Advancing Varicocele Management: A Comprehensive Study on the Efficacy and Outcomes of Endovascular Techniques in a Tertiary Health Care Setting

Abstract

Purpose The aim of the study is to report the clinical outcomes of embolization for symptomatic varicoceles.

Methods In this institutional review board approved prospective study, 126 patients (median age: 30.58 ± 6.13 years) with 43 bilateral and 83 unilateral varicoceles were included. The majority of patients had pain as the major complaint, while 21 patients had associated infertility. The technical and clinical success and complications were studied.

Results The technical success was 100% (169/169 varicoceles). There was a significant reduction in the grading of varicocele on ultrasound postprocedure (p < 0.001). Ninety-eight percent had a reduction in their pain score. The preprocedural mean pain score was 6.4 ± 1.30, which decreased to 1.3 following the procedure. An overall satisfaction score of 9 of 10 was also noted. Out of 126 patients, 94.5% patients had uneventful recovery, while 7 patients had few minor complications. One patient had recurrence and received a repeat embolization.

Conclusion Embolization is safe and effective in the treatment of varicocele.

Keywords

varicocele - embolization - infertility

Introduction

Varicoceles are the abnormal dilatation of the pampiniform plexus of veins in the spermatic cord. The incidence of varicoceles is approximately 15% in the general population, 35% in men with primary infertility, and approximately 80% in men with secondary infertility.[1]

The cause of varicocele is multifactorial. The usual anatomical variation in the draining of left and right gonadal veins itself is a major reason. Secondary varicoceles can be caused by compression of the pampiniform plexus of veins by abdominal/pelvic tumors, hydronephrosis, and hydroureter.[2]

Most varicoceles remain asymptomatic, and asymptomatic patients do not require therapy. The most common presenting symptoms are orchialgia and in some cases infertility. Although the intervention does not guarantee improvement in pregnancy rates, various studies have shown improvement in the semen analysis following the procedure.[3]

Various methods of treatment are available for varicocele and include open surgical repair, laparoscopic or microsurgical repair, and endovascular management.[4] Open surgical repair is the conventional method for the treatment of varicocele. The inability to identify the collateral vessels during surgical procedures is the major cause of recurrence. Also, surgical repair requires invasive anesthetic techniques and a longer hospital stay.[3] Endovascular management of varicocele gives an added advantage of visualization of collaterals, which can be treated to reduce recurrence. Endovascular therapy is minimally invasive and is performed under local anesthesia with minimal blood loss.[5] [6] Thus, it requires a shorter hospital stay and can be done as a day care procedure and does not cause a scar.

This study emphasizes both qualitative and quantitative evaluations of varicocele embolization, incorporating patient-reported outcomes and sonological assessments. While most existing research has compared endovascular therapy to surgical methods, this study focuses on different embolic materials and techniques, examining their success rates, complications, and overall procedural efficiency, thereby offering valuable insights into patient outcomes.

Materials and Methods

This prospective study was conducted at a hospital in Bengaluru during the period from November 2020 to June 2023. The study was approved by the institutional ethical and research board.

Patients and Clinical Workup

All patients who presented to our hospital for endovascular therapy of varicocele were included in this study. The patients underwent clinical examination, followed by laboratory investigations and ultrasound examination. Patients were included if their age was between 18 and 60 years, and if their scrotal ultrasound demonstrated a varicocele. Patients were excluded if they had elevated serum creatinine or prothrombin time/international normalized ratio or abdominal mass on clinical examination or ultrasound imaging and renal vein thrombosis or renal mass on ultrasound imaging. Duplex ultrasound was used to grade the varicocele initially ([Fig. 1]) and during follow-up using the Sarteschi classification.[7] Pain scores and satisfaction scores were obtained pre- and postprocedure from all patients. The scores were obtained using a visual analog scale with scores from 1 to 10, with 10 being the highest level of pain and highest level of satisfaction. Patients who underwent embolization for complaint of infertility underwent a preprocedural semen analysis, which was followed up in the third week and 6 months after the procedure.

Fig. 1 Ultrasound image of varicocele pre-embolization. (A) Grayscale ultrasound showing dilated pampiniform plexus of veins. (B) Color Doppler imaging showing reflux in the dilated veins during Valsalva maneuver.

Postprocedure duplex was performed in the third week after the procedure ([Fig. 2]).

Fig. 2 Ultrasound images of a patient postembolization show no dilatation of the veins or reflux in the veins post-Valsalva maneuver.

