Surgical Treatment Of Varicocele Associated With Nutcracker Syndrome

ObjectiveTo conclude and evaluate the effectiveness and safety of various surgical treatments for nutcracker syndrome（NCS）related varicocele（VC）.MethodsThis research consists of two parts:Part 1:Retrospectively analyzed the clinical data of 34 patients with moderate to severe left varicocele who were admitted to our hospital from February 2016 to November2020.Part 2:Search the literature on the surgical treatment of patients with NCS combined with VC in the databases of Pub Med,Medline,Cochrane,CNKI,Wan Fang,and Wei Pu.Analyze the data in accordance with the principles of systematic review and meta analysis（PRISMA）.ResultsPart 1:Low-position ligations of LSV under microscope were performed in all 34 cases successfully.Among these patients,17 of 19with testicular discomfort and pain were significantly relieved after the operation.There were no complications,such as hydrocele and scrotal edema,with the surgery.After the follow-up of 3-15 months,there were no recurrences.In the patients,LSVD,sperm density,and forward motility sperm count were significantly improved after 3 months（P<0.05）.There were no statistical significant differences in PV₁,PV₂,PV₁/PV₂,LRVD₁,LRVD₂and LRVD₂/LRVD₁between pre-surgery and post-surgery（P>0.05）.Part 2:A total of 158 relevant documents were retrieved.After reading abstracts and comprehensive screening,12studies were finally included for systematic analysis.A total of 274patients underwent microscopic spermatic vein ligation+spermatic cord-inferior abdominal venous bypass,78 patients underwent microscopic spermatic vein low ligation,and 52 patients underwent high spermatic vein ligation.Literature analysis shows that the semen density and sperm motility of patients after the three methods have been significantly improved.Patients who underwent microscopic spermatic vein ligation+spermatic cord-inferior abdominal venous bypass surgery had significantly reduced LRV pressure and alleviated symptoms such as hematuria and low back pain;patients who underwent microscopic spermatic vein ligation had no obvious postoperative NCS and clinical symptoms Changes,but the hematuria improved;after high ligation of the spermatic vein,some patients had worse hematuria than before.ConclusionNCS only shows that the microscopic spermatic vein ligation is safe and effective in patients with moderate to severe LSV varicocele.It can significantly improve the relevant clinical symptoms and improve the quality of semen after the operation,without causing the nutcracker phenomenon to aggravate and other related clinical manifestations of NCS.Microscopic spermatic vein ligation+spermatic cord-inferior abdominal venous bypass surgery has a good effect,but the operation is complicated and difficult,which limits its development.High ligation of the spermatic vein may lead to aggravation of NCS and is not recommended.（Abbreviation:NCS,nutcracker syndrome;LSVD,the left spermatic vein diameter;AO,abdominal aorta;SMA,superior mesenteric artery;LRV,left renal vein;PV₁,flow rate of LRV at the angle between AO and SMA;PV₂,flow rate of LRV near renal hilum;LRVD₁,inner diameter of LRV at the angle between AO and SMA;LRVD₂,inner diameter of LRV near the renal hilum）...