Tauber antegrade sclerotherapy: the importance of phlebography in choosing the correct vein


 Tauber antegrade sclerotherapy can be considered an established procedure for the treatment of varicocele in paediatric age. Herein, we share our experience with this technique and its tricks. The choice of the spermatic vein should be very accurate during the Tauber procedure, and a correct intraoperative phlebography is mandatory to avoid complications.

procedure was converted to a retroperitoneal approach (Palomo). In four patients (4.5%), a transient post-operative hematoma was observed. Recurrence occurred in 4 patients (4.5%), and a redo Tauber procedure was successfully performed. Interestingly, in two patients, a vascular anomaly was noted during phlebography. In the first case, we identified the left spermatic vein during the contrast medium injection into a vein of the deep pampiniform plexus, but we noted a collateral vein starting from the proximal tract of the spermatic vein and headed toward the left colic space (Fig. 2). As we could not predict the collateral vein's course, we decided to stop the Tauber procedure and selectively ligate the veins. In the second case, during the contrast medium injection into a vein of the superficial pampiniform plexus, the cremasteric area was identified at the lower abdominal wall level (Fig. 3). Consequently, we decided to ligate the vein and choose a deeper vein of the plexus and completed the Tauber procedure. At 6 months clinical and ultrasound follow-up, no residual varicocele was observed in the patients. The postoperative testicular volume is not considered a valuable parameter to evaluate the outcome of the procedure, and thus it is not usually needed.
The choice of the vein should be accurate when performing the Tauber procedure. The plexus' superficial vessels may often flow into the cremasteric area that leads blood to the inferior abdominal wall. Additionally, it may be more challenging to cannulate a superficial vein than a deep plexus vein for the lower dimensions, resulting in perivasal tissue bleeding or hematoma; subsequently, choosing another vein may not be simple. Although many researchers suggested performing a preoperative phlebography before proceeding with sclerotherapy, some authors described serious complications such as ischemic necrosis of the sigmoid colon and lower abdominal wall necrosis even with a non-identification of abnormal venous communications. 3 Consequently, we are convinced that a correct intraoperative phlebography is mandatory to avoid complications.
Based on our experience, the left spermatic vein should always be followed to the intersection with the left renal vein to identify some high collateral veins, such as internal iliac afferent veins, which may not be detected during incomplete phlebography. Thus, the patient should be carefully positioned on the operating table to allow the performance of an adequate phlebography, especially in the case of a tall patient. Notably, the operating table should be correctly positioned to enable a proper kidney visualization. Lastly, the patient should maintain the Valsalva manoeuvre during phlebography and the sclerosing agent injection. In fact, the Valsalva manoeuvre could make visible the inversion of the venous flow throughthesmallveinsintheinternaliliacveins,thuspreventingoneofthe mostseverecomplicationsrelatedtothisprocedure. 4 In conclusion, although Tauber antegrade sclerotherapy can be considered a safe and effective procedure in the treatment of idiopathic varicocele in paediatric age, some challenging complications could be avoided through attending to small, but not negligible, technical details.

Data availability statement
The material that support the findings of this study are available on request from the corresponding author.

Ethics approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Written informed consent was obtained from the individuals/legal guardians for the publication of any potentially identifiable images or data included in this article.