During the period from August 2017 to December 2018, we prospectively analyzed preoperative and post-operative alteration of semen parameters (at 3 and 9 months) of 63 patients with clinically evident varicocele referred to our tertiary hospital.
Patients were divided into two groups: group 1, thirty-three patients who underwent subinguinal microsurgical ligation, and group 2, thirty patients who underwent percutaneous embolization.
Patients with unilateral or bilateral varicocele diagnosed clinically and confirmed by U/S (GE logiq P5) with abnormal semen parameters (count, motility, and abnormal forms) were included, while patients with recurrent varicocele or azoospermia, bleeding tendency, and any contraindication to the injection of contrast such as high serum creatinine or allergy were excluded as well, as well as patients with sperm count less than 1 million, as they need further investigations with karyotyping.
All cases were evaluated in the andrology clinic and referred for intervention after patient counseling. The choice of the technique was taken by the patients themselves after discussing the advantages and the disadvantages of each procedure without any financial issue for both procedures.
Pre-operative assessment included complete detailed history, physical examination, scrotal ultrasound, and Doppler and semen analysis.
Doppler US was done by the same expert radiologist with complete comment on the testis as regards the size, echogenicity, and vascularity and the pampiniform plexus of veins as regards the diameter and flow direction with and without Valsalva maneuver (Fig. 1).
Correlation between clinical examination and scrotal Doppler was done with grading of the varicocele into subclinical, grade I, grade II, and grade III according to the Dubin grading system [7].
Semen analysis was performed preoperative and post-operative at 3 and 9 months, patients were advised to do it after abstinence of at least 7 days, all samples were sent to the hospital laboratory, and data about volume, count, motility, and normal forms were recorded.
Interventional technique
Percutaneous embolization
The procedure was done under local anesthesia using Siemens axiom artis cath/angio system. Vascular access was done via the right internal jugular vein which is preferred for early patient ambulation. U/S-guided vascular access was done using a 16-G puncture needle. A Terumo guide wire (0.035″) (Terumo, Japan) was introduced through needle to the internal jugular vein (IJV) down to the subclavian vein (SCV) crossing the right atrium down to the inferior vena cava (IVC). Vascular sheath was applied, a 4-F vertebral catheter (Boston Scientific, USA) was introduced over the wire, the wire was withdrawn, and the catheter was manipulated under fluoroscopic guidance where the spermatic vein was identified from the IVC on the right side and from the left renal vein on the left side.
The catheter was introduced till the pelvic inlet mid-inguinal point just above the scrotal neck. Spermatic vein venography was done to ensure the diagnosis, where the venography was positive if the contrast reflux to the pampiniform plexus of vein (sometimes Valsalva was needed to confirm diagnosis).
Catheterization of the spermatic vein was done followed by complete embolization using histoacryl (B. Braun, German) lipiodol emulsion (Guerbet, USA) with the ratio 2 lipiodol to 1 histoacryl (Fig. 2).
The histoacryl lipiodol emulsion was injected slowly with catheter pullback technique together with external inguinal compression to avoid the escape of emulsion into the scrotal sac and Valsalva to avoid the escape of the emulsion into the renal vein (Fig. 3).
Subinguinal microsurgical approach
After sterilization, a 3-cm transverse subinguinal incision was done (the approach was done without delivery of the testis). Using surgical loups with a magnification power of 4.5 times, external spermatic fascia was opened and the spermatic cord structures were retracted, and then identification of all spermatic cord veins was done followed by double ligation using 3-0 vicryl sutures (Fig. 4) after preservation of the arteries (confirmed by feeling arterial pulsations) and lymphatic channels. Closure of the subcutaneous tissue using interrupted sutures 3-0 vicryl was done, and the skin was closed using 4-0 undyed vicryl sutures.
Ethical consideration
An informed consent was obtained from the patient concerning the complication of the procedure, the complication of the glue, and the acceptance to be enrolled in the study.
Statistical analysis
Data were coded and entered using the statistical package SPSS (Statistical Package for the Social Sciences) version 23. Data were summarized using mean, standard deviation, median, minimum, and maximum in quantitative data and using frequency (count) and relative frequency (percentage) for categorical data. Comparisons between quantitative variables were done using chi-squared test and paired t test. P value less than or equal 0.05 was considered statistically significant.