Percutaneous Venography and Occlusion in the Management of Spermatic Varicoceles

Transcription

1 635 Percutaneous Venography and Occlusion in the Management of Spermatic Varicoceles z. j. B. Morag Rubinstein1 B. Goldwasser A. Yerushalmi3 B. Lunnenfeld3 Spermatic venography was performed in 140 patients; the main indications were subfertility and abnormal spermatogenesis. Of these 140 patients, 1 13 had positive examinations, with 33 of them having bilateral varicoceles. Of 146 total varicoceles demonstrated, 42 were found on the right side; the advantage of using the jugular vein approach in both the diagnosis and percutaneous treatment of these cases is stressed. Of the 146 varicoceles, 128 were successfully occluded using spring coils. Because of the frequency of bilateral subclinical varicoceles, spermatic venography and percutaneous embolization is recommended in all men with subfertility and oligoteratoasthenospermia. The association of male subfertility and clinical varicocele of the testis has been well documented [1, 2]. More recently, attention has been directed at the subclinical vancocele, which can be conclusively demonstrated only by spermatic venography [3]. A decreased sperm count and abnormal sperm motility and morphology have been shown to occur with all degrees of varicocele, whether clinically apparent or not. The size of the varicocele seems not to influence the degree of infertility [4]. Since the report of Tulloch in 1952 [5], the surgical treatment of varicocele, irrespective of its size, has been by ligation of the incompetent spermatic vein [1]. However, the recent introduction of radiologic methods for the percutaneous occlusion of blood vessels now allows the diagnostic procedure of spermatic venography to be combined with the definitive occlusion of the spermatic vein when indicated [6]. We present our experience with 1 40 patients who underwent spermatic venography and percutaneous spermatic vein occlusion, when indicated, between January and September This report deals primarily with the radiologic aspects of the procedure, both diagnostic and therapeutic. The detailed clinical evaluation before the radiologic study and the postocciusion response will be covered in a separate report. Received November 28, 1983; accepted after revision April 25, Department of Diagnostic Radiology, Sackler School of Medicine, Tel-Aviv University, Chaim Sheba Medical Center, Tel-Hashomer, Israel Address reprint requests to B. Morag. 2 Department of Urology, SaCkler School of Medione, Tel-Aviv University, Chaim Sheba Medal Center, Tel-Hashomer, Israel Department of Endocrinology, SaCkler School of Medicine, T&-Aviv Lkiiversity, Chaim Sheba Medical Center, Tel-Hashomer, Israel AJR 143: , September X/84/ American Roentgen Ray Society Subjects and Methods One hundred forty patients, aged i 8-40 years, were examined. Patients were referred from the urology and endocrinology departments after undergoing detailed clinical, endocrinologic, and spermatologic examinations. Most patients had oligoteratoasthenospermia (OTA) syndrome, either with or without a clinically apparent varicocele. A few patients with symptomatic varicocele were referred specifically for percutaneous spermatic vein occlusion. Of the 1 40 patients, 26 had previously undergone high ligation of the left spermatic vein and were referred for radiologic study either because of persistent or recurrent varicocele or because of OTA syndrome. Initially, the right and left spermatic veins were both examined only in patients who had clinical suspicion of a right-sided varicocele or in whom left venous ligation had been performed. When it became apparent that subclinical right varicoceles were more common than expected, both sides were then routinely studied.

