Journal of Pediatric Urology (2017) 13, 305.e1e305.e6

Department of PaediatricUrology, Royal ManchesterChildren’s Hospital, OxfordRoad, Manchester, UK

Correspondence to: R.M.Cervellione, Department ofPaediatric Urology, RoyalManchester Children’s Hospital,Oxford Road, Manchester, M139WL, UK, Tel.: þ44 161 7018161

Raimondo.cervellio-ne@cmft.nhs.uk(R.M. Cervellione)

Keywords

Antegrade sclerotherapy; Vari-cocele; Adolescent

Received 22 August 2016Accepted 29 December 2016Available online 29 January2017

http://dx.doi.org/10.1016/j.j1477-5131/Published by Elsevi

Antegrade sclerotherapy in adolescentvaricocele patients

D.J.B. Keene, R.M. Cervellione

Summary

IntroductionIn the 1970s, Tauber described the antegradesclerotherapy technique to treat varicoceles, andreported a 10% recurrence rate. The present studyaimed to evaluate paediatric success rates and theeffect of modifications to the surgical technique.

MethodsA prospective study was performed of all adolescentpatients undergoing antegrade sclerotherapy sur-gery. Each patient had an idiopathic varicocele withspontaneous venous reflux on Doppler examination,and underwent cannulation of a pampiniform plexusvein via a scrotal incision under general anaesthetic.Aethoxysklerol� 3% (2 ml/kg) maximum 3 ml wasinjected into the pampiniform plexus vein underfluoroscopic monitoring. Success was assessed byclinical examination and Doppler ultrasound 3, 6 and9 months after surgery. Data were presented asmedian (interquartile range). Patients were splitinto three groups: Group A e liquid sclerotherapywith Y connector; Group B e liquid sclerotherapy

Table Group-wise comparison of success rates

Group A

Modifications totechnique

Liquid sclerotherapy þintravenous connector

Number of patients 14Age of patients (yrs) 14.6 (13.5 � 15.0)Success (%) 58%

*P Z 0.03 (Gp A vs B), **P Z 0.01 (Gp A vs C).

purol.2016.12.018er Ltd on behalf of Journal of Pediatric Urology Compa

direct to cannula; and Group C e foam sclerotherapydirect to cannula. Fisher’s exact test was used tocompare the success rates in each group.

ResultsA total of 91 patients underwent antegrade sclero-therapy. The median age was 14.8 years (range13.7e15.5). Eleven persistent varicoceles occurredand were diagnosed by Doppler ultrasound. Thesuccess rate of surgery was 58% in Group A, 90% inGroup B and 96% in Group C. Success was signifi-cantly higher in Group B and Group C compared withGroup A. No testicular atrophy occurred; two woundinfections, two haematomas and one hydrocelewere recorded (Table).

ConclusionIntroduction of antegrade sclerotherapy in theadolescent population resulted in a safe and cost-effective method for the management of adolescentvaricocele. Several modifications to the techniquehave been introduced to achieve a high success rate(96%) with minimal complications.

using Fisher’s exact test.

B C

Liquid sclerotherapydirect to cannula

Foam sclerotherapydirect to cannula

50 2714.7 (13.6 � 15.4) 15.2 (14.1 � 16.6)90% 96%

ny.

mailto:Raimondo.cervellione@cmft.nhs.ukmailto:Raimondo.cervellione@cmft.nhs.ukhttp://crossmark.crossref.org/dialog/?doi=10.1016/j.jpurol.2016.12.018&domain=pdfhttp://dx.doi.org/10.1016/j.jpurol.2016.12.018http://dx.doi.org/10.1016/j.jpurol.2016.12.018http://dx.doi.org/10.1016/j.jpurol.2016.12.018

305.e2 D.J.B. Keene, R.M. Cervellione

Introduction

Varicocele is a common urological condition and presents in8e16% of adolescent males [1]. The majority of adolescentpatients with a varicocele remain asymptomatic. Varico-celes are associated with an increased risk of subfertility inadult males [2]. The challenge for managing children andadolescents with varicoceles is to avoid under or overtreatment [1].

