Testicular varicoceles

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Testicular varicoceles

• P. Beddy, et al.
• Clinical Radiology (2005) 60, 12481255

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• Type of study review, but written as
  tutorial/editorial
• Aim (not mentioned!! review of papers on
  varicocel
• Method of search no methods mentioned

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Varicocele

• an abnormal venous dilatation in the pampiniform
  plexus
• affects 15 of men
• presentation pain, swelling, sub-fertility
• Most asympt

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(No Transcript)
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Etiology

• retrograde flow into internal spermatic vein
• dilatation/ tortuosity of the pampiniform plexus
• Less frequent causes
• compression of renal vein (tumour)
• aberrant renal vein
• obstructed renal vein

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Presentation

• LgtR
• (R.sp.v. enters obliquely into IVC protective?)
• right side
• new in older

R/O mass??
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Diagnosis

• clinical if gt3-4 mm (use valsalva)
• Amelar grading
• Grade 1 only palpable during Valsalva
• Grade 2 palpable without the Valsalva
• Grade 3 visible on examination

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Imaging

• US
• high-freq transducer (at least 7 MHz)
• Sensitivity 98
• Specificity 100
• Hamm et al. (1986) US in 118 patients, 2 mm
  was used as the lower limit for venous
• dilatation.
• features on grey scale us
• at least 2-3 veins of the pampiniform plexus,
• 1 vein diameter gt23 mm in a supine position
• evidence published study of 21 patients with
  clinically palpable varicoceles (ref Rifkin et
  al. The role of diagnostic ultrasonography in
  varicocele evaluation. J Ultrasound Med 1983).

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Diagnosis Colour doppler

• Evaluation in standing position
• (varicoceles to fill)
• Diagnosis detection of reverse flow in the
  incompetent vein
• Reflux
• permanent
• (significant for a varicocele)
• Intermittent
• brief (physiological)

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Diagnosis doppler

• sensitivity
• 93 (n14 pts. Petros et al. 1991)
• clinic exam sensitivity 71

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Diagnosis venography

• Gold standards
• normal venogram
• a single testicular vein is seen up to the
  inguinal ligament
• and into the spermatic cord
• Varicocele
• enlarged int spermatic vein
• reflux into abdominal, inguinal, scrotal or
  pelvic portions of the spermatic vein

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Diagnosis MRI (MRV)

• gadolinium-enhanced imaging
• delayed imaging in venous
• dilated vessels and prominence of the pampiniform
  plexus
• indication
• evaluate the presence of obstructing masses
• Conventional venography is contraindicated
• assessment of recurrent varicoceles.

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Treatment

• symptomatic
• subfertility
• percutaneous embolization (choice)
• surgical (failed catheterization)
• Recurrence rate similar
• randomised, prospective study. Barbalias et al.
  1998

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Percutaneous embolization

• Selective catheterization of the spermatic vein
• embolization with a sclerosing agent or a solid
  coil

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• Coil distal the level of inguinal lig.
• prox 23 mm of renal vein
• all collateral veins occluded

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Sclerosing agents

• such as sodium tetradecyl sulphate
• reflux into pampiniform plexus is prevented by
  external pressure

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Radiological Rx

• success rate gt 90
• Failure due to unsuccessful catheterization or
  anatomical variants

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Good

• Easy to read
• General overview of clinical dxRx
• Nice pictures with appropriate titles/legends

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Bad

• No method of review
• emphasis on personal practice without research
  evidence back up

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Would you base your practice on this review?

• No!!!