2 636 MORAG ET AL. AJR:143, September1984 TABLE 1 : Percutaneous Spermatic Venography and Venous Occlusion in 140 Patients Approach Femoral vein (n = 108): Left Right Jugular vein (n = 32): Left Right Total varicoceles diagnosed Positive Venography, no Successful Occlusion, no.(%) 73 (93.5) 15 (62.5) 24 (92) i6(89) i46 i 28(87.5). Found in 1 13 patients; 27 patsents had normal examinations. The first 108 patients were examined via a right femoral vein approach under local anesthesia. With a widely curved, 6.5 French, end-hole catheter, the left spermatic vein was catheterized in almost all instances. Occasionally, when this was unsuccessful, a Cobra (Cook) catheter was substituted. This Cobra catheter was also used in initial attempts to catheterize the right spermatic vein. When the right spermatic vein could not be catheterized with this catheter, a preformed Adrenal Venogram catheter (Cook) was used. The last 32 patients studied were examined by means of percutaneous catheterization of the right internal jugular vein using a slightly curved end-hole or a H 1 Cerebral catheter (Cook). On catheterizing the origin of the spermatic veins, 3 ml of contrast material was hand-injected without undue pressure. If no significant reflux down the vein occurred, this injection was repeated with the patient performing the Valsalva maneuver. Injection with the patient erect was used when these injections failed to show reflux. We considered a patient to have a varicocele when complete retrograde filling of the entire spermatic vein down to the pampiniform plexus was demonstrated. The size of the varicocele was graded as follows: small, when filling of only slightly enlarged veins occurred; moderate, when well marked enlargement of the veins was noted; and severe, when there was massive dilatation of the spermatic vein and plexus. When a vancocele was demonstrated, the catheter was advanced into the spermatic vein over a straight Teflon-coated guide wire. The optimal site for occlusion was assessed according to the venogram. When multiple veins were present, either proximally or distally, they were either all occluded by multiple coils, or the catheter was advanced to a position where only a single vein existed and the coil placed there, the object always being to ensure that no vein bypassed the site of occlusion. Most occlusions were performed at the L2-L4 levels, but some coils were introduced as low as the inferior border of the sacroiliac joint. Two coils were used in most instances, with complete occlusion usually occurring within mm after coil insertion. The patients were kept under observation for a few hours before being allowed to leave the hospital. Results (table 1) Of the 140 patients examined, 27 had normal spermatic veins. Of the other 1 13 patients, 33 had bilateral varicoceles, 71 unilateral left-sided, and nine unilateral right-sided lesions. Of the 1 40 patients examined, 26 had undergone prior surgical ligation of the left spermatic vein. In these patients, both right and left spermatic veins were routinely examined and in eight of them, both veins were found to be normal. Despite the previous surgical ligation, patent left spermatic veins and varicocele filling were demonstrated in 1 4 patients, Fig. 1 -Normal anatomy of spermatic veins with their connections to renal capsular, retroperitoneal, and pelvic veins. with four of these also having right varicoceles. The remaining four patients had right-sided varicoceles only, with the left side successfully ligated. No major complications occurred in this series. Minimal perivenous contrast extravasation around the spermatic veins was noted in 20 instances, almost invariably associated with guide wire and catheter manipulation in attempts to introduce the catheter deep into the vein in preparation for occlusion coil placement. Initially, computed tomography was performed when contrast extravasation was seen, but as no hematoma was found in any of these patients, this examination is no longer performed. Spasm of the spermatic vein occurred in 1 0 patients. In two of these, the spasm prevented adequate catheter introduction, and percutaneous occlusion of the vein was not possible. In the other eight instances, the spasm passed after a few minutes and occlusion was then successfully performed. Of the 1 04 patients with left-sided varicoceles, 97 had successful occlusion of the incompetent spermatic vein. In two cases, vein spasm prevented adequate catheter introduction. The other five patients had multiple small proximal

