Combination of High Ligation and Intraoperative Embolization using Polidocanol for Treatment of Varicoceles

Summary

To reduce the postoperative recurrence rate of varicocelectomy, we combined high ligation of varicocele with intraoperative embolization. We injected polidocanol from the spermatic vein during surgery to embolize the branches of the spermatic vein and collateral veins. This is an alternative surgical method for the treatment of varicocele.

Abstract

Varicoceles are dilated veins within the pampiniform plexus and are relatively common in the general male population. The spermatic vein has many branches in the scrotal segment and then gradually merges into 1-2 trunks after passing through the internal inguinal ring. The key to a successful varicocelectomy is to ligate all the spermatic veins while protecting the testicular arteries and spermatic lymphatic vessels from damage. The small veins, including the branches of spermatic veins and collateral veins, are easily missed for ligation during conventional high ligation of varicocele, which has been suggested as a major cause of postoperative recurrence. Although microsurgery effectively reduces the risk of missing ligation of the spermatic veins during surgery, it has several shortcomings, such as long operation time and a steep learning curve. More importantly, this technique is difficult to carry out in primary hospitals due to the requirement of specialized equipment. Therefore, an attempt to modify the traditional high ligation aiming to reduce the postoperative recurrence rate has been carried out here. The protocol here combines traditional high ligation with intraoperative embolization to seal off the branches of the spermatic vein and collateral veins. We rapidly injected foamed sclerosant into the internal spermatic vein under direct observation after separation of the spermatic vein and then ligated all the veins. The foamed sclerosant through the varicose vein hampers endothelial cell growth, promotes the growth of thrombus and fibrosis, and ultimately forms fibrous streaks that permanently fill the venous. The results showed a more satisfactory effect on reducing the postoperative recurrence rate compared with traditional high ligation. Since this protocol is simple to carry out and has better results in reducing the recurrence rate, this can be an alternative surgical method for the treatment of varicocele, especially in primary hospitals.

Introduction

Varicoceles, with an incidence of approximately 15%-20% in the general male population and 35%-40% among the infertile population, is one of the major causes of infertility^1,2,3. In addition, varicoceles can cause pain and discomfort and a decline in androgen levels⁴. In recent decades, different surgical procedures have been consistently applied to treat varicoceles, including high ligation of varicocele, inguinal and sublingual micro varicocelectomy, laparoscopic spermatic vein ligation, and interventional embolization⁵. High retroperitoneal ligation of the spermatic vein is the traditional surgical procedure used to treat varicoceles⁶. Moreover, it is the simplest surgical procedure for the surgical treatment of varicocele and is easy to carry out at any center. However, this method easily misses ligating the branch veins, which can subsequently lead to postoperative recurrence. Laparoscopic ligation of the spermatic vein may risk damaging the abdominal organs. Furthermore, the risk of arterial damage and the requirement for specialized equipment are high. It has been demonstrated that micro varicocelectomy produces better results than other surgical procedures in improving semen quality and reducing the postoperative recurrence rate. Therefore, micro varicocelectomy has been considered as the golden standard of surgical treatments for varicocele. However, this technique has several shortcomings, such as long operation time and a steep learning curve. More importantly, the requirement for specialized equipment and the difficulty in carrying out the technique in primary hospitals.

We present a new surgical procedure that is not limited by the equipment and, thus, can be applied in any center. We also expect this procedure to achieve a better effect on reducing the postoperative recurrence rate. Based on the procedure of traditional high ligation, we applied intraoperative embolization simultaneously with high ligation. We injected embolic agents from the internal spermatic vein under direct observation during surgery to embolize the branches of spermatic vein, aiming to cover the possibility of missing ligation. The procedure may block the veins as completely as possible and reduce the postoperative recurrence rate. Since the procedure derives from traditional high ligation of spermatic vein, there is no limit of equipment, and it is easy to be performed by any surgeon and can be carried out in most centers.

High ligation combined with intraoperative embolization (HLIE) has a short learning curve and can lead to complete occlusion of the spermatic vein. After being reviewed and approved by the First Affiliated Hospital, Sun Yat-sen University, on January 10, 2013, we began applying HLIE and evaluating its outcomes in comparison with traditional high ligation.

Protocol

All procedures in the following protocol were reviewed and approved by the First Affiliated Hospital, Sun Yat-sen University.

1. Patient preparation

1. Apply the following inclusion criteria: male sex; varicoceles during physical examination and on ultrasonography; infertility or abnormal semen or unrelieved pain by drugs.
2. Apply the following exclusion criteria: other known causes of male infertility, such as cryptorchidism, cancer, scrotum and reproductive tract surgery, hypogonadism, and azoospermia.
3. Perform a testicle and spermatic cord palpation and ultrasound examination to determine the classification of varicocele. Place the patient in a standing position and confirm whether there is a dilated and clumped venous plexus on the scrotum skin.
4. Examine the patient's spermatic cord to confirm whether the spermatic veins dilate during spontaneous respiration and Valsalva's movements (after deep inhalation, close the glottis tightly, then exhale forcefully to increase abdominal pressure). Perform an ultrasound examination to evaluate the diameter of the spermatic vein.
5. Inform the patient of the benefits and risks of surgery, including excessive bleeding and blood transfusion, testicular atrophy, recurrence, scrotal edema, hydrocele, and postoperative infection, then obtain written consent.
6. Carry out the surgery under epidural anesthesia or general anesthesia with the patient placed in a supine position.

