Galore International Journal of Health Sciences and Research Vol.5; Issue: 2; April-June 2020 Website: www.gijhsr.com Review Article P-ISSN: 2456-9321

Variations in Testicular : An Anatomico-Clinical Review

Gupta Nidhi1, Dwivedi Amod2, Pandey Suniti3

1Assistant Professor, Department of Anatomy, GSVM Medical College Kanpur 2Consultant Urologist, Dr. Amod Uro-Gynae Centre, Kanpur 3Professor & Department Head, Department of Anatomy, GSVM Medical College Kanpur

Corresponding Author: Gupta Nidhi

ABSTRACT and redistributes itself into thin walled vascular network over the spermatic The pattern of formation of individual testicular cord called as . This and their disposition within plexus entwines the testicular (TA) abdominopelvic cavity exhibit spectrum of while ascending along the ventral surface of variations on either side of body. The the ductus deferens in the . [1] anatomical aspects of its number, formation, course, valvular configuration, termination, Pampiniform blends at the ontogeny and clinical connotations have been level of internal inguinal ring to constitute studied in abundance. As the majority of the venae commitantes of TA. Immediately depictions discussed in past comprised of either after leaving the internal inguinal ring, two one or arbitrary combination of few such to three slender trunks of venae features, the evaluation of an aberrant commitantes entangling encountered variation based upon comparison subsequently combines to form a single vein vis-à-vis the available literature becomes termed as testicular veins (TVs), at the level cumbersome and inconclusive. Therefore, the of fourth lumbar vertebra on either side. [2] consolidation of all information hitherto TVs contains inconsistent regarding a particular feature would serve as a unidirectional valves in its course. [3]TVs platform to compare and assess the basis of such variations. conclude on different veins on either side. The current endeavor compiles and highlights After formation, the left the relevant facts of individual morphological (LTV) ascends perpendicularly to drain into parameter of testicular veins. The parameters left (LRV). The LRV, after considered are Formation of testicular veins, collecting left testicular tributary and left numbers, course and termination, valvular suprarenal vein (LSRV), crosses the design collateral communications and abdominal (AA) superficially to drain Ontogenic revelation of errors, which can into inferior vena cava (IVC).However, the correlate with anomaly in testicular veins. right testicular vein (RTV) on the other These refinements in approach to variant hand discharges unswervingly in the (IVC) anatomical architecture strengthen the outlook while maintaining an ascending oblique for clinical practices and academic opinions: thereby, supplementing precise management of course. As the TVs may demonstrate a related venous disorders. spectrum of dissimilarity vis-à-vis contralateral side in same individual and Keywords: Pampiniform plexus: Testicular vein: even same side in two different individuals, Variation: Varicocoele: Development. an optimum analysis of deviation in structural architecture and its distribution in BACKGROUND population is necessary. Therefore, probable The venous stream of human testis ontogenic revelation and review of literature emerges from its dorsal aspect, drains is endeavored, to consolidate the scattered

