Cord Block Research Articles

Effects of extrinsic cardiac nerve stimulation on atrial fibrillation inducibility: The regulatory role of the spinal cord.

To investigate the effect of the mutual regulation of the extrinsic cardiac nerves on atrial electrophysiology and atrial fibrillation (AF) vulnerability. Fourteen dogs were randomly divided into two groups: spinal cord stimulation (SCS) group (n = 7) and spinal cord block (SCB) group (n = 7). SCS was performed with 90% of the threshold voltage stimulating the T1 -T2 spinal level, while SCB was performed by injecting 2% lidocaine into the epidural space at the T2-3 level. The effective refractory period (ERP), ERP dispersion, and AF inducibility were measured during atrial pacing combined with different extrinsic cardiac nerve stimulation. ERPs were decreased in the atrium and pulmonary veins and ERP dispersion was increased from baseline during left cervical vagus nerve stimulation (VNS) or left stellate ganglion stimulation (SGS) in the two groups. When combined with SCS, VNS resulted in diminished ERPs at all recording sites, longer ERP dispersion and more episodes of AF than were observed during VNS, whereas ERPs were greater and correspondingly fewer episodes of AF occurred during SCS combined with SGS than SGS. In the SCB group, ERPs were shortened, ERP dispersion was lengthened, and episodes of AF were increased during SGS after SCB. SCS enhanced the activity of the left vagus nerve but attenuated the left stellate ganglion and superior left ganglionated plexus. SCS modulates extrinsic and intrinsic cardiac nerve activity among the vagus nerve, stellate ganglion, and ganglionated plexus. SCS facilitates the effect of VNS and attenuates the effect of SGS on atrial electrophysiology.

PD05-04 EARLY EXPERIENCE WITH MICROSURGICAL SPERMATIC CORD DENERVATION IN A CANADIAN CENTRE

You have accessJournal of UrologyInfections/Inflammation/Cystic Disease of the Genitourinary Tract: Prostate & Genitalia I1 Apr 2017PD05-04 EARLY EXPERIENCE WITH MICROSURGICAL SPERMATIC CORD DENERVATION IN A CANADIAN CENTRE Darby Cassidy Darby CassidyDarby Cassidy More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.353AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Microsurgical spermatic cord denervation (MSCD) is an effective surgical technique to manage chronic medically refractory orchalgia, but has not been widely accepted by Canadian Urologists. This paper reviews the early experience of a single Urologist in Canada METHODS 18 consecutive testicular units underwent MSCD over a 48 months by a single surgeon in a Canadian centre. All patient's had reversible causes of pain ruled out and had a successful diagnostic spermatic cord block. RESULTS A total of 18 patients underwent microsurgical spermatic cord denervation by a single surgeon over 4 years. The average patient age was 45 years. The average pre-procedural pain score was 8.5/10. The average post procedural pain score in respond was 0.4/10. The overall success rates was 83% (15/18), with a complete response seen in 61% (11/18) and a partial but acceptable response in 22% (4/18). The failure rate was 17% (3/18) with these patients demonstrating no significant change in their postoperative pain scores. The complication rate was 11% (2/18) with 1 postoperative testicular loss and 1 postoperative hydrocele. The recurrence rates was also 11% (2/18) with these patients having a recurrence in their pain after 6 months of follow-up. CONCLUSIONS Chronic orchialaia is a challenging entity to treat with poor reported success rates in the literature for both medical and surgical treatments. Our results are consistent with the medical literature. Microsurgical spermatic cord denervation does offer a favourable success rate and acceptable complication rate and should be considered part of the armamentarium for the treatment of chronic medically refractory orchialgia. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e118 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Darby Cassidy More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Anesthetic effects of different volumes of lidocaine for spermatic cord block in cattle

