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Testicular Varicocoele
Introduction
Varicocoeles in the scrotum are a common cause of pain and infertility. Southern Sydney Angiography has successfully performed about 2,000 varicocoele embolisations over the past 10 years making us the most experienced unit in the country for this procedure. Patient satisfaction with this minimally invasive procedure is extremely high.


Definition
A varicocoele is a network bunch of enlarged veins in the scrotum. These are adjacent to the testis and can feel like a "bag of worms". It may not cause any symptoms but it can cause pain, and occasionally infertility. The increased temperature in the scrotum may decrease sperm production. It is a correctable cause of male infertility.


Cause
The veins in the body are the low pressure component of the cardiovascular system. Because the system is a low pressure one it relies on valves to ensure that blood only flows in the correct direction - back to the heart. The blood from the left testis drains up to the left kidney vein via the left testicular vein. There is one valve at the junction of the testicular vein and the left kidney vein. If this valve is absent or does not work then blood from the left kidney will flow back from the kidney toward the left testis and cause the varicocoele. Over time the veins next to the testis will become swollen from pressure.


Embolization
A common technique to treat testicular varicocoele is called testicular vein embolization. This involves puncturing the skin with a needle and then passing a very thin plastic tube into the body. The entry point is a vein in the neck or the top of the leg. Both are safe and equally comfortable. As no cut is made in the skin, no mark will be left on the skin. The tube then passes inside the body which the patient cannot feel. It is passed into the testicular vein just above the left hip and then the vein is blocked with fine stainless steel filaments called coils. These block the vein and prevent blood from the left kidney from swelling the veins next to the testis. Coils are very safe and have been in use for over thirty years. They can be considered in a similar manner to fillings in teeth. They are designed to occlude veins. In addition, a small amount of liquid sclerosant (called "fibrovein") is injected into the vein which ensures that the vein does not re-open after blockage.


Where does the Blood Go?
When the testicular vein is blocked the blood will pass back toward the heart by alternative or "collateral" channels. These are small channels and do not allow reversal of flow which was the underlying cause of the varicicoele.


How effective is embolization?
The success rate for curing the variciocoele is above 90% for embolization.


How is the embolisation performed?
It is performed by an interventional radiologist in an angiography suite as an out-patient or day procedure. A light sedation is given. The skin is numbed by local anaesthesia. Either the jugular vein in the neck or the femoral vein in the groin is used for access.” To be replaced by “Either a vein in the neck or a vein at the top of the leg (depending on patient preference) is used for access. Both are equally safe and comfortable and will not leave any mark or scar, as it is only a puncture not a cut. Using x-ray guidance the tube is directed into the left kidney vein and then down the left testicular vein until it is just above the left hip. Small amount of contrast (X-ray dye) is injected to confirm position. Stainless steel or platinum coils are used to block the faulty vein. Sometimes sclerosing agent is also used to reduce the chance of recurrence. Only the vein above the hip is treated not the varicocoele directly - the change in pressure dynamics will then lead to the variciocele resolving after about 6 weeks. The procedure itself usually takes about 30 minutes.


What happens after the procedure?
You will be resting in the recovery for 1-2 hours until the sedation wears off. You need to arrange transport as you are not allowed to drive after the sedation. When you get home you should take it easy. Drink plenty of fluid. Normal activity can be resumed the following day except that you should avoid strenuous physical activity for 5 days after-that is no marathons, weightlifting etc. You can experience mild discomfort in the abdomen and flank for up to 7 days - it is not severe. The variciocoele should resolve after about 6 weeks. You should also see your urologist for further follow-up. Sperm count can be performed after three months.


Are there any complications with embolization?
Minor complications although uncommon may occur such as bruising at the entry site, mild back ache and nausea. Transient swelling and pain of the scrotum may occur. All of these symptoms normally resolve within a week. Migration of coils in the lungs is exceptionally rare and usually has no significant consequence.


Should I be concerned about radiation?
The x-ray dose of the procedure is low. The testes are outside of the radiation field for testicular vein embolization. The gonadal dose and hereditary effect is very low.


Who are interventional radiologists?
They are doctors sub specialized in using catheter based devices to treat disease using imaging guidance such as X-ray, CT and ultrasound. Traditional surgery cuts the skin to see inside. We puncture the skin to perform surgical procedures and use the imaging equipment to see inside the body. Because there is no wound there is very little discomfort or recovery required.


Other Links
Other useful information ccan be found at the following link:
http://www.sirweb.org/patients/varicoceles

 

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