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Varikocelės gydymas antegradine skrotaline skleroterapija ir jos rezultatų palyginimas su kitais gydymo metodais ir operacijomis

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dc.contributor.author Mickevičius, Ramūnas
dc.date.accessioned 2017-08-21T08:06:39Z
dc.date.available 2017-08-21T08:06:39Z
dc.date.issued 2005
dc.identifier.uri http://repository.lsmuni.lt/handle/1/60005
dc.description.abstract ABBREVIATIONS ASS antegrade scrotal sclerotherapy Endo general anesthesia Loc local anesthesia LV laparoscopic varicocelectomy ns not significant RS retrograde sclerotherapy SD standard deviation SEVA spermatico-epigastric venous anastamosis Δ difference between value INTRODUCTION Varicocele is an enlargement of the veins of the spermatic cord, which may cause infertility of men and pain in the testicle. This disease is cured in various interventional and surgical ways of treatment. Open surgeries according to Palomo and Ivanisevic are considered to be a classical way of treatment of varicocele. However, during two recent decades open surgeries are performed less in relation to wound infections that make 5.8% (Zuckerman et al. 1994) and a rather big number (16%) of recurrence of a disease (Rothman et al. 1981, Cayan et al. 2000, Kass et al. 2001). More simple and minimally invasive ways of treatment of varicocele are being searched. Retrograde sclerotherapy of the veins of the spermatic cord (RS) or embolization is an easier procedure and patients spend less time in hospital. However, these interventions are not available to perform in 15-30% of all cases (Porst et al. 1984, Okuyama et al. 1988, Winkelbauer et al. 1994, Abdulmaaboud et al. 1998), and the frequency of recurrence makes 10-15% (Lenk et al. 1994, Punekar et al. 1996). After the introduction of microsurgical equipment, the veins of the spermatic cord are ligated using magnification in order to reduce complications and recurrences, and to improve venous blood flow from the testicle and blood circulation in it. These microsurgical operations help to reduce the frequency of recurrence accordingly by 3.1% (Lima et al. 1997, Camogli et al. 2003) and 1-2% (Marmar et al. 1985, Goldstein et al. 1992) but expensive magnification equipment, as well as experience in work with it, is necessary. Laparoscopic method of treatment (LV) is a good modality of treating varicocele as well. After the performance of this type of operations, specific complications may occur that are related to the insufflations of gas and the increase of pressure in the abdominal cavity (Bongard et al. 1994, Tan et al. 1995, Esposito et al. 2001). Moreover, complex complications of the peritoneal cavity may occur (Bongard et al. 1994, Chrouser et al. 2004), and the equipment is expensive. Antegrade scrotal sclerotherapy (ASS) has turned out to be the least technically complicated intervention, whereas the frequency of recurrence is 5-13% (Tauber et al. 1994, Mottrie et al. 1995, Ficarra et al. 2002, Yaman et al. 2005). Despite of numerous surgical varicocele treatment methods, there is no uniform opinion which modality is the best; also there is lack of extensive comparative randomized studies of the treatment quality assessment. The research has been accomplished at the Department of Urology of Kaunas University of Medicine, and the results of four modalities of varicocele treatment have been analyzed, compared and summarized. Moreover, prospective analysis and evaluation of the results of antegrade scrotal sclerotherapy, i.e. minimally invasive method of varicocele treatment, has been made in detail. Aim of the study was to find out the efficacy of antegrade scrotal sclerotherapy as a method of treatment of varicocele, comparing this method with other interventional and surgical methods of treatment, moreover, to substantiate the expedience of the use of antegrade scrotal sclerotherapy on the basis of this study. Objectives of the study: 1. To compare the early results of treatment after antegrade scrotal sclerotherapy, retrograde sclerotherapy, laparoscopic varicocelectomy and spermatico-epigastric venous anastamosis. 2. To compare varicocele recurrences after antegrade scrotal sclerotherapy, retrograde sclerotherapy, laparoscopic varicocelectomy, and spermatico-epigastric venous anastamosis. 3. To compare the amount of spermatozoids of the patients with varicocele, in one milliliter of the ejaculate with the size of the testicles after antegrade scrotal sclerotherapy, retrograde sclerotherapy, laparoscopic varicocelectomy and spermatico-epigastric venous anastamosis. 4. To determine the risk factors increasing the possibility of varicocele recurrence after antegrade scrotal sclerotherapy. The novelty and originality of the study There are few studies in medical literature presenting comparison of antegrade scrotal sclerotherapy, retrograde sclerotherapy, laparoscopic varicocelectomy and spermatico-epigastric venous anastomosis in varicocele treatment. These treatment modalities were compared using the method of retrospective analysis. Recently, the literature has discussed antegrade scrotal sclerotherapy and described as an easiest and cheapest modality of varicocele treatment. This study has been performed in order to evaluate the impact of antegrade scrotal sclerotherapy on the diameter of the spermatic cord vein, the volume of the testicles, and the quantitative and qualitative parameters of the sperm. The