ObjectiveTo evaluate three volumes of lidocaine for spermatic cord block to perform castration in cattle. Study designRandomized blinded clinical study. AnimalsThirty mixed-breed Nellore cattle, aged 28–40 months and weighing 395±21 (352–452) kg [mean±standard deviation (range)]. MethodsCattle were restrained in a chute and allowed to stand without sedation. Three milliliters of 2% lidocaine without epinephrine were infiltrated subcutaneously at each site of scrotal incision in all animals. The animals were allocated to three groups of 10 animals each. Lidocaine 2% was injected into each spermatic cord using a volume of 2, 3 or 4 mL in groups A, B, or C, respectively. The total volumes of lidocaine used were 10, 12, and 14 mL in groups A, B, and C, respectively. The duration of surgery and the retraction of the testicle (scored as positive or negative according to retraction of the testicle) during the procedure were recorded. The data were statistically analyzed by one-way anova followed by Tukey’s and chi-square tests. Differences were considered significant when p<0.05. ResultsThe mean surgical time was shorter in group C than in groups A and B (p<0.001). In groups A, B and C, 90%, 60% and 10% of the animals showed retraction of the testicle, respectively. Fewer animals retracted the spermatic cord in group C than in group A (p=0.002) and B (p=0.02). Conclusions and clinical relevanceOptimal spermatic cord block was achieved by injection of 4 mL of 2% lidocaine 5 minutes before castration and following incisional infiltration of lidocaine, in adult cattle weighing about 400 kg.

Disc associating axial pain were indicated by PLL resection in ACDF surgery

The generation and tissue origination of disc-associated axial pain is still under exploration. This study was performed to evaluate disc-associated axial pain and to explore whether it originates in the disc or its surrounding components. A 6-year series of 88 single-level Smith-Robinson disc and posterior longitudinal ligament (PLL) resections performed to treat single-level cervical spondylotic myelopathy was retrospectively examined. All single-level anterior disc decompressions were performed under local infiltration anesthesia; the PLL was not anesthetized to avoid cervical cord block. The patients were grouped by disc level. The centered foci of the pain localization were subjectively recorded before, during, and after the operation. Radiological examinations (plain X-ray, computed tomography, and magnetic resonance imaging) were performed before and after the operation to diagnose the compression and evaluate the decompression. All 88 patients who underwent single-level PLL resection had no intraoperative pain responses except during resection of the PLL. Their provoked pain responses were similar to their familiar pain responses. The axial pain disappeared postoperatively. Complications developed in six patients (6.8%). All patients recovered well, and the absence of the axial pain was maintained at the 12-month follow-up. Preoperative axial pain due to single-level disc protrusion was triggered and aggravated only during PLL resection and disappeared postoperatively. This implies that the intervertebral PLL could be the site of origination of axial pain. Axial pain from the PLL at different disc levels had different distributions.

Symptomatic male with subclinical varicocele found on ultrasound evaluation.

Subclinical varicocele is a common incidental ultrasound finding detected during evaluation of men with infertility or presenting with chronic scrotal content pain. Studies regarding this disease entity mainly investigated the value of its management in infertile men rather than for pain relief. Current guidelines do not indicate varicocelectomy for subclinical varicocele. Coming across such a diagnosis in the context of chronic orchialgia, the clinician should be careful in ruling out other potentially treatable etiologies. Conservative measures are initially recommended. However, if pain persists, spermatic cord denervation may be an option provided that a favorable response to spermatic cord block has been achieved.

Microsurgical Spermatic Cord Denervation as a Treatment for Chronic Scrotal Content Pain: A Multicenter Open Label Trial

We prospectively evaluated the results of microsurgical spermatic corddenervation in a series of patients with chronic scrotal content painin amulticenter study, including 1 center in Germany and 3 centers in Chile. A total of 50 patients with chronic scrotal content pain more than 3 months in duration were prospectively selected for standardized operative microsurgical spermatic cord denervation as pain treatment. In all patients preoperative management included a positive response to a spermatic cord block test with local anesthesia. Pain severity was assessed using an analog visual pain scale (range 0 to 10) for 30 consecutive days. A total of 52 testicular units were operated on using a subinguinal approach. In all cases a surgical microscope was used to identify the arteria testicularis. No intraoperative complications were observed and no testicular units were lost. Two reoperations were performed, including 1 for hematocele and 1 for hydrocele. Six months after surgery 40 patients (80%) were completely pain-free. In 6 patients (12%) intermittent testicular discomfort persisted, which could be managed by acetaminophen on demand. Four patients (8%) had no change in pain severity after surgery. After proper selection of patients microsurgical spermatic cord denervation seems to be a safe and efficient procedure to treat chronic scrotal content pain. Considering the limitations of the study, a randomized, controlled trial with longer followup is highly warranted.

