Recurrent varicocele: causes and treatment

Introduction. Among the different options for varicocele surgery, microsurgical varicocelectomy demonstrates the best results, but a relapse is subsequently detected in 1–3% of cases. It was previously believed that the cause of recurrence lies in the presence of various sources of venous outflow from the testicle, but recent studies show that the collaterals of the gonadal vein are the main reason of recurrence.

Purpose of the study: to determine the leading cause of recurrence, to evaluate the effectiveness and optimal surgical tactics depending on the method of primary treatment.

Materials and methods. Surgical treatment of 74 patients with recurrent varicocele was performed for 5 years. Depending on the method of primary treatment, two groups were formed: 1 – relapse after non-microsurgical varicocelectomy (n=37), 2 – relapse after microsurgical varicocelectomy (n=37). Patients of the first group underwent microsurgical subinguinal varicocelectomy. Patients of the second group underwent endovascular surgery or redo microsurgical varicocelectomy.

Results. 1 group. Scrotal pain syndrome was relieved in 90% of cases (n=18). Among patients with complaints of infertility (n=8), natural pregnancy occurred in 57,1% (n=4). An improvement in sperm parameters was found among 18 (75%) patients with pathospermia. The US-recurrence rate was 5.4% (n=2), clinical manifestation revealed in 1 case (2,7%). Intraoperatively, preserved branches of the gonadal vein were detected in all cases.

2 group. Scrotal pain syndrome was relieved in 95,8% of cases (n=23). Among patients with complaints of infertility (n=11), natural pregnancy occurred in 27,3% (n=3). An improvement in sperm parameters was found among 14 (73,7%) patients with pathospermia. The US recurrence rate after repeated microsurgery was 13% (n=3), after endovascular intervention – 38.5% (n=5). Clinical manifestation and indications for reoperation were identified in one patient who underwent endovascular embolization. Other cases of the second recurrence were subclinical, no indications for surgical treatment were identified. Renospermatic reflux was determined in all cases of phlebographic recurrence confirmation. No patients with ileospermatic reflux, as well as May-Turner syndrome, were identified. In 8 cases of phlebography, there was no technical possibility to perform embolization; in 3 patients, recurrence was not confirmed. Always the intact gonadal vein branches were identified mainly in the immediate vicinity of the testicular artery, in case of repeated microsurgical operation. There were no cases of testicular atrophy or postoperative hydrocele in any of the groups.

Conclusion. Missing collaterals from the gonadal vein basin play a key role in the genesis of varicocele recurrence. When choosing a surgical treatment option for patients with recurrent varicocele, it is necessary to take into account the method of primary treatment. The main factor to minimize the recurrence risk is the obligatory using of microsurgical techniques and a thorough revision of the spermatic cord components during the primary operation.