Procedure

After administering local anesthesia at the puncture site, access to the right internal jugular vein was obtained. The gonadal veins were catheterized using a 5-Fr Vert diagnostic catheter. Venography was performed during a Valsalva maneuver to assess the reflux into the pampiniform plexus of veins ([Fig. 3A]). A microcatheter was used to selectively catheterize the gonadal vein and embolization was performed. Postprocedure venogram was performed to confirm the absence of reflux ([Fig. 3B]).

Fig. 3 (A) Venogram of the left gonadal vein showing dilated and tortuous pampiniform plexus of veins. (B) Postcoiling of the left gonadal vein showing absent filling of distal vessels.

Different embolization techniques were used in our study. Two coils with Gelfoam (sandwich technique) were used in 21 patients, while 26 patients underwent embolization with only coils. In the Gelfoam technique, Gelfoam was used as an embolic material between two coils. In the multiple-coil technique, coils were placed in the gonadal vein at the pelvic brim and packed with another coil above. If any collateral is seen, then the second coil is placed above the level of joining of the collateral. Coils were placed as far from the renal vein as possible to prevent coil migration. The coils used in this study were Nester coils (Cook Medical) with size ranging from 6 to 8 mm in diameter and 12 to 14 cm in length. N-butyl cyanoacrylate (n-BCA), also known as Histoacryl, mixed with lipiodol for a concentration of 33%, was used in 82 patients.

Study Outcomes

Treatment effectiveness was assessed based on the change in the pain scores and satisfaction scores. The scores were obtained after 3 weeks of follow-up after the procedure. The patients were also analyzed based on their pain scores and satisfaction scores using a visual analog scale both pre- and postprocedure. Any complications encountered during the procedure or at a later period were also noted.

Results

There were 126 patients in this study: 73 (58%) patients were in the age group of 21 to 30 years, 47 (38%) patients were in the age group of 31 to 40 years, and 3 (2%) patients each in the age groups of 41 to 50 and 51 to 60 years. The mean age of the patients was 30.58 ± 6.13 years, with age ranging from 24 to 60 years.

A left varicocele was noted in 83 (66%) patients, whereas 43 (34%) patients had a bilateral varicocele. Pain was the presenting symptom in104 (82.5%) patients. Twenty-one (17%) patients presented with a history of infertility and 1 (0.8%) patient reported erectile dysfunction.

On duplex ultrasound, 94/169 (56.6%) varicoceles were grade III, 47/169 (28.4%) were grade IV, 15/169 (9%) were grade II, 7/169 (4.5%) were grade I, and 3/169 (1.5%) were grade V.

The embolization procedure was technically successful in all (100%) of varicoceles. Following the embolization procedure, 149/169 (88.1%) varicoceles demonstrated complete resolution on duplex ultrasound. In 27/169 (10.4%) cases, the varicoceles remained at grade I, and in 4 (1.5%) cases it remained at grade III. The reduction in grades was significant after the procedure (p < 0.001).

Cyanoacrylate glue embolization was done in 76% patients. Coil embolization was done in the rest of the patients with a minimum of two coils on each side. One patient underwent coil with glue embolization. There was no noteworthy difference in the postprocedural ultrasound grading or satisfaction scores in patients who underwent glue and coil embolization.

Of the 169 varicoceles in 126 patients, 130 (77.5%) reported moderate pain of visual analog score between 4 and 7, and a median pain score of 6 (interquartile range [IQR], 5–7), followed by 35 (20.9%) reporting severe pain with a visual analog score of between 8 and 10, and median pain score of 8 (IQR: 8–8) and only 3 (1.5%) reporting mild pain with a visual analog score of 1 to 3 and a median pain score of 3 (IQR: 3–3). Overall mean pain score of all the sites was 6.40 ± 1.30.

Improvement in pain scores was significantly (p < 0.001) high after embolization. Pain resolved following embolization in 82/169 (48.5%) varicoceles. The pain remained mild in 79 (47%) varicoceles and moderate in 8 (4.5%; [Fig. 4]).

Fig. 4 Line diagram showing the pre- and postprocedure median pain scores. VAS, visual analog scale.

The median pain scores were significantly less (p < 0.001) after embolization in all the three groups ([Fig. 5]; mild pain group, moderate pain group, and severe pain group) and also in all varicoceles. The average postprocedure reduction in pain scores in those with mild, moderate, and severe pain was 2, 4.67, and 6.85, respectively.

Fig. 5 Fluoroscopic images of a patient who underwent coil embolization with recurrence. (A) Absent filling of distal veins during venogram in a patient following coil embolization. (B) Venogram showing filling of veins through collaterals when the patient presented with recurrence. Coils in the gonadal vein noted in situ. (C) After glue embolization of the collateral vessels, the collateral vessels showing glue cast and absent filling.