MP25-13 MICROSURGICAL DENERVATION OF THE SPERMATIC CORD FOR ORCHIALGIA: RESULTS AND PHENOTYPIC ANALYSIS OF TREATMENT FAILURES

INTRODUCTION AND OBJECTIVES: Microsurgical denervation of the spermatic cord is an established technique for chronic orchialgia with variable outcomes. We present our initial results, with an emphasis on the clinical phenotype of patients who did not improve METHODS: Data was extracted from our Men’s Health registry for men with orchialgia who had MDSC between Sept 2010 and Aug 2014. All patients reported temporary resolution of their pain following a cord block with 0.25% bupivacaine. RESULTS: There were 22 procedures in 20 patients (2 staged bilateral). Age ranged from 22 to 62 years (mean 38.5). Symptom duration ranged from 6 to 240 months (median 24). Five patients had prior vasectomy. Other prior surgeries included 3 epididymectomies, 3 orchidopexies and 1 inguinal hernia repair. Four patients had pelvic floor spasm and either declined pelvic floor physical therapy (2) or didn’t improve with therapy (2). At last follow up (range 6-38 months) 15 procedures led to complete pain resolution (68.1%). Of the 7 procedures that did not resolve the pain, 1 patient admitted that the cord block did not work, 2 patients had pelvic floor spasm and refused pelvic floor physical therapy, 1 was resolved following ablation of the genitofemoral nerve and 1 patient was diagnosed with fibromyalgia. There was no significant difference in age or symptom duration by surgical outcome. Surgical complications were minor including 1 patient with scrotal bruising and 1 with prolonged incisional pain CONCLUSIONS: MDSC can provide durable pain relief in a subset of patients with orchialgia with minimal morbidity. Patients with a systemic pain syndrome are unlikely to have resolution by simply removing the initial pain generator and therefore prior to MDSC it is important to demonstrate pain resolution with cord block and to identify and treat any systemic conditions, especially pelvic floor spasm.

PD20-08 MICROSURGICAL SPERMATIC CORD DENERVATION FOR CHRONIC SCROTAL CONTENT PAIN: RESULTS OF A MULTICENTER PROSPECTIVE STUDY

