1758 MULTIDISCIPLINARY APPROACH FOR VARICOCELE

ease. Ofthe patients 251 with 277 total varicoceles were treated with sclero-embolization. In the majority of these cases a transbrachial approach was used. Open surgery was performed initially in 88 patients with 89 total varicoceles. The decided advantage of percu- taneous sclero-embolization was obviously an institutional bias, based on the experience of the authors with the procedure. Of the varicoceles 79% disappeared and, thus, treatment was considered successful in those cases. Of 42 patients with residual varicoceles 7 underwent a second sclero-embolization and 35 underwent surgery. Of the patients who underwent sclero-embolization 17 had painful swelling of the scrotum and 4 (2%) were hospitalized for a few days.

Of surgical treatments 89% were considered successful. Six pa- tients underwent a second operation. Complications in the surgical group included an 11.28 incidence of late hydrocele. Only 2 of the 15 patients with a hydrocele required surgery. The authors noted a marked improvement in surgical outcome, since ligation of the entire spermatic cord above the vas deferens.

Several issues need to be addressed when evaluating this type of new approach toward varicocelectomy. One must look at short-term outcome data. We must understand the morbidity and cost of the less invasive versus the time-honored surgical procedure. Finally, one must always consider the ultimate long-term outcome. With respect to the short-term outcome, the authors quoted a 79% success rate for sclero-embolization, including what they term partial success. It is unclear what a partial success indicates and removing that data appears to drop the overall success rate significantly. The mor- bidity appears to be acceptable using the less invasive sclero- embolization technique. Unfortunately, any complications regard- ing placement of the brachial or femoral venous catheters or any other complications with respect to venography or sclerotherapy are not reported. While the authors have minimized the 2% hos- pitalization rate after sclero-embolization it is significant. The cost of outpatient varicocelectomy, including fees for surgeons, hospital and anesthesia, was approximately $2,500. The cost of sclero-embolization is nearly identical a t our institution. However, sclero-embolization takes approximately 4 hours, whle surgical in- tervention takes approximately 1 hour. Finally, we were unfortu- nately not provided followup, long-term data on testicular size, or

any data on semen analyses or fertility. Furthermore, the long-term surgical outcome is challenged by the fact that the authors are now performing a new surgical approach, which includes a high ligation, retroperitoneal approach.

In conclusion, it appears that the bias of the authors is towards percutaneous sclerotherapy. Unfortunately, this preference is based on short-term outcome data and not on long-term success, cost- effectiveness or morbidity. Thus, percutaneous sclero-embolization appears to be slightly less successful than surgery, equally as costly, and more prone to postoperative and perioperative morbidity. Until such a time that a comparison study can be done that offers both techniques prospectively, percutaneous sclero-embolization will most likely receive less enthusiastic support from the medical com- munity that treats these patients.

Allen D. Seftel Department of Urology Case Western Reserve University Cleveland, Ohio

REPLY BY AUTHORS

We would like to focus on some points that may not have been understood. The success rate accounts for cases in which reflux totally disappeared after treatment. Partial success accounts for cases in which reflw was still present after treatment, although it was less and not so severe that a new intervention was required. Partial success was not included in the success rate.

Follow-up was minimum of 6 months (average 1 year), which seems to us to be sufficient to detect any persistent recurrent vari- coceles. We listed all complications detected. Fortunately, at our hospital the cost for percutaneous sclerosis as outpatient treatment is approximately $1,000. At our vascular radiology department about 500 men and boys with varicocele are treated yearly. The duration of the percutaneous sclerosis procedure ranges from 30 to 60 minutes. Average radiological exposure time is 4 minutes. We believe that a multidisciplinary approach that reduces surgical therapy by 70% cannot be deemed aggressive.