The median satisfactory score was 7 (IQR: 7–7) in patients with mild pain, 9 (IQR: 8–10) in patients with moderate pain, and 10 (IQR: 9.25–10) in patients with severe pain. The median satisfactory scores were not significantly different between the pain groups (p > 0.05).

Twenty-one patients had undergone the procedure for treatment of infertility. Semen analysis follow-up revealed that 15 patients had an improvement in total sperm count and motility. Few patients (5) with abnormal morphology or motility did not show noteworthy improvement.

Procedure-related complications occurred in 7 patients. Two (1.1%) patients developed funiculitis. These patients were treated with intravenous antibiotics and oral analgesics, which resulted in complete resolution of symptoms. Two patients had inadvertent asymptomatic embolization of n-BCA to pulmonary circulation. Contrast extravasation was seen in one patient. During the procedure, one patient had a coil migration while positioning the last coil in the left internal spermatic vein. The coil was seen to be prolapsed into the left renal vein. The migrated coil was immediately retrieved using a snare. The patient did not experience any symptoms related to the migration or features of pulmonary embolism. Recurrence of varicocele was seen in one patient, which was treated with a repeat procedure ([Fig. 5]).

Discussion

This prospective study included 126 patients with 169 varicoceles: 83 (66%) left varicoceles and 43 (34%) bilateral varicoceles.

The technical success rate was 100% with complete cessation of flow distal to the embolized segment of the gonadal veins. Various studies have reported a technical success rate of 90 to 97%.[5] [8] [9] A study conducted by Cassidy et al[10] on varicocele embolization from a single center demonstrated that the reported 13% technical failure is largely related to failure to occlude the right gonadal vein. This was found to be due to significantly more challenging catheterization of the right internal spermatic vein because of its acute angulation with the inferior vena cava.

Our study reported significant improvement in pain scores following varicocele embolization. The study by Muthuveloe et al[11] on effectiveness of varicocele embolization for varicocele-related orchialgia also showed a significant reduction in postembolization median pain scores with a reduction in the postembolization analgesia requirements. Their data suggested that embolization success rates for pain worked best in those with moderate or severe pain while those with mild pain did not experience any benefit.

Among the patients who had undergone the procedure for treatment of infertility, there was improvement in total sperm count and motility, while patients with abnormal morphology or motility did not show noteworthy improvement. A review of various studies on varicocele management for infertility has shown improvement in semen parameters postprocedure.[12] [13] [14] [15] [16] Infertile men with nonobstructive azoospermia and clinical varicocele may benefit from varicocelectomy as it increases sperm retrieval rate by 2.6 times when compared with untreated patients.[11] It is important to note that because of the increase in seminal quality, even the couples in whom natural pregnancy was not achieved after varicocele treatment might have achieved better results with assisted reproductive techniques.[14] [17]

During the procedure, one patient had a coil migration ([Fig. 6]) while positioning the last coil in the left internal spermatic vein, which was immediately retrieved using a snare. Some literature reviews have discussed coil migration to distant sites. This was noted as a very rare complication and was associated with a very distal release of the coils.[18]

Fig. 6 (A) Coil mass protruding into the left renal vein. Multipurpose catheter noted in the renal vein. (B) Coil being removed using a snare.

Another complication that was addressed was development of funiculitis in two patients who underwent glue embolization, which was treated with medical management resulting in complete recovery. Various studies have shown that postoperative pain is seen to be more frequent with glue embolization when compared with the use of coils, and this was related to the secondary phlebitis they cause.[2] [19] [20] [21]

Minor contrast extravasation was noted in a patient during the procedure ([Fig. 7]). That patient was also managed conservatively. No further increase in extravasation was noted in the patient at the final check venogram. A study done by Makris et al[22] noted higher rates of spermatic vein perforation and contrast extravasation in patients who underwent glue embolization when compared with other techniques (p < 0.05). However, in our study, only one case of contrast extravasation was noted and it was in a patient with coil embolization.

Fig. 7 Fluoroscopic image showing contrast extravasation during venogram of the left gonadal vein.

Recurrence was noted in a patient at 3 months of follow-up. The patient had undergone coil embolization with placement of two coils. Later on, the patient had developed collaterals, which showed reflux on examination. The patient underwent repeat embolization with the use of glue as an embolic agent. Further follow-up examinations showed no reflux on resting/Valsalva maneuver. Recurrence occurs owing to the aberrant anatomy or development of collaterals on a later period. Makris et al[22] observed a much lower recurrence rate with glue embolization (<5%) when compared with the use of coils and sclerosants for embolization (8–11%). Another interesting observation was that the combination of coils with sclerosants and coils with glue did not improve the recurrence rates when compared with coils alone.

