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Use of Venography as an Aid in Varicocelectomy
0022-534 7/87 /1381-1041$02.00/0 Vol. 138, October Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1987 by The Williams & Wilkins Co.
USE OF VENOGRAPHY AS AN AID IN VARICOCELECTOMY MARK R. ZAONTZ AND CASIMIR F. FIRLIT From the Division of Urology, Children's Memorial Hospital and Department of Urology, Northwestern University Medical School, Chicago, Illinois
ABSTRACT
Venography has been proposed as an aid in preventing persistent varicoceles after internal spermatic vein ligation. Since 1984, 10 patients between 4 and 18 years old underwent successful outpatient varicocelectomy with high ligation and intraoperative internal spermatic venography to assure that all appropriate veins and collaterals had been isolated before ligation. (J. Ural., part 2, 138: 1041-1042, 1987) A persistent varicocele after a well planned and meticulous high ligation of the internal spermatic vein creates considerable frustration for the physician, patient and family. Even in the best of hands a persistent varicocele may occur at a rate of 5 to 16 per cent. 1• 2 In 1978 Sayfan and Adam introduced the concept of intraoperative venography, suggesting that failure rates postoperatively may be improved with this modality. 2 Kogan suggested the use of intraoperative venography following internal spermatic vein ligation to assure accurate surgical anatomy and, thereby, to prevent postoperative persistent varicoceles.3 Experience with persistent postoperative varicoceles prompted us to incorporate venography as modified from the aforementioned descriptions. MATERIALS AND METHODS
From November 1984 through May 1986, 10 boys 4 to 18 years old (mean age 13 years) were evaluated and treated surgically for scrotal varicoceles. Signs and symptoms included a decreased ipsilateral testicular mass in 8, pain in 1 and a large recurrent varicocele in an 11-year-old prepubertal boy. All 10 cases were treated surgically on an outpatient basis through a suprainguinal muscle-splitting approach (Palomo method). 4 A 3 to 4 cm. incision was made approximately 2 cm. below and medial to the anterosuperior iliac spine. The internal spermatic vein(s) was located in the retroperitoneum after minimal medial mobilization of the peritoneum. The venous trunks then were isolated and occluded with a small vessel loop. A hemostat placed on the distal end of the loop was used to tent up the veins, providing a good angle for needle cannulation. The vas deferens was identified and any dilated or tortuous veins likewise were occluded. To assess the vascular anatomy and to demonstrate the presence of venous collaterals not seen or occluded intraoperative venography was used. The patient was placed in a 45degree reverse Trendelenberg position. The largest internal spermatic vein was cannulated with a 25 gauge butterfly needle distal to the vessel loop. A 10 cc syringe with 30 per cent iodinated contrast medium was hand injected and a single lower abdominal/scrotal radiograph was taken (fig. 1). Any unrecognized spermatic vein and/or collateral vessel seen was ligated subsequently. The accuracy of venous anatomy allowed for avoidance of spermatic artery ligation and incorrect venous ligation. Lymphatic vessels were preserved or ligated if necessary. All involved veins were double-ligated proximally and distally with 3 or 4-zero nonabsorbable suture with a segment of each involved vein excised.
cured successfully. An 11-year-old boy had undergone reoperation for a persistent varicocele treated originally 3 years previously. Venography in this patient clearly demonstrated a previously missed internal spermatic vein (fig. 2). In 2 boys 14 and 16 years old the left testis increased in size equal to that on the right side during the 1-year followup. There were no changes in testicular size in the other boys during this study. A 17-year-old boy is now free of pain after having presented with inguinal scrotal discomfort. There were no recognized hydroceles or testicular atrophy after this procedure. Two boys required more than 1 intraoperative x-ray owing to improper vessel cannulation. In 1 patient a testicular arteriogram (fig. 3, A) and in the other a venogram of the pelvic vein plexus (fig. 3, B) were done before correct internal spermatic vein identification. DISCUSSION
Internal spermatic vein venography was first introduced by Ahlberg and associates. 5 •6 Then percutaneous venographic techniques to treat varicoceles, including the use of sclerosing agents, embolization and detachable balloons, became popu-
RESULTS
Followup ranged from 3 months to 1.5 years (mean 0.83 years). In 10 consecutive patients 10 varicoceles have been
FIG. 1. Internal spermatic veins demonstrated by intraoperative venography.
