Mechanisms of recurrent varicocele after balloon occlusion or surgical ligation of the internal spermatic vein.

Clinical recurrence of varicocele developed in eight of 70 patients (11%) who underwent balloon occlusion of the internal spermatic vein (ISV) at the level of the third or fourth lumbar vertebra. Five patients also underwent venography for postoperative recurrence of varicocele. Recurrence was due to either collateral veins that bypassed the balloon occlusion or surgical ligation. The ISV was reconstituted in the pelvis of five of the eight patients following balloon occlusion, and in all patients following surgical ligation. Two patients who had recurrence after balloon embolization had clinically undetected right sided varicoceles. The technique of balloon occlusion of the spermatic vein should be modified: in most cases the balloon should be placed in the inguinal segment of the vein below the point where the collateral veins enter the ISV. The best site for balloon detachment can be determined by test occlusion and ISV venography to observe for blood flow within the collateral veins beyond the balloon. Venography is performed prior to detachment, and if the anatomy suggests a likely recurrence, the position of the balloon is shifted, which offers an advantage over other methods of treatment.