FERTIUTY AND 8TERIUTY
6, Decemher 1978
Copyright c 1978 The American Fertility Society
RIGHT-SIDED VARICOCELE ASSOCIATED WITH SITUS INVERSUS
JOEL SAYFAN, M.D.*
YEHUDA G. ADAM, M.D., F.A.C.S.
Department of Surgery "A," Asaf-Harofe Hospital, Tel Aviv University
Medical School, Zerifin, Israel
Valvular incompetence ofthe left internal sper-
matic vein resulting in dilatation of the pampini-
form plexus is the most common cause of varico-
cele.1 Because ofthe anatomical asymmetry of
the course of the internal spermatic veins-the left
drains to the left renal vein and the right to the
inferior vena cava-the left testicular venous sys-
tem is more vulnerable to develop reflux due to
valvular incompetence. When bilateral or right-
sided varicoceles are infrequently present, it is
essential to consider and to rule out a ret-
roperitoneal process as the underlying etiology.
However, another rare etiologic factor should be
considered in patients with right-sided varico-
celes-namely a congenital transposition of the
testicular venous drainage, as occurs in complete
situs inversus. Dubin and Amelar2 reported such a
patient in a review of a series of 504 patients with
varicocele infertility; however, the underlying
vascular anomaly was not documented. Since
January 1973, to date over 350 patients were oper-
ated upon in this department for varicocele. Of
these, a young male was found to have a right-
sided varicocele accompanied by complete situs
inversus. The following case report is based on
documentation of this anomaly by operative inter-
nal spermatic vein phlebography.
CASE REPORT
A 19-year-old male was admitted to the Asaf-
Harofe Hospital with increasing pain, swelling,
and heaviness in the right scrotum of several
months' duration. The past history was entirely
Received July 27, 1978; accepted August 17, 1978.
*To whom reprint requests should be addressed.
716
Vol. 30, No.
Printed in U.S.A.
unremarkable. The physical examination re-
vealed an apical beat in the fourth intercostal
space in the right midclavicular line. Percussion
and palpation of the abdomen disclosed a normal-
sized liver in the left upper quadrant.
There was a well-developed varicocele in the
right scrotum. The remainder of the physical
examination was unremarkable. Laboratory find-
ings were within normal limits. A chest x-ray
revealed a dextrocardia and an electrocardiogram
was confirmatory. An intravenous pyelogram was
normal. To verify and to document the venous
anomaly, intraoperative right internal spermatic
phlebography was performed before high ligation
of this vein. Contrast material (20 ml) was injected
into the exposed and cannulated right internal
spermatic vein and the resulting venography
showed the "mirror image" of normal anatomical
topography; the right internal spermatic vein
joined the right renal vein with an incompetent
valve at their confluence (Fig. 1). The vein was
ligated above the internal inguinal ring level. The
postoperative course was uneventful. The patient
was discharged on the 3rd postoperative day.
DISCUSSION
The estimated incidence of varicocele in the
young male population is about 10%.3 In the sub-
fertile male the incidence increases to between
20% and 39% in reported series. 3 • 4 The general
consensus is that the overwhelming majority of
varicoceles are on the left, and only in 2% are the
varicoceles bilateral or on the right side. It is a
rightly accepted clinical practice to perform an
intravenous pyelogram on patients with right or
bilateral varicoceles to exclude internal spermatic
Vol. 30, No.6 COMMUNICATIONS-IN-BRIEF 717

FIG. 1. Operative right internal spermatic phlebography, demonstrating its

junction with the right renal vein in a patient with complete situs inversus and a
right-sided varicocele.

vein compression due to a space-occupying lesion
in the retroperitoneum. Nevertheless, this exami-
nation will not reveal a vascular anomaly which
could be the cause of valvular incompetence at the
internal spermatic vein-renal vein confluence.
In the case presented the situs inversus raised
the possibility of such a valvular insufficiency on
the right side. Confirmation was achieved by in-
traoperative internal spermatic phlebography. It
seems that in every case of right-sided varicocele,
one has to consider a vascular anomaly, with or
without situs inversus, as the underlying etiology.
Operative phlebography is the simplest and safest
solution to this problem.
SUMMARY
In the overwhelming majority of cases, varico-
cele appears in the left scrotum, the reason being
the anatomical dissimilarity of the two sides. In
patients with right-sided or bilateral varicocele,
further investigation to rule out a retroperitoneal
pathology, especially neoplastic, is indicated. On
rare occasions, however, a vascular anomaly as the
underlying pathology must be considered.
A patient is presented with a complete situs
inversus accompanied by a right-sided varicocele.
Intraoperative right internal spermatic phlebo-
graphy revealed that this vein drained into the
right renal vein, and valvular incompetence at
718 COMMUNICATIONS-IN-BRIEF
their confluence was the etiology of the disease.
Intraoperative internal spermatic phlebo-
graphy in patients with right-sided or bilateral
varicoceles is recommended as the simplest and
safest means to demonstrate the etiology of this
disease.
December 1978
REFERENCES
1. Kohler FP: On the etiology of varicocele. J Urol 97:741,
1967
2. Dubin L, Amelar RD: Varicocelectomy as therapy in male
infertility: a study of 504 cases. J Urol 113:640, 1975
3. Hendry WF, Sommerville IF, Hall RR, Rugh RCS: Investi-
gation and treatment of the subfertile male. Br J Urol
45:684, 1973
4. Dubin L, Amelar RD: Etiologic factors in 1294 consecutive
cases of male infertility. Fertil Steril 22:469, 1971