The role of veno-venous shunting in the treatment of recurrent varicocele caused by renal venous hypertension, brief review and clinical cases

Recurrent varicocele is one of the most common complications associated with the treatment of varicocele. According to the analysis of domestic and foreign literature, the recurrence rate can reach 29% and above, which depends on the type of surgical intervention. In 50% of cases, the reason of varicocele development is hypertension in upper segments of the venous network. This hypertension is caused by various types of arterio-venous conflicts and developmental abnormalities of the urogenital system. Therefore, undiagnosed and uncorrected hemodynamic disorders in the renal venous basin are one of the reasons for recurrent varicocele after performing surgical treatment. Such hemodynamic disorders are a significant predisposing factor for the development of vascular nephropathy and renal arterial hypertension. In this context, the most preferable approach is performing shunting operations that preserve bypass of renal-caval blood flow. Two cases of recurrent varicocele are presented in this article, that show the effectiveness of creating veno-venous anastomoses. Each patient had recurrent left-sided varicocele and Nutcracker syndrome. Patient O. had recurrent varicocele after two laparoscopic varicocelectomies, while patient P. had recurrent varicocele after subinguinal microsurgical varicocelectomy. Both cases had laboratory signs of developing nephropathy in addition to venous hypertension (elevated levels of cystatin C in blood plasma and albumin in urine). Proximal testicular-inferior-epigastric venous anastomosis was performed on patient O, while proximal venous anastomosis between the internal spermatic vein and the deep iliac circumflex vein was performed on patient P. Follow-up examination showed positive results of surgical treatment. According to post-surgery ultrasound, patients did not have dilated veins in scrotum and pathological reflux. They had normalization of venous pressure in the left renal vein and resolution of nephropathy symptoms. A year after the surgery, patient O’s level of urine albumin decreased from 40.0 mg/L to 5.0 mg/L, and the level of cystatin C in his blood plasma decreased from 1.55 mg/L to 0.89 mg/L. Three months after the surgery, patient P’s level of urine albumin decreased from 133.3 mg/L to 20.0 mg/L, and the level of cystatin C in his blood plasma decreased from 1.37 mg/L to 0.74 mg/L. Thus, the formation of a renocaval venous shunt proves to be pathogenetically substantiated for patients with renospermatic varicocele and left kidney venous hypertension. The most optimal methods for performing a bypass venous shunt are the microsurgical formation of a testicular-inferior-epigastric venous anastomosis or anastomosis between the internal spermatic vein and the deep iliac circumflex vein. These surgical interventions help to reduce elevated pressure in the left renal venous basin and prevent the progression of hypertensive nephropathy, while microsurgical ligation of venous spermatic trunks helps to prevent recurrence of varicocele.