Galore International Journal of Health Sciences and Research (www.gijhsr.com) 56 Vol.5; Issue: 2; April-June 2020 Gupta Nidhi et. al. Variations in testicular veins: an anatomico-clinical review information about variations obtained in Variations in the formation of testicular autopsy, radiographic and operative study. veins: Three venous trails were proposed to The current review, evaluate the explain the drainage of testis and associated formation of TVs, their disposition in the scrotal structures. [8] The first trail consists abdominopelvic cavity, coexistence of of pampiniform plexus, which drains the accessory or supernumerary vessels leading venous blood from the marginal vein of the to numerical discrepancy, their pattern of epididymis in addition to ‘submediastinal drainage and clinico-embryological coronary plexus’ (formed by venous deductions. The augmented comprehension channels draining the parenchyma of of variant patterns in TVs is imperative for testis),[9] through ‘centripetal and centrifugal success of invasive intervention practiced venous counter current pathways. [8] Second by the surgeons, radiologist and urologist in pathway consists of veins draining the vas general; consequently, the thoughtfulness deferens and the third track comprises of about the array of disparity in cremasteric vein, which is interposed retroperitoneal urogenital veins is valuable between external and internal spermatic in the background of unorganized literature fascia.[8] Thin walled pampiniform venous encompassing all relevant attributes. plexus (syn. spermatic venous plexus) is fabricated by the venous networks draining DISCUSSION testis at the level of and The TVs express noteworthy convey venous blood in intrascrotal and anatomical inconsistency in their formation, intrainguinal preceding tracts of TVs. In disposition, morphological characteristics, another portrayal, the testicular venous anastomosis, number, valvular configuration networks in the spermatic cord were and drainage pattern. [4-7]Traditionally, their outlined in ‘two major groups’ coexisting variations were classified considering the side by side. [10] However, further number of veins and effluence pattern into exploration exposed that while profuse four categories. [4] Type 1.Totally duplicated veno-venous anastomosis takes place within LTV: Type 2.Partially duplicated LTV: one group, the anastomoses linking two Type 3. Bilaterally duplicated TVs with groups were observed to be quite scarce. [11] beaded wall: and Type 4. The drainage of After meticulous investigations, vascular LTV and RTV into IVC and RRV arrangement of pampiniform plexus were respectively. The categorical details of each classified into four broad groups. [11] particular entity like formation, number, ‘Group-I’ revealed firm plexus entwining itinerary, valvular composition and endings testicular artery through veno-venous were sparingly audited in the literary works. anastomoses: ‘Group-II’ was formed by Majority of earlier investigations have veno-venous anastomosis among each other described their observations based upon one located in fatty tissue with no distinct or more random combination of specific relation with the testicular artery: ‘Group- attributes, consequently it becomes at times III’ resulted from anastomoses between very intricate and cumbersome to analyze ‘Group-I’ and ‘Group-II’: and ‘Group-IV’ one study vis-à-vis other. Since, the decisive emphasized distinct arteriovenous statistical frequencies of such variations are anastomosis with the testicular artery. Based discrete, unsorted and not weighed against upon hemodynamics, three mechanisms for amongst different studies; a fair compilation venous drainage of testis were asserted of such findings is called for, taking into namely: ‘direct testicular outflow’ where the account individual parameters under which blood directly channelized into pampiniform the discrepancies of TVs may be plexus: ‘indirect testicular outflow’ in which categorized. Therefore, the differences in the blood reaches pampiniform plexus with particular characteristic are evaluated in involvement of the communicating veins: different relevant subheadings. and ‘mixed outflow’ where outflow into vas

Galore International Journal of Health Sciences and Research (www.gijhsr.com) 57 Vol.5; Issue: 2; April-June 2020 Gupta Nidhi et. al. Variations in testicular veins: an anatomico-clinical review deferens exist side by side with ‘indirect Retrograde spermatic venography has testicular outflow’.[12] Moreover, the revealed the accurate structure of venous scrupulous dissection suggested that, the networks in pampiniform plexus, which is initial column of veins of the epididymis localized as condensed dye stained area in and the caudal veins of the epididymis radiographic images. However, the staining forms the ‘testicular venous arch’.[12]This can range from sparse condensation to its ‘arch’ anastomoses with cremasteric venules frank absence. On the odd occasion when at that specific site, where the tail of plexus is absent, testis was found to be epididymis transits into and rudimentary within the inguinal canal. [16] was named as ‘testicular venous plexus’. [12] Variation in the number of testicular When traced further, fine venous veins: TVs usually exist solitarily on either intermediaries, derived from the side but can be double triple, quadruple on organization of pampiniform plexus within either side in different individual or the spermatic cord, pierced the cord to exit concomitantly in the same individual. [3-5]It on its dorsal aspect and emerged as slender can be nonexistent in a small number of vessels running within the inguinal canal. In cases, where it is associated with a little while, these channels coalesce again characteristic agenesis of testis. [16] The to appear as venae commitantes of testicular remarkable inconsistencies in the number of artery, at the level of internal inguinal ring. TVs with particular analysis of its [13] Physiologically, varicocoele distribution on either side have been development is precluded by the frequently recorded (Table 1). [4,7,17-19]. coordinated activity of muscular layer in Variations in the number of testicular veins pampiniform venous plexus, which propel can be associated with partial or complete the venous blood against gravity. [14] duplication of certain venous channels Classically two thin veins leaving internal meant for draining the developing testis or inguinal ring has been described as venae owing to failure of regression of those commitantes of the testicular artery, [13] channels that normally would have nevertheless it has been found that their dissolved.[20-21] mean numbers may range from 5.6+-2.2.[15]

