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Difficulty: MediumUrologic Surgery

An ambulatory 61-year-old man presents to his primary care provider reporting a persistent feeling of heaviness and a dull ache in his right scrotum that he first noticed three weeks ago. He denies any history of scrotal trauma, dysuria, gross hematuria, urgency, or fevers. His medical history includes essential hypertension and hyperlipidemia, both well-controlled with medication. He has a 40-pack-year smoking history. His temperature is 37.1°C (98.8°F), blood pressure is 138/86 mmHg, and pulse is 76/min. Physical examination of the genitalia reveals a soft, irregular, tortuous mass in the right hemiscrotum that feels like a 'bag of worms.' When the patient is asked to lie in the supine position, the mass does not decrease in size. Both testicles are palpable, symmetric, and without firm nodules. Transillumination of the scrotum is negative. Which of the following is the most appropriate next step in management?

  1. Computed tomography scan of the abdomen and pelvisAnswer
  2. B
    Scrotal ultrasonography with Doppler
  3. C
    Reassurance and application of a scrotal supporter
  4. D
    Measurement of serum alpha-fetoprotein and beta-human chorionic gonadotropin
  5. E
    Percutaneous embolization of the gonadal vein

Answer

Computed tomography scan of the abdomen and pelvis
The correct answer is a computed tomography (CT) scan of the abdomen and pelvis. This patient presents with a new-onset, right-sided varicocele that fails to decompress when he assumes a supine position. A varicocele is an abnormal dilation of the pampiniform plexus veins. The vast majority of varicoceles are primary and left-sided because the left gonadal vein drains into the left renal vein at a perpendicular angle, leading to higher resistance to venous return. In contrast, the right gonadal vein drains directly into the inferior vena cava (IVC) at an oblique angle. Therefore, a right-sided varicocele or one that does not decrease in size when the patient lies supine is highly suspicious for a secondary cause, specifically an obstruction of the IVC or the right gonadal vein. In an older male with a significant smoking history, this presentation strongly points toward right-sided renal cell carcinoma (RCC) that has invaded the renal vein and extended into the IVC as a tumor thrombus. The most appropriate next step in management is cross-sectional imaging, such as a CT scan of the abdomen and pelvis, to evaluate for an intra-abdominal mass or malignancy.

Step-by-Step Solution

1
Analyze the physical examination findings of the scrotum.
The patient has a right-sided extratesticular mass resembling a 'bag of worms' that fails to decompress when he assumes a supine position.
To differentiate between a typical primary varicocele and a secondary varicocele with red-flag features.
2
Determine the anatomical implications of a right-sided, non-decompressing varicocele.
It indicates possible obstruction of the inferior vena cava (IVC) rather than the left renal vein.
The right gonadal vein drains directly into the IVC, unlike the left gonadal vein which drains into the left renal vein.
3
Identify the most likely underlying pathology and select the appropriate diagnostic step.
An intra-abdominal malignancy, particularly a right-sided renal cell carcinoma extending into the IVC, must be ruled out using cross-sectional imaging of the abdomen and pelvis.
Secondary varicoceles in older men with a significant smoking history carry a high risk of retroperitoneal malignancy.

Key Concept

A right-sided varicocele or a varicocele that fails to decompress in the supine position strongly suggests a secondary obstruction of the inferior vena cava, commonly by a renal cell carcinoma tumor thrombus, requiring immediate cross-sectional imaging of the abdomen and pelvis.
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Topics

Urologic Surgery

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