A Varicocele is an abnormal dilatation of the pampiniform venous plexus, the venous drainage of the testes. The cause of the dilatation is incompetence of the gonadal (Testicular) veins and may be associated with male infertility and testicular pain. The testicular pain is quite typical with dull ache in the scrotum occurring as the day develops precipitated by prolonged sitting or standing.
Due to the anatomy of the venous drainage of the left and right testicular veins, with the left testicular vein draining into the left renal vein, varicoceles far are more common on the left ~ 70% with right or bilateral varicoceles in 10-15%. The exact aetiology causing the testicular vein incompetence is unknown. Varicoceles can be treated by a number of techniques from open surgery, laparoscopic surgery and minimally invasive techniques through a 1-2mm incision. Varicocele embolisation is becoming the preferred option to many patients.
What is the treatment for a Varicocele?
Varicocele’s are imaged with duplex ultrasound which accurately demonstrates dilated testicular veins which typically distends with increased flow on Valsalva manoeuver (pushing down). Varicocele’s are graded 1-3 with grade 3 demonstrating virtual free reflux on breathing without the need for a Valsalva. Minimally invasive embolisation via a small 1-2mm incision using only local anaesthetic, as a day case is becoming the preferred option as it is successful, quick and safe. The precise diagnosis is made during testicular vein venography (picture of the veins using a catheter placed inside them), which is performed just prior to the embolisation procedure. Treatment is performed using coils to block the vein.
Technical success is reported in 98% of cases with recurrence rates at 6 weeks between 7-16%. If varicoceles recur patients typically proceed to a surgical procedure and it is also true that recurrences after surgery can be successfully treated with an embolisation procedure. The procedure is very safe but as with all medical procedures there are some risks. The main risk with this procedure is failure and embolisation coil migration. If migration occurs then usually the coil can be retrieved but occasionally it ends up in a safe place that will not cause any serious problems.
When will a patient need Varicocele Embolisation performed ?
Varicocele embolisation is offered to any patient who is symptomatic and has clinical and imaging features consistent with the diagnosis. Patients with infertility or a low sperm count would be considered with an asymptomatic varicocele. Patients are informed regarding other options including conservative measures and surgery to allow each individual to make an informed decision.
What happens during Varicocele Embolisation procedure?
Varicocele embolisation is a minimally invasive procedure performed by a specially trained interventional radiologist in the interventional radiology suite. You will lie on your back during the procedure and you may also be connected to equipment to monitor your heart beat and blood pressure. During this procedure, the interventional radiologist inserts a tube (catheter, a long thin plastic tube, usually around 2 mm in diameter into a vein). This is commonly done using a vein at either your groin or neck. Local anaesthetic is used to numb the skin before the procedure. You will feel a slight pin prick when the local anaesthetic is injected. You may feel slight pressure when the catheter is inserted but no serious discomfort.
Using the X-ray for image guidance the catheter is positioned into the testicular veins and contrast is injected to confirm incompetence. If an abnormality is shown, the same catheter can be used for treatment to deliver the embolisation coils and block the abnormal vein. In a small percentage of cases, the procedure is not technically possible and the catheter cannot be positioned appropriately. If this occurs then another approach may be required. At the end of the procedure the catheter is removed and pressure is applied to the area to stop any bleeding. You will typically need to stay in bed for 1hr post procedure.
How should I prepare?
Varicocele embolisation is carried out as a day case procedure under local anaesthetic. You may be asked not to eat for 4hrs before the procedure, although you may still drink clear fluids such as water. If you have any allergies or have previously had a reaction to the dye (contrast agent), you must tell the radiology staff before you have the test.