Table 1: Variations in the number of testicular veins Researcher No. of veins on the left side No. of veins on the right side Favorito et al (17) (Total=122 veins in 100 cadaver) (Total=115 veins in (adult cadaveric study) 1 vein in 82 cases 100 cadaver) 2 veins in 15 cases 1 vein in 85 cases 3 veins in 02 cases 2 vein in 15 cases 4 veins in 01 case. Favorito et al (17) (Total=32 veins in 24 fetal cadavers) (Total=24 veins in 24 (fetal cadaveric study) 1 veins in 16 cases fetal cadavers) 2 veins in 08 case 1 vein in 24 fetal cadavers Asala et al (4) Variations were seen in 21.3% cases with preponderance on the left side. Also in 18.8% of these variant TVs, there was evidence of partial or complete duplication with or without beading Shafik et al (18) Duplication of right TV in 4% cases. Yang et al (7) Triplication of left TV in 1 case. Lechter A et al (19) Triplication of left TV in 1 % case.

Variations in the course and termination spermatic cord. The tracing becomes much patterns of TVs. Although the testicular easier after these tributaries merges and exit venous course is assessed at four different internal inguinal ring as definitive venae levels; namely scrotal, inguinal, pelvic and commitantes, which later forms TVs. The lumbar, [3] yet, the precise macroscopic LTV passes dorsal to lower descending localization remains obscure until well- colon and inferior margin of duodenum. [13] formed tributaries emanate out of the Ventrally, it is crossed by left colic vessels.

Galore International Journal of Health Sciences and Research (www.gijhsr.com) 58 Vol.5; Issue: 2; April-June 2020 Gupta Nidhi et. al. Variations in testicular veins: an anatomico-clinical review

[13] The RTV is positioned behind the cast study, the course, tributaries and terminal ileum and horizontal part of the communication, having enormous duodenum. Ventrally, the root of mesentery, contribution in physiopathogenesis of ileocolic and right colic vessels spans it. The various vascular conditions had been differential termination of LTV and RTV at ascertained.[3,17] The commonly encountered different sites generate altered unusual fate of TVs as regards to their hemodynamics, which is accused for unfamiliar drainage site had been greatly induction of varicocoele more frequently in worked upon(Table 2 & 3). [2, 4, 6, 7, 17, 22-28] the left side.[21] With the help of corrosion

Table 2: Variations in the drainage pattern of left testicular veins Infrequent site of termination of left testicular vein Researchers Incidence Into the IVC Vesalius A(vide 22) ------Into the prerenal segment of IVC Asala et al(4) ------Into accessory renal vein Asala et al(4) ------Bensussan et al(2) ------Into left Tubbs et al(23) ------Into left eleventh posterior intercostals vein Rai et al(24) ------As a common trunk constituted by left testicular vein and left supra-renal veins draining into IVC Malcic-Gürbüz et al(25) ------

Table 3: Variations in the drainage pattern of right testicular veins Infrequent site of termination of right testicular vein Researchers Incidence Into right renal vein Favorito et al (17) In 1% case Asala S et al (4) In 1.25 % case Bensussan et al(2) In 5 % cases Favorito et al (adult cadaver study)(17) In less than 1 % case Favorito et al (fetal cadaver study)(17) In 4.2% cases Zumstein (vide 22) 1.8 % cases At the junction of renal vein and IVC Xue et al(6) ------Favorito et al adult cadaver study(17) 12.2% cases Asala et al(4) ------Into accessory renal vein Asala et al(4) ------Left margin of inferior vena cava Yang et al(7) ------The pre-renal segment of inferior vena cava Paraskevas et al (22) ------The lower portion of inferior vena cava Adachi (28) ------Right Subcostal vein Paraskevas et al (22) ------Tubbs et al(54) ------As a common trunk constituted by right renal vein and right Bensussan et al(2) ------testicular vein

