Analysis of internal spermatic vein embolization through catheter versus laparoscopic high ligation in treatment of left varicocele

Abstract

Objective

Varicocele is a common disease in young and middle-aged men. This study aims to compare the efficacy of internal spermatic vein embolization of left varicocele versus laparoscopic high ligation.

Methods

From January 2017 to September 2018, a total of 69 varicocele patients were admitted and given the opportunity to choose the treatment option. Among these, 26 patients were treated with sclerosing agent injection, while 43 patients underwent laparoscopic surgery. They were followed up for 12 months after surgery, and the technical success rate, recurrence rate, complication rate, cost, operative time, and hospitalization time with regard to these two methods were analyzed.

Results

All patients completed the medical procedures. There was no recurrence in patients in the sclerotherapy group during the follow-up period; however, the complication rate was 19.2%. Furthermore, the operative time, hospitalization time, and cost of treatment were 31.1 ± 11.1 min, 1.2 ± 0.49 days, and 9613.11 ± 895.97 Yuan, respectively. In the laparoscopic group, 9 patients underwent laparoscopic bilateral high ligation, while 34 patients received treatment on the left side alone. The recurrence rate of left varicocele was 4.7% and the complication rate was 44.2%. Furthermore, the operative time, hospitalization time, and treatment cost were 50.4 ± 14.48 min, 4.0 ± 2.02 days, and 10,948.29 ± 2547.00 Yuan, respectively. Moreover, there were statistically significant differences (P < 0.05) in operative time, hospitalization time, and treatment cost. Patients in the sclerotherapy group had an advantage with respect to the overall complication rate when compared with patients from the laparoscopic group (X² = 4.448, P < 0.05), and there was a statistically significant difference in hydrocele (X² = 4.555, P < 0.05). However, there was no significant difference in the recurrence rate between these two groups (X² = 1.245, P > 0.05).

Conclusion

Patients who underwent sclerotherapy showed a higher technical success rate, a lower recurrence rate, fewer complications, and shorter hospitalization time compared to those treated with laparoscopic ligation. Transcatheter sclerosing agent injection may be a preferable treatment option for patients with unilateral varicocele.

Keywords

Varicocele foam sclerosing agent embolization laparoscopic surgery

Background

Varicocele is one of the most common diseases in young and middle-aged men. The incidence of varicocele is approximately 8%–23% in men, and approximately 40% in infertile patients.¹ It is a vascular lesion that refers to abnormalities of the spermatic plexus in expansion, elongation, circuity, testicular venous insufficiency, and venous hyperemia. These factors subsequently lead to testicular hypoxia, oxidative stress, and reverse flows that transfer renal and adrenal metabolites to the scrotum. This can cause scrotal pain, abdominal pain, atrophy, and progressive testicular function decline, which is a common reason for infertility in adults.^2,3 Varicocele is more common on the left side due the following factors: (1) the left side of the spermatic vein is longer than the right side, the right side is directly connected to the inferior vena cava, and the left side of the spermatic vein often presents in a right angle to the left side of the renal vein; (2) the “nutcracker” phenomenon; the lower part of the left spermatic vein is located behind the sigmoid colon, which can easily lead to venous blood obstruction; and (3) the valve function at the entrance of the left renal vein is incomplete.

At present, the main methods include surgical and endovascular treatment. The surgical methods include open surgery, laparoscopic surgery, and microsurgery. Since 1955, ligation has been the main treatment for varicocele,⁴ while the endovascular treatment of varicocele was first described as an option in the late 1970s.⁵ With the development of interventional techniques, improvement of embolization materials, advantages of small trauma, and rapid recovery, transcatheter foam sclerosing agent embolization has become an increasingly concerned and applied surgical method.

In the present study, we retrospectively compared the technical success rate, complication rate, recurrence rate, operative time, hospitalization time, and financial burden with respect to patients who received internal spermatic vein embolization and patients who were treated with laparoscopic high ligation.

Materials and methods

General materials

A total of 69 varicocele patients who were admitted to our hospital between January 2017 and September 2018 were included in the study. Patients admitted to the Department of Vascular Surgery received internal spermatic vein embolization (sclerotherapy group, n = 26), whereas patients admitted to the Department of Urology underwent laparoscopic high ligation (laparoscopic group, n = 43). All patients were given the opportunity to choose the department to be admitted to and the treatment option. The evaluation of patients began with their physical examination; visual examination and palpation were performed on the scrotum using patient relaxation techniques and the Valsalva maneuver. The classification was proposed by Dubin and Amelar⁶ as follows: palpable only by Valsalva maneuver (grade I); palpable at rest, but not visible (grade II); and visible and palpable at rest (grade III). Then, all patients underwent scrotal color Doppler ultrasonography and were diagnosed with varicocele. The age of patients in the sclerotherapy group ranged between 15 and 55 years (28.2 ± 11.7 years), while the age of patients in the laparoscopic group ranged between 17 and 60 years (32.8 ± 13.5 years) (Table 1). The treatment indications included testicular pain, discomfort, asymmetry, testicular or inguinal swelling, and prophylactic treatment; the patient’s willingness to be treated was also taken into consideration. Since most of the patients were young and unmarried and most of them asked for treatment due to subjective discomfort and physical examination findings, the semen parameters were not tested before and after surgery.

