Pelvic varicocele B-ORTFS
A technical success was achieved in all patients.
A colic-like pain occurred after the injection of sclerosing agent with spontaneous resolution after 5 minutes in two (40%) patients.
No other complications were observed.
Mean fluoroscopy time was 23.4 minutes ± 3.91.
Follow-up
No recurrences of PCS were observed during the 12 month follow-up period.
A substantial reduction in size of the pelvic varices with no signs of blood flow was observed at the 3,
6 and 12-month control color-Doppler US.
SSS assessed at 1,
3,
6 and 12 months revealed a significant improvement of symptoms (Student’s t test P<0.01).
(Table 2).
DISCUSSION
Conventional surgical and laparoscopic techniques are associated to reported rates of residual pain of 33% and recurrence of 20% .
Although laparoscopic techniques have reduced aesthetic damage and hospitalization times,
they have failed to significantly affect morbidity and costs .
The first successful endovascular treatment of pelvic varicocele was described in 1993 by Edwards et al using metal coils (2).
Subsequently embolization with various glues and sclerosing agents has been described with reported pain resolution rates ranging between 60-100% (2,
3,
4).Contrarily to surgical techniques,
endovascular techniques are minimally invasive and may be performed in a Day-Hospital setting,
thus further reducing costs and patient discomfort.
The preparation and use of STS foam was first described in 1999 by Tessari for the sclerotherapy of varicous veins .
We have previously reported our experience with Trans-catheter Foam Sclerotherapy using 3% STS foam in male and female varicocele (4).
In our experience,
the benefits of using this sclerosing agent in the form of foam are an increased contact with the endothelial surface,
the malleability of the foam allowing the complete filling of the varices through the ovarian veins without the need of selectively catheterizing low-flow collaterals and the need for smaller volumes of sclerosing agent reducing toxic effects and risk of embolization.
Furthermore,
the use of STS can be considered less invasive as it does not involve the positioning of extraneous bodies such as metal coils that may be associated to re-canalisation,
coil erosion,
varicocele recurrence through unembolised low-flow collaterals and migration (3).
The use of balloon-occluded retrograde transvenous embolization (B-RTO) was first described by Kanagawa et al for the treatment oflarge gastric fundal varices with a spontaneous splenorenal shunt.
This technique is also used for the treatment of refractory portosystemic encephalopathy caused by a large splenorenal shunt.
Balloon-occluded retrograde transvenous embolization from the hypogastric veins has been previously described as a completion of pelvic varicocele embolization with residual low-flow collaterals tributary to the hypogastric vein (1).
As previously described,
thanks to the characteristics of the 3% STS foam,
TCFS with this sclerosing agent is sufficient to completely fill and occlude pelvic varices in case of low-flow collaterals to the hypogastric arteries or contralateral ovarian vein (4).
Differently,
we performed B-ORTFS in case of atypical high-flow venous collaterals.
The identification of all high-flow collaterals and the simultaneous balloon-occlusion of the major venous vessels to which they are tributary enables the complete opacification of the pelvic varices with contrast agent and the exclusion of further atypical high-flow collaterals.
The sclerosing agent successively injected through the ipsilateral ovarian vein replaces the contrast medium.
This enables to determine when the pelvic varices are completely filled with the sclerosing agent,
thus optimizing the amount of 3% STS foam required and avoiding its systemic dispersion.
In case of stagnation of the contrast medium in the pelvic varices after balloon-occlusion,
one of the balloon catheters needs to be momentarily deflated in order to allow the out-flow of the contrast medium and re-inflated immediately after.
The balloon-occlusion kept for 30 minutes is sufficient to determine an endothelial damage leading to complete sclerotization of the pelvic varices.
During the follow-up period,
no recurring pelvic varices were detected and a significant and persistent improvement of symptoms (pelvic pain,
dyspareunia,
menstrual pain and urinary urgency) was observed (Student’s t test; P<0.05).