Varicocele surgery or embolization: Which is better?

Abstract

Introduction: Varicocele remains the most commonly identifiedcorrectable cause of male factor infertility. Surgical correction isthe most commonly performed technique to treat varicoceles with a technical failure rate of less than 5%. An attractive alternative to surgery is the selective catheterization and embolization of the gonadal vein. This data are limited by small series.Methods: We reviewed a total of 158 patients. These patientsunderwent embolization for clinical varicoceles and male factorinfertility between 2004 and 2008. Of these, 56% underwentattempted bilateral embolization, 43% unilateral left-sided embolization and 1.3% unilateral right-sided embolization.Results: Of these patients who underwent attempted bilateralembolization, 19.3% did not experience a successful obliterationof the right gonadal vein and 2.3% (2/88) experienced a failure rate in the embolization of the left gonadal vein. Of the 2 attempts at unilateral right-sided embolization, there were no failures. Of the 68 unilateral left-sided embolization attempts, there was a 4.4% failure rate. Of all of the right-sided embolization attempts, 18.9% failed, while 3.2% of the left-sided attempts failed.Conclusion: This review represents the largest contemporary series of varicocele embolization outcomes currently in the literature. Our 19.3% technical failure rate for bilateral varicocele embolization is higher than the current published rate of 13% and is largely related to failure to successfully occlude the right gonadal vein. This supports our belief that bilateral varicoceles are best managed with a primary microsurgical approach, where technical failure rates are expected to be less than 5% based on published data. Men withunilateral left-sided varicoceles should be offered both options as they have similar failure rates, but with embolization offering some clear advantages to the patient.