Varicocele and Nutcracker Syndrome

Abstract

Abbreviations AMP, aortomesenteric portion; ANOVA, analysis of variance; LRV, left renal vein lthough the causes of infertility in men are of various characters and origins (eg, developmental defects and exposure to harmful agents), a substantial proportion, especially secondarily infertile men, have the clinically detectable and correctable vascular abnormality varicocele.Despite various theories, the underlying cause of varicocele remains enigmatic. The role of intrinsic anatomic differences between the left and the right renal vein drainage systems has been implicated in the development of this condition. A greater length of the left internal spermatic vein in comparison with the right system and higher venous pressure on the left side caused by the junction of the left internal spermatic vein with the left renal vein (LRV) at a right angle are the most commonly considered factors because they lead to subsequent propagation of the elevated pressure to the left scrotal vein 1 and possibly determine the onset of varicocele. A ArticleObjective. Varicocele is a vascular lesion commonly associated with infertility. Its etiology is only partly understood; hence, the purpose of the study was to establish its correlation with intrinsic anatomic differences and nutcracker syndrome. Methods. A total of 93 patients with varicocele and 76 patients without varicocele were enrolled. The diagnosis of varicocele was based on physical examination, followed by sonographic evaluation of the hilar portion and aortomesenteric portion (AMP) of the left renal vein (LRV). The anteroposterior diameter in millimeters and peak flow in centimeters per second in each region were measured. Results. A total of 28 patients with the nutcracker syndrome were identified in the study group (30.10%), and 2 were identified in the control group (2.63%). The mean diameters of the hilar portion and AMP of the LRV were significantly different in varicocele-affected patients compared with the control group (P < .0001 for both). The mean peak velocities in the hilar portion and AMP were significantly different in patients with varicocele (P < .0001). Patients with varicocele and nutcracker syndrome did not have a significant difference in either the hilar or AMP diameter compared with patients with varicocele without nutcracker syndrome. They had a significant difference in both the hilar and AMP peak flow velocity (P = .0001 for both). Conclusions. Our findings indicate that nutcracker syndrome is a frequent finding in varicocele-affected patients and should be routinely excluded as a possible cause of varicocele. In addition, intrinsic anatomic differences in the AMP and hilar portion of the LRV could be directly responsible for the onset of varicocele.

Left Renal Atrophy in Sickle Cell Diseases

“…An unusual manifestation of the nutcracker syndrome includes varicocele formation and varicose veins in the lower limbs (26). Another study has shown that the nutcracker syndrome is a frequent finding in varicocele patients (27), so it should be routinely searched in cases with left varicocele.…”

Nutcracker Syndrome Accompanying Pelvic Congestion Syndrome: Color Doppler Sonography and Multislice CT Findings: A Case Report

“…However, the diagnostic procedure considered that the reference standard for establishing the diagnosis of NCS is invasive selective left renal phlebography with measurement of the pressure gradient between the LRV and inferior vena cava (1, 6, 10). Retrograde phlebography and cine video-angiography with reno-caval pressure gradient determination is accepted as the gold standard in establishing the final diagnosis of NCS.…”

“…In the differential diagnosis of NCS and accompanying pelvic congestion syndrome, pathologies that cause pain and hematuria such as lithiasis, congenital vascular malformations, tumors, infections, parenchymal or urinary tract abnormalities, painful pelvic syndromes and organ or neighboring structure alterations must be excluded (6, 10). Supportive treatment is adequate if the symptoms are mild in NCS.…”

Metachronous metastasis to the spermatic cord from renal cell carcinoma presenting as a high scrotal mass: a case report

“…Almost all cases of RCC metastasis to the spermatic cord have occurred ipsilaterally on the left side, except for 2 case reports of contralateral RCC metastasis [ 8 , 9 ] . The anatomic differences between the left and the right renal vein drainage systems likely explain this [ 10 ] . Spermatic cord involvement by RCC can be either asynchronous or metachronous [ 11 ] .…”