A cost outcome study of varicocoele embolisation and future pregnancy in an Australian public hospital setting.

INTRODUCTION: Varicocoele is commonly encountered in males with infertility. Studies have shown that varicocoele repair (surgery or embolisation) can improve the rate of subsequent pregnancy. In Australia, there have been no studies assessing the cost of varicocoele embolisation and current practice is based on international data. This study aimed to assess the cost of varicocoele embolisation and estimate the treatment cost per pregnancy. METHODS: Retrospective cost-outcome study of patients treated by embolisation between January 2018 and 2023. A bottom-up approach was used to calculate procedure costs whereas a top-down approach was used to calculate costs for all other patient services, including direct and indirect costs. To calculate cost per pregnancy, costs were adjusted according to existing published data on the rate of pregnancy after embolisation. RESULTS: Costing data from 18 patients were included, of median age 33.5 years (range 26-60) and median varicocoele grade 2.5 (range 1-3). All patients had unilateral treatment, most commonly via right internal jugular (16 patients, 89%) and using a 0.035″ system (17 patients, 94%). The median cost for the entire treatment including procedural, non-procedural, ward and peri-procedural costs was AUD$2208.10 (USD$1405 or EUR€1314), range AUD$1691-7051. The projected cost to the healthcare system per pregnancy was AUD$5387 (USD$3429 or EUR€3207). CONCLUSION: Total varicocoele embolisation cost and the cost per-pregnancy were lower than for both embolisation and surgical repair in existing international studies. Patients undergoing varicocoele treatment should have the option to access an interventional radiologist to realise the benefits of this low-cost pinhole procedure.

Retrograde sclerotherapy of male varicocele with veno-venous shunts - incidence and management: a single-centre experience.

OBJECTIVES: The aim of our study is to compare the incidence of veno-venous shunts in male varicocele and evaluate the possibility to exclude them with manual compression or/and scrotal ligation in order to carry out the procedure of retrograde sclero-embolization. METHODS: In our retrospective study, all patients undergone retrograde sclerotherapy for varicocele in our Interventional Radiology Unit in the last four years were evaluated. Collaterals toward other venous shunts were identified and how many and which patients would be able to complete the procedure safely were considered. RESULTS: Of the 91 patients, as many as 22 (i.e., 24.17%) patients presented anatomical variants, consisting on shunting into left iliac vein (9 [9.89%]), lumbar left veins (3 [3.29%]), right iliac vein (1 [1.09%]), both iliac veins (1 [1.09%]), left femoral vein (1 [1.09%]) or a more proximal portion of the ISV itself without shunting (3 [3.29%]). Patients with duplication could benefit from a more distal injection in order to prevent back-flow; of the 19 left, nine successfully underwent sclerotherapy with manual compression or/and scrotal ligation, whereas in 10 flow through the collaterals could not be interrupted and patients were demanded for surgery. CONCLUSIONS: Many patients with abnormal communications between the internal spermatic vein and the iliac veins (that is, shunts towards the iliac veins) may as well undergo retrograde sclerotherapy safely if compression/ligation is applied. ADVANCES IN KNOWLEDGE: No large previous study highlighted the impact of veno-venous shunts in technical feasibility of retrograde sclerotherapy of varicocele.

Varicocele Embolization: An Assessment of the Quality and Readability of Online Patient Information.

