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Ovarian Varices in Healthy Female Kidney Donors: Incidence, Morbidity, and Clinical Outcome

¹ Department of Radiology and the Interventional and Vascular Unit, Rabin Medical Center, Beilinson Campus, Petah Tiqva 49100 and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
² Department of Radiology, Hillel-Yaffe Medical Center, Hadera, Israel.

Received September 27, 2001; accepted after revision March 6, 2002.

 
Presented at the annual meeting of the Cardiovascular and Interventional Radiology Society of Europe, Prague, September 1999.

Address correspondence to G. N. Bachar.

Abstract

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OBJECTIVE. Kidney donation is associated with ligation of the ovarian vein and is comparable to ovarian vein embolization. We evaluated the incidence, morbidity, and clinical outcome of ovarian varices in healthy female kidney donors before and 6 months after nephrectomy.

MATERIALS AND METHODS. Between 1994 and 2001, 273 healthy female kidney donors underwent preoperative abdominal aortography. The study group consisted of 27 women (9.9%) in whom retrograde flow in an incompetent left ovarian vein was noted during the venous phase of imaging. All patients underwent left nephrectomy with left ovarian vein ligation. Only women with retrograde flow in the left ovarian vein were asked to complete a questionnaire about the incidence and intensity of pelvic pain before and 6 months after nephrectomy.

RESULTS. Twenty-two of the 27 left-kidney donors with retrograde flow in the ovarian vein were available for follow-up. Thirteen (59%) of those 22 reported chronic pelvic pain. After nephrectomy, the pelvic pain completely resolved in seven (54%), improved in three (23%), and persisted in three (23%).

CONCLUSION. Our study found a 9.9% prevalence of ovarian varices in the general population. Our findings suggest that more than half (59%) the patients with ovarian varices have pelvic congestion syndrome and that most (77%) of them might benefit from ovarian vein embolization or ligation.

Introduction

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Chronic pelvic pain is defined as noncyclic abdominal and pelvic pain of at least 6 months' duration. It is a common problem in women, accounting for 10-40% of all gynecologic visits [1]. One of the causes of chronic pelvic pain is vascular congestion resulting from retrograde flow in an incompetent ovarian vein, which is termed "pelvic congestion syndrome." Pelvic congestion syndrome was first described by Richet in 1857 [2] and Aran in 1858 [2], and was described in the modern literature by Taylor [3] in 1949 and Allen and Masters [4] in 1955. Pelvic congestion syndrome remains less well recognized than varicocele, the corresponding entity in men [5]. Signs and symptoms appear after pregnancy. Pain intensity heightens before or during the menses and is aggravated by prolonged standing, fatigue, and coitus. The differential diagnosis includes endometriosis, adenomyosis, pelvic adhesions, atypical menstrual pain, urologic disorders, irritable bowel syndrome, gastrointestinal disorders, and psychosocial problems. In two independent series, Hobbs [2] and Edwards et al. [6] successfully treated affected patients with ovarian vein ligation.

The aim of this retrospective study was to examine the clinical outcome of healthy female kidney donors who were found to have retrograde flow in an incompetent ovarian vein on preoperative abdominal aortography and who underwent left ovarian vein ligation during left nephrectomy.

Materials and Methods

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From 1994 to 2001, 273 healthy female kidney donors underwent preoperative abdominal aortography at our center. The procedure was performed in an interventional radiology suite equipped with an Integris 3000 digital unit (Philips Medical Systems, Best, The Netherlands). With the patient in the supine position, vascular access was obtained through the femoral artery. A single arterial puncture was made with a 19-gauge needle (Cordis; Johnson and Johnson, Berk, United Kingdom), and a 5-French catheter (Cordis) was introduced into the abdominal aorta above the origin of the renal vessels. Flush aortography was performed with iopromide (Ultravist 350; Schering, Berlin, Germany) and the renal vascular anatomy was revealed in three phases: arterial, nephrographic, and venous. The ovarian vein was also evaluated in the venous phase. When the renal vein was not seen, selective angiography of the renal artery was performed on each side.

The reported upper limit of the normal diameter of the ovarian vein on venography is 5 mm. We defined ovarian veins with a diameter of 8 mm or more as clearly abnormal; this value has been associated with the presence of enlarged parauterine veins [7, 8].

All donors underwent left nephrectomy and left ovarian vein ligation.

Only patients found to have ovarian varices on venous phase imaging were asked to complete a questionnaire describing the frequency and intensity of pelvic pain and other symptoms before and 6 months after nephrectomy. Pain intensity was scored on a modified visual analog scale of 0 (no pain) to 10 (unbearable pain). This quantitative method has been found to be sensitive and reproducible [9, 10].

Results

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Of the 273 patients, 27 (9.9%) were found to have retrograde flow in an incompetent left ovarian vein during the venous phase of aortography. The diameter of the left ovarian vein in those patients ranged from 8 to more than 10 mm and was considered abnormal (Fig. 1). Twenty-two of the women were available for follow-up and constituted the study group of our retrospective analysis.

View larger version (160K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1. —45-year-old woman with chronic pelvic pain. Venous phase digital subtraction angiogram shows circumaortic left renal vein. Note tip of catheter in aorta and spontaneous reflux of contrast medium into ipsilateral dilated ovarian vein. R = renal, V = vein.

The mean age of the study group was 43 years (range, 18-76 years). Eighteen patients were premenopausal, two were perimenopausal, and two were postmenopausal. Sixteen were multiparous (gravid 2, para 2) and four were nulliparous.

Results of the questionnaire showed that 13 (59%) of the 22 left-kidney donors with retrograde flow in the left ovarian vein had pelvic symptoms before surgery: chronic pelvic pain in all 13 and dysmenorrhea in three of the 13.

