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Outpatient Embolotherapy of Varicocele
DISEASES OF BLOOD VESSELS, HYPERTENSION AND RENOVASCULAR SURGERY
with 173 seconds of fluoroscopy time. After the procedure all patients began a course of oral urinary alkalization with sodium-potassium citrate, with the goal of maintaining urinary pH between 6.5 and 7.0. Percutaneous procedures were required in 29 per cent of the patients and repeat ESWL was necessary in 24 per cent. However, these ancillary procedures were required only in patients with staghorn or solitary calculi of greater than 2.5 cm. All patients underwent an appropriate contrast study and renal ultrasonography for followup and to assess the efficacy of treatment. At 3 months 76 per cent of the patients were rendered free of stones and 90 per cent were without calculi at 5 months. The authors reinforce the efficacy of ESWL in the management of patients with uric acid calculi. Previous studies have documented that ESWL may enhance the rate of dissolution of such stones by about 50 per cent, presumably by increasing the surface area of the calculus available for dissolution. J.
M. K. 2 figures, 2 tables, 10 references
DISEASES OF BLOOD VESSELS, HYPERTENSION AND RENOVASCULAR SURGERY Outpatient Embolotherapy of Varicocele W. HALDEN AND R. I. WHITE, JR., Russell H. Morgan Department of Radiology and Radiologic Sciences, The Johns Hopkins Medical Institutions, Baltimore, Maryland Urol. Clin. N. Amer., 14: 137-144 (Feb.) 1987 The authors have developed a technique to occlude the internal spermatic vein with a selectively placed detachable balloon. This technique was used in 400 outpatients. The only contraindications to outpatient percutaneous embolotherapy are severe bleeding diathesis or a previous life-threatening reaction to radiopaque contrast material. The technique is described in detail. Postoperatively, varicocele recurrences most often are owing to parallel collaterals that are treated easily by embolotherapy. However, recurrences after embolotherapy usually are caused by high parallel or renal vein collaterals and they are much more difficult to re-embolize successfully. Embolotherapy was successful in 97 per cent of the cases. The complication rate was less than 2 per cent, including a mild allergic reaction, migration of the balloon to the lung early in the experience and an overnight hospital stay because of intractable nausea in 1 child. G. W. K. 7 figures, 2 tables, 12 references
Varicocele and its Surgical Management J. A. LA NASA, JR. AND R. W. LEWIS, Departments of Urology, Louisiana State University Medical Center and Charity Hospital of Louisiana, New Orleans, Department of Surgery, River Parishes Medical Center and Andrology Laboratory, La Place; Department of Urology, Tulane University Medical Center, New Orleans, and Delta Regional Primate Center, Covington, Louisiana Urol. Clin. N. Amer., 14: 127-136 (Feb.) 1987 The incidence of varicocele in men evaluated for infertility is 21 to 41 per cent, which is 3 times greater than that in the
661
general population. A varicocele is determined best by examining the scrotum with the patient in an upright position. Varicoceles are classified as grade 1-palpable with the aid of a Valsalva maneuver, grade 2-palpable without the aid of a Valsalva maneuver and grade 3-visible without palpation. A subclinical varicocele has been proposed when no varicocele is palpated but semen analysis demonstrates a stress pattern. Doppler stethoscopes, contact scrotal thermography, blood pooling, radioisotopic angiography and spermatic venography may be of some use to define poorly palpable lesions. Bilateral varicocele may be present in 15 to 65 per cent of the patients. Unilateral right varicoceles are present in about 8 per cent of the patients. There is an increased incidence of small testicular size on the side of the varicocele, especially in elderly subfertile men. It appears that elevation of testicular temperature is the single most important factor in impaired spermatogenesis. Some infertile men with varicoceles have an alteration in the hormonal integrity of the hypothalamic pituitary testicular axis. Nine to 16 per cent of the boys in late childhood and adolescence have varicoceles. The presence of a varicocele is not itself an indication for an operation. Patients who have problems with fertility and a stress pattern on seminal cytology studies are the principal candidates. Adolescents who have a difference in testicular size also are candidates. Additionally, patients with pain may be surgical candidates. The acute onset of a varicocele, especially on the right side, should suggest the possibility of a retroperitoneal process causing occlusion of venous output. The conventional operation for repair of a varicocele is ligation of the varicose spermatic veins, either through an inguinal incision or a retroperitoneal incision just above the internal ring. The authors used microdissection of the spermatic cord at the external inguinal ring to accomplish this ligation. Compared to the more classic procedures this technique has less chance of damaging the spermatic artery, better identification of lymphatics, decreased postoperative pain and a shorter period of convalescence. An alternative method of treatment is selective venography followed by balloon occlusion of the venous outflow. G. W. K. 5 figures, 5 tables, 46 references
Sex Hormones and Coronary Artery Disease C.G.CHUTE,J.A.BARON,S.R.PLYMATE,D.P.KIEL,A.T. PAVIA, E. C. LOZNER, T. O'KEEFE AND G. J. MACDONALD, Departments of Medicine and Pathology, DartmouthHitchcock Medical Center, Hanover, New Hampshire and Madigan Army Medical Center, Tacoma, Washington Amer. J. Med., 83: 853-859 (Nov.) 1987 Several lines of evidence suggest that sex hormones may have a role in ischemic heart disease. Previous investigators have found an increased risk of coronary heart disease in men with high levels of circulating estrogens. To elucidate this relationship further, a case control study of atherosclerotic coronary artery disease and sex hormones was done in male patients. Hormone levels in men with severe atherosclerotic coronary artery disease documented at angiography were compared to those in men virtually free of disease and to those in a group of control subjects without signs or symptoms of atherosclerotic coronary artery disease. The authors found significantly lower serum testosterone levels among men with atherosclerotic coronary artery disease compared to the control subjects. This relationship was attenuated but it still was significant when
with 173 seconds of fluoroscopy time. After the procedure all patients began a course of oral urinary alkalization with sodium-potassium citrate, with the goal of maintaining urinary pH between 6.5 and 7.0. Percutaneous procedures were required in 29 per cent of the patients and repeat ESWL was necessary in 24 per cent. However, these ancillary procedures were required only in patients with staghorn or solitary calculi of greater than 2.5 cm. All patients underwent an appropriate contrast study and renal ultrasonography for followup and to assess the efficacy of treatment. At 3 months 76 per cent of the patients were rendered free of stones and 90 per cent were without calculi at 5 months. The authors reinforce the efficacy of ESWL in the management of patients with uric acid calculi. Previous studies have documented that ESWL may enhance the rate of dissolution of such stones by about 50 per cent, presumably by increasing the surface area of the calculus available for dissolution. J.
