Beyond Tying Knots: Can Venous Bypass Shape the Future of Testicular Hemodynamics in Varicocele Treatment? - A Systematic Review.

Purpose: Varicocele, present in 15-20% of males and linked to 35-40% of primary infertility, is commonly treated with microsurgical ligation. This review compares venous shunting techniques such as spermatic-inferior epigastric vein anastomosis with ligation in terms of efficacy, safety, and clinical outcomes, especially in complex cases like recurrence or Nutcracker Syndrome. Methods: We included randomized, prospective, retrospective, and cohort studies comparing venous shunting (eg, spermatic-inferior epigastric vein anastomosis) with ligation or without control group. We searched PubMed, EBSCO, ProQuest, EMBASE, and Scopus on 31 April 2025. Risk of bias was assessed using the Newcastle-Ottawa Scale and JBI (Joanna Briggs Institute) for case series. Outcomes assessed included operative time, semen parameters, hormonal levels, recurrence, and complications. This study was registered in PROSPERO (CRD420251060842). Results: Twelve studies (n = 420 patients) were included. Shunting demonstrated improvements in semen quality (eg, sperm motility: 59.4% vs 41.6% post-ligation) and lower recurrence rates (0-5% vs 5-15%). However, operative times were longer (99-146 vs 48-92 minutes). Shunting also showed benefits in vascular parameters and testicular volume, particularly in NCS-associated cases. Complications were rare, with minor issues like scrotal edema reported. Conclusion: Venous shunting shows promise as an alternative in selected varicocele patients, with potential benefits in semen motility, pain relief, and recurrence reduction. However, the current evidence is limited, heterogeneous, and largely non-randomized. Shunting should therefore be considered experimental, requiring advanced microsurgical expertise, and further high-quality trials are needed before incorporation into standard guidelines.