Back to Fall Congress

Background: Disagreement exists regarding the role of the deferential venous system (DS) in the pathogenesis of varicocele as to whether it is a primary contributor (iliac-deferential reflux) or secondarily involved (venous overflow from the plexus pampiniformis). The role of iliac-deferential reflux in the pathogenesis of varicocele, its clinical evidence, as well as its possible management remain controversial too. At our institution varicocele has been traditionally corrected with transperitoneal laparoscopic occlusion of the only internal spermatic vessels, according to the laparoscopic Palomo technique, even in those cases with evident dilatation of the DS, noted during laparoscopy. The aim of this study was to evaluate the significance of DS dilatation detected during laparoscopy, in order to understand whether it is due to iliac-deferential reflux, potentially causing varicocele persistence, or to venous shunt from the plexus pampiniformis, likely to resolve spontaneously after occlusion of the internal spermatic vessels only.
Methods: Between 2007 and 2012, 102 consecutive patients with a varicocele were treated with the transperitoneal laparoscopic Palomo technique. All were studied preoperatively with clinical examination and doppler ultrasound (DU) study of the internal spermatic system. Indications for correction were Amelar-Dubin grade 3 varicocele, or grade 2 varicocele associated with testicular hypotrophy or persistent symptoms. During laparoscopy, in 26/102 patients a DS dilatation (1 or more veins) was noted and not occluded. These patients were evaluated at a mean follow up of 2.5 years (range 6 months - 5.5 years), with clinical and DU examination. Persistence or resolution of varicocele, testicular volume, deferential vein dilatation, and both spermatic and iliac-deferential reflux were evaluated.
Results: Twenty-five/26 (96%) patients had resolution of varicocele both at clinical and DU examination, with no residual deferential vein dilatation and no testicular hypotrophy. In 1 of these 25 a secondary hydrocele developed. One/26 patients had varicocele persistence both on clinical and DU examination, with DU evidence of isolated iliac-deferential reflux (Coolsaet type II varicocele).
Conclusions: Most DS dilatations detected during laparoscopic Palomo spontaneously resolve after occlusion of the internal spermatic vessels only. Therefore DS dilatation in patients with varicocele would most likely be due to venous overflow from the plexus pampiniformis. The role of iliac-deferential reflux in the pathogenesis of varicocele should be considered negligible. Taking into account the single case of persistence of type II varicocele, pre-operative DU study of both spermatic and DS should be introduced in the diagnostic evaluation of patients with suspected varicocele. Indeed, only a combined diagnostic approach with both preoperative DU study of the DS and transperitoneal laparoscopy could help in better understand the actual role of deferential reflux in varicocele.