Hydrocele aspiration and injection sclerotherapy under local anaesthetic: a viable alternative to open surgical repair

Introduction: Hydroceles could cause discomfort, scrotal heaviness, cosmetic problems or adversely impact quality of life. Conventional treatment involves open surgical repair under general anaesthetic. Aspiration and injection sclerotherapy is however an attractive alternative since literature suggests it has comparable outcomes, lower complication rates and can be performed under local anaesthetic (LA) in timely manner. Patients and Methods: Consenting patients were prospectively recruited following necessary approvals. The procedure was carried out under LA and ultrasound guidance at our urology clinic. The hydrocele was drained and sclerosant (3% sodium tetradecyl sulphate) immediately injected into the tunica vaginalis. Post-procedure followup ranged from 3-12months. Results: Thirty-two patients with 35 procedures (2 re-do, 1 bilateral) were studied. Average volume drained was 283ml (18-1000ml). Overall success rate was 77.1% (complete resolution- 21 [60.0%], mild re-accumulation without need for re-intervention- 4 [11.4%], moderate re-accumulation successfully treated with re-do sclerotherapy- 2 [5.7%]). Large/significant recurrence was noted in 8 (22.9%) patients- they all had large (>200ml) hydroceles ab-initio and went on to have straightforward open surgical repair. One procedure was abandoned due to traumatic aspiration and was excluded. Conclusions: Hydrocele aspiration and injection sclerotherapy under LA is safe, easy to set-up and effective, with trend towards better outcomes for smaller hydroceles. This treatment could ease waiting-list pressures occasioned by the COVID-19 pandemic and should be considered as part of informed consent process for all men with hydroceles. Further data is required to define most suitable patients and also to fully assess ease of hydrocele repair after failed sclerotherapy.

Is endovascular treatment of the great saphenous vein (with immediate foam sclerotherapy of superficial tributary veins) in an outpatient clinic really safe and profitable?

BACKGROUND: This preliminary study aimed to evaluate the safety of radiofrequency (RF) thermoablation of the great saphenous vein (GSV) with immediate foam sclerotherapy of superficial tributary veins performed in the outpatient clinic (Hospital Department). Further, we also evaluated the cost reduction compared to the same procedure performed in the operating room. METHODS: Thirty patients were evaluated for RF thermoablation of the GSV. Foam sclerotherapy was performed with 1-3%sodium-tetra-decyl-sulphatefoam (Tessari’s method). We evaluated the possible risks of the procedure and methods to resolve them. We compared the costs of both procedures performed in the operating room and in the outpatient clinic. RESULTS: We had complete occlusion of the GSV in 28/30 patients (93.3%). Periodic check-up revealed a reflux through an anterior lateral saphenous vein in one patient and a long saphenous stump in another patient. There were no severe intraoperative complications. In two cases, it was necessary to convert the radiofrequency procedure into foam sclerotherapy (using the hollow probe as a long catheter in one case and using needle injection in the second case). In another case, it was necessary to perform surgical cannulation of the GSV. There were no severe postoperative complications. Moreover, the cost of the operating room procedure was € 1226.50, while that of the outpatient clinic procedure was € 1082.65 (cost reduction, 12.5%). CONCLUSIONS: This procedure is safe and sufficiently cost-effective to perform in an outpatient clinic and the operating room can hence be reserved for patients with more serious pathologies. These results should be validated in further studies with larger sample size.

One-year results of treatment of incompetent truncal veins and incompetent perforators using high intensity focused ultrasound (HIFU)