Immense regards should be abnormal TV is encountered. Numerous acknowledged for initial attempt in variations in the termination of TVs suggest identifying bilateral incomplete duplication valuing and visualizing entity in wider of TVs, recorded as a landmark variant panorama. A cautious scrutiny should be observation by Andreas Vesalius, very considered as an integral step in early, in 1543, in his historical textbook of interventions concerning the TVs. As the human anatomy entitled “De humani TVs open into IVC or LRV on right and left corporis fabrica” .[22] In that case, the RTVs side respectively, an angle is formed at the terminated in RRV and IVC and LTVs site of termination named as ‘angle of terminated on the LRV and IVC.[22] The drainage’. The RTV drains at an acute angle variations in termination of TVs correlate into IVC, whereas the LTV drains with alteration in morphogenesis of perpendicularly into LRV thereby placing particular developmental vascular segments. the pampiniform plexus against high It is quite likely, that the same segment hydrostatic pressure generated by a lengthy might produce additional aberrations in column of blood. In particular, this conjunction with the anomalous TVs. For ‘orthogonal junction’ of LTV and LRV is that reason, plausible coexistent anomalous accused for the development of varicocoele veins must be sought after, once an mainly on the left side. [13] Statistically, it

Galore International Journal of Health Sciences and Research (www.gijhsr.com) 59 Vol.5; Issue: 2; April-June 2020 Gupta Nidhi et. al. Variations in testicular veins: an anatomico-clinical review was concluded that the outlet angle of LTVs Valvular variations of testicular vein: In were more than RTVs (p<0.01) in fetal general, it has been presumed that while the life.[29] Although, the angles of termination internal spermatic vein consist of valves the between TVs and collecting conduit have external spermatic vein are devoid of it. [16] been often neglected, it has been suggested Few scholars considered the valves are as a causal factor in few clinical conditions totally absent in testicular venous related to vascular affliction.[5] In another pathways.[5,30] In earlier studies, valves in detailed study comprising both adult and internal spermatic vein were found to be fetal specimen certain variations were present in 60% and 77% on left and right disclosed as regards TVs.[17] On the right side respectively,[16] where they manifested side, in adults, the angles of drainage were incompetency in as much as 36% of cases. found to be acute in 98% cases (RTV Later, it was proposed that more valves drained into IVC) and perpendicular in 1% prevailed on the left side (62%) compared to case (RTV drained into RRV). In fetus, the the right (48%).[30] Higher incidence of angle was acute in 95.8% (RTV drained into testicular valves was found in 77% and 84% IVC) and straight in 4.2% cases, [17] (RTV of left and right sided veins in another drained into RRV). On the left side, in study.[31] In a different study, RTV had adults, the angle of drainage was valves in 41.93% cases compared to the perpendicular in 95% cases (LTV drained 51.52% incidence of left counterpart.[32] into LRV) and variable in remaining 5% Thus, we see, while some studies infer cases. However, what was noteworthy is lower incidence of testicular valves on left that no matter how many number of LTVs side[11,32-33]; others advocated the higher might coexist, they all have a propensity to incidence on the left side.[19,34] The valves open into LRV unlike its counterpart. In were classified into two categories: ‘the fetus, the angle was straight in 93.75% and ostial valves’ found at the site where the acute in remaining 6.25%, [17] tributaries open into definitive TVs and ‘the On developmental backdrops, it can parietal valves’ lodged within the lumen of be hypothesized that, in cases where either the TVs.[35-36] Through Testicular valves the testicular or collecting veins, that is, comprises of either a single or a double IVC and LRV, divulge variations, the cusps: the later are more profound.[34-36] presenting angle may be different from what Following an additional study, where is observed in general. This probability may valvular incompetence was found to be as be presumed because if the draining channel much as 74%, role of pre-operative of testicular tributary or termination of TVs spermatic venography was emphasized, as it displays alteration either alone or in assess valvular mechanism and combination, and acquire atypical position, insufficiency besides outlining the details of the relocated angulations might present TVs.[20] Interestingly, competent valves accordingly. Hence, based upon preliminary have been found to interrupt retrograde survey, it is suggestible that specific spermatic venography, thus obscuring the patterns of angle of drainage can be utilized visualization of testis. Although much as a tool of radiographic interpretation in incriminated as an etiological factor, predicting unseen variations in testicular valvular incompetence did not seem to veins, since the alteration of angle points mandate the development of varicocoele. [37] towards anomalous termination pattern. Nonetheless, due to lack of adequate Presence of collaterals of testicular veins statistical confidence interval, the and their pattern: TVs send collaterals to standardization of radiological observation communicate with suprarenal, lumbar and of drainage angle in venography, as a accessory testicular vein if present. [22] predictor for existent testicular or renal Additional collaterals were found to venous anomaly remains hurdled. manifest anastomosis with ipsilateral