Various other complications have been reported in studies like inguinal hematoma, temporary puncture site pain, contrast allergy, and, rarely, hydrocele formation.[9] However, we did not experience any of those complications. In the varicocele embolization technique, there is super-selective sclerosis of the spermatic vein with sparing of the spermatic artery and lymphatic vessels that drain the testis; hence, the occurrence of hydrocele is very rare.[23] [24] Meanwhile, hydrocele is one of the commonest complications in surgical techniques because of the inability/difficulty for selective ligation of spermatic veins.

In our study, we were not able to assess the dose of radiation for each patient, which was mentioned as a limitation of the procedure. But various studies have stated that dose of radiation using modern appliance and rational procedure is very low.[3] [12] Methods such as shielding the gonads (avoiding primary beam exposure to the scrotum), collimation of beam to smallest practical area, and using pulsed fluoroscopy and image capture to minimize angiographic runs have been shown to keep the doses within the range of other diagnostic procedures such as computed tomography (CT) scan, and gonadal dose values are low enough to exclude induction of deterministic and hereditary effects.[18] [25]

Surgical techniques in varicocele treatment vary from traditional techniques, laparoscopic ligation, and microsurgical techniques. Open retroperitoneal high ligation technique had a high recurrence/persistence rate (9–45%), while the recurrence rate for the microsurgical technique was only 0 to 2%, comparable to the embolization technique's recurrence rate.[4] In the microsurgical technique, the incision is made over the pubic ramus just below the external ring, followed by careful dissection of cord structures to reduce complications like recurrence, hydrocele, testicular artery injury, and vas injury. These complications would not arise in case of the embolization technique owing to its selective catheterization of the gonadal vein and sparing of lymphatics in the procedure. There is also the added advantage of visualization of collaterals during the endovascular technique. According to various studies, gonadal radiation in an already vulnerable population is the main disadvantage of embolization when compared with surgical techniques, which can be tackled using gonadal shields and other dose reduction techniques during the procedure.

Although we were not able to compare embolization with surgical varicocelectomy by itself, various studies showed promising results for embolization over varicocelectomy. The study by Feneley et al[26] on postoperative recovery time of patients showed an average of 2 to 3 weeks of recovery for surgical varicocelectomy, while it was only 2 days for complete recovery for embolization patients. Regarding hospital cost analysis, the study by Bechara et al[27] found that although the procedural cost for surgical varicocelectomy is lower than that of embolization, the overall cost is lower for embolization since embolization is a daycare procedure, while varicocelectomy requires an overnight stay.

Conclusion

Varicocele embolization demonstrates significant effectiveness in treating varicocele, as evidenced by the high technical success rate (100%) and substantial improvement in both ultrasound grading and patient-reported pain scores. Nearly 90% of varicoceles showed complete resolution, and the majority of the patients experienced total pain relief postprocedure. Additionally, improvements in sperm count and motility were observed in a notable proportion of infertility patients. Despite a few minor complications, the procedure remains safe with a low adverse event rate. Hence, the need for newer technologies and techniques is apparent. Advancements in embolic materials, imaging systems, and procedural methods could further enhance the success rates, minimize complications, and provide more targeted treatment options for patients.

Conflict of Interest

None declared.

Ethical approval

This study was approved by institutional ethical committee. Informed consent was obtained.

