The Nutcracker Syndrome: an Underdiagnosed Cause for High Grade Varicocele

Background: the nutcracker syndrome represents a clinicalcondition caused by compression of the left renal vein (lrv)between the superior mesenteric artery (sma) and the aorta. oneof its manifestations is left-sided varicocele. the aim of this studyis to determine the prevalence of nutcracker syndrome in patientswith primary and recurrent high grade left-sided varicocele.methods: fifty patients with primary and recurrent high gradeleft-sided varicocele were enrolled in this study. color dopplerultra-sonography (us) of renal vessels was done and diameterof lrv and peak systolic velocity (psv) were measuredin renal hilum and in site of compression of lrv betweensma and the aorta and then magnetic resonance angiography(mra) of renal vessels was done.results: thirty six patients (72%) had primary high gradevaricocele and 14 patients (28%) had recurrent high gradevaricocele. twelve patients (33%) with primary high gradevaricocele and seven patients (50%) with recurrent varicocelehad evidences of ncs in color doppler us and mra. thedifferences of lrv diameter in ncs group and in patientswithout ncs were statistically significant (p<0.001).the differences of psv in the lrv at the hilar portion inthe ncs group and in the patients without ncs were not statisticallysignificant.the differences of psv in the lrv at the aortomesentericportion in the ncs group and in the patients without ncswere statistically significant (p< 0.001).in all patients with ncs, mra showed dilatation and compressionof lrv at site of passage between aorta and sma.conclusion: ncs should be suspected in patients with highgrade primary and recurrent varicocele.