Antegrade scrotal sclerotherapy for treating primary varicocele in children

This study by Zaupa et al evaluated the effectiveness and limitations of antegrade sclerotherapy (AS) for the treatment of primary varicocele in childhood.

Over 8 years, 88 patients (mean age 13.3 years, range 9-18) with primary varicocele underwent AS (91 varicocele ablations in all). The indications for surgery were testicular pain (16 boys, 18%), a large varicocele with cosmetic implications, testicular hypotrophy (one) and in 71 (81%) the varicocele was detected incidentally during a routine physical examination; all were left-sided. According to the classification used by Tauber, 46 (52%) varicoceles were grade II and 42 (48%) grade III. The clinical and ultrasonography (US) results were evaluated over a median follow-up of 11 months (range 3-60), and the operative duration, X-ray exposure time, persistence rate of varicoceles and complications were compared with other techniques.

In 11 patients there was a palpable difference in size between the testicles, but in only five (6%) was testicular hypotrophy (testicular volume (<75% testicular volume vs. the normal side) confirmed by US. The mean operative time for AS was 33.2 min. In 16 (18%) patients it was necessary to expose a second or third vein because the first vein chosen was unsuitable for sclerotherapy. The mean operative radiation exposure was 2.18 seconds. One patient (1%) was treated with a high ligature of the testicular vein (Palomo procedure) after initial unsuccessful AS, and was excluded from the analysis. Eighty-four (97%) patients were eligible for follow-up. Six (7%) had a persistent varicocele (four grade II, two grade III), four of whom had repeat sclerotherapy successfully (no recurrence at follow-up). Fourteen (15%) patients had enlarged testicular veins only on US (varicocele grade 0). No patient developed a hydrocele after AS, There were complications after surgery in 3 (3%) patients (two superficial wound infections, one scrotal haematoma together with focal testicular necrosis).

The group concluded that AS is an efficient minimally invasive surgical method for correcting varicoceles in older children, although the operative duration is sometimes longer than in adults, and surgery can be more difficult because of the smaller veins. Partial testicular necrosis, despite correct AS, is a very rare but serious complication. The only aspect not answered by this study is...did the 71 patients (81%) where the varicocele was detected incidentally during a routine physical examination really need an operation?  Was there a role for semen analysis in this population? One should consider acquiring a semen analysis at 17 to 18 years of age before recommending surgery since the true reason for worrying about varicoceles is infertility. Pain and cosmesis are different issues.

By Pasquale Casale, MD


Reference: 

BJU International, 97(4):  809-812, April 2006.

http://www.ncbi.nlm.nih.gov/entrez/

Zaupa P, Mayr J, Hollwarth ME

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