PEDIATRIC UROLOGY

Antegrade Scrotal Sclerotherapy for Treating Primary Varicocele in Children
Zaupa P, Mayr J, Hollwarth ME
Department of Paediatric Surgery, Medical University of Graz, Graz, Austria
BJU Int. 2006; 97: 809-12

• Objective: To evaluate the effectiveness and limitations of antegrade sclerotherapy (AS) for the treatment of primary varicocele in childhood.
• Patients and Methods: From December 1996 to December 2004, 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 (range) follow-up of 11 (3-60) months, and the operative duration, X-ray exposure time, persistence rate of varicoceles and complications were compared with those using other techniques.
• Results: 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 (SEM) operative duration for AS was 33.2 (2.14) 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 (0.21) s. 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 three (3%) patients (two superficial wound infections, one scrotal haematoma together with focal testicular necrosis).
• Conclusions: 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.
  
• Editorial Comment
  This paper provides more data on a new, innovative and “minimally invasive” treatment for varicocele. The technique, which uses a short time of fluoroscopy to assess venous drainage and a venous injection of a sclerosing agent, should be associated with minimal postoperative morbidity.
  The authors used the technique in 88 patients over 6 years. Mean fluoroscopy time was 2 seconds and mean operative time was 33 minutes. In recent years, the procedure has been done as a “day surgery”. The authors report that there was a persistent varicocele in only 6 patients and no postoperative hydroceles. There was a postoperative increase in relative volume of the affected testis in 4 of 5 evaluable cases. One patient had an ischemic necrosis of the upper pole of the testis, presumably due to the sclerosing agent entering the testicular circulation.
  The series is a bit unusual in that very few of the patients had testicular hypertrophy/atrophy. In our experience, a small left testis is the primary reason for operative intervention. If there is only a limited benefit to the procedure, then the risk of the procedure may be more than the benefit. Concerning also is a 7% recurrence rate (and this seems to exclude one patient who underwent a Palomo repair for a failure!). This is higher than anticipated, as is the wound infection rate of 2% and the incident of testicular ischemia.
  Overall, this is an interesting contribution on a minimally invasive treatment of varicocele in adolescents. It is a technique worth exploring, but is clearly not without complications. In my opinion it should be reserved for patients with stronger indications.

Dr. Barry A. Kogan
Chief and Professor of Urology and Pediatrics
Albany Medical College
Albany, New York, USA