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FIG. 2. Missed internal spermatic vein from prior surgery demonstrated by venography.
FIG. 3. A, testicular arteriogram performed because of inadvertent arterial cannulation. B, pelvic vein plexus seen after injecting vein deep to internal spermatic venous trunks.
lar. 1 - 9 Over-all the results were excellent, morbidity was minimal and open surgery was avoided. Coolsaet advocated preoperative venography of the renal, internal spermatic and common iliac veins to determine the optimal level at which to perform varicocelectomy. 10 In his series of 67 patients 20 per cent had varicoceles attributed to obstruction of a common iliac vein with the internal spermatic vein acting as a release valve for drainage. High ligation of the internal spermatic vein accordingly would be potentially detrimental. Anatomically, venous drainage of the left pampiniform plexus includes 3 groups of veins that intercommunicate. The internal (anterior) spermatic vein group enters the left renal vein. The middle deferential group follows the vas deferens to the pelvic venous plexus including the hypogastric vein. The posterior group (external spermatic, cremasteric or funicular) drains along the posterior aspect of the spermatic cord and empties into branches of the superficial and deep epigastric and pudendal veins. Open surgery for varicoceles remains a common method of treatment. 11- 13 Sayfan and Adam correctly indicated that a patent, second internal spermatic vein and/or an involved cremasteric vein can be missed during surgery and they recommended intraoperative venography as an adjunctive procedure to prevent this possibility. 2 Kogan's concept of intraoperative post-ligation venography is an accurate and cost-effective answer to Coolsaet's proposal. 3 We modified Kogan's technique further by performing pre-ligation venography to ensure not only correct ligation of all involved veins but to avoid ligating those structures not anatomically correct. This procedure is easy to perform, radiation exposure is minimal and operative time is slightly prolonged. Primarily, intraoperative venography provides peace of mind for the surgeon that a reoperation may be avoided.
REFERENCES
1. Holschneider, A. M., Butenandt, 0., Schuster, L., Schaupp, D., Tewes, G., Mengel, W. and Hamberger, J.: Operative therapy of varicocele in childhood. Z. Kinderchir., 24: 252, 1978. 2. Sayfan, J. and Adam, Y. G.: Intraoperative internal spermatic vein phlebography in the subfertile male with varicocele. Fertil. Steril., 29: 669, 1978. 3. Kogan, S. J.: Prevention of persistent varicocele. Soc. Ped. Urol. Newsletter, p. 6, February 22, 1984. 4. Palomo, A.: Radical cure of varicocele by a new technique. Preliminary report. J. Urol., 61: 604, 1949. 5. Ahlberg, N. E., Bartley, 0. and Chidekel, N.: Retrograde contrast filling of the left gonadal vein: a roentgenologic and anatomical study. Acta Rad. (Diagn.), 3: 385, 1965. 6. Ahlberg, N. E., Bartley, 0. and Chidekel, N.: Right and left gonadal veins: an anatomical and statistical study. Acta Rad. (Diagn.), 4: 593, 1966a. 7. Seyferth, W., Jecht, E. and Zeitler, E.: Percutaneous sclerotherapy of varicocele. Radiology, 139: 335, 1981. 8. Formanek, A., Rusnak, B., Zollikofer, C., Castanada-Zuniga, W. R., Narayan, P., Gonzalez, R. and Amplatz, K.: Embolization of the spermatic vein for treatment of infertility: a new approach. Radiology, 139: 315, 1981. 9. Walsh, P. C. and White, R. I., Jr.: Balloon occlusion of the internal spermatic vein for the treatment of varicoceles. J.A.M.A., 246: 1701, 1981. 10. Coolsaet, B. L. R. A.: The varicocele syndrome: venography determining the optimal level for surgical management. J. Urol., 124: 833, 1980. 11. Dubin, L. and Amelar, R. D.: Varicocele size and results of varicocelectomy in selected subfertile men with varicocele. Fertil. Steril., 21: 606, 1970. 12. Dubin, L. and Amelar, R. D.: Varicocelectomy: 986 cases in a twelve-year study. Urology, 10: 446, 1977. 13. Szabo, R. and Kessler, R.: Hydrocele following internal spermatic vein ligation: A retrospective study and review of the literature. J. Urol., 132: 924, 1984.