Table 1.

General information of patients.

Group	Sclerotherapy	Laparoscopic
Number	26	43
Position
Left	26	43
Right	0	9
Age (years)	15–55 (28.2 ± 11.7)	17–60 (32.8 ± 13.5)
Dubin classification
III	16 (61.5%)	33 (76.7%)
II	8 (30.8%)	8 (18.6%)
I	2 (7.7%)	2 (4.7%)
Symptoms
Pain	4 (15.4%)	12 (27.9%)
Belly	11 (42.3%)	27 (62.8%)
Asymptomatic	11 (42.3%)	4 (9.3%)
Intravenous diameter of left spermatic vein
Calm state (mm)	0.24 ± 0.06	0.25 ± 0.05
After Valsalva maneuver (mm)	0.35 ± 0.06	0.38 ± 0.08

Internal spermatic vein embolization via catheter

Preparation of the foam sclerosing agent

At the medical center, 1% lauromacrogol (Tianyu Pharmaceutical Co. Ltd, Shanxi, China) injection, a three-way syringe, and 10-ml sterile plastic syringe were used to prepare the foam sclerosing agent in the ratio of 1:4 using the Tessari method⁷ in order to prevent it from losing its effectiveness due to decrease in concentration.

Treatment procedure

All patients were laid on a digital subtraction angiography operating table, and the right femoral vein was punctured using the Seldinger technique under local anesthesia. Then, a 4F vascular sheath and a 4F pigtail catheter were introduced to perform the inferior vena cava angiography; the left renal vein opening was located at the lower margin of the first lumbar level. Under fluoroscopy, a 4F Cobra catheter was introduced into the inferior vena cava with the help of a guide wire, which was successfully placed into the left renal vein, and subsequently into the internal spermatic vein. When it was difficult to enter into the internal spermatic vein, the catheter was placed in the renal vein to first perform the angiography and observe the position of the internal spermatic vein, and then determine whether an anatomic variation is present. Next, the position of the 4F single-curved duct, which was on the edge of the sacroiliac joint, was changed (additional collateral veins originated from the edge of on the edge of the sacroiliac joint, and hence, the catheter was placed at the level of these branches, allowing all the collateral veins to be treated). In the case of patients who underwent the Valsalva maneuver and imaging, the internal spermatic vein and its branch expansion, circuity, valvular insufficiency, and contrast reflux were stranded on the distal spermatic vein plexus. The foam sclerosing agent was prepared after the diagnosis of varicocele and its branches, and 6 ml of sclerosing agent was slowly injected under the Valsalva maneuver. Ten minutes after administering the injection, the patient underwent intravenous angiography again and was instructed to perform the Valsalva maneuver to observe the reflux. For patients who still had a reflux, 2 ml of foam sclerosing agent was injected again. The puncture point was pressurized and bandaged, and the patient was instructed to lie down for 6 h (Figure 1). Ten minutes after the first injection of 6-ml foam sclerosing agent, which was the time window for the foam sclerosing agent to fully act, another angiography was performed through the catheter to determine whether there was still reflux in the spermatic vein. If there was no reflux, it indicated that the embolism was complete. The sclerosing agent embolization was performed by experienced operators.

Figure 1.

Sclerotherapy procedure. (a) The 4F single-curved duct positioned on the edge of the sacroiliac joint is shown. Patients undergoing the Valsalva maneuver, and imaging in the spermatic vein and its branch expansion, tortuosity, valvular insufficiency, and obvious contrast reagents reflux were observed, and contrast reagents were stranded on the distal spermatic vein plexus; (b) the sclerosing agent was slowly injected with the Valsalva maneuver; and (c) the patient underwent angiography again and no reflux was observed.

These were the objective angiographic endpoints.