You have accessJournal of UrologySexual Function/Dysfunction/Andrology: Surgical Therapy1 Apr 2014PD20-08 MICROSURGICAL SPERMATIC CORD DENERVATION FOR CHRONIC SCROTAL CONTENT PAIN: RESULTS OF A MULTICENTER PROSPECTIVE STUDY Marcelo Marconi, Cristian Palma, Mauricio Olea, Thorsten Diemer, and Wolfgang Weidner Marcelo MarconiMarcelo Marconi More articles by this author , Cristian PalmaCristian Palma More articles by this author , Mauricio OleaMauricio Olea More articles by this author , Thorsten DiemerThorsten Diemer More articles by this author , and Wolfgang WeidnerWolfgang Weidner More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1698AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Introduction and Objectives Microsurgical Spermatic Cord Denervation (MSCD) has become a consented procedure for the treatment of Chronic Scrotal Content Pain (CSCP). Previous reports success rates range from 71% to 100%. Surgical approach can be either performed using a microscope or surgical loupes. Objective: To evaluate in a multicenter (1 Center in Germany, 3 in Chile) prospective series of 40 patients with CSCP, the results of MSCD, using either a loupe assisted approach (magnification 3.5x) or a surgical microscope (magnification 20x) Methods Forty patients with CTP were prospectively enrolled in the study. In order to be a candidate to MSCD all patients meet criteria for CSCP definition and had a positive response to a spermatic cord block test with bupivacaine and no response to a placebo injection (saline solution). Pain severity was measured using an Analog Visual Pain (AVS) scale for the last 30 days (Range 0 -10). The surgery was performed in an ambulatory basis, 13 patients were operated using surgical loupes and 27 using a microscope. Patients were controlled one week, three and six months after surgery with a color doppler ultrasound of the testis. Results A total of 43 testicular units were operated. The mean duration of surgery was 65 minutes (Range 50 – 95 minutes). No intraoperative complications were observed and all patients were operated in an ambulatory basis. No testicular units were lost and the color doppler ultrasound was normal in all cases. Three and six months after surgery 32 patients (80%) were pain free with no need of further oral analgesia. Eight patients (20%) persisted with intermittent testicular discomfort, six could be managed with on demand paracetamol, and two had no change in pain severity. No statistically significant differences were observed between patients operated using loupes or microscope regarding operation time and success rate. Conclusions Microsurgical spermatic cord denervation is a safe procedure with high success rate. The loupe assisted approach is comparable to the classical microscopic approach. © 2014FiguresReferencesRelatedDetailsCited byMarconi M, Palma C, Troncoso P, Dell Oro A, Diemer T and Weidner W (2018) Microsurgical Spermatic Cord Denervation as a Treatment for Chronic Scrotal Content Pain: A Multicenter Open Label TrialJournal of Urology, VOL. 194, NO. 5, (1323-1327), Online publication date: 1-Nov-2015. Volume 191Issue 4SApril 2014Page: e614 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Marcelo Marconi More articles by this author Cristian Palma More articles by this author Mauricio Olea More articles by this author Thorsten Diemer More articles by this author Wolfgang Weidner More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Microsurgical vasovasostomy for the treatment of intractable chronic scrotal pain after vasectomy

Microsurgical vasovasostomy for the treatment of intractable chronic scrotal pain after vasectomy

Does a Positive Response to Spermatic Cord Block Predict Response to Microdenervation of the Spermatic Cord for Chronic Scrotal Content Pain?

Microdenervation of the spermatic cord (MDSC) has been demonstrated to be an effective treatment for men with intractable scrotal content pain. This study evaluates the correlation between a positive response to a spermatic cord block with local anesthetic and the subsequent surgical outcome following MDSC. Pre- and post-cord block pain and pre- and post-MDSC pain. A retrospective review of 74 patients (77 testicular units) who underwent MDSC from 2006 to 2010 was performed. Pre- and post-spermatic cord block pain scores based on a 0-10 visual analog scale (VAS) were compared with pre- and post-MDSC pain scores. A positive response to the block was defined as greater than or equal to 50% temporary reduction of pain based on VAS. The average patient age was 42 years with a mean follow-up of 10 months. The mean duration of symptoms before surgery was 69 months. Mean pre-cord block pain score was 8 with an 89% average decrease in pain following the block. Mean post-MDSC pain score was 2 with an average decrease of 73%. The level of temporary improvement from the cord block appeared to be a useful predictor of sustained improvement with MDSC (P = 0.05). Positive response to spermatic cord block was an independent predictor of MDSC response (P = 0.03). Men with chronic orchialgia who have a positive response to a spermatic cord block are likely to have durable and complete resolution of symptoms after undergoing MDSC. The amount of pain relief obtained after the cord block correlates with pain relief after undergoing a MDSC. Men with chronic orchialgia who desire surgical correction should undergo a preoperative spermatic cord block as part of their complete evaluation. The result of the cord block can help guide the practitioner and the patient toward definitive surgical management via MDSC.