• References

• 1 Beutner S, May M, Hoschke B. et al. Treatment of varicocele with reference to age: a retrospective comparison of three minimally invasive procedures. Surg Endosc 2007; 21 (01) 61-65
• 2 Iaccarino V, Venetucci P. Interventional radiology of male varicocele: current status. Cardiovasc Intervent Radiol 2012; 35 (06) 1263-1280
• 3 Ferguson JM, Gillespie IN, Chalmers N, Elton RA, Hargreave TB. Percutaneous varicocele embolization in the treatment of infertility. Br J Radiol 1995; 68 (811) 700-703
• 4 Chan P. Management options of varicoceles. Indian J Urol 2011; 27 (01) 65-73
• 5 Nabi G, Asterlings S, Greene DR, Marsh RL. Percutaneous embolization of varicoceles: outcomes and correlation of semen improvement with pregnancy. Urology 2004; 63 (02) 359-363
• 6 Marsman JW. The aberrantly fed varicocele: frequency, venographic appearance, and results of transcatheter embolization. AJR Am J Roentgenol 1995; 164 (03) 649-657
• 7 Liguori G, Chiapparrone G, Bucci S. et al. Varicocele. In: Martino P, Galosi AB. eds. Atlas of Ultrasonography in Urology, Andrology, and Nephrology. Cham: Springer International Publishing; 2017: 511-521
• 8 Puche-Sanz I, Flores-Martín JF, Vázquez-Alonso F, Pardo-Moreno PL, Cózar-Olmo JM. Primary treatment of painful varicocoele through percutaneous retrograde embolization with fibred coils. Andrology 2014; 2 (05) 716-720
• 9 Baigorri BF, Dixon RG. Varicocele: a review. Semin Intervent Radiol 2016; 33 (03) 170-176
• 10 Cassidy D, Jarvi K, Grober E, Lo K. Varicocele surgery or embolization: which is better?. Can Urol Assoc J 2012; 6 (04) 266-268
• 11 Muthuveloe DW, During V, Ashdown D, Rukin NJ, Jones RG, Patel P. The effectiveness of varicocele embolisation for the treatment of varicocele related orchalgia. Springerplus 2015; 4 (01) 392
• 12 Wunsch R, Efinger K. The interventional therapy of varicoceles amongst children, adolescents and young men. Eur J Radiol 2005; 53 (01) 46-56
• 13 Esteves SC, Miyaoka R, Roque M, Agarwal A. Outcome of varicocele repair in men with nonobstructive azoospermia: systematic review and meta-analysis. Asian J Androl 2016; 18 (02) 246-253
• 14 Agarwal A, Deepinder F, Cocuzza M. et al. Efficacy of varicocelectomy in improving semen parameters: new meta-analytical approach. Urology 2007; 70 (03) 532-538
• 15 Baz AAA, El Shantely KM, Hassan TA, Mohamed SG, Sakr SI. Role of magnetic resonance imaging in the evaluation of the anterior knee pain. Egypt J Radiol Nucl Med 2019; 50 (01) 109
• 16 Practice Committee of American Society for Reproductive Medicine. Report on varicocele and infertility. Fertil Steril 2008; 90 (5, Suppl): S247-S249
• 17 Bedaiwy MA, Sharma RK, Alhussaini TK. et al. The use of novel semen quality scores to predict pregnancy in couples with male-factor infertility undergoing intrauterine insemination. J Androl 2003; 24 (03) 353-360
• 18 D Beecroft JR. Percutaneous varicocele embolization. Can Urol Assoc J 2007; 1 (03) 278-280
• 19 Urbano J, Cabrera M, Alonso-Burgos A. Sclerosis and varicocele embolization with N-butyl cyanoacrylate: experience in 41 patients. Acta Radiol 2014; 55 (02) 179-185
• 20 Heye S, Maleux G, Wilms G. Pain experience during internal spermatic vein embolization for varicocele: comparison of two cyanoacrylate glues. Eur Radiol 2006; 16 (01) 132-136
• 21 Reiner E, Pollak JS, Henderson KJ, Weiss RM, White Jr RI. Initial experience with 3% sodium tetradecyl sulfate foam and fibered coils for management of adolescent varicocele. J Vasc Interv Radiol 2008; 19 (2, Pt 1): 207-210
• 22 Makris GC, Efthymiou E, Little M. et al. Safety and effectiveness of the different types of embolic materials for the treatment of testicular varicoceles: a systematic review. Br J Radiol 2018; 91 (1088): 20170445
• 23 Granata C, Oddone M, Toma P, Mattioli G. Retrograde percutaneous sclerotherapy of left idiopathic varicocele in children: results and follow-up. Pediatr Surg Int 2008; 24 (05) 583-587
• 24 Alqahtani A, Yazbeck S, Dubois J, Garel L. Percutaneous embolization of varicocele in children: a Canadian experience. J Pediatr Surg 2002; 37 (05) 783-785
• 25 Gazzera C, Rampado O, Savio L, Di Bisceglie C, Manieri C, Gandini G. Radiological treatment of male varicocele: technical, clinical, seminal and dosimetric aspects. Radiol Med 2006; 111 (03) 449-458
• 26 Feneley MR, Pal MK, Nockler IB, Hendry WF. Retrograde embolization and causes of failure in the primary treatment of varicocele. Br J Urol 1997; 80 (04) 642-646
• 27 Bechara CF, Weakley SM, Kougias P, Athamneh H, Duffy P, Khera M. et al. Percutaneous treatment of varicocele with microcoil embolization: comparison of treatment outcome with laparoscopic varicocelectomy. Vascular 2009; 17 (suppl 3): S129-S136

Publication History

Article published online:
11 February 2025