AIMS AND OBJECTIVES: Varicocele embolization is a growing treatment modality owing to the safety, efficacy, and quick return to work following the procedure. The internet is the most dominant source of information for many. We aimed to assess the quality of information accessible by patients considering treatment. MATERIALS AND METHODS: A list of applicable, commonly used searchable terms was generated. Each term was assessed across the five most-used English language search engines to determine the two most commonly used terms. These two terms were then investigated across each search engine, with the first 25 web pages returned by each engine included for analysis. Duplicate web pages, nontext content such as video or audio, and web pages behind paywalls were excluded. Web pages were analyzed for quality and readability using validated tools including DISCERN score, JAMA Benchmark Criteria, HONcode Certification, Flesch Reading Ease Score, Flesch-Kincaid Grade Level, and Gunning-Fog Index. Secondary features including age, rank, author, and publisher were recorded. RESULTS: The most common applicable terms were "Testicular embolization" (378,300 results) and "Varicocele embolization" (375,800 results). Mean DISCERN quality of information provided by websites is "fair"; Adherence to JAMA Benchmark Criteria was 13.5%. Flesh-Kincaid readability tests demonstrated an average "9th grade" reading level. Scientific journals showed the highest quality scores, but were least up to date with an average web page age of 11.2 years. Web pages produced by "for-profit" organizations were the second most current (average age 2.7 years), but displayed the lowest quality of information scores. CONCLUSION: While quality of online information available to patients is "fair," adherence to JAMA benchmark criteria is poor. "For-profit" organization websites are far more numerous and significantly more up-to-date, yet showed significantly lower quality of information scores. Scientific journals were unsurprisingly of higher quality, yet more challenging for the general public to read. These findings call for the production of high-quality and comprehensible content regarding interventional radiology, where physicians can reliably direct their patients for information.

A systematic review of clinical practice guidelines and best practice statements for the diagnosis and management of varicocele in children and adolescents.

A systematic review was conducted to identify and qualitatively analyze the methods as well as recommendations of Clinical Practice Guidelines (CPG) and Best Practice Statements (BPS) concerning varicocele in the pediatric and adolescent population. An electronic search was performed with the MEDLINE, EMBASE, Science Direct, and Scielo databases, as well as guidelines' Web sites until September 2015. Four guidelines were included in the qualitative synthesis. In general, the recommendations provided by the CPG/BPS were consistent despite the existence of some gaps across the studies. The guidelines issued by the American Urological Association (AUA) and American Society for Reproductive Medicine (ASRM) did not provide evidence-based levels for the recommendations given. Most of the recommendations given by the European Association of Urology (EAU) and European Society of Pediatric Urology (ESPU) were derived from nonrandomized clinical trials, retrospective studies, and expert opinion. Among all CPG/BPS, only one was specifically designed for the pediatric population. The studied guidelines did not undertake independent cost-effectiveness and risk-benefit analysis. The main objectives of these guidelines were to translate the best evidence into practice and provide a framework of standardized care while maintaining clinical autonomy and physician judgment. However, the limitations identified in the CPG/BPS for the diagnosis and management of varicocele in children and adolescents indicate ample opportunities for research and future incorporation of higher quality standards in patient care.

[Evaluation of testicular growth after varicocele treatment in early childhood and adolescence based on the technique used (Palomo, Ivanissevich and embolization)]. / Valoración del crecimiento testicular tras el tratamiento del varicocele en la infancia y adolescencia en función de la técnica empleada (Palomo, Ivanissevich y embolización).

OBJECTIVES: To analyze, depending on the technique employed, recurrence, symptomatic improvement and testicular growth following treatment of testicular varicocele. MATERIAL AND METHODS: Descriptive retrospective study of 69 pediatric and adolescent males diagnosed with varicocele treated in our center by open technique according Ivanissevich technique (IT), Palomo (PT) and percutaneous embolization (PE) between 2000-2014. Variables analyzed were age, symptoms, differential testicular volume (RV), employed technique, recurrence, symptomatic improvement and RV after treatment. Association between qualitative variables was evaluated (chi-square test or Fisher's exact test). RESULTS: 69 patients with a median age of 14 years (7-19) were studied. PE was performed in 37 patients (53,6%), PT in 23 (33,3%) and IT in 9 (13%). Recurrence occurred in 16 patients (23,2%), 80% of them had been treated with PE. Eleven patients had pain (15.9%), there was improvement in 100% of patients treated with PE, but none of those treated by PT or IT improved. At diagnosis, 37 patients (53.6%) had decreased testicular volume (left testicular hypotrophy), in 28 cases the RV was >20%. After treatment, the RV was normalized in 11 cases (39,2%). CONCLUSIONS: The choice of therapeutic technique in pediatric varicocele should be based on patient characteristics, symptoms, experience center for embolization and previous recurrence. Regardless of the chosen technique, 39,2% of testicular hypotrophy with VD >20% present at diagnosis normalized after treatment.