THE JOURNAL OF UROLOGY
Copyright© 1987 by The Williams & Wilkins Co.
USE OF VENOGRAPHY AS AN AID IN VARICOCELECTOMY MARK R. ZAONTZ AND CASIMIR F. FIRLIT From the Division of Urology, Children's Memorial Hospital and Department of Urology, Northwestern University Medical School, Chicago, Illinois
ABSTRACT
Venography has been proposed as an aid in preventing persistent varicoceles after internal spermatic vein ligation. Since 1984, 10 patients between 4 and 18 years old underwent successful outpatient varicocelectomy with high ligation and intraoperative internal spermatic venography to assure that all appropriate veins and collaterals had been isolated before ligation. (J. Ural., part 2, 138: 1041-1042, 1987) A persistent varicocele after a well planned and meticulous high ligation of the internal spermatic vein creates considerable frustration for the physician, patient and family. Even in the best of hands a persistent varicocele may occur at a rate of 5 to 16 per cent. 1• 2 In 1978 Sayfan and Adam introduced the concept of intraoperative venography, suggesting that failure rates postoperatively may be improved with this modality. 2 Kogan suggested the use of intraoperative venography following internal spermatic vein ligation to assure accurate surgical anatomy and, thereby, to prevent postoperative persistent varicoceles.3 Experience with persistent postoperative varicoceles prompted us to incorporate venography as modified from the aforementioned descriptions. MATERIALS AND METHODS
From November 1984 through May 1986, 10 boys 4 to 18 years old (mean age 13 years) were evaluated and treated surgically for scrotal varicoceles. Signs and symptoms included a decreased ipsilateral testicular mass in 8, pain in 1 and a large recurrent varicocele in an 11-year-old prepubertal boy. All 10 cases were treated surgically on an outpatient basis through a suprainguinal muscle-splitting approach (Palomo method). 4 A 3 to 4 cm. incision was made approximately 2 cm. below and medial to the anterosuperior iliac spine. The internal spermatic vein(s) was located in the retroperitoneum after minimal medial mobilization of the peritoneum. The venous trunks then were isolated and occluded with a small vessel loop. A hemostat placed on the distal end of the loop was used to tent up the veins, providing a good angle for needle cannulation. The vas deferens was identified and any dilated or tortuous veins likewise were occluded. To assess the vascular anatomy and to demonstrate the presence of venous collaterals not seen or occluded intraoperative venography was used. The patient was placed in a 45degree reverse Trendelenberg position. The largest internal spermatic vein was cannulated with a 25 gauge butterfly needle distal to the vessel loop. A 10 cc syringe with 30 per cent iodinated contrast medium was hand injected and a single lower abdominal/scrotal radiograph was taken (fig. 1). Any unrecognized spermatic vein and/or collateral vessel seen was ligated subsequently. The accuracy of venous anatomy allowed for avoidance of spermatic artery ligation and incorrect venous ligation. Lymphatic vessels were preserved or ligated if necessary. All involved veins were double-ligated proximally and distally with 3 or 4-zero nonabsorbable suture with a segment of each involved vein excised.
cured successfully. An 11-year-old boy had undergone reoperation for a persistent varicocele treated originally 3 years previously. Venography in this patient clearly demonstrated a previously missed internal spermatic vein (fig. 2). In 2 boys 14 and 16 years old the left testis increased in size equal to that on the right side during the 1-year followup. There were no changes in testicular size in the other boys during this study. A 17-year-old boy is now free of pain after having presented with inguinal scrotal discomfort. There were no recognized hydroceles or testicular atrophy after this procedure. Two boys required more than 1 intraoperative x-ray owing to improper vessel cannulation. In 1 patient a testicular arteriogram (fig. 3, A) and in the other a venogram of the pelvic vein plexus (fig. 3, B) were done before correct internal spermatic vein identification. DISCUSSION
Internal spermatic vein venography was first introduced by Ahlberg and associates. 5 •6 Then percutaneous venographic techniques to treat varicoceles, including the use of sclerosing agents, embolization and detachable balloons, became popu-
RESULTS
Followup ranged from 3 months to 1.5 years (mean 0.83 years). In 10 consecutive patients 10 varicoceles have been
FIG. 1. Internal spermatic veins demonstrated by intraoperative venography.
