At a Glance:

What is varicocele embolization or varicocele treatment without surgery?

Varicocele embolization procedure is a minimally invasive alternative to varicocele surgery in which tiny coils and/or a liquid substance is placed in a blood vessel to divert blood flow away from a varicocele. The procedure is performed using a catheter under imaging guidance by an interventional radiologist (IR) in an outpatient setting.

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What is a varicocele?

A varicocele is a medical condition in which a group of veins within the scrotum become abnormally enlarged. It is similar to a condition called varicose in the legs. The scrotum is a male reproductive structure that consists of a sac holding the testes, blood vessels, and a part of the spermatic cord. The testes produce the sperms that travel through the spermatic cord. The sperms are ejaculated through the urethra.

A varicocele can be unilateral, i.e. on the left or right side, or sometimes bilateral, i.e. present on both sides, though it is more common on the left side. The occurrence of varicoceles is common. It is estimated that 15 of every 100 men have the condition.

The testicular artery is the main source of blood supply to the testicles. The blood from the testicles flows out via the testicular veins. In a normal situation, the direction of blood flow in the testicular veins is unidirectional, i.e it flows towards the heart from the testicles in one direction. This unidirectional flow of blood is maintained by a series of valves in the testicular veins. The flow of blood in the reverse direction back to the testicles is prevented by these valves. Some times, these valves fail to perform their normal function for reasons unknown, or they may be absent. As a result, the blood starts pooling in the veins around the testicle, and a varicocele develops. The gravity lets the abnormal veins fill up, as a result, varicocele is more easily observed in a standing position. Varicoceles do not cause symptoms most of the times and they are usually harmless. However, occasionally, they may cause an aching or discomfort in the scrotum. In some cases, a varicocele may cause progressive testicular atrophy, low sperm production and poor sperm quality, which can cause infertility.

Who is an interventional radiologist (IR)?

Interventional radiology is a sub-specialty of radiology that uses minimally-invasive image-guided techniques to diagnose and treat diseases in nearly every organ system of the body.

Interventional radiologists are specialist radiology doctors who use imaging equipment like x-ray, fluoroscopic guidance, MRI, CT, and ultrasound to determine exactly where to go inside the body and perform the required therapeutic procedure.

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What are the indications for varicocele embolization?

A varicocele may not require treatment in every case. However, if the condition causes symptoms like pain, testicular atrophy or infertility or if a person with varicocele needs to undergo assisted reproductive technique, treatment for varicocele is indicated.

The main treatment options for varicocele are:

• Surgery
  • Open surgery
  • Laparoscopic surgery
  • Microsurgery
• Varicocele embolization

Even though the success rates of surgery and varicocele embolization may be similar, the recovery time after embolization is much shorter. So varicocele embolization is usually a preferred option if a person has a unilateral varicocele. Surgery, especially microsurgery is considered to be a better option for varicocele affecting both testicles.

What can one expect before the varicocele embolization procedure?

Perioperative evaluation of the person is done by the doctors based on the following investigations and information:

Clinical history and physical examination: During the initial consultation with the IR/urologist, he or she will review the person’s medical history and advise relevant investigations, usually a scrotal ultrasound.

A brief physical examination will be performed at the time of the consultation. If the doctor determines that the person is a suitable candidate for the procedure, he or she may be explained the procedure to be followed before the surgery.

Before the procedure: The doctor would recommend preparatory instructions depending on the person’s medical status. Some common recommendations are:

• Any past problems with drug allergies or contrast dye should be disclosed to the treating doctor during the medical history.
• Pre-anesthetic checkup to determine fitness for anesthesia.
• It is recommended not to eat or drink for 8-12 hours before the procedure.
• The doctor’s instructions about any prescription medication that a person may be on, should be adhered to. For example, if a person is on an anticoagulant or antiplatelet medication, he may be recommended to stop it before the procedure. If the person takes medicines for diabetes, there may be some alteration required in the dosing at the time of the procedure.
• The person may be placed on antibiotics before the procedure.
• Stopping smoking beforehand is advisable if a person is a smoker.

