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Recurrence after microsurgical repair of the adolescent varicocele: the fate of nutcracker phenomenon.
Marcos G. Machado, MD, Bruno Cezarino, MD, Roberto Iglesias, MD, Francisco T. Denés, MD.
.University of São Paulo, São Paulo, Brazil.

BACKGROUND: Varicocele is a vascular lesion commonly associated with imparied testicular growth in adolescent population and infertility in adult population. Its etiology is only partly understood. Subinguinal microsurgical repair in adults has been performed with good results and low recurrence rate. This experience started to be replicated in adolescent population. Nutcracker phenomenon refers to compression of the left renal vein, most commonly between the aorta and the superior mesenteric artery and is reported to be a major cause of hematuria and/or left isolated varicocele. The objective of this report is to correlate microsurgical repair failure of the adolescent varicocele and occurrence of nutcracker phenomenon.
METHODS: From year 2014 to 2017 we retrospectively analyzed seven patients who presented early varicocele recurrence after microsurgical repair. All of them had left isolated grade III varicocele with testicular asymmetry higher than 15%. All patients underwent microsurgical left varicocelectomy in a high volume institution with good previous experience in adult surgery. Considering recurrence is very rare using microsurgical technique in adult population, a closer look on this group of young patients was taken.
RESULTS: Searching for similarities among this group, interestingly we observed that all of patients were tall and thin, with a slender body shape (marfanoid habitus). During the investigation of secondary causes of varicocele, surprisingly, all the seven patients presented with Nutcracker Phenomenon by CT Scan or Doppler ultrasound. After this finding, redo repair was proposed using a high gonadal vein ligation right below the renal vein using preferably laparoscopic approach. Success rate after second procedure was 100%.
CONCLUSIONS: Despite the short number of patients and low term follow up, we conclude that this particular experience raised three important questions to be addressed. First: should we investigate nutcracker phenomenon in patients with high-grade left isolated varicocele? Second: does nutcracker phenomenon play a major hole on adolescent varicocele? Third: Are pediatric patients better served by high vein ligation techniques than microsurgical approach?


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