Galore International Journal of Health Sciences and Research (www.gijhsr.com) 60 Vol.5; Issue: 2; April-June 2020 Gupta Nidhi et. al. Variations in testicular veins: an anatomico-clinical review retroperitoneal veins of renal capsule, veins.[41-42] The subcardinal veins (SCVs), and colon in 21% and 31% cases on right composed by the internal veins of the and left side respectively.[22] In another Wolffian body on the lateral sides of median study, 74% exhibited collateral plane of fetus, initially adjuncts and later communication with renal capsular, ureteral takes over the drainage system of erstwhile and colonic veins on its lateral side, which posterior cardinal vein (PCV) drainage for suggest the higher incidence of the growing mesonephros.[41-42] These inconspicuous collateral communication.[30] SCVs, anastomoses with each other through Contralateral TVs also communicate with extensive vascular networks across midline each other through collateral networks of called as ‘median subcardinal venous ureteric veins, which traverse midline to network’ (MSCVP) ventral to aorta.[41-42] constitute ‘testicular plexus’.[18] The Expeditiously, the PCV starts disappearing incidence of testicular plexus at the level of in the middle region of the embryo and fifth lumbar vertebra is reported to be 55% subsequently the chief drainage of in literature.[18] In a unique case, the two mesonephros is substituted predominantly TVs on either side were connected through by (MSCVP). During 6-7th weeks, an several channels, where a few of them appended dorsal venous network named as drained into common .[38] supracardinal veins (SpCVs), develops to However, evidences of cross drain the posterior abdominal wall near the communication between right and left region, where PCV have regressed. The testicular venous system in pelvic retro SpCV elongates to restore the venous pubic and scrotal region were missing in stream between iliac anastomoses and microdissection.[5,30]Another venous conduit persistent PCV cranially. Along its length, named ‘nephrogenital vein’, have been this SpCV communicates with each other mentioned to join the variant lateral TVs and the SCVs through intersupracardinal after crossing outer renal border.[18] and subsupracardinal anastomoses Occasionally, this ‘nephrogenital vein’ may respectively. At the start, the venous communicate with colonic veins.[18] systems so formed are symmetrical on both Perirenal venous circle formed by such side and drains into corresponding sinus anastomosing veins have been found in 45% venosus.[41-42] The structural changes during and 37% cases in left and right side remodeling of right atrium results in shift of respectively.[39] hemodynamics; thereby, resulting in redesigning of draining veins. Because of Ontogeny of variant testicular veins: these changes, certain important events Genesis of unusual pattern in vasculature is occur in succession towards establishment attributed to complex array of sources of of a mature drainage system. vasculogenesis, sequential emergence of The events in normal development (Fig primordial vessels, establishment of 1A) and their apparent errors vascular motif during development owing to accountable for the frequently relevant anastomosis in addition to concurrent variations are conferred as under: regression and persistence of selective The right half of MSCVP receives: cranial vessels based upon functional predominance portion of SpCV, which involutes in in primitive architecture until formulation of majority of its length and eventually persist definite structural design.[40] The variants as a stump draining the right suprarenal observed in urogenital venous system gland: the mesonephric vein of the right comply with errors during vasculogenesis; side, which forms future RRV: and the hence, can be suitably rationalized. During caudal right SCV, which later Figures out as 4th week of development, the mesonephros RTV. This portion of MSCVP along with its grows decidedly and attains extensive tributaries, contributes for the formation of vascularization through posterior cardinal pararenal portion of IVC. Caudally it

Galore International Journal of Health Sciences and Research (www.gijhsr.com) 61 Vol.5; Issue: 2; April-June 2020 Gupta Nidhi et. al. Variations in testicular veins: an anatomico-clinical review connects with the right subsupracardiac The caudal segment of right SCV may anastomotic channel (future postrenal aberrantly drain into the mesonephric vein segment of IVC) and cranially with draining the right kidney. This conduit subcardinal –hepatocardiac anastomotic presents as anchorage of RTV on RRV (Fig channel (future pre- renal segment of IVC). 1B).

