Acute Varicocele Revealing Renal Cancer

Abstract

A 65-year-old man with no notable medical history presented to the urology clinic with swelling in the area of the left testicle that had started 4 weeks earlier. Examination of the scrotum revealed an enlarged varicose vein along the left spermatic cord (Panel A, arrows), and abdominal palpation revealed a mass in the right flank. Computed tomography of the abdomen and pelvis revealed multiple bilateral renal tumors (Panel B, arrows), with the largest tumor located in the left kidney. Open radical nephrectomy of the left kidney was performed, and the results confirmed the diagnosis of renal-cell carcinoma. One week later, the varicocele disappeared. A varicocele is a dilatation of the pampiniform plexus of the spermatic cord; this network of veins is dependent on the spermatic vein. Varicocele occurs more commonly on the left side because the spermatic vein opens at a sharp angle into the left renal vein, whereas the right spermatic vein opens into the larger inferior vena cava. An acute nontraumatic varicocele, especially on the left side, may indicate the presence of a retroperitoneal mass.

Ultrasound evaluation of varicoceles: systematic literature review and rationale of the ESUR-SPIWG Guidelines and Recommendations

“…Other paraneoplastic signs such as fever or general malaise may also be present with retroperitoneal tumours. A number of case reports and small case series suggest that varicoceles are a possible mode of presentation of retroperitoneal tumours [148][149][150][151][152]. This led to the dogma that an extended abdominal ultrasound examination should be performed in all patients with a newly diagnosed varicocele.…”

“…The ESUR-SPIWG believes that US examination should always be extended to the abdomen in children less than 9 years presenting with an acute varicocele, to rule-out a renal or retroperitoneal tumour. In adults, the alleged association between varicoceles and retroperitoneal masses is based on a limited number of series and case reports in which the varicocele was a late sign of a symptomatic, palpable lesion [152,[166][167][168][169].…”

Tumor thrombus: incidence, imaging, prognosis and treatment

“…Tumor thrombus may be asymptomatic or may cause a variety of symptoms including varicocele, lower extremity swelling, cardiac dysfunction, pulmonary embolism, or Budd-Chiari syndrome (9)(10)(11)(12). In the absence concurrent invasion of Gerota's fascia or the ipsilateral adrenal gland, RCC with tumor thrombus is staged as T3 (2) ( Table 1).…”

Curated findings and implications in duplex ultrasound interrogation of the scrotum or varicoceles

“…This anatomical difference induces relatively weak hemodynamics in the left testicular vein, which accounts for the predominance of left sided varicocele 6,7 . Other causes include that the incompetence of venous valves results in reflux of venous blood and increases hydrostatic pressure; "nutcracker" phenomenon that the proximal left renal vein decreases with decrease in the aortomesenteric distance and angle; renal tumor compression, and so on [6][7][8][9] . In addition, we believe that the common presence of anatomical variations of testicular vessels and relevant vessels may be also the cause of varicoceles [10][11][12][13][14][15] .…”

“…In accordance to ultrasound evaluation of varicoceles: guidelines and recommendations of the European Society of Urogenital Radiology Scrotal and Penile Imaging Working Group (ESUR-SPIWG) for detection, classification, and grading, varicoceles is defined by the presence of multiple veins greater than 3.0 mm with concomitant retrograde blood 4,5 . Copious studies on diagnosis, grading, mechanism, and management of varicoceles have been published, many consensuses have achieved, however, some controversies and concerns remain unsolved [2][3][4][5][6][7][8][9][10] . The purpose of this study was to curate clustered findings of duplex ultrasound in the evaluation of the scrotum and spermatic venous varicoceles, and deliver more response to the present concerns.…”