Paradigm shift and long-term results in the diagnosis and treatment of pelvic venous disorder.

Abstract

Objective: Pelvic venous disorder (PeVD) is a heterogeneous condition with a range of presentations, including chronic pelvic pain (CPP), hematuria, flank pain, dyspareunia, pelvic, and lower extremity varicose veins. The clinical, anatomical, and hemodynamic diversity of PeVD complicates standardized management. We developed a personalized diagnostic and therapeutic protocol and evaluated its long-term outcomes.

Methods: Patients presenting with CPP, with or without symptoms of renal or iliac vein obstruction, visual analogue scale (VAS) for pain of >5, and gonadal or pelvic varicose vein incompetence underwent one of the following procedures based on their anatomical, and hemodynamic profiles: (1) ovarian and pelvic varicose vein embolization, (2) spermatic vein embolization, (3) iliac vein stenting, or (4) renal vein stenting. Procedures were performed with intraoperative venography and intravascular ultrasound assessment.

Results: Between January 2012 and May 2022, 175 patients with PeVD were treated, of whom 146 cases (83.4%) were followed for >2 years (mean, 110.0 ± 1.6 months). Treatment methods included iliac vein stenting (78 cases [53.4%]), ovarian vein embolization (45 cases [30.8%]), spermatic vein embolization (17 cases [11.7%]), and renal vein stenting (6 cases [4.1%]). Preoperative and postoperative VAS scores and Short Form-36 quality-of-life scores were as follows: iliac vein stenting: VAS, 8.1 ± 1.8 to 2.89 ± 1.7 (P < .001); Short Form-36, 35.8 ± 23.4 to 78.4 ± 11.8 (P < .001); ovarian vein embolization: VAS, 8.5 ± 1.5 to 3.1 ± 1.1 (P < .001); Short Form-36, 36.7 ± 22.6 to 74.7 ± 11.8 (P < .001); spermatic vein embolization, VAS, 8.3 ± 1.1 to 3.1 ± 0.4 (P < .001); Short Form-36, 33.8 ± 33.8 to 77.4 ± 13.7 (P < .002); renal vein stenting, VAS, 8.7 ± 0.9 to 1.8 ± 1.1 (P < .001); Short Form-36, 48.45 ± 33.8 to 79.4 ± 10.9 (P < .001). Complications included two cases (4.4%) of intraoperative, asymptomatic gonadal vein bleeding with very low-volume static contrast extravasation, which were managed conservatively. The reintervention rates after primary treatment were as follows: iliac vein stenting 10.2%, ovarian vein embolization 13.3%, spermatic vein embolization 0%, and renal vein stenting 16.6%.

Conclusions: PeVD is a heterogeneous clinical condition requiring thorough preoperative assessment of reflux and venous obstruction. Although isolated CPP often benefits from gonadal and pelvic vein embolization, most patients with CPP related to chronic venous disease or renal vein symptoms improve with iliac or renal vein stenting alone, avoiding posterior gonadal vein embolization.