Laparoscopic high ligation

Treatment procedure

The patient was placed in a supine position and general anesthesia was administered. The pressure for the pneumoperitoneum was set at 13 mmHg; a 10-mm trocar was placed in the lower margin of the umbilicus, and 5-mm trocars were placed at the middle point of the umbilicus and at the left and right anterior superior iliac spine. The exploration revealed that the left internal spermatic vein had vascular tortuosity. Then, the side peritoneum was cut at approximately 3 cm from the inner ring of the left groin, allowing the internal spermatic vein to be free to protect the internal spermatic artery. Afterwards, the internal spermatic vein was ligated with a double silk thread and cut off in the middle of the ligation line. The procedure performed on the right side was the same as the procedure performed on the left side. The laparoscopic high ligation was performed by experienced operators.

Observation

All patients were followed up for 12 months after surgery through telephone calls and outpatient appointments, and physical examination and scrotal color Doppler ultrasonography were carried out. The following information was gathered: (1) technical success rate; (2) recurrence rate after the 12-month follow-up; (3) incidence of complications, such as hydrocele, scrotal pain, testicular atrophy, phlebitis, allergic reaction, etc.; (4) operative time; (5) length of hospital stay; and (6) treatment costs. The presence of reflux observed through Doppler ultrasonography suggested clinical recurrence, while the absence of reflux indicated successful treatment (Figure 2). The technical success in the sclerotherapy group was defined as complete embolization of the spermatic vein below the sacroiliac joint level, with no contrast agent reflux. The technical success with respect to the laparoscopic technique was defined as successful ligation of the left spermatic vein. Postoperative recurrence was defined as the rediscovery of varicose veins in the scrotum observed by scrotum Doppler ultrasound during the follow-up period. The complications caused by sclerosing agent injection are described in the European Guidelines for Sclerotherapy in Chronic Venous Disorders (2014).⁸ Complications that are unique to the treatment of varicocele, such as hydrocele and injury to the testicular artery during surgery, were also included.^9,10

Figure 2.

Ultrasound images. (a) Patients undergoing the Valsalva maneuver can observe the reflux signal before the operation. (b) During the follow-up period, no obvious reflux signal was observed in patients undergoing the Valsalva maneuver, and clinical cure was achieved.

Inclusion and exclusion criteria

The inclusion criteria were mainly based on the results of the Doppler ultrasonography, which indicated the internal spermatic vein reflux, and the patients were graded according to their physical examination. The secondary criterion was subjective discomfort, such as pain or discomfort in the abdomen or the scrotum. Patients with clotting disorders, abdominal surgery, or other contraindications were excluded.

Statistical analysis

SPSS 20.0 statistical software was used to analyze the data. In order to compare the clinical features of these two groups, t-test was used for continuous variables, while Chi-square test was used for categorical variables. Count data were expressed by the rate, while measurement data were expressed as mean ± standard deviation. A P-value < 0.05 was considered statistically significant.

Results

Basic situation

In the present retrospective study, no significant difference was observed regarding the baseline characteristics shown in Table 1. All patients successfully completed the procedures. In the sclerotherapy group, 20 patients achieved a satisfactory effect from injecting 6 ml of sclerosing agent only once, while the remaining 6 patients were successfully treated after injecting 2 ml of sclerosing agent again during the operation. In the laparoscopic group, 9 patients underwent bilateral laparoscopic high ligation, while the remaining 34 patients received treatment on the left side alone. No serious complications occurred in these two groups, such as deep venous thrombosis, pulmonary embolism, stroke, or vessel rupture.

Comparison of operative time, hospitalization time, and cost

The mean operative time for patients in the sclerotherapy group was 31.1 ± 11.1 min, which was significantly shorter when compared to the laparoscopic group (50.4 ± 14.48 min) (t = 5.833, P < 0.05). The mean hospitalization time was also significantly shorter in the sclerotherapy group (1.2 ± 0.49 days) when compared to the laparoscopic group (4.0 ± 2.02 days) (t = 8.543, P < 0.05). In addition, there was a statistically significant difference in the average cost between the sclerotherapy group and the laparoscopic group (9613.11 ± 895.97 Yuan and 10,948.29 ± 2547.00 Yuan, respectively) (t = 3.131, P < 0.05); the costs were lesser in the sclerotherapy group (Table 2).

Table 2.

Comparison of operation time, hospitalization time, and expenses.