Figure Legends for FIG1A-1O. ARV = Accessory Renal Vein, D = Diaphragm, IVC= Inferior Vena Cava, LEIV = Left , LCIV = Left , LIIV = Left , LIPV = Left , LRV = Left Renal Vein, LSCV=Left Subcostal Vein, LSRV= Left Suprarenal Vein, LT = Left Testis, LTV = Left Testicular Vein, PVP = Pampiniform Venous Plexus, RCIV = Right Common Iliac Vein, REIV = Right External Iliac Vein, RIIV = Right Internal Iliac Vein, RIPV = Right Inferior Phrenic Vein, RRV= Right Renal Vein, RT = Right Testis, RTV= Right Testicular Vein, RSCV= Right Subcostal Vein.

Occasionally, the caudal segment of explain the drainage of RTV at or near the right SCV relocates its opening adjacent to junction of IVC with RRV (FIG 1C). the site, where the right mesonephric vein If the caudal right SCV migrates cranially to drain into right half of MSCVP. This can drain into subcardinal-hepatocardiac

Galore International Journal of Health Sciences and Research (www.gijhsr.com) 62 Vol.5; Issue: 2; April-June 2020 Gupta Nidhi et. al. Variations in testicular veins: an anatomico-clinical review anastomoses, the RTV consequently opens If there is duplication of left into prerenal portion of IVC (FIG 1D). subsupracardiac anastomotic channel, LTV Alternatively, caudal right SCV may end up may hook either its attachment on the main prematurely by connecting itself with right or the accessory segment, whereby subsupracardiac anastomotic channel. This justifying the drainage of LTV into corresponds to termination of rtv into accessory LRV (Fig 1K). postrenal segment of IVC (Fig 1E). Similarly, faulty relocation of caudal left The right half of MSCVP, after receiving SCV on subcardinal-hepatocardiac the end of caudal SCV, can fail in anastomoses can channelize the LTV into subsequent transformation needed for usual prerenal segment of IVC (Fig 1L). pattern. Impediment in integration of these During development, the cranial and caudal two veins, alter the eventual yield, in which left SCVs connected through the left half of it seems that the RRV have drained on the MSCVP maintains almost a continuous left aspect of inferior vena cava (Fig 1F). venous column. Occasionally, the terminal The same segment can rent into right SpCV. opening of caudal left subcardinal venous The azygous vein and its tributaries portion may instead, establish a connection represent developmental persistent cranial with cranial SCV, bypassing the part of SpCV, therein the RTV can open conventional pathway. This incident can into any of the above vessels (FIG 1G). validate the drainage of LTV into LSRV This shape up can coexist with unremitting (Fig 1N). additional mesonephric veins, which in Rarely, the caudal portion of left SCV may future might persist as accessory renal veins circumvent the left half of MSCVP and (FIG 1H). cranial part of SCV in succession, and Occasionally an aberrant channel develops directly open into cranial portion of left from right caudal SCV and empty into the SpCV. As the cranial parts of SpCV form mesonephric vein. If both the draining hemiazygous system and its tributaries. The channels endure, it appears as partial LTV can open into the tributaries namely; duplication of RTV with one tributary left lumbar left Subcostal and even lower ending normally and the other draining into posterior (Fig1G). RRV (FIG 1I). An additional aberrant channel can emanate Duplication of right cranial SCV can lead to from the normally disposed caudal left consecutive duplication of RTV (FIG 1J). SCV, and can establish connection with The left half of MSCVP shrinks in right half of MSCVP. If both normal and comparison to the right side. Owing to aberrant channel of drainage of left SCV shrinkage, it reassembles into a small trunk persists, this aberration presents as partial that represent forthcoming terminal medial duplication of LTV, where one tributary portion of LRV. This segment receives three drains into LRV as usual, while the other important vessels: the cranial part of left into IVC ( Fig 1O). SCV, which forms future left suprarenal vein: the caudal portion of left SCV, which Clinical implication of anatomical forms LTV: and the left subsupracardinal variations of testicular veins: The anastomotic channel (draining the left dilatation of pampiniform venous plexus mesonephros), which later forms the leads to clinically significant condition remaining lateral LRV. called varicocoele. The incidence of The caudal SCV may duplicate, triplicate or varicocoele is approximately 15% in healthy quadruplicate and all of them may possibly and 40% in infertile/sub fertile man: and is discretely open into the shrunken left half of known to exist in both children and MSCVP, giving picture of LRV receiving adult.[20.43] Varicocoele is crucial reason for several LTVs (Fig 1J and 1M). physiopathogenesis of male infertility owing to disorder in maintenance of scrotal

