Prof. Dirk A. Loose M.D.
Consultant Surgeon
Specialist in vascular medicine

ISSVA 23rd International Workshop, 12.-15. May 2020 in Vancouver

Abstract: Congenital vascular malformations in the genital area, a special therapeutic challenge: interventional and/or vascular surgery.

D.A.Loose, C.Gebhardt, M.Schlunz-Hendann, F.Brassel

Venous malformations   are mostly to be observed on the extremities. It is not uncommon for the genital region to be affected as well. These malformations occur both in isolation and in combination with venous malformations of adjacent regions. Since neither a medical specialty such as gynecology, urology, reconstructive surgery, pediatric surgery, vascular surgery or interventional radiology feels responsible for this pathology, in general there is no clear diagnostic or even therapeutic concept. We therefore consider it useful to point out our experience in diagnostics and in therapy, in order possibly to receive suggestions or an exchange of experiences from other centers.

Affected patients with vascular malformations in the genital area, who have been treated in our "Center for the treatment of vascular malformations in Hamburg" and in the "Radiology Center of Sana Hospitals Duisburg-Wedau" in the past 30 years have been regularly monitored. The long-term outcome of the treatment was recorded with special consideration of complaints, improvement of the quality of life and recurrence of malformations. The treatment of the venous malformations in the genital area was primarily interventional or primary vascular surgery and in combination first interventional and afterwards vascular surgery.

The diagnosis of these findings is problematic because of the anatomical-topographical localizations on the one hand and the need to detect the complete extent of the malformation and the affected adjacent tissue structures. It has been shown that the sole MRI diagnostics cannot detect the special pathology in most of the cases:  it often shows only "the tip of the iceberg". Also, the color-coded duplex sonography can only represent individual aspects of the pathological structures in the genital area. That is why the additional ascending phlebographic diagnostics has its special value in these cases. In addition, we also attach great importance to a varicography of the predominantly involved structures, e.g. the labia maiora. This diagnostic has special value in order to be able to determine the therapeutic options.

We treated 21 male patients aged 5-72 years and 99 female patients 4-56 years old. Of the male patients, 3 were interventionally treated with sclerotherapy (Aethoxysklerol foam plus fibrin glue). Of the female patients, 14 could be cared for by sclerotherapy.  All other patients in this study (18 male and 85 female) were treated by vascular surgery. Treatment with sclerotherapy usually required three to four sessions, while vascular surgery required  one or two treatment steps. If only the genital was infiltrated by  venous malformations ,the recurrence rate was 30%, after sclerotherapy and after vascular surgery. When venous malformations also affected surrounding structures, the relapse rate was 40%.

After individual diagnosis (duplex ultrasonography, venography) taking into account the venous hemodynamics in case of venous malformations, invasive therapy should be used at an early stage. It should be considered to what extent only the genital area is affected or also adjacent tissue structures. Several treatment steps are required for sclerotherapy and vascular surgery. The recurrence rate is 30-40%