Scrotal antegrade sclerotherapy for the adolescent varicocele
Reviewed by Neil Featherstone

The incidence of varicocele in adolescent males is around 15%. Treatment indications include symptoms (pain) and evidence of a smaller testis. Numerous surgical techniques are described but there is a lack of randomised controlled trials (RCT), specifically in adolescents. This is a prospective RCT study from Hong Kong comparing laparoscopic Palomo surgery (LPS) with scrotal antegrade sclerotherapy (SAS). Consecutive patients diagnosed with varicocele (2015-2020) with indications for surgery were eligible. Participants were randomly allocated to either the SAS or LPS group. All procedures were performed by three paediatric urologists or by higher surgical trainees under their supervision. SAS was performed under general anaesthesia (GA). Sodium tetradecyl sulphate (STS) mixed with lipiodol and air foam (2ml STS, 0.5ml lipiodol, and 2.5ml air made up to 5ml microfoam sclerosant) was used to inject the spermatic vein until it reached the level of the renal vein. LPS was performed under GA and involved mass ligation of the testicular vessels using four 5mm hem-o-loks after the varicocele was manually emptied via direct compression by the assistant. One hundred and sixteen patients agreed to participate; three patients were lost to follow-up. Recurrence rates (approximately 5%) and testicular catch-up growth measured at standardised intervals were similar in both the SAS and LPS groups. There were seven new postoperative hydroceles observed after LPS (13%) but none after SAS (0%). This study represents the first RCT to compare LPS and SAS as varicocele management strategies in adolescents. Both have similar outcomes but less postoperative hydroceles were noted with SAS. Outcomes presented are excellent (95% success) and similar to those previously presented to us at our British Association of Paediatric Urologists annual meeting by the Manchester group (David Keene and Max Cervellione) who have moved to using antegrade foam sclerotherapy for varicocele treatment. My personal preference, following paediatric urological training, is interventional radiological coiling of the spermatic vein (undertaken via the internal jugular route) – this is often undertaken under GA, but some of the older boys are able to tolerate local anaesthesia – again, outcomes are excellent and there are less postoperative hydrocoeles compared to a laparoscopic Palomo approach.

Prospective randomised controlled trial comparing laparoscopic Palomo surgery vs scrotal antegrade sclerotherapy in adolescent varicocele.
Chung KLY, Hung JWS, Yam FSD, et al.
JOURNAL OF UROLOGY
2023;209:600-10.