A transbranchial approach for the percutaneous therapy of pediatric varicocele.

Purpose: Male varicocele affects children with the same incidence as it does adults. The association between asymptomatic idiopathic varicocele and male infertility and the poor recovery of testicular function after varicocele repair in adulthood have called for noninvasive clinical and instrumental diagnosis and increasingly early treatment. The department of Pediatric Surgery at our Hospital has screened schoolchildren for the early diagnosis and treatment of childhood varicocele. Our Vascular and Interventional Radiology department has proposed percutaneous treatment for varicocele correction. We report our 10-year experience with percutaneous sclerotherapy of pediatric varicocele with a retrograde transbranchial approach.

Materials And Methods: From a screening programme involving schools 467 boys were selected who were positive for idiopathic varicocele at clinical examination and at Doppler CW, at rest and during Valsalva manoeuvre. Patients with grade III, or symptomatic grade II varicocele, testicular hypotrophy, or with a dilation of the testicular veins greater than 2.2 mm at baseline were referred for percutaneous treatment. Percutaneous treatment was performed with a transbrachial approach in the basilic vein. After searching for incontinence of the internal right spermatic vein, left renal phlebography was performed in order to identify any incontinence of the left spermatic vein. This vein was then selectively catheterised to perform sclerosis. Tungsten coil embolisation was also performed over a number of years. Follow-up consisted of clinical examination, Doppler CW, Doppler US, or colour Doppler US performed at 3, 6, and 12 months.

Results: The radiological procedure was only diagnostic in 78 cases (16.7%). Basilic vein spasm and collaterally-supplied varicocele forced us to discontinue the procedure. The use of materials with smaller diameters and the professional development of the radiological team helped improve the catheterisation rate with time. Using the transbrachial approach alone a total of 287 left-sided, 15 right-sided and 52 bilateral varicoceles were treated. Whereas in two cases of bilateral varicocele a dissection at the origin of both spermatic veins prevented the use of sclerotherapy--though the patients were found to be cured at follow-up with Doppler US--on the left the procedures were continued with a transfemoral approach due to difficulties with the transbrachial catheterisation. As for the left-sided varicoceles, sclerosis were performed in 230 procedures, whereas sclerosis and embolisation on 87 patients. The success rate was 92% for sclerosis, and 86% for sclerosis and embolisation. No major complications were observed.

Discussion: Percutaneous treatment is a minimally invasive and relatively non-traumatic interventional radiology procedure, able to confirm the presence of varicocele, accurately map the venous system and allow selective therapy. Our experience with 467 patients over 10 years has allowed us to compare two therapeutic options: sclerosis and sclerosis combined with embolisation.

Conclusions: Percutaneous treatment of varicocele with the transbrachial approach proved to be a safe, effective, inexpensive, and minimally invasive procedure. It can be suggested as the first therapeutic option for varicocele correction, especially for boys and for bilateral forms.