results of the study have been compared with analogous results reported in the literature. Practical importance of the study After the accomplishment of the retrospective part of the study it was found out that antegrade scrotal sclerotherapy was the best way to cure varicocele among the four operations used in this study. Prophylactic indication for treatment of varicocele has been rejected. The efficacy of minimally invasive way of treatment of varicocele (antegrade scrotal sclerotherapy), the frequency of complications, and recurrence of the disorder has been also evaluated. A new prognostic factor increasing the probability of recurrence of varicocele after antegrade scrotal sclerotherapy has been found too, in the presence of which the patient can be informed about the risk of recurrence or can be offered more complicated methods of treatment resulting lower frequency of the recurrence. PATIENTS AND METHODS Retrospective study During the period from January 1998, to November 2001, five hundred and forty-eight patients with varicocele were operated. The patients underwent the following surgical operations listed in Table 1. Table 1. Types of surgical operations and number of the operated patients Type of operation Number of operations Ivanisevic operation (IO) 5 Spermatico-epigastric venous anastamosis (SEVA) 42 Retrograde sclerotherapy (RS) 307 Laparoskopic varicocelecktomy (LV) 25 Antegrade scrotal sclerotherapy (ASS) 169 Total 548 Five patients have had the operation of Ivanisevič but they have not been included in the study due to their small number, so 543 cases have been analyzed. From 1988, almost all patients had retrograde sclerotherapy. If RS operations could not be performed due to the anatomic lesions of the testicle vein, from 1989 patients had spermatico-epigastric venous anastamosis or (since 1995) laparoscopic operation and since 1996, antegrade scrotal sclerotherapy. RS and LV have been performed since 1995; since 1996, RS, LV, and ASS. In 1996, ASS was introduced into surgical practice, when the articles, claiming that it was the easiest and cheapest surgical operation to cure varicocele, were published. If ASS operation failed due to anatomic lesions of the testicle vein (contrast medium gets into the inferior vena cava) or when the operator could not find suitable vein for cannulation due to the lack of experience, the patients underwent RS or LV. Technique of retrograde sclerotherapy (RS) RS was performed by invasive radiologists in the operating room of the Division of Invasive Radiology. This operation was done employing local anesthesia, puncturing the femoral vein and inserting the catheter. During the procedure the contrast agent was injected through the catheter under X-ray control into the spermatic vein. Then the catheter was placed in the spermatic vein, and a sclerosing agent was injected. Until 1989, absolute alcohol (2 mL) with 3 mL of 40% glucose solution was used in the Division of Invasive Radiology for performing retrograde sclerotherapy. During the period of 1989-1993, ten mL of 3% Trombovar solution was used. Since 1994, eight mL of 3% Aetoxysklerol solution has been used. After the procedure, a compression bandage was applied on the site of puncture of the femoral vein. Technique of antegrade sclerotherapy (ASS) Antegrade scrotal sclerotherapy was performed applying local anesthesia. An incision of 1-1.5 cm was done about 1.5 cm lower than the root of the penis. The spermatic cord was exposed, and the vein of the pampiniform plexus was disclosed. The proximal end was ligated, and an intravenous catheter of 24G was inserted into the distal end of this vein. Contrast agent (3-6 mL of 76% Urografin solution) was injected through it. During Valsalva maneuver, when it was ascertained that contrast medium was flowing into the kidney vein, 1 mL of air and 3 mL of 3% Aetoxysklerol solution were injected. The distal end of the vein was ligated. The sheet of the spermatic cord and skin were stitched up. After the operation, an aseptic cooling bandage was put on the wound. Technique of laparoscopic varicocelectomy (LV) Laparoscopic varicocelectomy was performed under general anesthesia. During the operation, two trocars of 10 mm length (one, near the umbilicus, for the optics, and manipulative one, on the right pararectally between the umbilicus and symphysis), and one trocar of 5 mm diameter (manipulative, on the left pararectally between the umbilicus and symphysis). CO2 at 10-15 mmHg pressures was used during the operation for distension of the peritoneal cavity. The peritoneum was incised lengthwise about 1 cm higher than the inner ring of the inguinal canal, in the length of 1-1.5 cm along the testicular veins. The veins were exposed, ligated, and cut to save the testicular artery and lymphatic vessels. After the operation, the wound was covered with an aseptic bandage. Technique of spermati
dc.language.iso lit
dc.subject Antegrade scrotal sclerotherapy
dc.subject Varicocele
dc.subject Antegradinė skrotalinė skleroterapija
dc.subject Treatment
dc.subject Gydymas
dc.subject Varikocelė
dc.title Varikocelės gydymas antegradine skrotaline skleroterapija ir jos rezultatų palyginimas su kitais gydymo metodais ir operacijomis
dc.title.alternative The treatment of varicocele by antegrade scrotal sclerotherapy and the comparison of its results with other modalities of varicocele treatment
dc.type Daktaro disertacija


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