Image-Guided Treatment of Varicoceles: A Brief Literature Review and Technical Note

Varicoceles have been associated with orchialgia, subfertility, hypogonadism, and testicular hypotrophy. Testicular hypotrophy (particularly in adolescents), ipsilateral testicular pain, and male factor infertility with abnormal sperm analysis and clinical varicocele are indication to treat varicoceles patients. We have reviewed the literature on pathogenesis, patient selection, vascular anatomy, treatment techniques, and outcomes. Treatment options include surgical and image-guided approaches. Varicocele embolization is a safe and durable technique which provides pain relief and improved fertility in a well-chosen patient population. In our experience, a combination of coil embolization and sclerotherapy provides favorable clinical outcomes.

A varicocele is the abnormal dilatation of the pampiniform venous plexus which is typically caused by reflux or less commonly by obstruction. It is a common condition present in approximately 15% of the adolescent and adult male population, affecting 35% of men with primary infertility, and up to 80% of men with secondary infertility.[1] The incidence increases as the prepubertal male enters adulthood, from around 1% at 10 years of age to a plateau of nearly 14% in late adolescence.[1] Varicoceles are more frequent and larger on the left; however, some series have placed the percentage of bilateral varicoceles up to 50%.[2] A unilateral right-sided varicocele is rare (0.4%)[3] [4] and as such deserves clinical workup for underlying pathologic etiology. However, the most common cause of a right-sided varicocele is variant anatomy, with right spermatic vein entering the right renal vein similar to usual anatomy of the left side.[1] [5]

Presentations of varicocele include decreased testosterone levels, subfertility/infertility, testicular atrophy, and scrotal pain.[6] The complex pathogenesis of varicocele-induced testicular dysfunction is incompletely understood, involving multiple factors such as altered blood flow, increased temperature, oxidative stress, and reflux of gonadotoxic metabolites leading to a progressive toxic effect that results in low testosterone levels and impaired spermatogenesis.[6]

Despite the association between varicoceles and testicular dysfunction, the cause and effect relationship between this condition and male infertility has not been established with 85% of males who have varicoceles remaining fertile. In cases of male factor infertility, varicocele remains the most common, correctable diagnosis. Varicocele repair is proven effective to improve sperm parameters and pregnancy rates.[6] [7] There is also a growing understanding of the relationship between varicocele and hypogonadism, demonstrated by beneficial molecular effects of varicocele repair on spermatogenesis and testicular microenvironment.[5]

• References

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