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1042
ZAONTZ AND FIRLIT
FIG. 2. Missed internal spermatic vein from prior surgery demonstrated by venography.
FIG. 3. A, testicular arteriogram performed because of inadvertent arterial cannulation. B, pelvic vein plexus seen after injecting vein deep to internal spermatic venous trunks.
lar. 1 - 9 Over-all the results were excellent, morbidity was minimal and open surgery was avoided. Coolsaet advocated preoperative venography of the renal, internal spermatic and common iliac veins to determine the optimal level at which to perform varicocelectomy. 10 In his series of 67 patients 20 per cent had varicoceles attributed to obstruction of a common iliac vein with the internal spermatic vein acting as a release valve for drainage. High ligation of the internal spermatic vein accordingly would be potentially detrimental. Anatomically, venous drainage of the left pampiniform plexus includes 3 groups of veins that intercommunicate. The internal (anterior) spermatic vein group enters the left renal vein. The middle deferential group follows the vas deferens to the pelvic venous plexus including the hypogastric vein. The posterior group (external spermatic, cremasteric or funicular) drains along the posterior aspect of the spermatic cord and empties into branches of the superficial and deep epigastric and pudendal veins. Open surgery for varicoceles remains a common method of treatment. 11- 13 Sayfan and Adam correctly indicated that a patent, second internal spermatic vein and/or an involved cremasteric vein can be missed during surgery and they recommended intraoperative venography as an adjunctive procedure to prevent this possibility. 2 Kogan's concept of intraoperative post-ligation venography is an accurate and cost-effective answer to Coolsaet's proposal. 3 We modified Kogan's technique further by performing pre-ligation venography to ensure not only correct ligation of all involved veins but to avoid ligating those structures not anatomically correct. This procedure is easy to perform, radiation exposure is minimal and operative time is slightly prolonged. Primarily, intraoperative venography provides peace of mind for the surgeon that a reoperation may be avoided.
REFERENCES
1. Holschneider, A. M., Butenandt, 0., Schuster, L., Schaupp, D., Tewes, G., Mengel, W. and Hamberger, J.: Operative therapy of varicocele in childhood. Z. Kinderchir., 24: 252, 1978. 2. Sayfan, J. and Adam, Y. G.: Intraoperative internal spermatic vein phlebography in the subfertile male with varicocele. Fertil. Steril., 29: 669, 1978. 3. Kogan, S. J.: Prevention of persistent varicocele. Soc. Ped. Urol. Newsletter, p. 6, February 22, 1984. 4. Palomo, A.: Radical cure of varicocele by a new technique. Preliminary report. J. Urol., 61: 604, 1949. 5. Ahlberg, N. E., Bartley, 0. and Chidekel, N.: Retrograde contrast filling of the left gonadal vein: a roentgenologic and anatomical study. Acta Rad. (Diagn.), 3: 385, 1965. 6. Ahlberg, N. E., Bartley, 0. and Chidekel, N.: Right and left gonadal veins: an anatomical and statistical study. Acta Rad. (Diagn.), 4: 593, 1966a. 7. Seyferth, W., Jecht, E. and Zeitler, E.: Percutaneous sclerotherapy of varicocele. Radiology, 139: 335, 1981. 8. Formanek, A., Rusnak, B., Zollikofer, C., Castanada-Zuniga, W. R., Narayan, P., Gonzalez, R. and Amplatz, K.: Embolization of the spermatic vein for treatment of infertility: a new approach. Radiology, 139: 315, 1981. 9. Walsh, P. C. and White, R. I., Jr.: Balloon occlusion of the internal spermatic vein for the treatment of varicoceles. J.A.M.A., 246: 1701, 1981. 10. Coolsaet, B. L. R. A.: The varicocele syndrome: venography determining the optimal level for surgical management. J. Urol., 124: 833, 1980. 11. Dubin, L. and Amelar, R. D.: Varicocele size and results of varicocelectomy in selected subfertile men with varicocele. Fertil. Steril., 21: 606, 1970. 12. Dubin, L. and Amelar, R. D.: Varicocelectomy: 986 cases in a twelve-year study. Urology, 10: 446, 1977. 13. Szabo, R. and Kessler, R.: Hydrocele following internal spermatic vein ligation: A retrospective study and review of the literature. J. Urol., 132: 924, 1984.