Testicular asymmetry (>20%) is seen in approximately10% of teenagers with a varicocele [2]. Patients with largervolume differentials have more impaired semen parameters[3]. “Catch-up growth” following varicocele surgery is seenin this group [4,5]. Other indications for varicocele surgeryinclude symptoms of pain or heaviness, which is usuallydescribed as a dull ache around the scrotum that is wors-ened after long periods of standing [6,7]. Routine spermanalysis is being increasingly offered to physically matureadolescents and young adults [3,8], with varicocele surgerybeing offered when subfertility is detected [1].

Many techniques have been described for the manage-ment of varicocele, including: open inguinal [9], highretroperitoneal [10], laparoscopic (with or without arteryand lymphatic sparing) [11] and sclerotherapy [12]. There isgreat variability in practice regarding choice of surgicaltechnique, and with each technique comes differingcomplication rates [13,14]. Tauber described the antegradesclerotherapy (AS) technique in the 1970s to treat varico-celes, and reported a 10% recurrence rate [12]. Within thepaediatric population, a 10% recurrence rate and 14% risk ofhydrocele was reported [15].

The present study aimed to: further evaluate paediatricoutcomes following AS in the management of varicocele;assess complications; and demonstrate the effect ofmodifying the surgical technique on success.

Methods

A prospective study was performed of all adolescent pa-tients presenting to the Varicocele Clinic with idiopathicleft sided varicocele. All varicoceles that were includedwere clinically evident: Grade II or Grade III according tothe Dubin and Amelar clinical classification [16]. Every pa-tient underwent testicular venous Doppler and only thosewith spontaneous venous reflux on Doppler ultrasound wereincluded [17]. Paediatric testicular volume was predictedusing the formula: volume in ml Z 0.52 � L �W � H, withthe definition of asymmetry being a difference in volume of>20% [18,19]. Patients included underwent surgery be-tween 2012 and 2016. The indications for surgery included:pain; testicular asymmetry >20%; subfertility on spermanalysis at 17 years of age (sperm concentration

Antegrade sclerotherapy 305.e3

occurred during the study. Two wound infections and twohaematomas were recorded. Testicular asymmetryimproved in all 28 patients who had an initial median vol-ume difference of 33.9% (range 26e40.8) and a final volumedifference of 10% (range 0e17).

All 38 patients treated for pain had resolution of painsymptoms following surgery. One of the three patientstreated for sub-fertility had, to date, performed a repeatsperm test postoperatively. His sperm parameters were allimproved: sperm concentration from

Figure 2 a. Antegrade venography demonstrates a singleinternal testicular vein. b. Foam sclerotherapy is seen to fillthe internal testicular vein and displace the contrast up to therenal vein.

305.e4 D.J.B. Keene, R.M. Cervellione

Antegrade sclerotherapy was initially described in the1970s. It has shown to have the highest economic effec-tiveness of all forms of surgical management for varicocele,costing £36.64 per case when performed under localanaesthetic [27], and has a low complication rate in adults[13,23]. Paediatric studies have reported persistent vari-cocele rates of 2% [28], 4.5% [29], 7% [30] and 10% [15]. Thevariations in recurrence rates may be due to the differ-ences in the clinical grades of varicoceles treated in eachstudy. Those studies using screening to identify patientshave a higher proportion of small varicoceles (Grades 1 and2), which may be less prone to persistence [12]. Zaupa

reported that less than half of their patients had Grade-3varicoceles [30] compared to 86% in the present series.

Adult studies have reported complications of AS,including: scrotal haematoma in 2.2% of patients, testicularatrophy at a rate of 0.6%, haematoma and wound infectionsin 3% [30]. In the present series, two patients (2.2%)experienced a scrotal haematoma and there were no casesof testicular atrophy.