Group	Operation time (min)	Length of stay (day)	Cost (Yuan)
Sclerotherapy	31.1 ± 11.1	1.2 ± 0.49	9613.11 ± 895.97
Laparoscopic	50.4 ± 14.48	4.0 ± 2.02	10,948.29 ± 2547.00
t value	5.833	8.543	3.131
P	<0.05	<0.05	<0.05

Comparison of complications

One patient in the sclerotherapy group developed chest tightness after surgery and was given symptomatic treatment, including oxygen inhalation. These symptoms were observed for three days prior to discharge. At one week after surgery, one patient reported scrotal pain; phlebitis caused by the foam sclerosing agent was considered to be the cause. The patient was given oral analgesic drugs to activate blood circulation and remove the blood stasis, and the symptoms disappeared after 14 days of treatment. Furthermore, skin rash with pruritus was observed in two patients, which was considered to be an allergic reaction of the contrast. This symptom disappeared after administering oral anti-allergic drugs. One patient had hydrocele during the follow-up period, but no other common complications occurred.

Ten patients in the laparoscopic group presented with hydrocele. Scrotal pain occurred in three cases, and this was attributed to pulling of the spermatic cord during surgery. The testicular artery was injured in four cases, and testicular atrophy occurred in two cases after the operation.

Compared with the laparoscopic group, the sclerotherapy group had an advantage in regard to the overall incidence of complications (X² = 4.448, P < 0.05), and there was a statistically significant difference in hydrocele (X²=4.555, P < 0.05) (Table 3).

Table 3.

Comparison of complications between the two groups.

Group	Chest tightness	Hydrocele	Scrotal pain	Artery injury	Allergic	Atrophy
Sclerotherapy	1/26	1/26	1/26	0/26	2/26	0/26
Laparoscopic	0/43	10/43	3/43	4/43	0/43	2/43
X ²		4.555	0.291	2.567		1.245
P		<0.05	>0.05	>0.05		>0.05

Follow-up results

During the follow-up with respect to the sclerotherapy group, the ultrasound Doppler examination revealed no reflux or recurrence. In the laparoscopic group, two patients had recurrence at six and nine months of follow-up, with a recurrence rate of 4.7% (2/43). There was no significant difference between these two groups (X²=1.245, P > 0.05).

Discussion

Varicocele is a common disease seen in adult males the commonly accepted treatment indications include: (1) abnormal semen analysis; (2) volume of the affected side observed to be 2 ml, or over 20% less than that of the normal side; (3) bilateral varicocele; and (4) obvious symptoms of varicocele. In this study, however, complaints of testicular swelling and pain and unsatisfactory or asymmetrical testicular appearance were the primary reasons for surgical treatment as most of the recruited patients were young or middle-aged adults.

Doppler ultrasonography has been considered to be a reliable method for the diagnosis of varicoceles and the selection of treatment plan in varicocele patients.¹¹ The most widely accepted standard is >3.0–3.5 mm diameter of the internal spermatic vein observed during the Valsalva maneuver.¹² In this study, all patients were diagnosed with varicocele using scrotal color Doppler ultrasonography. Patients treated with sclerosing agent also underwent routine intravenous angiography before the operation in order to identify the accessible varicose veins and confirm the parallel with the spermatic vein and the branches of the communication.

Retrograde foam sclerosing agent embolization through a catheter is a widely accepted treatment method for varicocele with the following advantages: (1) minimal invasiveness; (2) complete embolization; (3) no need of general anesthesia; (4) high compliance of patients; and (5) short operation time. Here, we reported that the average operative time in the sclerotherapy group was 31.1 min, which was much shorter than that in the laparoscopic group (50.4 min).

Paradiso et al.¹³ showed that Tauber’s antegrade sclerotherapy was a simple and feasible technique to treat all kinds of varicocele with low complication, recurrence, and persistence rates. However, the procedure is often performed as open surgery and is carried out in the case of treatment of multiple varicose veins. Hence, it is not as microinvasive as retrograde sclerotherapy.

The technical failure rate of percutaneous sclerosis ranges between 5% and 20% due to anatomical abnormalities, venous spasm, or technical difficulties.^5,14,15 Moreover, sometimes it may be difficult to place the catheter into the spermatic vein during the operation. However, for all the patients in this study, catheters were successfully placed into the left internal spermatic vein, and patients underwent sclerotherapy with a success rate of 100%, which was higher than previously reported. These results were probably attributable to the small sample size of this cohort.