Galore International Journal of Health Sciences and Research (www.gijhsr.com) 63 Vol.5; Issue: 2; April-June 2020 Gupta Nidhi et. al. Variations in testicular veins: an anatomico-clinical review temperature viable for spermatogenesis.[33] fields and methods. Even though, the Varicocoele can lead to partial or complete treatment of varicocoele is widely testicular atrophy as the escalated pressure recommended and routinely done, a very in the capillary bed of testis can decrease large metanalysis have disproved the revival blood flow promoting gonadal ischemia.[44] of fertility in sub fertile cases. [51] The contrast reflux from the LRV into TVs, Spontaneous phlebothrombosis of down to pampiniform plexus have been pampiniform venous plexus can rarely found in majority of varicocoele. Another simulate incarcerated inguinal hernia, hence variant, Intratesticular varicocoele is defined must be included in differential diagnosis of as intratesticular dilated veins > 2mm in inguinal lump. Anatomical structural response to Valsalva maneuver; and variants can constrict and impair renal whether it causes, or does it reflect testicular venous drainage and had been seen as a atrophy needs evaluation.[45] The application phenomenon of flow reversal in renal and success of sclerotherapy, open or video- angiography.[52] Obstructive uropathy laparoscopic surgeries for treatment of progressing to hydronephrosis, attributable varicocoele requires the interpretation of to compression of right ureter by RTV.[53] relevant vascular system and anatomical and left ureter by thrombophlebitis has been variations encountered.[46] The recorded in the past.[54] Bilateral spermatic accomplishment of access for sclerotherapy venography is advocated in all cases with via the basilic, transfemoral or transjugular irregular spermiograms as bilateral route needs prior workup of venous incompetence of the veins is hypothesized a architecture to avoid impediment and situation which leads to primary sterility as hemorrhages. Although the primary a rule and not as a chance alone.[37] The treatment of varicocoele consists of ligating distribution of collaterals of TVs accounts TVs with selective preservation of vas for tumor secondaries in kidney, colon and deferens and testicular artery. [47] Recently pancreas when the mode of metastasis is additional ligature of testicular artery is hematogenous.[55] Presence of additional advocated because little veins in proximity TVs can accelerate and escalate the of the adventitia of artery can reopen up and quantum of tumor spread even higher. Renal assume the function of drainage, leading to carcinoma is notorious for tumor thrombus frequently encountered clinical formation in IVC and had been found to recurrence.[48] Consequently, the prior seed into testis through retrograde venous cognizance of anastomosing pattern of pathways. [56] The left and right variant supernumerary and collaterals veins displays different outline of regional spread presages the urologist about its recurrence of testicular malignancies that mirror the hazard, which is as high as 20%.[49] difference in venous drainage on either side. Intelligent presumption of existence of Typically, while the lymphatics of the left anatomical variation aided with thorough testicle drain into paraaortic lymph nodes, pre-operative investigation against the right testicle is drained through background of literature minimizes the interaortocaval lymph nodes. As the probability of reappearance of varicosity lymphatics, emanating from testis travels and subsequent patient morbidity owing to along the venous pathways, therefore any multiple surgeries. Of late, microsurgical aberration in termination of TVs sub-inguinal ligature close to testicle is consequently lead to unloading of metastatic preferred over retroperitoneal ligature of seeds in those lymph nodes, which lies in vessels, as the likelihood of collateral proximity of collecting conduits. When venous reactivation through retroperitoneal burdened by the vascular variations, anastomoses is avoided.[50] These successful consideration of this phenomenon might changes in intervention in varicocoele help oncologist in planning staging and justify the current trend of shift in surgical adequate surgeries with least recurrence of