OBJETIVOS: Analizar en función de la técnica empleada para tratamiento de varicocele, la recurrencia, alivio sintomático y crecimiento testicular en pacientes pediátricos y adolescentes. MATERIAL Y METODOS: Estudio descriptivo retrospectivo de 69 pacientes pediátricos y adolescentes diagnosticados de varicocele tratados en nuestro centro mediante abordaje abierto según técnica de Ivanissevich (TI), Palomo (TP) y embolización percutánea (EP) entre 2000-2014. Las variables fueron edad, síntomas, volumen testicular diferencial (VD), técnica empleada, recurrencia, mejoría sintomática y VD tras el tratamiento. Se evaluó la asociación entre variables cualitativas (test de Chi cuadrado o prueba exacta de Fisher). RESULTADOS: Se estudiaron 69 pacientes con mediana de edad de 14 años (7-19). Se realizó EP a 37 pacientes (53,6%), TP a 23 (33,3%) y TI a 9 (13%). Presentaron recurrencia 16 (23,2%), de ellos el 80% habían sido tratados mediante EP. Once pacientes tenían dolor al diagnóstico (15,9%), tras el tratamiento 100% de los tratados mediante EP presentaron alivio, mientras que en ninguno de los tratados mediante TI o TP mejoró el dolor. Al diagnóstico 37 pacientes (53,6%) presentaron hipotrofia testicular izquierda, en 28 casos el VD fue >20%. Tras el tratamiento, el VD se normalizó en 11 casos (39,2%). CONCLUSIONES: La elección de la técnica terapéutica de varicocele en pacientes pediátricos y adolescentes debería depender de las características del paciente, presencia de síntomas, experiencia del centro y recurrencia previa. Independientemente de la técnica elegida el 39,2% de hipotrofias testiculares con DV >20% al diagnóstico alcanzaron la normalización del volumen testicular tras el tratamiento.

Percutaneous treatment of varicocele with microcoil embolization: comparison of treatment outcome with laparoscopic varicocelectomy.

Successful treatment of a testicular varicocele, which can result in scrotal pain and swelling as well as male subfertility, can be accomplished via operative ligation of the varicocele or interventional treatment with coil embolization of the testicular vein. This study compared the treatment outcome of percutaneous embolization treatment versus laparoscopic varicocelectomy in patients with symptomatic varicoceles. Patients with varicoceles undergoing either laparoscopic varicocelectomy or percutaneous coil embolization of the testicular vein during a recent 5-year period were analyzed. Treatment outcome and hospital costs of these two minimally invasive treatment modalities were compared. Forty-one patients underwent percutaneous coil embolization of the testicular vein, which were compared with a cohort of 43 patients who underwent laparoscopic varicocelectomy. Technical success in interventional and laparoscopic treatment was 95% and 100%, respectively. The mean operative time or procedural time was 63 +/- 13 minutes and 52 +/- 25 minutes for interventional and laparoscopic cohorts (not significant), respectively. Embolization treatment resulted in two recurrent varicoceles (4.8%) compared to one patient following laparoscopic repair (2.3%, not significant). Embolization treatment was associated with a lower complication rate than laparoscopic repair (9.7% vs 16.3%, p = .03). Regarding cost analysis, no significant difference in hospital cost was noted between the interventional or laparoscopic treatment strategies. Both laparoscopic varicocelectomy and coil embolization are effective treatment modalities for varicoceles. With lower treatment complication rates in the interventional treatment group, coil embolization of the testicular vein offers treatment advantage compared with laparoscopic repair in patients with varicoceles.

Induction of spermatogenesis in men with azoospermia or severe oligoteratoasthenospermia after antegrade internal spermatic vein sclerotherapy for the treatment of varicocele.