The main complications of sclerosing agent embolization include vascular injury, thrombophlebitis, allergic reaction, and ectopic embolization. In the sclerotherapy group, one patient developed thrombophlebitis and presented with testicular pain. Previous evidence suggested that the prevention of excessive application of sclerosing agents into the scrotum might reduce the possibility of thrombophlebitis and patient discomfort. Motta et al.¹⁶ used tourniquet ligation on the upper part of the scrotum to prevent the sclerosing agent from possibly flowing back into the scrotum, reducing the possibility of phlebitis and scrotal pain in patients. As no contrast agent was added to the sclerosing agent during surgery, the possibility of the occurrence of abnormal embolization could not be completely ruled out. Another patient in the sclerotherapy group presented with mild chest tightness after the operation, which resolved spontaneously after surgery. A small amount of sclerosing agent ectopic embolization was also observed, which suggested that injecting the sclerosing agent through a balloon catheter might lead to a more complete embolization, with more advantages in controlling the sclerosing agent.¹⁷ Previous data have shown that sclerosing agent injection resulted in lower incidence of complications compared to traditional surgery and laparoscopy.¹⁸ Lymphatic ligation is considered to be an important reason for testicular function decline.¹⁹ Moreover, hydrocele is a common complication in surgical operations (10% for traditional high ligation,¹⁰ 6% for laparoscopy,²⁰ and rare occurrence for embolization²¹). The risk of scrotal edema and hydrocele can be greatly reduced by protecting the lymphatic system. In this study, only one case exhibited hydrocele in the sclerotherapy group compared to 23.3% of the cases in the laparoscopic group, probably due to patient age, anatomy, and operations being performed by different surgeons. Most varicocele recurrences and postoperative hydrocele formations are observed in patients with more than 12 months of follow-up.²² Hence, appropriate length of postoperative surveillance is deemed necessary for all patients.

The ultimate goal of treatment is to block the fluid from the internal spermatic and existing collateral veins from flowing back into the spermatic venous plexus. The failure and recurrence of varicocele is mostly seen due to the inability to eliminate the collateral supply from the abdomen, pelvis, or other parts. These branches communicate with the spermatic vein mostly between the initial part of the internal spermatic vein and the deep inguinal ring.²³ Moreover, 19% of patients have abnormal anatomical conditions,²⁴ which are difficult to detect by laparoscopy and surgical approaches. In the present study, there was no recurrence in any patient in the sclerotherapy group during the follow-up period. In contrast, two patients in the laparoscopic group experienced a recurrence, one at six months and one at nine months after surgery.

Patients treated with sclerotherapy also showed rapid recovery (being able to get out of bed six hours post operation and being discharged one day post operation).¹⁸ Feneley et al.²⁵ reported that patients who underwent surgery needed two to three weeks of recovery, while patients who received embolization therapy merely needed two days to fully recover. Consistent with previous studies, the hospitalization time for patients in the sclerotherapy group (1.2 ± 0.49 days) was significantly shorter compared to the hospitalization time for patients in the laparoscopy group (4.0 ±2.02 days).

The financial burden of varicocele treatments should also be considered. Bechara et al.¹⁴ reported that radiotherapy was more cost-effective than surgery. However, there is some concern among people about the effects of radiation during surgery. According to Malekzadeh et al.,²⁶ the radiation dosage in this operation was within the safe range. However, as many patients had a fear of radiation, especially patients with infertility, a lead plate was used to protect the genitals during the operation. Furthermore, we showed that the average cost for the sclerotherapy group was significantly lower than that for the laparoscopic high ligation group (9613.11 Yuan vs. 10,948.29 Yuan).

There are certain limitations of this study. This study was conducted at a single center and retrospectively compared the two methods in a small group of patients. Further investigations involving multiple centers will be needed to ascertain the superiority of transcatheter sclerosing agent injection in varicocele patients. In addition, a longer follow-up period will be needed to further validate the efficacy and safety of the sclerosing agent injection method. Other parameters such as the quality, concentration, and mortality of sperm may also be assessed. Moreover, patients enrolled in this retrospective study were given the opportunity to choose their treatment plans, which may have introduced bias into the analyses.

Conclusion

This retrospective study compared the efficacy and outcomes of sclerosing agent embolization and laparoscopic high ligation for varicocele patients. The use of lauromacrogol foam sclerosing agent for the treatment of varicocele was also introduced. According to our results, patients treated with sclerosing agent injection showed higher technical success rate, lower recurrence rate, fewer complications and shorter hospitalization time, and also had a lesser financial burden compared to patients who underwent laparoscopy. Moreover, sclerotherapy does not require general anesthesia, which is another advantage of this method. Foam sclerosing agent has been shown to selectively block the circulation of the internal spermatic vein without damaging the accompanying arteries and lymphatic vessels, which is the most fundamental cause of recurrence and hydrocele after laparoscopy. Thus, transcatheter sclerosing agent injection may be a preferable treatment option for patients with unilateral varicocele.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work is supported by the “Effects of percutaneous drug-mechanical thrombolysis on the incidence of thrombotic sequelae in lower extremity deep venous thrombosis,” Science and Technology Development Plan of Jinan in 2017 (No. 201704134).

ORCID iD

Qing-Yi Meng

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