After nephrectomy, pelvic pain resolved completely in seven (54%) of the 13 patients, improved in three (23%), and persisted in the remaining three (23%). One patient became pregnant after nephrectomy and gave birth to a healthy child.

Discussion

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A recent population-based study in the United States of 5263 women who were 18-50 years old found a 15% prevalence of chronic pelvic pain [11]. However, the rates of the specific causes were not examined. In our study, the prevalence of ovarian varicocele was found to be 9.9%. To the best of our knowledge, ours is the first report in the English literature on the incidence of pelvic congestion syndrome in the general population. Furthermore, our study shows that ovarian varices are symptomatic in only 59% of patients, which supports earlier suggestions that pelvic congestion syndrome is due to a combination of factors [2].

The ovarian veins follow a vertical course in the retroperitoneum that is parallel to the spinal column. They drain into the renal vein on the left side and into the anterolateral wall of the inferior vena cava on the right. This system is part of the extremely complex venous interconnections of the female pelvis that also include connections between the uteroovarian and salpingoovarian veins through the broad ligament, and connections with rectal, vaginal, and vesical veins. Blood flow is directed into the internal iliac vein or distally to the deep femoral vein or into the obturator, inferior gluteal, or external pudendal veins. As in male varicocele, primary valvular incompetence of the ovarian veins may be caused by a chronic increase in peripheral resistance associated with compression of the left ovarian vein by the ipsilateral common iliac artery or the left renal vein (retroaortic renal vein or nutcracker venous resistance). In our study, 20% of the patients with retrograde flow in the left ovarian vein had one of these anatomic variants (Fig. 1).

Pelvic varices can be detected on Doppler sonography, CT, or MR imaging [12,13,14]. Color duplex sonography and pelvic sonography are the screening methods of choice, because they can distinguish varices from cystic adnexal masses by revealing blood flow within the varices. However, normal findings on sonography, even when it is performed with the patient in the erect position, are not conclusive. Selective venography is the gold standard for diagnosis. Furthermore, the pelvic venous anatomy still needs to be evaluated using selective phlebography before embolization [15]. Findings of ovarian vein diameter of 8 mm at its widest point, uterine vein engorgement, and congestion of the ovarian plexus, are indicative of pelvic congestion syndrome.

In our study, retrograde venous flow and incompetent ovarian vein valves were noted incidentally during angiography before kidney donation. Therefore, performing ovarian vein venography would have been unethical, especially because we believe that this invasive examination should be reserved for those patients who have agreed to be treated by an endovascular approach. Nevertheless, we detected two of the criteria of pelvic congestion syndrome: retrograde flow in incompetent venous valves and enlargement of the ovarian vein [15]. Moreover, we found the retrograde flow using the physiologic method of renal artery aortography and not by venous selective catheterization, which some authors think may aggravate the reflux [15].

The treatment of ovarian varicocele consists of embolization or ligation of the ovarian vein. Villavicencio et al. [14] combined extraperitoneal resection of the ovarian vein with ligation of the internal iliac vein tributaries. Although treatment is usually bilateral [15, 16], we observed a 77% rate of symptomatic relief—complete in 54% and partial in 23%—with unilateral ovarian vein ligation. These findings are similar to those of earlier reports. Capasso et al. [15] noted pain relief at an average of 16.4 months after embolization in 74% of 19 women with pelvic congestion syndrome, including complete relief in 58%. Similarly, Hachan et al. (presented at the Society of Cardiovascular and Interventional Radiology meeting, March 1998), in a series of 23 women followed up for 15 months, found a 78% improvement rate, with 13% of the other patients showing no change and the remaining 9% having worsening of symptoms.

Most (73%) of the patients in our study were multiparous, which is in agreement with the findings of Ahlberg et al. [16], who found a significantly greater number of incompetent valvular structures in the ovarian veins in multiparous patients than in nulliparous patients.

Our study, being retrospective, has several limitations. The study group was part of a large group of 273 women who, before kidney donation, underwent diagnostic angiography in which ovarian varices were incidental findings. None of the patients was examined because of complaints of pelvic pain, which is usually the case in pelvic congestion syndrome. They were also not examined by a gynecologist after the aortography, because that was beyond the scope of the examination. Furthermore, the aortography was done with the patients in the supine position, whereas in other studies of selective ovarian venography [6, 17], the imaging was done with the patient in the semierect position and during both normal breathing and Valsalva's maneuver. Valsalva's maneuver can increase the rate of detection of ovarian varices by as much as 60% [18]. We found a prevalence of only 9.9%. Moreover, we observed a 77% rate of symptomatic relief—complete in 54% and partial in 23%—with unilateral ovarian vein ligation. Because the differential diagnosis of pelvic pain is quite broad and includes various gynecologic, urologic, and psychosocial problems, we cannot attribute the relief of the symptoms to the nephrectomy and ovarian vein ligation alone.

In conclusion, our study shows that the prevalence of ovarian varices is 9.9%. Our findings suggest that more than half the patients with ovarian varices have pelvic congestion syndrome. We recommend that diagnostic workup for idiopathic chronic pelvic pain include screening for ovarian varices by noninvasive methods such as Doppler sonography and CT. In that way, selective venographic studies are performed before endovascular treatment [12, 15]. Most patients with pelvic congestion syndrome might benefit from ovarian vein embolization or ligation.

References

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This Article Abstract Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Belenky, A. Articles by Bachar, G. N. Search for Related Content PubMed PubMed Citation Articles by Belenky, A. Articles by Bachar, G. N. Social Bookmarking                      What's this?