AIM: To evaluate the treatment outcome of antegrade internal spermatic vein sclerotherapy in men with non-obstructive azoospermia or severe oligoteratoasthenospermia (OTA) as a result of varicocele. METHODS: Between September 1995 and January 2004, 47 patients (mean age 33.8 +/- 6.3 years) underwent antegrade internal spermatic vein sclerotherapy for the treatment of varicocele with azoospermia (14 patients) or severe OTA (33 patients). Testicular core biopsy was also performed in complete azoospermic patients who provided informed consent. The outcome was assessed in terms of improvement in semen parameters and conception rate. RESULTS: Forty-two (89.4%) of 47 patients had bilateral varicocele. Serum follicle stimulating hormone (FSH) did not differ between patients with azoospermia and severe OTA. After the follow-up of 24.8 +/- 9.2 months, significant improvement was noted in mean sperm concentration, motility and morphology in 35 patients (74.5%). Comparison between groups during the follow-up revealed significantly higher values of sperm concentration, motility and normal morphology in the severe OTA group. Pregnancy was achieved in 14 cases (29.8%). Testicular histopathology of the azoospermic patients with postoperative induction of spermatogenesis revealed maturation arrest at spermatid stage, Sertoli-cell-only (SCO) with focal spermatogenesis or hypospermatogenesis. None of the patients with pure SCO pattern or maturation arrest at spermatocyte stage achieved spermatogenesis after the treatment. Preoperative serum FSH levels didn't relate to treatment outcome. CONCLUSION: Antegrade internal spermatic vein sclerotherapy is an easy and effective treatment for symptomatic varicocele. It can significantly reverse testicular dysfunction and improve spermatogenesis in men with severe OTA, as well as induce sperm production in men with azoospermia, improving pregnancy rates in subfertile couples.

Analysis of radiation doses in the percutaneous treatment of varicocele in adolescents.

PURPOSE: Varicocele is a common clinical condition that affects 15% of the male population and is an important cause of male infertility. Fluoroscopy-guided percutaneous treatment with retrograde sclerosis is a good alternative to surgery. We report our experience in calculating the total radiation dose to patient and the associated risk. MATERIALS AND METHODS: Our study was performed on 67 patients undergoing percutaneous treatment of varicocele with transbrachial approach and retrograde sclerosis. Thirteen dosimeters with two TLD detectors were positioned on the patients' skin. Calculation of the Entrance Surface Dose and application of appropriate transmission coefficients of the depth-dose allowed us to determine the Equivalent Doses for the single organs. Similar studies were conducted during plain abdominal x-ray and urography for comparative purposes. RESULTS: The mean effective dose during percutaneous treatment of varicocele was 18 mSv, whereas the dose for abdominal x-ray was 1.31 mSv and that for urography was 4.6 mSv. DISCUSSION AND CONCLUSIONS: Examinations involving the use of x-rays have been estimated to contribute to half of all the radiation absorbed by the population, and the number of both diagnostic examinations and interventional procedures is steadily rising. Radiation exposure, especially in children, requires special consideration. Percutaneous treatment of varicocele is a valuable alternative to surgery, not least because of reduced exposure. The use of specially-built lead coats and the creation of regional referral centres employing specialised staff are two possible measures that could further reduce radiation doses and dispel concerns about this procedure.

[Percutaneous, laparoscopic, and surgical treatment of idiopathic varicocele: analysis of costs]. / Il trattamento percutaneo, laparoscopico e chirurgico del varicocele idiopatico: analisi dei costi.

Idiopathic varicocele can compromise the spermatogenetic function of the testicle and associate with alterations of the semen quality. The treatment of varicocele stops the progress of testicular damage and improves spermatogenesis and semen parameters. These are the main alternatives to the traditional surgical treatment of varicocele retrograde percutaneous occlusion of the internal spermatic vein using sclerosing agents and embolizing devices (either separately or in combination), microsurgical ligation via inguinal or sub-inguinal approach, laparoscopic ligation and, more recently, antegrade scrotal sclerotherapy. None of these techniques can be considered the "gold standard" therapy. Literature does not point out any significant difference between them, either considering the absence of reflux percentage, or the improvement of semen quality, or the pregnance rate. Therefore cost comparison may be a valid criterion in the choice of treatment for varicocele correction. The total cost of the surgical retroperitoneal unilateral ligation of the internal spermatic vein is 968,805 Lire, while for the bilateral ligation it is 1,118,285 Lire. The costs of sclerotherapy and percutaneous embolization are respectively of 698,750 Lire and 1,708,950 Lire. The combination of the two techniques amounts to 1,918,230 Lire. Laparoscopic bilateral ligation costs 2,437,935 Lire. Antegrade scrotal sclerotherapy costs 191,035 Lire if unilateral, 216,580 Lire if bilateral. After considering these data we can say that antegrade scrotal sclerotherapy is the first choice economically in the treatment of both unilateral and bilateral varicocele.

