Large bowel infarct following antegrade scrotal sclerotherapy for varicocele: A case report

Abstract

Varicocele is the main cause of male infertility. Treatment stops continuous damage to spermatogenesis, thereby potentially improving fertility. Among all the available procedures, the antegrade scrotal sclerotherapy (ASS), a combined radiological-surgical approach first introduced by Tauber, is gaining more popularity due to its minimal invasiveness. We report the case of a 35-year old man who was subjected to a colonic resection after antegrade scrotal sclerotherapy for varicocele. The procedure was necessary due to the embolization of venous anastomosis between the spermatic and mesenteric veins, which were not detectable at the preoperative phlebography. IntroductionVaricocele represents the main cause of male infertility and leads to changes in testicular spermatogenesis in 60% to 70% of cases. Treatment prevents continuous damage to spermatogenesis, thereby potentially improving fertility. Successful treatment of varicocele improves semen quality in 40% to 60% of patients and recovers fertility in 10% to 40%.1 Among all the available procedures, the antegrade scrotal sclerotherapy (ASS) is a combined radiological-surgical approach first introduced by Tauber in 1988 2 and is usually performed under local anesthesia. The procedure starts with a short longitudinal scrotal incision at the base of the scrotum, isolation of the funiculum and identification of the most enlarged vein. Thereafter, a small incision of the vein allows for the insertion of a 23-gauge needle to perform a venogram by iodine contrast. In the end atoxysclerol mixed with air is injected. [2][3][4][5] This technique is well-established to treat varicocele. It is easier, faster and less invasive than open surgical and laparoscopic treatments.5 It results in a persistence rate as high as 9% in adults and 3% in children. 6 An analysis of seminal parameters showed a statistically significant improvement in the rate of fast progressive spermatozoa and reduction of immotile spermatozoa in patients who underwent ASS compared to open surgery. 5 Reported complication rates are low and they include scrotal hematoma, sterile epididymitis (due to paravascular application of the sclerosing agent), testicular atrophy (accidental sclerotherapy of the testicular artery), as well as intestinal 7 and abdominal wall necrosis (accidental sclerotherapy of the cremasteric artery). 2 Case reportA 35-year-old man presented with severe oligoasthenospermia and diagnosed with third grade varicocele on ultrasound. After we explained the therapeutic options to the patient, he agreed to undergo antegrade scrotal sclerotherapy. Incising the base of the scrotum, the funiculum was identified and 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 vessel lumen with saline solution; the iodine contrast was then injected to perform a venogram (Fig. 1). Finally, during the Valsalva manoeuvre, 1 mL of air was injec...

Spinal Cord Injury Following Antegrade Scrotal Sclerotherapy for Varcicocele: A Case Report

“…However, preoperative phlebography did not identify anastomoses between left spermatic and ascending lumbar veins in our reported case. Additionally, we found in literature a case of large bowel infarct after ASS for varicocele [8]. Similarly to our patient’s story, the anastomoses between spermatic and mesenteric veins were not identified during preoperative phlebography [8].…”

“…Similarly to our patient’s story, the anastomoses between spermatic and mesenteric veins were not identified during preoperative phlebography [8]. The authors postulated that Valsalva maneuver associated with the air-block technique might have opened undetectable venography anastomoses due to an increased intravascular pressure [8]. This explanation could be suitable to our case of spinal cord injury following ASS.…”

“…Additionally, we found in literature a case of large bowel infarct after ASS for varicocele [8]. Similarly to our patient’s story, the anastomoses between spermatic and mesenteric veins were not identified during preoperative phlebography [8]. The authors postulated that Valsalva maneuver associated with the air-block technique might have opened undetectable venography anastomoses due to an increased intravascular pressure [8].…”

Ischemic colitis following left antegrade sclerotherapy for idiopathic varicocele

“…However, only a few case reports have been published on a further unusual complication, ischemic colitis or sigmoid infarction (Iaccarino and Venetucci, ; Fulcoli et al, ; Spiezia et al, ; Vicini et al, ). This ischemic colitis has been hypothetically ascribed to: an arterial thrombosis due to pre‐existing vascular disease combined with a sudden perioperative hypotension (Spiezia et al, ); an accidental intra‐arterial (testicular artery) injection of the sclerosis fluid, refluxing into the aorta from the spermatic artery, and following the flow of the inferior mesenteric artery with occlusion damage (Spiezia et al, ); erroneous sclerotherapy of the cremasteric vein (tributary of the external iliac vein) or the deferential vein (tributary of the internal iliac vein) (Fulcoli et al, ); or an (unproven) abnormal communication between the testicular and mesenteric circulations (Spiezia et al, ).…”

“…The scarcity of such references contrasts with the published epidemiological data, which reveal abnormal communications between the left colic and left testicular veins in 7.8% (Salerno et al, ) to 9.2% (Bigot et al, ) of cases, described as a venous trunk with competent valves (5.1%), or communicating venules (3.1%), or single/double anastomoses (1%), with only an outline estimate (77%) reported by Wishahi (). However, despite the hypothetical prevalence of this anatomical variation, some urologists and interventional radiologists report that they cannot correctly visualize it by intraoperative phlebography, although they are aware of its possible presence and check carefully (Fulcoli et al, ; Vicini et al, ). Consequently, there is a catastrophic adverse event.…”