Introduction, Objectives, and/or Purpose: Incompetent truncal and perforating veins of the legs contribute to a variety of conditions collectively called chronic venous insufficiency (CVI). Symptoms and signs of CVI adversely affect patient's quality-of-life. These can range from tired and heavy legs, through varicose veins, swollen ankles, fasciocutaneous damage all the way to leg ulceration. International guidelines recommend the treatment of venous reflux using endovenous thermal ablation as a first-line, and foam sclerotherapy as a second-line treatment. Both of these ablate the incompetent vein. There has been a push towards less invasive techniques, but most of these still involve endovenous cannulation. High-Intensity Focused Ultrasound (HIFU) is a completely non-invasive ablative technique. The HIFU technique uses to ultrasound systems within one machine. The first, a greyscale ultrasound with a colour flow capability, is used to identify the target vein and to target the focused ultrasound. The second is a conical focused ultrasound beam, that focuses on a point approximately 5 mm high by 3.6 mm circumference. In this focus area, temperatures can rise to 70-90°C. This is sufficient to ablate biological tissue. Objectives: (1) To assess the success of using HIFU for the treatment of incompetent truncal veins (GSV, SSV, AASV). (2) To assess the success of using HIFU for the treatment of incompetent perforator veins. (3) To determine the success of adjuvant foam sclerotherapy with of after HIFU, as a treatment protocol. Methods: A retrospective audit of 55 patients treated with HIFU using the Sonovein device (Theraclion, Paris, France) between May 2019 and September 2020 was performed. Due to the COVID-19 pandemic, and consequent travel restrictions and lockdowns, not all patients could return for follow-up DUS at the planned time intervals (1-2 weeks, 6- 8 weeks, 6 months, 1-year post-treatment). DUS outcome of the treated vein was graded: 1. complete success (complete atrophy of the target vein) 2. partial success (≥ 1 patent section;none giving rise to recurrent varicose veins / subclinical reflux not requiring treatment) 3. partial failure (≥ 1 patent section giving rise to significant recurrent varicose veins) 4. complete failure. Initially, we performed HIFU of incompetent veins and then completed the procedure with ultrasound-guided foam sclerotherapy. Later, the foamsclerotherapy was delayed and only used if required.We analysed the success rate of HIFU alone in those patients who had only HIFU treatment. In those who had additional foam sclerotherapy, we analysed the success rate of HIFU and foam sclerotherapy starting from the date of the foam sclerotherapy, regardless of whether it was performed on the same day as HIFU or subsequently. Results: Fifty patients (female:male 39:11) returned for at least one follow-up scan giving a 90.9% response rate for at least 1 scan. Due to the COVID-19 pandemic, and consequent travel restrictions and lockdowns, not all patients could return for follow-up DUS at planned time intervals (1-2 weeks, 6-8 weeks, 6 months, 1-year post-treatment). There were 78 legs treated, and 41 truncal veins and 146 incompetent perforator veins. Truncal veins: Twenty-nine patients (41 truncal veins in 35 legs) had at least one follow-up scan. Ten patients (15 truncal veins) had concurrent foam sclerotherapy, and nineteen patients (26 truncal veins) did not. Of these nineteen patients, seven patients (10 truncal veins) received foam sclerotherapy within one year of having HIFU treatment. Twelve patients (16 truncal veins) did not receive foam sclerotherapy at all. Those patients having HIFU only showed an 83.3% (15 out of 18) closure at 6- 8 weeks (Figure 1). The results for HIFU and foam sclerotherapy are shown in Figure 2. Despite difficulties in getting patients back for scans, closure rates of 83.3% and 100% were found between 9 and 12 months and over 12 months, respectively. Perforator veins: Forty-three patients (146 perforator veins in 68 legs) attended at least once. Suc essful ablation was seen in 88% at 6 months and 70% at one year in those not having foam sclerotherapy, and 83.3% and 100% in those having HIFU and foam sclerotherapy. Conclusions: High Intensity Focused Ultrasound (HIFU) is a new technique that can treat incompetent truncal and incompetent perforator veins extracorporeally. We have reported the one-year results of patients having either HIFU alone, or HIFU combined with ultrasound guided foam sclerotherapy. Allowances need to be made for the sporadic follow-up due to the COVID-19 pandemic, and also the fact that we changed our protocols of treatment as we got more experienced. Hence, even although we are reporting what is in effect the learning curve for this technique, the outcomes are not dissimilar from the early outcomes from endovenous thermal ablation. Increased speed of treatment with a corresponding reduction in the need of any local anaesthetic is being introduced, and further audits will be performed in the future to ensure the success rates are maintained or improved.

Sclerotherapy with 3% polidocanol foam for third- and fourth-degree hemorrhoids as "bridge treatment" during the COVID-19 pandemic in Italy.

PURPOSE: In Italy, colorectal surgery has been strongly affected with the vast majority (90%) of operations treating benign diseases, with an estimated overall 12-week cancellation rate of 72%. Little is known on how to best manage patients with benign diseases and the consequences this interruption of care will have in post-pandemic times. Proctologic diseases have social, psychological, and healthcare repercussions for their high incidence and great impact on the quality of life. METHODS: We decided to treated 10 urgent cases affected from III- and IV-degree hemorrhoids with 3% polidocanol foam in attempt to reduce hemorrhoidal symptoms while waiting for surgery so called "bridge treatment". RESULTS: During the follow-up no complications were occurred, and all patients had resolution of bleeding and pruritus with a mean VAS of 1 (range, 0-1). CONCLUSIONS: This treatment could reduce the bleeding that is the main symptom from which patients suffer and for which they underwent proctological evaluation and surgery. According to our preliminary experience in the impossibility of accessing the surgery during the COVID-19 pandemic, ST could be considered as the treatment of choice in those patients who are suffering from grade III- and IV-degree hemorrhoids while waiting for surgery.