Scleroembolizzazione varicocele ossia trattamento mininvasivo radiologico del varicocele.
Operatore: Prof. Patrizio Vicini
Large bowel infarct following antegrade scrotal sclerotherapy for varicocele: a case report.
- Vicini*, G.B. Di Pierro**, P. Grande**, G. Voria***, G. Antonini**, F. De Marco*, S. Di Nicola* V. Gentile**.
*Department of Urology, “I.N.I.” Italian Neurotraumatologic Institute Grottaferrata, Rome, Italy.
** Department of Urology, “Sapienza” Rome University, Rome, Italy.
*** Department of Urology, S. Sebastiano Hospital Frascati, Rome, Italy
Key words: varicocele, antegrade scrotal sclerotherapy, Tauber procedure, large bowel infarction
Varicocele represents the main cause of male infertility, causes changes in testicular spermatogenesis in 60-70% of cases. The treatment of this condition stops continuous damage to spermatogenesis, thereby potentially improving fertility. The successful treatment of varicocele causes an improvement in semen quality in 40-60% of patients and recovery of fertility in 10-40% (1). Among all the available procedures for the treatment of the varicocele, the antegrade scrotal sclerotherapy (ASS), a combined radiological-surgical approach first introduced by Tauber in 1988 (2) generally performed under local anesthesia. The procedure starts with a short longitudinal scrotal incision at the base of the scrotum with the isolation of the funiculum and identification of the most enlarged vein. Then a small incision of the vein allows the insertion of a 23-gauge needle to usually perform a venogram by iodine contrast and finally atoxysclerol mixed with air is injected (2-5). The procedure is an established procedure for the treatment of varicocele, is simple, rapid and less invasive than the open surgical and laparoscopic treatment (5). It results in a low persistence rate of 9% in adult and 3% in children, respectively; and improvement in sperm account according to the WHO criteria and a paternity rate of 42% (6). An analysis of seminal parameters shows a statistically significant improvement of the rate of fast progressive spermatozoa and reduction in immotile spermatozoa in those patients who underwent to ASS compared to the patients who underwent open surgery (5). The complication rate is very low including scrotal hematoma, sterile epididymitis (due to paravascular application of the sclerosing agent), testicular atrophy (accidental sclerotherapy of the testicular artery), partial abdominal wall necrosis (accidental sclerotherapy of the cremasteric artery) (2).
We describe the case of a 35 years-old man who presented severe oligoasthenospermia and on the ultrasound he was diagnosed with a third grade varicocele. After urological consult, he agreed to undergo antegrade scrotal sclerotherapy. The procedure was performed on January 2011 under local anaesthesia. After the incision at the base of the scrotum the funiculum was reached, the most enlarged vein was isolated and suspended between two slack sutures. A little incision of the vein was performed to insert a 23-gauge needle. The right position of the needle was checked by washing the vein with saline solution; iodine contrast was then injected to perform a venogram (Figure 1). Finally, during the Valsalva manoeuvre, 1 ml of air was injected, followed by 3 ml of 3% ethoxysclerol (air-block technique).
The patient started to feel intense pain located in the left iliac fossa and flank immediately after the injection of atoxysclerol. The physical examination evidenced an acute abdomen with positive Blumberg, abdominal distension and torpid peristalsis. A rectal probe was inserted, the patient was given prokinetics to facilitate intestinal peristalsis and steroids to reduce the inflammation but continued to complain about pain. Several CT scans were performed; the first displayed small aerial bubbles into mesenteric circulation of the sigmoid and descending colon (Figure 2-3). The finding seemed consistent with pneumatisation of the mesenteric venous plexus as a complication of the recent sclerotherapy and the tissues seemed minimally thickened with modest flogistic reaction of the loose tissue nearby. We decided to start an anti-coagulant therapy with low-molecular-weight heparin (LMWH) to prevent a potential venous thrombosis of mesenteric circle due to chemical injuries.
Further CT scans were inconclusive, while the patient’s pain increased. The WBC count raised until 19x 103 uL the day after the procedure and continued to increase the following days with a percentage of neutrophil granulocytes always between the 86-88%.
After consulting a general surgeon a rectoscopy was performed, but due to the presence of coagulated blood and mucus, it was inconclusive and definitely useless (Figure 4). A new CT scan reported a considerable aerial distension of the ileal and colic loops, mainly of the transverse and descending colon, with no radiocontrast agent detectable outside the rectal ampulla.
Eight days after the procedure, due to the persistence of severe pain resistant to morphine and BDZ and the presence of septic shock, the patient was immediately transferred to a general surgery unit, a new CT scan was performed and showed the presence of necrosis of the descending and sigmoid colon with faeces and air into abdomen. A colic resection with end colostomy was carried out, with the rectum sewn shut and embed in the pelvis for future anastomosis (among transverse colon and rectum), which was performed six months later with complete faecal continence of the patient.
In the literature, the existence of an anastomotic circle between the spermatic and mesenteric veins is not well documented, even if previous published data by Salerno et al (7) suggested to consider this finding as a risk for varicocele recurrence. Some authors do not routinely perform a preoperative phlebography (8) before proceeding with sclerotherapy. Considered that on the venography the presence of communications of the spermatic vein with visceral veins is reported in about 11% of patients (7), a complete angiographic study, maybe an antegrade phlebography, before antegrade sclerotherapy may represent a safer, if not compulsory, approach to guide the procedure.
Indeed, the presence of an anastomotic circle should prompt to stop the antegrade scrotal sclerotherapy in order to avoid possible injuries of the visceral vessels and proceed to surgical treatment for the varicocele.
In the present experience, on the phlebography internal spermatic vein is correctly visualized and there was no evidence of the presence of such anastomosis. Iodine contrast was injected to perform a venogram (not during Valsalva manoeuvre). (2) (figure 1)
Probably, the injection of 1 ml of air followed by 3 ml of 3% ethoxysclerol (air-block technique) during Valsalva manoeuvre caused an increased intravascular pressure, both due to presence of air and to Valsalva manoeuvre.
This event could have opened venous passages existing between the spermatic and the inferior mesenteric vein but not evident during phlebography.
Moreover, our opinion is that the injection of air followed by sclerotic agent has the ability to enter more easily into the venous passages existing between the spermatic and the inferior mesenteric vein, rather than the radiocontrast, as a result of different density between these two substances.
Therefore, the cause leading to the necrosis of the descending and sigmoid colon is thought to be a bowel infarct secondary to a venous thrombosis of the inferior mesenteric vein. On the other hand, given the small calibre of the vasculature, no interventional radiology procedure could be performed to attempt a thrombolysis after development of venous thrombosis.
No further imaging could have helped in the diagnosis, neither interventional radiology, due to the variability of the vasculature and the technical difficulty (9).
We suggest that a complete angiographic study, mainly an antegrade phlebography, before antegrade sclerotherapy may represent a safer approach to guide the procedure.
According to our experience, the performance of a pre-operative venogram during the Valsalva manoeuvre becomes imperative to reveal unknown anastomosis and stop the procedure before further vascular damages.
Further measures to prevent the side effect described above could be the reduction of the amount of air or using of another sclerotic agent, one of the same density as the radiocontrast during sclerotherapy.
Despite the fact that the Tauber approach represents a minimally invasive, well tolerated and easy to perform technique to treat varicocele, the difficulties to determine if there is communication between the intestinal and spermatic veins and the severe side effect that can arise from this could suggest to lean towards a “classic” surgical approach.
Patrizio Vicini, MD
Department of Urology, “I.N.I.” Italian Neurotraumatologic Institute Grottaferrata, Rome, Italy.
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