Trifecta Nerve Complex: Potential Anatomical Basis for Microsurgical Denervation of the Spermatic Cord for Chronic Orchialgia

We identified structural abnormalities in the spermatic cord nerves that may explain how microsurgical denervation of the spermatic cord provides pain relief in patients with chronic orchialgia. We retrospectively reviewed a prospective database to compare spermatic cord biopsy specimens from 56 men treated with a total of 57 procedures for microsurgical denervation of the spermatic cord for chronic orchialgia vs a control group of men without pain treated with cord surgery, including varicocelectomy in 4 and radical orchiectomy in 6. Tissue biopsies were obtained from mapped regions of the spermatic cord in all cases. Biopsies stained with hematoxylin and eosin were examined by an independent pathologist. Three human cadaveric spermatic cords were dissected to confirm localization of the nerve distribution identified on pathological mapping. We identified a median of 25 small diameter (less than 1 mm) nerve fibers in the spermatic cord. Of the 57 procedures for orchialgia 48 (84%) showed wallerian degeneration in 1 or more of these nerves but only 2 of 10 controls (20%) had such degeneration (p = 0.0008). In decreasing order of nerve density the 3 primary sites (trifecta nerve complex) of these changes were the cremasteric muscle fibers (19 nerves per patient), perivasal tissues and vasal sheath (9 nerves per patient), and posterior cord lipomatous/perivessel tissues (3 nerves per patient). Cord nerve distribution mapped by the biopsies was confirmed by cadaveric dissection. In men with chronic orchialgia there appears to be wallerian degeneration in reproducible patterns in the spermatic cord nerve fibers. Transection of these nerves may explain the effect of the denervation procedure.

Microdenervation of the Spermatic Cord for Chronic Scrotal Content Pain: Single Institution Review Analyzing Success Rate After Prior Attempts at Surgical Correction

Microdenervation of the spermatic cord is an effective treatment for men with intractable scrotal content pain. We evaluated a single center experience, analyzing patients in whom prior surgical attempts had failed to correct pain who subsequently underwent microdenervation of the spermatic cord. A retrospective chart review of 68 patients who underwent microdenervation of the spermatic cord from 2006 to 2010 was performed. Prior ipsilateral surgical procedures with the intent to correct scrotal content pain were selected, identifying 31 testicular units. Chart review was performed on 68 men with mean age of 42 years at presentation and a mean followup of 10 months. Patients in whom prior surgical correction had failed and who subsequently had microdenervation of the spermatic cord had a mean postoperative pain score of 3 (range 0 to 10) with an average decrease in pain of 67%. Those who had not undergone a prior attempt at surgical correction had a mean post-microdenervation of the spermatic cord pain score of 2 (range 0 to 10) and an average pain decrease of 79% which did not differ statistically from those in whom prior surgery failed. In addition, 50% of men who had undergone surgery before microdenervation of the spermatic cord had complete relief of pain after microdenervation of the spermatic cord vs 64% of those who had not undergone previous surgery. Men with chronic scrotal content pain in whom prior attempts to correct pain have failed have similar, albeit lower, success rates as those without prior surgical intervention. Therefore, men with chronic scrotal content pain in whom prior surgical management has failed and who have a positive spermatic cord block should be considered candidates for microdenervation of the spermatic cord.

