni S, Cavalleri S, Malossini G, Artibani W. Antegrade scrotal sclerotherapy in the treatment of varicocele: a prospective study. BJU Inter 2002; 89: 264-8.
[6] Kuenkel MR, Korth K. Rationale for antegrade sclerotherapy in varicoceles. Eur Urol 1995; 27: 13-7.
[7] De Groote P, Baert J, Carpentier P, Fonteyne E, Morelle V. Antegrade scrotal sclerotherapy in the treatment of varicocele. Acta Urol Belg 1995; 63: 57-62.
[8] Mottrie AM, Matani Y, Baert J, Voges GE, Hohenfellner R. Antegrade scrotal sclerotherapy for the treatment of varicocele in childhood and adolescence. Br J Urol 1995; 76: 21-4.
[9] Frangi I, Keppenne V, Coppens L, Bonnet P, Andrianne R, de Leval J.  Antegrade scrotal embolization of varicocele: results. Acta Urol Belg 1998; 66: 5-8.
[10] Fette A, Mayr J. Treatment of varicoceles in childhood and adolescence with Tauber's antegrade scrotal sclerotherapy. J Pediatr Surg 2000; 35: 1222-5.
[11] Mazzoni G, Spagnoli A, Lucchetti MC, Villa M, Capitanucci ML, Ferro F. Adolescent varicocele: Tauber antegrade sclerotherapy versus Palomo repair. J Urol 2001; 166: 1462-4.
[12] Sautter T, Sulser T, Suter St, Gretener H, Hauri D. Treatment of varicocele: a prospective randomized comparison of laparoscopy versus antegrade sclerotherapy. Eur Urol 2002; 41: 398-400.
[13] Goll A. Albers P, Schoeneich G, Haidl G, Burger R. Testicular loss due to hemorrhagic infarct in Tauber antegrade scrotal varicocele sclerotherapy. Urologe A. 1997; 36: 449-51.
[14] Ficarra V, Zanon G, DAmico A, Mofferdin A, Tallarigo C, Malossini G. Il trattamento percutaneo, laparoscopico e chirurgico del varicocele idiopatico: analisi dei costi. Arch It Urol Androl 1998; 52: 57-64.
[15] Johnsen N, Tauber R. Financial analysis of antegrade scrotal sclerotherapy for men with varicocele. Br J Urol 1996; 77: 129-32.

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Correspondence to: Vincenzo Ficarra, Cattedra e Divisione Clinicizzata di Urologia, Ospedale Policlinico -- Piazzale L. Scuro, 37134 - Verona - Italy.
Tel: +39-45-807 4370, Fax: +39-045-807 4080
E-mail: vincenzoficarra@hotmail.com
Received 2002-06-29      Accepted 2002-09-05