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Varicocele embolization was first performed in 1979 and since then, it has become more and more popular. The most distinct advantage of embolization is that during the procedure, a venography is done and the refluxing veins can be easily seen and differentiated from the normal veins. As a result, abnormal veins that cause varicocele can be correctly identified and successfully closed in the same session while the normal veins that have a good function are not touched. Other advantages of embolization include use of local anesthesia, absence of complications such as infection, hydrocele and testicular damage and possibility to discharge the patient several hours after the procedure. In one study, the patients who previously underwent both surgery and embolization were asked which treatment they would prefer and they all answered that they would prefer embolization (Fereley et al. Br J Urol).

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How is it performed?

Varicocele embolization is performed by interventional radiologists using the angiography device. For this, first the patient lies on the angiography table. After the skin is numbed at the armpit or groin, a small sheath is placed into the vein under ultrasound guidance. Then a tiny tube called catheter is advanced and placed into the main testicular vein. The patient is asked to perform a Valsalva maneuver (taking a deep breath and straining) to increase the pressure in the abdomen and provoke reflux. At the same time, a special dye called contrast is injected through the catheter, serial X ray films are taken and the refluxing veins are identified on the angiograpy screen. 

Then, the next step is to close these veins with embolization. For this, multiple coils are first pushed through the catheter and thightly packed into the refluxing vein at two levels, and the vein is mechanically occluded. Then, a sclerosing agent is mixed with air and turned into a “foam” and injected into the refluxing vein between the coils through the same catheter. The aim of foam injection is to close small abnormal veins that might later connect varicocele to refluxing vein and cause recurrence.

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After the embolization, the patient is asked again to perform a Valsalva maneuver and a venography is obtained to see if there is any more refluxing vein that requires treatment. If another refluxing vessel is seen it is embolized in the same manner. If no other refluxing vein is seen the catheter and sheath is removed and the procedure is terminated. After the embolization, the puncture site is compressed with hand until the bleeding stops and a bandage is applied. The patient may leave the hospital several hours later.

Please click to see the animation of varicocele embolization

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If the patient has bilateral (both-sided) varicoceles, the other varicocele is also treated in the same session. For this, the catheter is placed into the main testicular vein of the other testicle, the patient is asked to perform a Valsalva maneuver and the refluxing veins are identified on venography. Then, these veins are embolized with coils and foam in the same manner. In patients with bilateral varicoceles, the ideal treatment is embolization because it is possible to treat both varicoceles in the same session through the same entry site. 

The advantages and disadvantages of varicocele embolization

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• During the surgery, the veins are seen and tied up from outside and thus, there is always the risk of ligating other vessels unintentionally including the normal veins, arteries and lymphatic channels. In contrast, since embolization is performed inside the veins it is impossible to go out of the vein and harm the other vessel systems such as arteries and lymphatics. For this reason, testicular loss due to arterial damage or hydrocele due to closure of the lymphatic channels are never seen in embolization.

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• In both-sided varicocele, treatment can be performed in the same session through the same skin entry site. In surgery, two different incisions are necessary.
   

• If the patient has leg varicosities besides the varicocele, both may be caused by the refluxing testicular vein, and if this vein is embolized the both conditions can be treated.
   

• In embolization, there are no incision and stitches. Everything is done through a small hole in the vein.
   

• Embolization is performed under local anesthesia while in surgery, general or spinal anesthesia are needed.
   

• In embolization, patients may leave the hospital a few hours after the procedure, while in surgery hospitalization is generally required. After embolization, patIn embolization, patients may leave the hospital a few hours after the procedure, while in surgery hospitalization is generally required. After embolization, patients can do even strenuous activities a few days later but after surgery, this may take a few weeks.
   

• The most important disadvantage of embolization is the unavailability of the technical equipment (e.g. angiography device) and staff (e.g. interventional radiologist). For this reason, it can not be performed anywhere in the world.

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The stages of varicocele embolization: A sheath is placed into the vein of the armpit, the refluxing vein is identified with venography and then closed with coils and foam. The patient can stand up   and walk 10 minutes after the procedure.

In patients who have varicoceles on right and left sides, both varicoceles can be treated with embolization in the same session through a single venous puncture. 

In a patient with left varicocele, venography shows two veins going to the testicle. At first look, the larger vessel was estimated to be abnormal (A). Selective venography however, shows that the thinner vein was refluxing and the larger vein has a normal function (B,C). The thinner vein is then embolized with coils and foam (D). Had this patient been treated with surgery, the larger vein would have been ligated instead of the thinner vein which was abnormal. Thus, the varicocele would have been persisted after the operation and a normal vein would have been ligated for nothing.