Testicular Varicocoele Embolisation

WHAT IS A VARICOCOELE?

A varicocoele is an abnormally dilated network of veins in the scrotum. Veins are a low pressure system and rely on valves to return blood back to the heart. Varicocoeles are caused by incompetent (leaky) valves in the left testicular vein. This normally arises from the vein which drains the left kidney. When the blood flow in the left testicular vein is reversed, these veins adjacent to the testis will become engorged and enlarged.

An ultrasound with colour, depicting blood flow in a large left testicular variocele. The left testis is atrophied (shrunken) as a result
An ultrasound with colour, depicting blood flow in a large left testicular variocele. The left testis is atrophied (shrunken) as a result

HOW IS A VARICOCOELE DIAGNOSED?

A varicocoele may be diagnosed by visual inspection of the scrotum, which may look and feel like a “bag full of worms”. Most often, varicocoeles are confirmed with a scrotal ultrasound. The ultrasound can identify these numerous veins around the testis and measure their diameter both at rest and at forced respiration. The size of the testis can also be measured at this time.

An ultrasound demonstrating a large left varicocele. The left testis is atrophied (shrunken) as a result
An ultrasound demonstrating a large left varicocele. The left testis is atrophied (shrunken) as a result

WHY TREAT A VARICOCOELE?

Varicocoeles may cause a variety of symptoms.

Some varicocoeles cause discomfort. This is sometimes described as a dragging sensation or ache in the abdomen and groin. Some men describe this as worsening on prolonged standing or physical exertion.

Varicocoeles may also cause testicular atrophy (shrinkage) and may contribute to infertility. In patients trying to conceive, they may be advised by their urologists to have the varicocoeles treated.

Patients may also request to have their varicocoeles treated due to their size and appearance.

HOW IS A VARICOCOELE TREATED?

A varicocoele may be treated either surgically or by endovascular means. An Interventional Radiologist will treat a varicocoele utilising endovascular embolisation (occluding of a blood vessel). This is normally done with coils (thin titanium or stainless steel filaments) and sclerosant. The procedure is normally done in day surgery in an angiography suite with high quality x-ray equipment. Endovascular treatment avoids a scrotal incision and a general anaesthetic.

WHAT IS VARICOCOELE EMBOLISATION?

Dye injection confirms an incompetent (leaky) testicular vein. The dye refluxes down the incompetent vein, into veins surrounding the testis
Dye injection confirms an incompetent (leaky) testicular vein. The dye refluxes down the incompetent vein, into veins surrounding the testis

After sedation and local anaesthetic, the skin is punctured under ultrasound guidance to access a vein either just above the collar bone, the upper arm, or the groin. A scalpel is not used and so there should be no scar. Angiography (injection of contrast dye) is performed in order to show the origin, the course and the size of the left testicular vein. A thin catheter (less than 1.5mm diameter) is then advanced to the testicular vein and the vein is embolised with a combination of coils deployed throughout the catheter and with sclerosant. Care is taken to also shut off any side branches which may contribute to varicocoele supply.

Coils deployed with sclerosant via the catheter, taking care to also disrupt communication with any side branches. The coils and sclerosant occlude the leaky vein, preventing further reflux into the scrotum.
Coils deployed with sclerosant via the catheter, taking care to also disrupt communication with any side branches. The coils and sclerosant occlude the leaky vein, preventing further reflux into the scrotum.

The efficacy of endovascular embolisation is around 90%. The patient routinely returns home on the day of the procedure after a brief period of observation (normally around 2 hours).

Normal activity can normally be resumed the following day, although strenuous activity should be avoided for 5 days afterward. Mild discomfort may be experienced in the abdomen or flank for up to 7 days, although this is not normally severe.

http://www.sirweb.org/patients/varicoceles/