THE ROLE OF PHLEBOGRAFY IN THE TAUBER SCLEROTHERAPY: IS IT ALWAYS NECESSARY?

Michele Amenta1, Rodolfo Soncin1, Giovanni Olivo1, Rossella Bertoloni1, Marco Beringi1, Giuseppe Pecoraro1
  • 1 Ospedale di Isola della Scala (Isola della Scala )

Objective

Tauber anterograde sclerotherapy is a well established surgical procedure for the treatment of idiopathic varicocele (1-3).
The procedure is simple, but a detailed knowledge of the angioarchitecture of the spermatic cord is recommended to avoid complications (4).
The complications are scrotal haematoma, sterile epididymitis, testicular atrophy, partial abdominal wall necrosis (5).
It was a case of ischemic necrosis of the sigmoid colon (6).
The classic procedure begins with a plebography (4) of spermatic vein before injecting the sclerotic solution (7).
We decide to examine the possibility of performing the procedure without using contrast plebography.

Materials and Methods

Between January 2004 and June 2013 we treated 300 patients with left varicocele. The mean age was 22.4 years.
The most frequent spermiographyc abnormalities, evaluated with WHO criteria, were oligoastenospermia: severe in 121 (40.2%) and moderate in 137 (45,6%); astenospermia: slight in 42 (14,1%). Teratospermia: moderate in 59 (19,5%) and low grade in 81 (29,3%). 13 patients (4.3%) showed low astenospermia associated with testicular pain and unresponsive to medical therapy. Clinical history data was collected for all patients, together with a physical examination, and an echo-color-doppler examination of the spermatic veins in the standing and supine position.
All the patients were treated by modify Tauber antegrade sclerotherapy. Under local anesthesia a 2 cm vertical incision of the scrotum was made 2 cm below the root of the penis.
After isolating the spermatic cord and opening the spermatic fascia, the largest vein of the spermatic plexus was identify, isolated and hang up between two thread. Then a 24 Gauge double-channel needle was inserted in the vein. To ensure the correct position of the needle inside the vein we inject saline and if the fluid escapes from the veins we do not inject the air or sclerosing solutions as describes for the Tauber technique, but we are looking for another venous access.
Patients were follow-up after one week, then after one month after surgery. An andrologic evaluation including semen analysis was performed at 6 months including an echo-color-doppler examination of the spermatic vessels. The average follow-up is 11.87 months.

Results

Surgical time ranged from 15 to 25 minutes with a mean of 20 minutes. 7 immediate post-operative complications were observed (2,17%), both involving hematoma, which cleared up with conservative treatment. At one-week follow-up, we observed pain in 42 (14,1%) patients. Only 13 patients (4.34%) reporting taking NSAIDs. An inflammatory reaction was observed on the funicular portions in only 13 cases (4,34%). At one months follow-up we observed a complete regression of the reaction. Another examination was performed after other 3 months.
In 29 cases (9.78%) we observed persistent of the reflux.
Of the 271 patients without reflux the semen analysis returned to normal in 179 (66,3%) cases after 6 months and in 248 cases (82,6%) after 9 months.
In 26 patients (8,7%) the semen analysis improved while in 29 cases (9,7%) it remained unchanged.
Of the 13 patients with pain 7 reported no testicular pain while 6 reported no change.

Discussions

Varicoceles are the most common abnormality found in men with both primary and secondary
male factor infertility.
Although the exact mechanism of varicocele effect on fertility is highly debated, in general, the data seem to demonstrate that varicoceles have a deleterious effect on spermatogenesis.
Tauber anterograde sclerotherapy is a well established surgical procedure for the treatment of idiopathic varicocele (1-3).
The procedure is simple, but a detailed knowledge of the angioarchitecture of the spermatic cord is recommended to avoid complications (4).

The results obtained with the modified procedure were similar to those using the classical technique in terms of efficacy and side effects (5,8-10).

Conclusion

Based on available evidence in the literature, the results obtained with the modified procedure were similar to those using the classical technique in terms of efficacy and side effects (5,8-10). We observed a reduction in surgical time and costs, and above all we eliminated X-ray exposure. Considering the low persistence and complication rates in all patient categories (adolescents, adults, first diagnosis, and bilateral and recurrent disease) antegrade scrotal sclerotherapy (without X-ray exposure) can be proposed as a safe and efficacious first choice treatment for varicocele. A specific learning curve is required to achieve the best outcome, also in this type of surgery.

References

1) Tauber R.,. Anterograde scrotal sclerotherapy for the treatment of varicocele: tecnique and late results. J Urol 1994, Feb; 151 (2); 386-390
2) Mazzoni G., Spagnoli A., Lucchetti MC, Villa M., Capitanucci ML., Ferro F. Adolescent varicocele: Tauber antegrade sclerotherapy versus Palomo repair.J. Urol 2001, Oct; 166 (4); 1462-4
3) Lenz M., Hof N., Kersting-Sommerhoff B., Bautz W. Anatomic variants of the spermatic vein: importance for percutaneous sclerotherapy of idiopatic varicocele. Radiology, 1996 Feb; 198 (2): 425-31
4) Tauber R., Pfeiffer D., Bruns T. Plebography: why it is important to study radiological imaging of spermatic veins. Arch. Ital. Urol. Androl. 2003, Mar; 75 (75); 62-7
5) Tauber R., Pfeiffer D. Antegrade sclerotherapy for varicocele testis possible and avoidable complications. Urologe A. 2003, Sep; 42 (9) :1238-43
6) Fulcoli V, Costa G, Gigli F, Laurini L. Ischemic necrosis of the sigmoid colon after antegrade sclerotherapy of idiopathic varicocele: a case report. Urologia 2013; 80: 162-164.
7) Kuenkel MmR, Korth K. Rationale for antegrade sclerotherapy in varicoceles. Eur Urol 1995; 27(1):13-7
8) Tauber R., Johsen N. Antegrade scrotal sclerotherapy for treatement of testicular varicocele. Tecnique and late results. Urologe A. 1993, Jul; 32 (4): 320-6
9) Ficarra V., Porcaro AB., Rigetti R., Cerreto MA., Pilloni S., Cavalleri S., Malossni G., Artibani W. Antegrade scrotal sclerotherapy in the treatment of varicocele: a prospective study. BJU Int. 2002 Feb; 89 (3): 264-8
10) Goll A., Albers P., Schoeniech G., Haidl G., Burger R. Testicular loss due to hemorrhagic infart in tauber antegrade scrotal varicocele sclerotherapy. Urologe A. 1997, Sep; 36(5): 449-51

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