3 AJR:143, September1984 SPERMATIC VEIN VENOGRAPHY 637 Fig. 2.-Left varicocele. A, Cross-over at scrotal level from left to right. B, Fig. 3.-Left varicocele. A, Two proximal veins join to form single distal Filling of intemal iliac vein from spermatic vein. vein. B, Occluding coil (arrow) placed at junction of proximal veins. veins that filled the varicocele and that could not be selectively catheterized. Of the 42 patients with right-sided varicoceles, 31 had the offending vein successfully occluded. In nine of the other 11 patients, occlusions could not be performed because acute angulation between the spermatic vein and the vena cava prevented adequate catheterization of the vein via the femoral approach. Since using the jugular vein approach in 1 8 patients, failure to insert the catheter deeply into the right spermatic vein has occurred only twice; successful occlusion of the other 1 6 was achieved. Anatomy A diagrammatic representation of the normal anatomy of the spermatic veins and their connections to other veins is shown in figure 1. On the left side, the spermatic vein joined the left renal vein in all instances. A single left spermatic vein was demonstrated in 50 of the 104 patients with varicoceles. Multiple proximal veins between the renal vein and the level of the sacroiliac joint were seen in 22 patients, and in 32 patients, there were multiple distal veins at the level of the pelvis below the sacroiliac joint. When multiple veins were present, they were often of different caliber, with one of them dominant. This multiplicity of veins is of importance in the pathogenesis of recurrent varicoceles [7, 8]. In all 42 patients with right-sided varicoceles, the spermatic vein drained directly into the inferior vena cava. In no instance did a right spermatic vein enter the right renal vein in our series. A single right spermatic vein was demonstrated in 24 patients. Ten patients had multiple proximally situated veins and eight, multiple distally situated veins. Connection between the spermatic veins and other retropentoneal veins were noted in over half the patients. The most frequently seen connections were with the renal capsular, lumbar, or internal iliac veins. It is our impression that the demonstration of these connections is somewhat dependent on the amount and pressure of the contrast injection and the site at which it is delivered. The deeper the catheter was placed into the spermatic vein, the more likely were venous connections to be demonstrated. Crossover at the scrotal level was seen in only three patients (fig. 2). Discussion Improvement in sperm count and motility has been reported to occur in over 50% of patients with varicoceles after surgical ligation of the incompetent internal spermatic vein [9, 1 0]. In the past few years, it has been noted that spermatic venography, performed in subfertile males without a clinically obvious varicocele, reveals a subclinical varicocele in a large number of instances [1 1 ]. The exact incidence of such findings

4 638 MORAG ET AL. AJR:143, September 1984 Fig. 4.-Left varicocele. Normal main spermatic vein with competent valves Vancocele fills via collateral vein (arrows). Fig. 5.-Left varicocele. Diameter of coil slightly larger than vein to prevent dislodgment. Circumaortic renal vein. is difficult to assess, but figures varying from 25% to 75% have been reported [2, 12]. Right-sided varicoceles have been reported to account for only 5% of all varicoceles [ ]. However, recent reports suggest that right-sided varicoceles are much more common and may have an incidence approaching that of left-sided lesions [7, 1 6]. Formanek et al. [1 7] found right-sided vancoceles in 24 and left-sided varicoceles in 28 of 30 patients examined. Our experience supports the contention that rightsided lesions are much more common than previously suspected. Although a valve may be found at the origin of the right spermatic vein from the inferior vena cava, the usual normal venographic picture is that of valves at the pelvic or inguinal levels [7]. A varicocele was thus considered to be present when an injection of contrast material in the vein at or near its entrance into the vena cava showed filling of dilated veins down to the parnpiniform plexus without the demonstration of competent valves. Initially we studied the right side only when there was a clinical suspicion or when previous left sperrnatic vein ligation had been performed. From these patients, it became apparent that right varicoceles, especially of the subclinical variety, were commonly found, and now all patients have both spermatic veins routinely examined. Since using the jugular vein approach as suggested by Formanek et al. [17], we have demonstrated right varicoceles in 1 8 of the 32 patients studied. The clinical significance of these vancoceles and their effect on spermatogenesis will have to be assessed over long-term follow-up. Using the femoral approach, it was occasionally difficult to introduce the catheter sufficiently deeply into the right spermatic vein in order to place occluding devices. This accounted for most of the therapeutic failures in right varicoceles. Since using the jugular vein approach, this has no longer been a problem, and 1 6 out of 1 8 patients with right-sided varicoceles Fig. 6.