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How to perform varicocele embolization?

Varicocele embolization is done as an outpatient-based procedure. It takes an hour or two to perform. In general, the following may be expected:

• The person undergoing the procedure will sign the consent form for the procedure.
• The procedure is performed in the procedure room of the interventional radiology department. The person is made to lie on a special x-ray table on the back and covered with sterile drapes.
• The site preparation is done by cleaning the groin area with an antiseptic solution.
• A local anesthetic is injected into the inner portion of the upper thigh to numb the area. A catheter which is a thin, hollow medical grade tube is positioned into the identified vein using x-ray guidance.
• A contrast dye is injected into the catheter and viewed on an x-ray screen. The presence of dye in the desired area confirms that the catheter is in the right position. There may be a feeling of some warmth when the dye is injected.
• Once the catheter is positioned correctly, a small coil or a liquid known as a sclerosing agent is released into the affected vein which diverts the blood flow into other nearby veins. As the malfunctioning veins shut off, healthy veins start taking over their function thereby allowing the blood to exit the scrotum normally. This relieves pressure from the varicocele and restores proper blood flow.
• Once the procedure is complete, the IR will remove the catheter and press gently on the entry site to prevent any bleeding. A bandage will then be placed over the area of entry in the thigh.
• The medical team will carefully watch the person’s heart rate and blood pressure during the entire procedure.

What can one expect during recovery after varicocele embolization?

Once the procedure is done, the person will be carefully observed for some time, usually an hour or two, in the IR department to ensure that there are no problems. The IR staff will then provide instructions on when to eat, drink and mobilize after the procedure.

In most cases, the person can go home that same day, however, it is recommended to take it easy for the rest of the day. Recovery after treatment is generally considered to be quick, with only mild pain. Normal day to day activities can be carried out after 24 hours. Driving and activities requiring mental concentration should be deferred for at least 24 hours if a sedative medication was advised by the treating doctor. More strenuous activities, like jogging, should be undertaken only after a few days. Sexual activity may be avoided for a few weeks.

Any problems after the procedure like warmth and redness at the injection site should be brought to the notice of the treating doctor immediately. Follow up with the doctor is recommended. If infertility issues were present before treatment, a semen analysis is usually done after a few days of the procedure. It may take up to three months to detect improved sperm count and improvement in pregnancy rates.

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What are the advantages of varicocele embolization?

Varicocele embolization is a minimally invasive procedure that is an effective alternative to surgery for the treatment of varicocele. The procedure can be carried out with only a small incision or nick in the skin and it does not require any sutures. Even though embolization and surgery have both shown to be effective treatments for varicoceles; the embolization procedure has certain advantages over conventional surgery, namely:

• The main benefit of using interventional radiology techniques is that the need for large surgical incisions is avoided and it is also very safe, due to the possibility of visualizing the affected organ in real-time.
• Being minimally invasive, i.e a small nick and no stitches results in lesser pain than the surgical approach.
• The procedure is performed under local anesthesia and there is no need for general anesthesia.
• There is no surgical cutting required into the testicle, scrotum, or abdomen.
• It is a preferred treatment choice for persons with a recurrence of varicocele after surgery.
• The recovery time is shorter, and a person can be back to a normal routine in a much shorter time.
• Since the size of the incision is small and there is minimal manipulation of tissues, there is a reduced risk of infection and developing a hydrocele i.e. accumulation of fluids around a testicle.
• It is performed in an outpatient setting so the time required in the hospital is minimized and the person can recover in the comfort of own home.

What are the risks of varicocele embolization?

