Novel Hybrid Antegrade Coiling and Adjunct Sclerotherapy Technique for Pediatric Varicocele with Surgical Venous Access and Venographic Road Map
David Matthew Strauss, M.D.1, Laura Kidd, MD1, Raphael Yoo, MD2, David Goldstein, MD3, Gregory Dean, MD4.
1Temple University Hospital, Philadelphia, PA, USA, 2Nemours Children’s Hospital, Orlando, FL, USA, 3Jefferson Health System, Washington Township, NJ, USA, 4St Christophers Hospital, Philadelphia, PA, USA.
The optimal surgical management of pediatric varicoceles remains unsettled. We combine open surgical scrotal venous access and venography directed antegrade coiling with adjunct sclerotherapy. This novel approach avoids IR access through the jugular or femoral vein with targeted access only into the affected gonadal vessels. Additionally, this approach enables treatment of vascular variants which might be inadequately treated through alternative approaches.
Materials and Methods:
Patients ranged in age from 13-16. All patients had a grade 3 varicocele on exam with either significant volume loss on the affected side or pain. Our technique employs open scrotal access completed by the urological surgery team through a horizontal incision at the superior scrotal margin followed by exposure of the cord structures. A dilated gonadal vein is identified, isolated and then transected. The distal end is ligated for vascular control, and the proximal end is cannulated in conjunction with the interventional radiologist. A road map venogram is performed to confirm standard vascular anatomy of the left gonadal vessels. The entire gonadal vein is coiled, and adjunct sclerotherapy performed. Accessory drainage routes are identified and additionally coiled. (Figure 1) The patients were followed postoperatively.
Six patients were treated in this manner. There were no intraoperative complications or 30-day complications. All patients had initial postoperative visit within 3 months of the procedure, and none had detectible varicoceles. All patients remain without varicocele recurrence with short and median term follow up (median 18 months). Of note, aberrant drainage to the ipsilateral and contralateral internal iliac / hemiazygos systems were identified and treated in two patients.
A combined approach comprised of scrotal access with venous cannulation followed by venographic roadmap directed antegrade coiling and adjunct sclerotherapy is an effective option for the treatment of pediatric varicoceles. By performing concurrent venography, vascular variants can be addressed with the potential to decrease recurrence.
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