-Right varicocele. A, Multiple veins fill varicocele. Note connections to retroperitoneal and renal capsular veins. B, Multiple veins are occluded by three coils (arrows) placed at predetermined intervals according to anatomy demonstrated by venography. have been successfully treated by this technique. The high incidence of subclinical right-sided vancoceles is a possible cause of persistent OTA syndrome in patients in whom only the left side has been occluded. Thus, the right spermatic vein should be examined in all patients with OTA syndrome, irrespective of the clinical findings. Successful occlusion was achieved in 93% of left-sided varicoceles. In these instances, the catheter could be introduced deep into the spermatic vein, using either a fernoral or jugular vein puncture, allowing the occluding device to be placed selectively according to the anatomy (fig. 3). In seven patients in whom occlusion was not carried out, five had varicoceles filled via multiple proximally situated veins that could not be deeply catheterized (fig. 4). The other two patients developed persistent spasm of the spermatic vein, which prevented adequate catheter introduction. Various occluding devices have been used for spermatic vein occlusion, such as detachable balloons, sclerosing agents, Ivalon particles, and steel coils [1 4, ]. We have used steel coils in all our patients. These coils are available in

5 AJR:143, September1984 SPERMATIC VEIN VENOGRAPHY 639 Fig. 7.-Left varicocele after high Iigation. Ligated vein (arrow); varicocele fills via other veins. Fig. 8.-Recurrent left varicocele after ceilocciusion. A, Coil (arrow) successfully occludes spermat,c vein. B, One year later. Large collaterals bypass coli-ocduded main spermatic vein to fill vanceceie. various sizes, and the choice depends on the size of vein to be occluded. Using a coil slightly larger than the vein allows for good fixation (fig. 5), and coil migration has not been noted in any of our patients. Coils are easily and safely introduced through the same catheter used for the diagnostic venography, and multiple occlusions are often done at different levels to ensure that no collateral veins bypass a single occluded segment (fig. 6). Surgical ligation of the spermatic vein in patients with a clinical varicocele has a reported recurrence rate of 5%-20% [1 5]. In our patients in whom previous surgical ligation of the left spermatic vein had been performed, there was a 54% incidence of persistent filling of the left vancocele, either via veins bypassing the ligation (fig. 7) or via a large single vein. In the latter patients, the lack of visualization of the ligated vein can be explained by postulating that this vein had become completely thrombosed and a second patent vein filled the varicocele. Another possibility is that the vein onginally ligated was not the spermatic vein. Right-sided vancoceles were demonstrated in 30% of this group of post-leftligation patients. The high incidence of positive findings on both sides in the postligation patients indicates that venography is essential whenever there is no improvement in spermatogenesis or when a vancocele persists or recurs after surgery. The high incidence of multiple veins demonstrated on both sides offers a logical explanation for the failure of surgical ligation. Venography, by delineating the exact anatomy, allows the occluding device to be placed at an optimal site, and multiple occlusions can be performed at various levels according to the need. To date, we have had two recurrences after embolization. These patients had been treated early in the series, and only a single proximally placed coil had been used. Repeat venography showed that a previously demonstrated tiny connecting vein had become markedly enlarged and filled the varicocele despite occlusion of the main spermatic vein (fig. 8). However, it should be noted that the follow-up period has been short, and a detailed evaluation will be performed at a later date to assess the true recurrence rate. No major complications were encountered in our series. Contrast extravasation occurred during guide wire or catheter manipulation in 20 instances, causing transient discomfort that lasted only a few minutes. Spasm of the spermatic vein occurred in 1 0 patients, subsiding within a few minutes in eight (fig. 9). No instance of coil migration has been noted, although it should be stressed that to date not all patients have had follow-up abdominal radiography.

