Challenging the role of cremasteric reflux in the pathogenesis of varicocele using a new venographic approach

Purpose: Cremasteric or extrafunicular reflux is considered by many a major cause of primary and recurrent varicocele. Therefore, surgical techniques that allow ligation of the intrafurmicular and extrafunicular veins are oft en performed. We evaluated the incidence of cremasteric reflux in patients with primary or recurrent varicocele with a new and simple venographic tech nique. Materials and Methods: A series of 73 patients with primary (54) or recurre nt (19) varicocele underwent venography of the left iliac vein while standi ng and performing Valsalva's maneuver to reveal the possible presence of re flux in cremasteric or other extrafunicular veins. In patients with recurre nt varicocele antegrade transcrotal spermatic venography was also performed immediately before surgery. Results: None of the patients presented with reflux of contrast material fr om the left iliac vein to the left pampiniform plexus via the extrafunicula r veins. Cremasteric veins, in particular, were always continent at the con fluence with the epigastric vein even when grossly dilated at spermatic ant egrade venography in recurrent cases. Conclusions: Cremasteric reflux seems to have a limited role if any in the pathogenesis of primary and even recurrent varicocele. Dilatation of the ex trafunicular veins is not necessarily a sign of reflux but may represent on ly a consequence of venous overflow due to insufficiency of the internal sp ermatic vein and possibly partial obstruction of the left iliac vein. The r ationale of surgical treatments aimed at ligation of the extrafunicular vei ns should be questioned.