Microvascular Doppler–assisted Microsurgical Left Spermatic-inferior Epigastric Vein Anastomosis for Treating Nutcracker Syndrome–associated Varicocele

BACKGROUND: Nutcracker syndrome (NCS) is a rare cause of varicocele and its treatment is still controversial. OBJECTIVE: To summarize the surgical strategy and outcomes of microvascular Doppler (MVD)-assisted microsurgical left spermatic-inferior epigastric vein anastomosis (MLSIEVA) with microsurgical varicocelectomy (MV) at the same incision for treating NCS-associated varicocele. DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis of 13 cases of NCS-associated varicocele between July 2018 and January 2022 was performed. SURGICAL PROCEDURE: A small incision in the body projection corresponding to the deep inguinal ring was chosen as the surgical incision. All patients underwent MLSIEVA and MV with the assistance of MVD. MEASUREMENTS: Patients received real-time Doppler ultrasound (DUS) before and after surgery; urine red blood cells and protein were tested, with a follow-up time of 12–53 mo. RESULTS AND LIMITATIONS: All patients had no intraoperative complications, and all postoperative symptoms of hematuria or proteinuria, scrotal swelling, and low back pain disappeared. Comparing pre- and postoperative DUS, two patients did not show any improvement in their postoperative measurements. However, in the remaining patients, the internal diameter of the renal vein at the hilum portion and at the aortomesenteric angle portion, as well as their ratio, improved significantly compared with preoperative measurements. No complications or recurrence of varicocele was observed during postoperative follow-up. CONCLUSIONS: Our study suggests that MVD-assisted MLSIEVA with MV is feasible with no major short-term complication and effective regarding the treatment of varicocele and NCS. PATIENT SUMMARY: We investigated microsurgery mediated by microultrasound for the treatment of varicocele associated with nutcracker syndrome. We found this procedure to be safe and effective with good long-term results.