Benign Prostatic Hyperplasia: Long-term follow-up of prostate volume reduction after sclerotherapy of the internal spermatic veins

Abstract

The purpose was to examine the results of bilateral percutaneous sclerotherapy of the internal spermatic veins on prostate volume and prostatic symptoms. We previously showed that destruction of one-way valves in the internal spermatic veins (varicocele) elevates hydrostatic pressure in the vertical testicular venous drainage system in the erect human. This diverts free testosterone (FT) flow at high concentrations directly from the testes into the prostate. High intraprostatic FT prolongs prostate cell life and increases cell proliferation rate-synergistic effects resulting in increased cell population (BPH). Treatment by interventional radiology (or microsurgery) techniques eliminates this diversion of FT flow to the prostate and reverses these pathologic processes. A total of 206 BPH patients with varicocele underwent bilateral sclerotherapy of the ISV. Of these, 81.5% exhibited significantly reduced prostate volume and improvement in prostatic symptoms (measured by IPSS scores) during follow-up period of 12 to over 24 months. 8% went on to require surgery despite mild post-treatment improvement (TURP). The use of prostate medications along with the treatment may have a combined positive effect. Very large prostate volume and large residual volume may limit degree of improvement. It is concluded that effective treatment of varicocele restores normal supply of testosterone to the prostate solely via its arterial supply, resulting in significant decrease of prostate volume and prostatic symptoms. The procedure is safe with only minor transient side effects.

Paying the price for standing tall: Fluid mechanics of prostate pathology

“…Occluding the malfunctioning ISVs in patients with varicocele restores normal hemodynamics of the prostate 6 . Significantly, of the 206 patients treated for BPH by our own technique, 81.5% experienced significant symptom relief and reduction of prostate volume 12 . With the results we have achieved by eliminating the elevated pressures, we demonstrate the important role of fluid mechanics in BPH.…”

“…This can be accomplished by occluding each impaired vertically oriented large and small (capillary) vein in the testicular venous drainage which exerts high hydrostatic pressure when OWVs in the ISVs are destroyed. We accomplish this by our own procedure employing interventional radiology, venography, and sclerotherapy of the vertical testicular venous network (the Gat‐Goren Procedure 9,11,12 ; Figures 1C and 2). This can be achieved by microsurgery as well.…”

Prospective evaluation of the association between varicocele and benign prostatic hyperplasia in men over 40 years of age

“…Prostate growth in men over 40 years of age is a unique process as it occurs despite a progressive decrease in testosterone levels, a hormone that plays a preponderant role in stimulating stromal and epithelial growth of the gland (Feldman et al., 2002; Goren & Gat, 2018; Madersbacher et al., 2019; Roberts et al., 2004). This ‘paradox’ led Gat et al to formulate a hypothesis according to which the varicocele plays a predominant role in BPH development (De Caestecker et al., 2016; Gat & Goren, 2018; Gat et al., 2008; Goren & Gat, 2018). According to his theory, based on venographic studies, varicocele increases the hydrostatic pressure in the Santorini plexus, conditioning a flow of venous blood rich in testosterone through the deferential vein towards the pelvis.…”

“…Gat and colleagues published studies that support their theory. A retrospective review of 206 patients with BPH who underwent bilateral percutaneous sclerotherapy of the spermatic veins showed a statistically significant reduction in prostate volume and urinary symptoms score in 81.5% of patients after 24 months of follow‐up (Gat & Goren, 2018). In another study, they evaluated 901 patients with BPH, aged between 33 and 81 (Goren & Gat, 2018).…”

“…The discrepancy between Gat's publications and what was found in ours and other studies may have different explanations. The first is methodological: in the study that described a decrease in prostate volume by sclerotherapy of the gonadal veins, the result could be affected by the inclusion of patients taking a 5‐alpha‐reductase inhibitor (Gat & Goren, 2018). The study that described varicocele in all 901 patients with BPH did not have a control group and did not include an evaluation of the prostate volume: the inclusion criterion was the presence of urinary symptoms, and therefore, stating that varicocele is a characteristic of patients with BPH may be inaccurate (Goren & Gat, 2018).…”