Postoperative hydrocele formation has its highestcomplication rate following mass ligation procedures (openor laparoscopic Palomo) with rates quoted between 3 and23% [31]. Laparoscopic surgery remains the most widelyused surgical method for the management of adolescentvaricocele [32]. Techniques utilising methylene blue eitherto stain the lymphatic channels or to inject into the veinseffectively reduce the rate of hydrocele formation by 0e5%[33]. These techniques are more time consuming and costlycompared with AS. Antegrade sclerotherapy is naturallylymphatic sparing, and so results in low rates of post-operative hydroceles, which was confirmed in the presentstudy that reported a 1% hydrocele rate.

The present study reported 11 recurrences followingantegrade sclerotherapy, which were confirmed by Dopplerultrasound. All recurrences were treated successfully withrepeat AS. Group A had the highest recurrence rate (58%);this was thought to be due to the use of a Y-shaped intra-venous connector between the cannula and syringe. Wheninjecting such a small volume of sclerosant (maximum 3 ml)a significant portion remained within the connector, thusreducing its efficacy. After the first 14 procedures (GroupA), the syringe was connected directly to the cannula(Groups B and C). This ensured that all the sclerosant wasdelivered into the vein, ensuring maximum efficacy. Thecombined success rate after this adjustment to the tech-nique was 93% in Groups B and C, which was similar to the90% success rate reported by Tauber [12].

A second modification was introduced (Group C) with theAethoxysklerol� being prepared as a microfoam instead of aliquid. The preparation technique described by the manu-facturer involves mixing the Aethoxysklerol� with 7 ml ofair and making it into a foam using a micro-foam adaptor toproduce 10 ml of a stable, homogenous and viscousmicrofoam with fine bubbles [34]. The micro-foam fills theinternal testicular vein(s), displaces the omnipaque, andallows precise radiological control over the foam volumerequired (Figs. 1b and 2b). The viscosity of the microfoamreduces fast “run-off” into the renal vein and systemiccirculation; the white foam can be seen remaining in thepampiniform plexus veins during wound closure. Themicrofoam increases the surface area and contact timebetween the sclerosant and vessel wall. This technique hasbeen described for varicose vein treatment, with improvedefficacy and no safety concerns [35]. The median volume ofthe microfoam injected in the present study was 6 ml(range 5.5e8). Group C had a higher success rate (96%) thanGroup B (90%); however, with the smaller numbers in GroupC, to date, this did not achieve significance. The authorssuggest that a relative contraindication to the microfoampreparation of Aethoxysklerol� may be pre-pubertal pa-tients with very small pampiniform plexus veins. The highviscosity of the microfoam can occlude very small pampi-niform plexus veins before sufficient sclerosant has flowed

Antegrade sclerotherapy 305.e5

into the main internal testicular veins. In these patients,the sclerosant may be better injected “neat” with the 1 mlair-block technique, as described by Tauber [12] and as perGroup B patients.

Overall, the complication rates for this procedurecompared favourably to those reported in the literature. Thisexperience of AS in the adolescent population has demon-strated an initial steep learning curve to optimise the tech-nique by direct injection of the sclerosant into the cannulawithout the need for an intravenous connector. Preparationof the sclerosant as a micro-foam has made the techniquemuch more controlled, with reductions in the amount ofsclerosant injected and potential gains in success rates.

Conclusion

Introduction of antegrade sclerotherapy in the adolescentpopulation has resulted in a safe and cost-effective methodfor the management of adolescent varicocele. Several mod-ifications to the technique have been introduced to achieve ahigh success rate (96%) with minimal complications.

Conflict of interest statement

None.

Funding source

No external funding was received. The authors are bothNational Health Service Employees.

Ethical approval

NHS trust audit approval was obtained. Ethical approvalwas not required, except for the 21 patients co-enrolled inthe randomised controlled study of early varicocele surgeryversus conservative management [20] REC 09/H1013/15.

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Antegrade sclerotherapy in adolescent varicocele patientsIntroductionMethodsResultsDiscussionConclusionConflict of interest statementFunding sourceEthical approvalReferences