2. Pre-HLIE preparation

1. Monitor the patient's vital signs carefully by an anesthesiologist during surgery.
2. Sterilize the skin of the thigh, perineum, and abdomen 2x with iodophor. Create a longitudinal incision approximately 2-3 cm in length with a scalpel. Establish the incision by standard technique: 2 cm above the internal inguinal ring.

3. High ligation and intraoperative embolization (HLIE)

1. After incision of the subcutaneous tissue, cut the aponeurosis of the obliquus externus abdominis approximately 3 cm, and bluntly separate the muscles and transverse fascia below to expose the peritoneum and retroperitoneal adipose tissue.
2. Use a retractor to pull the muscles and peritoneum aside to have a clear view. The spermatic cord is just behind the peritoneum, between the peritoneum and retroperitoneal adipose tissue. Use a retractor to pull the adipose tissue aside and find the spermatic cord adjacent to the peritoneum, then bluntly separate the spermatic cord from surrounding connective tissue with forceps.
3. Grasp the ipsilateral scrotum by hand and pull the testicle to confirm the spermatic vein. Squeeze the testicle to promote venous drainage, which will be beneficial for intraoperative embolization with polidocanol. Cut the spermatic fascia with scissors to expose the spermatic vein, then bluntly separate the spermatic vein with forceps.
   NOTE: During surgical dissection of the spermatic vein, any injury to the accompanying arteries and lymphatic vessels should be avoided.
4. Prepare vascular hardening agent for embolization: Use two 10 mL sterile syringes to mix 5 mL of polidocanol and 5 mL of air. Do this until a 10 mL polidocanol foam sclerosant mixture is obtained; use this for embolization.
5. Make an approximately 0.2-0.3 cm longitudinal incision with a scalpel on the spermatic vein. Insert a 0.8 cm sterile syringe needle into the spermatic vein.
6. Inject the 10 mL polidocanol foam sclerosant mixture rapidly into the distal segment of the spermatic vein through the needle.
7. Remove the needle, and double ligate the spermatic vein with 3-0 non-absorbable suture line at sites approximately 0.5 cm proximal and distal to the incision of the vein.
8. Finally, check whether there is any bleeding at any point, including the spermatic cord, retroperitoneal adipose tissue, and muscles. If yes, stop the bleeding with an electrocoagulation electrotome carefully. Suture the abdominal incision with 3-0 absorbable suture material.

4. Postoperative management

1. Document the intra- and post-operative parameters carefully, including the diameters of the spermatic vein according to the results of ultrasound examination, operation time (from the beginning of incision to the end of suturing), and blood loss (calculated by vacuum drainage).
2. Perform patient follow-up after surgery at 1 month, 3 months, 6 months, and 1 year. Perform testicle examinations and ultrasound, pain scores (the visual analog scale (VAS) pain score to evaluate the pain of varicocele patients before and after surgery; Figure 1), semen analysis, and whether the patients had achieved impregnation or experienced scrotal edema, varicocele recurrence, or testicular atrophy.
3. Asses the effect of treatment, including semen parameters and pain score, recurrence rate, and probability of complications of HLIE, and perform statistical analysis with SPSS software, taking p < 0.05 as statistically significant.

Results

HLIE (Figure 2) was performed on 53 patients, and traditional HL was performed on 81 patients from 2013 to 2019. The mean ages of the two groups were 31.29 years (range 15 to 65) and 29 years (range 15 to 64), respectively. A total of 79.1% (n=106) of the patients were treated for a left-sided varicocele in this sample. The most common clinical grades are Grade II and Grade III (Grade II: venous clusters cannot be seen on the surface of the scrotum, but the spermatic vein is varicose by palp...

Discussion

This protocol presents a new surgical method for varicocele that combines traditional high ligation with intraoperative embolization to seal off the internal spermatic vein branches sufficiently. We expect to reduce the possibility of missing ligation of the small branches to reduce the postoperative recurrence rate by this method. The follow-up results show that this method can reduce the postoperative recurrence rate and improve the appearance of scrotum covered with varicose veins in the short term. The specific proce...

Materials

Name	Company	Catalog Number	Comments
3-0 absorbable suture material	Johnson & Johnson-Ethicon	20203021529
3-0 non-absorbable suture line	Johnson & Johnson	20202020196
electrocoagulation electrotome	Shinva	20183010484
forceps	Shinva	20140168
iodophor	ADF Hi-tec Disinfectants Co., Ltd.	2019029215
polidocanol	Shanxi Tianyu Pharmaceutical Co., Ltd.	H20080445
retractor	Shinva	20150218
syringes	Medicom	20153140848