Varicocele embolization is a safe option when performed by well-trained and experienced interventional radiologists. However, it is not entirely devoid of certain risks. These risks include general risks as well as some procedure-specific risks like:

General risks:

• Collateral damage to the nearby structures like soft tissues, nerves or blood vessels
• Side effects of anesthesia that may include:
• Drowsiness
• Headache
• Nausea
• Allergy
• Infection

Procedure specific risks include:

• Infection at the site of catheter insertion
• Allergic reaction to the dye
• There may be excessive bleeding or minor bruising in the groin where the catheter is inserted. Generally, the bruising resolves by itself within a few days.
• Sometimes the coil may migrate to block the enlarged vein
• The person may experience a dull aching in the groin or lower back that usually lasts for a couple of days. The pain may be well controlled with simple painkillers as advised by the treating doctor.
• Inflammation of the scrotum or the vein
• Sometimes, there the procedure may not work as expected and the varicocele may relapse.
• Occasionally, the coils or sclerosing agent may unintentionally spill into a different vein, which may then become blocked.

Individual risks may differ, depending on a person’s age and medical status. The outcomes of the procedure may also vary depending on the anatomy of the person’s varicocele.

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How to choose a facility for varicocele embolization procedure?

Considering the need for sophisticated equipment, infrastructure, and considerable interventional radiology expertise, varicocele embolization is recommended to be performed in specialized centers. Long term follow up to evaluate the performance of a new technique is a well-coordinated activity in such centers. Varicocele embolization technique requires experience and attention for performing the procedure under radiological guidance. This is one of the primary reasons that it is not performed commonly in all centers. Very few interventional radiologists are trained to perform the procedure.

Yashoda Institute of Interventional Radiology in Hyderabad is a high-volume tertiary referral center for interventional radiology procedures like varicocele embolization. Our expert IRs often treat patients who are turned away by less experienced centers as being too risky or complex.

Conclusion:

Regardless of which option a person chooses, surgery for varicoceles or embolization treatment of varicoceles can greatly alleviate a person’s symptoms of pain and discomfort if present. Some of the long-lasting benefits of varicocele treatment include the return of the testicles to normal size. In the case of men facing infertility issues due to varicocele, they can experience an increased sperm count, better quality of sperm, and better DNA quality in sperm. Some other benefits of varicocele treatment include the normalization of testosterone levels.

Technological advances like embolization techniques now provide alternative ways to a surgical procedure with comparable results. When diagnosed with a varicocele, embolization is a good alternative to surgery for the right candidate. Thus, men who earlier had less hope of correcting this problem, and reducing symptoms of pain, or creating a family without surgery, now have viable choices. A second opinion from an interventional radiologist may be sought by a person who is apprehensive about surgery if it has been recommended for the treatment of varicocele.

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Reference

• Mayo Clinic. Varicocele. Available at:  https://www.mayoclinic.org/diseases-conditions/varicocele/symptoms-causes/syc-20378771. Accessed on January 12, 2020
• National Health Services. Having a Testicular (Varicocele) Embolisation. Available at:  https://www.bsuh.nhs.uk/wp-content/uploads/sites/5/2016/09/Having-a-testicular-varicocele-embolisation.pdf. Accessed on January 12, 2020
• Asian Journal of Andrology. Percutaneous embolization of varicocele: technique, indications, relative contraindications, and complications. Available at:  http://www.ajandrology.com/article.asp?issn=1008-682X;year=2016;volume=18;issue=2;spage=234;epage=238;aulast=Halpern.Accessed on January 12, 2020
• Johns Hopkins. Embolization of varicocele. Available at:  https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/varicocele-embolization. Accessed on January 12, 2020

About Author –

Dr. Suresh Giragani, Consultant Neuro & Interventional Radiologist, Yashoda Hospitals - Hyderabad
MD (Radiology), DM (Neuroradiology)

Specialized in the comprehensive and widest range of vascular interventions covering neuro interventions, hepatobiliary interventions, venous, peripheral vascular interventions and interventions in cancer care.