6 640 MORAG ET AL. AJR:143, September 1984 Fig. 9.-A, Severe spasm of proximal segment of left spermatic vein (arrows). B, Relief of spasm after a few minutes allows catheter to be introduced deep into vein for coil insertion. We recommend the jugular approach whenever sperrnatic venography is to be performed. It is a simple, safe, and reliable procedure, performed under local anesthesia, for both the diagnosis and treatment of testicular varicocele. Each procedure lasted mm, even when bilateral lesions were encountered. The saving of hospitalization and operating room time are important additional economic factors in favor of this condition being treated in the radiology department on an outpatient basis. REFERENCES 1. Dubin L, Amelar RD. The varicocele and infertility. In: Amelar RD, Dubin L, Walsh PC, eds. Male infertility, chap 3. Philadelphia: Saunders, 1977: Narayan P, Amplatz K, Gonzalez R. Varicocele and male subfertility. Fertil Steril 1981;36: Bigot JM, Chatel A. The value of retrograde spermatic phlebography in varicocele. Eur Urol 1980;6:30i Rubin L, Amelar RD. Varicocele size and results of varicocelectomy in selected subfertile men with varicocele. Fertil Steril 1970;2i : TulIoch WS. A consideration of sterility factors in the light of subsequent pregnancies. II. Subfertility in the male. Transactions of the Edinburgh Obstetrical Society, Edinburgh MedJ 1952;59: Greenfield AJ. Transcatheteral vessel occlusion: methods and materials. In: Athanasoulis CA, Pfister RC, Greene RE, Roberson GH, eds. Interventional radiology, chap 5. Philadelphia: Saunders, 1982: Bigot JM, Barret F, Helenon C. Phlebography of the right spermatic vein in varicoceles. In: Jecht EW, Zeitler E, eds. Varicocele and male infertility: recent advances in diagnosis and therapy. Berlin: Springer-Verlag, 1982: RiedI P. Radiologic anatomy of the left testicular vein in varicocele. In: Jecht EW, Zeitler E, eds. Varicocele and male infertility: recent advances in diagnosis and therapy. Berlin: Springer- Verlag, 1982: Howards SS, Lipshultz LI. Symposium on male infertility: foreword. Urol Clin North Am 1978;5: Dubin L, Amelar RD. Varicocelectomy: 986 cases in twelve-year study. Urology 1977;iO: i 1. Gonzales R, Narayan P, Castaneda-Zuniga WR, Amplatz K. Transvenous embolization of the internal spermatic veins for the treatment of varicocele scrotic. Urol Clin North Am 1982;9: 177- i Camhaire F, Kunnen M, Vandeweghe M, Simons M. Comparison between different methods for the diagnosis of vancocele. In: Jecht EW, Zeitler E, eds. Varicocele and male infertility: recent advances in diagnosis and therapy. Berlin: Springer-Verlag, 1982: Belker AM. The varicocele and male infertility. Urol Clln North Am 1981;8:4i -5i 14. White RI, Kaufman SL, Barth KH, Kadir 5, Smyth JW, Walsh PC. Occlusion of varicoceles with detachable balloons. Radiology 1981;i 39: Kaufman SL, Kadir 5, Barth KH, Smyth JW, Walsh PC, White RI. Mechanisms of recurrent varicocele after balloon occlusion or surgical ligation of the internal spermatic vein. Radiology 1983;147: Chatel A, BIgot JM, Helenon C, Dectot H, Rotman J, Salat- Baroux J. lnter#{234}t de Ia phlebographie spermatique dans le diagnostic des st#{233}rilit#{233}s d origine circulatoire(varicocele). Ann Radio! 1978;2i : i7. Formanek A, Rusnak B, Zollikofer C, et al. Embolization of the spermatic vein for treatment of infertility: a new approach. Radiology 1981;i39:3i Seyferth W, Jecht E, Zeitler E. Percutaneous sclerotherapy of varicocele. Radiology 1981;i39: Thelen M, Weissbach L, Schramm P. The treatment of idiopathic varicocele by transfemoral spiral occlusion of the left testicular vein. In: Jecht EW, Zeitler E, eds. Varicocele and male infertility: recent advances in diagnosis and therapy. Berlin: Springer- Verlag, 1982: 1 47-i Si Addendum Since submission of this paper, 1 00 more patients have undergone spermatic venography, all via the jugular vein approach. Left varicoceles were demonstrated in 74 patients (69 successfully occluded) and right varicoceles were shown in 64 (63 successfully occluded). Of these 1 00 patients, 47 had bilateral varicoceles and only nine were normal on both sides.