M. K. 2 figures, 2 tables, 10 references
DISEASES OF BLOOD VESSELS, HYPERTENSION AND RENOVASCULAR SURGERY Outpatient Embolotherapy of Varicocele W. HALDEN AND R. I. WHITE, JR., Russell H. Morgan Department of Radiology and Radiologic Sciences, The Johns Hopkins Medical Institutions, Baltimore, Maryland Urol. Clin. N. Amer., 14: 137-144 (Feb.) 1987 The authors have developed a technique to occlude the internal spermatic vein with a selectively placed detachable balloon. This technique was used in 400 outpatients. The only contraindications to outpatient percutaneous embolotherapy are severe bleeding diathesis or a previous life-threatening reaction to radiopaque contrast material. The technique is described in detail. Postoperatively, varicocele recurrences most often are owing to parallel collaterals that are treated easily by embolotherapy. However, recurrences after embolotherapy usually are caused by high parallel or renal vein collaterals and they are much more difficult to re-embolize successfully. Embolotherapy was successful in 97 per cent of the cases. The complication rate was less than 2 per cent, including a mild allergic reaction, migration of the balloon to the lung early in the experience and an overnight hospital stay because of intractable nausea in 1 child. G. W. K. 7 figures, 2 tables, 12 references
Varicocele and its Surgical Management J. A. LA NASA, JR. AND R. W. LEWIS, Departments of Urology, Louisiana State University Medical Center and Charity Hospital of Louisiana, New Orleans, Department of Surgery, River Parishes Medical Center and Andrology Laboratory, La Place; Department of Urology, Tulane University Medical Center, New Orleans, and Delta Regional Primate Center, Covington, Louisiana Urol. Clin. N. Amer., 14: 127-136 (Feb.) 1987 The incidence of varicocele in men evaluated for infertility is 21 to 41 per cent, which is 3 times greater than that in the
661
general population. A varicocele is determined best by examining the scrotum with the patient in an upright position. Varicoceles are classified as grade 1-palpable with the aid of a Valsalva maneuver, grade 2-palpable without the aid of a Valsalva maneuver and grade 3-visible without palpation. A subclinical varicocele has been proposed when no varicocele is palpated but semen analysis demonstrates a stress pattern. Doppler stethoscopes, contact scrotal thermography, blood pooling, radioisotopic angiography and spermatic venography may be of some use to define poorly palpable lesions. Bilateral varicocele may be present in 15 to 65 per cent of the patients. Unilateral right varicoceles are present in about 8 per cent of the patients. There is an increased incidence of small testicular size on the side of the varicocele, especially in elderly subfertile men. It appears that elevation of testicular temperature is the single most important factor in impaired spermatogenesis. Some infertile men with varicoceles have an alteration in the hormonal integrity of the hypothalamic pituitary testicular axis. Nine to 16 per cent of the boys in late childhood and adolescence have varicoceles. The presence of a varicocele is not itself an indication for an operation. Patients who have problems with fertility and a stress pattern on seminal cytology studies are the principal candidates. Adolescents who have a difference in testicular size also are candidates. Additionally, patients with pain may be surgical candidates. The acute onset of a varicocele, especially on the right side, should suggest the possibility of a retroperitoneal process causing occlusion of venous output. The conventional operation for repair of a varicocele is ligation of the varicose spermatic veins, either through an inguinal incision or a retroperitoneal incision just above the internal ring. The authors used microdissection of the spermatic cord at the external inguinal ring to accomplish this ligation. Compared to the more classic procedures this technique has less chance of damaging the spermatic artery, better identification of lymphatics, decreased postoperative pain and a shorter period of convalescence. An alternative method of treatment is selective venography followed by balloon occlusion of the venous outflow. G. W. K. 5 figures, 5 tables, 46 references
Sex Hormones and Coronary Artery Disease C.G.CHUTE,J.A.BARON,S.R.PLYMATE,D.P.KIEL,A.T. PAVIA, E. C. LOZNER, T. O'KEEFE AND G. J. MACDONALD, Departments of Medicine and Pathology, DartmouthHitchcock Medical Center, Hanover, New Hampshire and Madigan Army Medical Center, Tacoma, Washington Amer. J. Med., 83: 853-859 (Nov.) 1987 Several lines of evidence suggest that sex hormones may have a role in ischemic heart disease. Previous investigators have found an increased risk of coronary heart disease in men with high levels of circulating estrogens. To elucidate this relationship further, a case control study of atherosclerotic coronary artery disease and sex hormones was done in male patients. Hormone levels in men with severe atherosclerotic coronary artery disease documented at angiography were compared to those in men virtually free of disease and to those in a group of control subjects without signs or symptoms of atherosclerotic coronary artery disease. The authors found significantly lower serum testosterone levels among men with atherosclerotic coronary artery disease compared to the control subjects. This relationship was attenuated but it still was significant when