Male Vericocele and Pelvic Congestion Syndrome

[madman]

Abstract

Male varicocele and pelvic congestion syndrome (PCS) are common pathologies with high predominance in young patients, having a high impact on the quality of life and infertility. Lately, the use of different endovascular embolization techniques, with various embolizing agents, shows good technical results and clinical outcomes. With the aim of presenting the “state of the art” of endovascular techniques for the treatment of male varicocele and PCS, and to discuss the performance of the different embolic agents proposed, we conducted an extensive analysis of the relevant literature and we reported and discussed the results of original studies and previous meta-analyses, providing an updated guide on this topic to clinicians and interventional radiologists. We have also underlined the technical aspects for the benefit of those who approach this type of interventional treatment. Our review suggests promising results in both the endovascular embolic treatment of male varicocele and PCS; for varicocele, a success rate of between 70% and 100% and a recurrence rate of up to 16% is reported, while for PCS it has been found that technical success is achieved in almost all cases of endovascular treatment, with a highly variable recurrence rate based on reports. Complications are overall rather rare and are represented by periprocedural pain, migration of embolic media, and vascular perforations: severe adverse events have been reported very rarely.




1. Introduction

Scrotal varicocele in men and pelvic congestion syndrome (PCS) in women represent two relatively frequent pathological conditions in the young-adult population, with important implications on quality of life and a significant impact on fertility. In these two conditions, gonadal venous vessels are abnormally dilated (sometimes secondary to other causes) and flow is slow and retrograde in the gonadal vein.

Traditionally, the resolutive treatment of these pathologies was based on surgery, but in recent decades interventional radiology has taken hold on this topic: there are several reports with large case series and various meta-analyses that demonstrate that, overall, transcatheter endovascular treatments are (at least) not inferior to the surgical approach, both in terms of technical and clinical success, even after prolonged follow-up, and that complications are relatively rare [1].

*The aim of this study was to illustrate the main embolic agents used in the percutaneous treatment of male varicocele and pelvic congestion syndrome, evaluating their mechanism of action, the technical differences of use, the complications, and the technical success rate and the relapse rates for each embolic agent.

We conducted an extensive analysis of the relevant literature through the PubMed and Google Scholar databases, re-evaluating previous meta-analyses, guidelines, original studies, and case reports with the aim of illustrating the role of various embolic agents in male and female pathology and of providing an updated guide on this topic to clinicians and interventional radiologists. We reported the main clinical and instrumental features of scrotal varicocele and PCS and proposed a review of embolic agents, commenting on their indications, technical aspects, expected outcomes, and possible complications in adult patients.


1.1. Male Varicocele
1.2. Pelvic Congestion Syndrome




2. Embolic Agents
2.1. Solid Agents
2.2. Liquid Agents



3. Clinical Results in Male Varicocele

4. Clinical Results in Pelvic Congestion Syndrome




5. Conclusions

For both male varicocele and pelvic congestion syndrome, different and heterogeneous endovascular treatment techniques have been reported for the local application of liquid or embolic agents, in some cases also in combination (coils and sclerosant, occluding balloon and sclerosant).

Some studies presented in this narrative review of the literature are detailed to allow them to be replicated in daily clinical practice. Overall, endovascular techniques proved to be relatively well tolerated because they were less invasive and with shorter hospitalizations than traditional surgery (often one-day setting). For the treatment of male varicocele with embolizing agents and endovascular techniques, a rather variable technical success rate is reported in the studies, ranging from 70% to 100%, and recurrence rates of up to 16% of cases in the observational studies have been described: it should be noted that the recurrence rate is slightly higher than for surgical procedures, and this should be discussed with the patient undergoing the procedure. The treatment of PCS with endovascular embolism has a rather high success rate, reported between 96% and 100% in the series that we have reviewed, while the recurrence rate is highly variable according to the authors, ranging from 0% to 39% (worse results if only sclerosing agents are used).

The main complications reported in the literature, for both the treatment of male varicocele and PCS, are represented by the migration of embolizing media in distal sites, in collateral circulation or in the pulmonary circulation, but the consequences in all reported cases have been self-limiting.

In this scenario, the interventional radiologist becomes the main element of both the diagnostic and the therapeutic aspects.

 

[madman]

Table 1. This table summarizes the embolic agents used in gonadal vein embolization.

 

[madman]

Figure 1. The drawing shows spermatic vein embolization with coils: coils are first deployed as distal as possible and up to the inguinal canal. Then, a sandwich occlusion of the spermatic vein is performed with additional coils in the proximal part of the spermatic vein.

 

[madman]

Figure 2. The drawing shows spermatic vein embolization with glue: glue is sequentially injected and pushed into the distal intrapelvic segment of the gonadal vein as well as into the collaterals; injection should be stopped before the pampiniform plexus is reached.

 

[madman]

Figure 3. The drawing shows spermatic vein embolization with sclerosing agent: the sclerosant is administered through a catheter whose tip is placed in the most distal part of the ISV, at the level of the sacroiliac joint. Additional coils are deployed at the proximal part of the spermatic vein according to the sandwich technique.

 

[madman]

Figure 4. The drawing shows spermatic vein embolization with a sclerosing agent according to occluding balloon technique: this technique refers to the use of a temporary proximal OB catheter in addition to the distal barrage, to stop the retrograde blood flow. The sclerosing agent is injected through the OB catheter into the distal portion of the ISV.

 

[madman]

Table 2. This table summarizes the publications taken into consideration, the embolic materials used, the technical success rate, the recurrence rate, and complications for male varicocele.

 

[madman]

Figure 5. Drawing shows left and right ovarian veins and left and right hypogastric veins embolization with coils, as reported by Laborda et al. [76].

 

[madman]

Figure 6. Drawing shows left and right ovarian veins embolization with glue: embolization should start from the distal portion of the ovarian vein at the level of the upper half of the sacroiliac joint, to include possible collateral branches.

 

[madman]

Figure 7. . Drawing shows left ovarian vein embolization using the stop-flow foam sclerotherapy (SFFS) reported by Gandini et al. [82]: the sclerosing agent was injected into the pelvic vessels after having inflated the balloon catheter to occlude the major tributary vessels (hypogastric and/or ovarian veins) and excluding high-outflow venous collaterals.

 

[madman]

Figure 8. Drawing shows left ovarian vein embolization with sclerosing agent and coils: an occluding balloon is advanced to the lower third of the sacroiliac joint for the embolization of the gonadal vein; balloon insufflation was maintained for 5 min after the administration of sclerosant and the procedure was completed with the placement of metallic coils as reported by Meneses et al. [84].

 

[madman]

Table 3. This table summarizes the publications taken into consideration, the embolic materials used, the technical success rate, the recurrence rate, and complications for male pelvic congestion syndrome.