Galore International Journal of Health Sciences and Research (www.gijhsr.com) 64 Vol.5; Issue: 2; April-June 2020 Gupta Nidhi et. al. Variations in testicular veins: an anatomico-clinical review left over. The awareness of variations in for various procedures undertaken in testicular vessels is indispensable for the topographically very important area related success of mobilization and fixation to and drained by TVs. achieved in orchidopexy. [57] The alternative presence of vascular supply and drainage REFERENCES must be explored and ensured beforehand to 1. Standring S, Ellis H, Healy J, Johnson D, address any complication during the Williams A. Gray’s Anatomy. 39th ed. procedure and ascertain post-operational Edinburgh: Elsevier Churchill Livingstone; 2005.p 1274. viability.[57] Frequent complications owing 2. Bensussan D, Huguet JF. Radiological to lack of awareness of these variations may anatomy of the testicular vein. Anat. Clin. complicate laparoscopic surgeries of [58] 1984; 6(2):143–54. abdominal and region. . The 3. Sofikitis N, Dritsas K, Miyagawa I, compression of TVs by arched TA can Koutselinis A. Anatomical characteristics of instigate renal venous hypertension, which the left testicular venous system in man. may account for unexplained possibility of Arch Androl. 1993; 30:79–85. proteinuria, hematuria in addition to 4. Asala S, Chaudhary SC, Masumbuko- varicocoele. [59] With the advent of Kahamba N, Bidmos M. Anatomical multidetector computer tomography curved variations in the human testicular blood planar and volume rendered images varices, vessels. Ann. Anat. Anat. Anz. Off. Organ Anat. Ges. 2001 Nov; 183(6):545–9. varicocoele, testicular vascular pedicle sign 5. Wishashi MM. Anatomy of the venous and phlebolith in testicular vein can be [60] drainage of the human testis: testicular vein precisely assessed. . Moreover, it can cast, microdissection and radiographic differentiate the dilatation in lumen of TVs demonstration. A new anatomical concept. brought about by varicocoele or portal Eur. Urol. 1991; 20(2):154–60. hypertension.[59] A meticulous attention is 6. Xue H-G, Yang C-Y, Ishida S, Ishizaka K, called for if more than one vein is located in Ishihara A, Ishida A, et al. Duplicate lumbar region.[3] Hence, under light of testicular veins accompanied by anomalies literature, spermatic venography must of the testicular . Ann. Anat. Anat. address the spectrum of variations and their Anz. Off. Organ Anat. Ges. 2005 Sep; subsequent influence in etiopathogenesis of 187(4):393–8. 7. Yang C-Y, Xue H-G, Tanuma K, Ozawa H. relevant venous disorders. The appraisal of Variations of the bilateral testicular veins: aberrant morphology along with deviant embryological and clinical considerations. distribution of TVs is very crucial for the Surg. Radiol. Anat. Sra. 2008 Feb; success of retroperitoneal and male 30(1):53–5. infertility surgery. 8. Gaudin J, Lefèvre C, Person H, N’Guyen- Huu, Senecail B. The venous hilum of the CONCLUSION testis and epididymis: anatomic aspect. The inclusive acquaintance of Surg. Radiol. Anat. 1988 Sep 1; 10(3):233– disparity in gonadal vascular networks 42. provides valuable and safe information for 9. Pais D, Fontoura P, Esperanca-Pina J. The planning invasive as well as noninvasive transmediastinal arteries of the human testis: an anatomical study. Surg Radiol Anat. surgical and radiological procedures. 2004; 26:379–83. Anatomist and clinicians manipulating these 10. Ergün S, Bruns T, Tauber R. Vascular areas should consider the anatomical organization of the pampiniform plexus in curiosity for such encountered variations the man and its significance for antegrade under specified attributes and defer from sclerosing of testicular varicocoele. Urol. combining various parameters of Ausg. 1996 Nov; 35(6):463–7. morphology. The individual and discrete 11. Ergün S, Bruns T, Soyka A, Tauber R. detailing under parameters discussed will Angioarchitecture of the human spermatic serve to formulate the acceptable guidelines

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59. Lelli F, Maurelli V, Maranillo E, computed tomography. Jpn. J. Radiol. 2011 Valderrama-Canales FJ. Arched and Apr; 29(3):161–5. retrocaval testicular arteries: A case report. Eur. J. Anat. 2013 Aug 23; 11(2):119–22. How to cite this article: Nidhi G, Amod D, 60. Karcaaltincaba M. Demonstration of normal Suniti P. Variations in testicular veins: an and dilated testicular veins by multidetector anatomico-clinical review. Gal Int J Health Sci Res. 2020; 5(2): 56-68.

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