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 intrafunicular and extrafunicular veins are often performed. We evaluated the incidence of cremasteric reflux in patients with primary or recurrent varicocele with a new and simple venographic technique. Materials and Methods: A series of 73 patients with primary (54) or recurrent (19) varicocele underwent venography of the left iliac vein while standing and performing Valsalva's maneuver to reveal the possible presence of reflux in cremasteric or other extrafunicular veins. In patients with recurrent varicocele antegrade transcrotal spermatic venography was also performed immediately before surgery. Results: None of the patients presented with reflux of contrast material from the left iliac vein to the left pampiniform plexus via the extrafunicular veins. Cremasteric veins, in particular, were always continent at the confluence with the epigastric vein even when grossly dilated at spermatic antegrade 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 extrafunicular veins is not necessarily a sign of reflux but may represent only a consequence of venous overflow due to insufficiency of the internal spermatic vein and possibly partial obstruction of the left iliac vein. The rationale of surgical treatments aimed at ligation of the extrafunicular veins should be questioned.