Rationale for antegrade sclerotherapy in varicoceles.

Clipping of the testicular veins in varicocele in principle follows open surgical treatment modalities such as the Palomo and Bernardi operations by disrupting venous reflux of the testicular veins. Thus, success rates of laparoscopic varicocelectomy range around 85% as well. As a less invasive means of treatment, retrograde (interventional) sclerotherapy of varicocele has produced long-term results as favorable as those of open surgical procedures. Antegrade sclerotherapy was introduced by Tauber as an equivalent, but even less invasive treatment modality, done by the urologist. We have performed antegrade sclerotherapy in more than 80 patients with left-sided primary varicocele. The procedure was done in local anesthesia via a scrotal incision and lasted between 12 and 60 min. If different treatment modalities yield similar long-term results, they must be valued according to how these outcomes are achieved. With antegrade sclerotherapy, the urologist has a modality at hand that is not only less invasive than laparoscopic varicocelectomy, but bears fewer risks for the patient, requires less personnel and costs less. Therefore, we consider laparoscopic varicocelectomy indicated only if antegrade sclerotherapy cannot be performed or has been tried twice without success. However, it may still be considered in bilateral varicoceles.

Clinical outcome and cost comparison of percutaneous embolization and surgical ligation of varicocele.

We reviewed the records of 81 consecutive subfertile men with oligospermia and/or asthenospermia, treated for varicocele with either percutaneous embolization or surgical ligation between 1987 and 1991, and compared the outcomes and costs of the two procedures. All men had presented with infertility of at least 6 months duration, and in most cases female factors had been previously evaluated and treated. Patients were offered a choice of embolization or ligation of the internal spermatic vein. Forty-five men (56%) underwent ligation, and 36 men (44%) opted for embolization. The mean age, serum follicle-stimulating hormone, pretreatment sperm density, motility, and concentration of motile sperm were similar for the two groups. Seminal quality improved in 65% of all patients after varicocele ablation (46 of 71). Improvements were seen in postoperative sperm density (P < 0.01), motility (P < 0.002), and concentration of motile sperm (P < 0.001). Thirty-nine percent of the assessable patients established pregnancies during the study interval (26 of 66). The two treatment groups did not differ significantly with regard to the likelihood of postoperative improvement in sperm density (P = 0.64), motility (P = 0.33), concentration of motile sperm (P = 0.11), or pregnancy rate (P = 0.83). Percutaneous embolization and surgical ligation of varicocele are equally effective in improving male infertility and cost about the same. Embolization offers the potential advantage of shorter recovery to full activity as compared to surgical ligation. Where experienced interventional radiologists are available, percutaneous embolization should be offered as an alternative to open ligation.

Varicocele em adolescentes: atualizaçäo de conduta / Varicocele in adolescent

É feita uma revisäo atualizada da etiopatogenia e fisiopatologia da varicocele. Com base nestes conhecimento, säo discutidos os critérios para a indicaçäo do tratamento da varicocele, que pode ser conservador ou curúrgico, cujas técnicas cirúrgicas säo comenradas. As indicaçöes säo apresntadas na forma de algoritmo, através das quais säo especificadas as correlaçöes clínicas e laboratoriais. Como conclusäo da experiência de um serviço, apresenta-se a proposta para avalaçäo de adolescentes portadores de varicocele, elaborada por uma equipe multiprofissional e por alguns especialistas, na qual é salientada, inclusive, a importância da abordagem dos aspectos psicossociais

The role of venography and sclerotherapy in the management of varicocele.

Venography has recently been introduced in routine diagnostic evaluation of varicocele, and a pathogenetic classification based on venographic findings has been proposed. Transcatheter sclerotization of the internal spermatic vein completes the angiographic management of varicocele. After venographic classification of 56 cases, the patients with type-1 varicocele (reno-spermatic reflux) were treated by transcatheter sclerotization (group A, 25 patients) or high inguinal surgical ligation (group B, 15 patients). The results were quite similar, whereas the cost/benefit ratio was favorable to sclerotherapy.