Vasectomy reversal with ultrasonography‐guided spermatic cord block

Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Vasectomy reversal is often performed in general or neuraxial anaesthesia. Even though the site of vasectomy reversal is easily amenable to regional/local anaesthesia, spermatic cord blocks are rarely applied because of their risk of vascular damage within the spermatic cord. Recently, we described the technique of ultrasonography (US)-guided spermatic cord block for scrotal surgery, which, thanks to the US guidance, at the same time avoids the risk of vascular damage of blindly performed injections and the risks of general and neuraxial anaesthesia. Vasectomy reversal can easily be done in regional anaesthesia with the newly described technique of US-guided spermatic cord block without the risks of vascular damage by a blindly performed injection and the risks of standard general and neuraxial anaesthesia. In addition, this technique grants long-lasting postoperative pain relief and patients recover more quickly. Microsurgical conditions are excellent and patient satisfaction is high. Thanks to these advantages, more patients undergoing vasectomy reversal might avoid general or neuraxial anaesthesia. • To assess the success rate, microsurgical conditions, postoperative recovery, complications and patient satisfaction of ultrasonography (US)-guided spermatic cord block in patients undergoing microscopic vasectomy reversal and to compare them to a control group with general or neuraxial anaesthesia. • The present study comprised a prospective series of 10 consecutive patients undergoing US-guided spermatic cord block for microscopic vasectomy reversal. • The cohort was compared with 10 patients in a historical control group with general or neuraxial anaesthesia. • Nineteen of 20 (95%) blocks were successful, defined as no pain >3 on the Visual Analogue Scale (VAS), no additional analgesics and/or no conversion to general anaesthesia. Median pain was 0 on the VAS (range 0-5). Additional analgesics were requested in one (5%) block, and there was no conversion to general anaesthesia. • Microsurgical conditions were excellent. • In the spermatic cord block vs general/neuraxial anaesthesia groups, median times (range) between surgery and first postoperative analgesics, alimentation, mobilization and hospital discharge were 12 (2-14) vs 3 (1-6), 1 (0.25-3) vs 4 (3-6), 2 (1-3) vs 6 (3-10), and 4 (3-11) vs 8.5 (6-22) h, respectively. • No complications were reported after the spermatic cord block. • Patient satisfaction was excellent. • US-guided spermatic cord block for microscopic vasectomy reversal is highly successful and provides long-lasting perioperative analgesia. • Times to alimentation, mobilization and hospital discharge are shorter under US-guided spermatic cord block than under general/neuraxial anaesthesia. • Additional anaesthetic pain management might, however, be required unexpectedly with US-guided spermatic cord block.

A Novel Treatment of Chronic Orchialgia

We evaluated the effectiveness of pulsed radiofrequency (PRF) denervation of spermatic cord for the treatment of chronic orchialgia. Five patients diagnosed with chronic orchialgia were evaluated with a thorough medical and psychiatric history, physical examination, and scrotal Doppler ultrasound, urinary system x-ray film, and urine analyses. One of the patients had bilateral chronic orchialgia. All of the patients had pain for a period of at least 3 months, and multiple conservative therapies failed to alleviate the pain. The patients, who had temporary pain relief after undergoing outpatient diagnostic cord block, were determined to be candidates for PRF denervation. PRF denervation of spermatic cord was performed for 6 testicular units. Visual analog scores were noted before and after the procedure. There were no pathologic conditions that indicated chronic orchialgia in any of the patients. No complications, including testicular atrophy or hypoesthesia of the scrotal or penile skin, occurred after the procedure. Mean visual analog scores before and after the procedure were 9 and 1, respectively. None of the patients needed any analgesics after the procedure or during the follow-up period. Mean follow-up period was 20 ± 2.5 weeks. No recurrence was noted, and none of the patients needed additional therapy. This is a limited case report on the short-term use of PRF. Randomized, placebo-controlled, and long follow-up period studies are needed to better assess the efficacy of this procedure for chronic orchalgia.

Treatment of post-operative orchialgia with therapeutic unilateral penile and spermatic cord block

Treatment of post-operative orchialgia with therapeutic unilateral penile and spermatic cord block

SU‐E‐T‐416: Geometric and Dosimetric Effects of Residual Setup Error on the Cord and Larynx in Split‐Field Head and Neck Radiation Therapy

Purpose: In split‐field head and neck radiation therapy, image guided alignment of the superior IMRT field may result in large setup errors in the supraclavicular field. The goal of this study was to quantify geometric and dosimetric effects of residual setup error on the cord and larynx using the split‐field technique. Methods: Cord and larynx contours of 27 patients were propagated from a planning CT onto daily in‐room CTs using deformable registration. Cord contours were divided into superior and inferior structures at the match plane. Interfractional variations in the position of the larynx, superior cord, and inferior cord centroids were measured. Deformable registration allowed the calculation of cumulative dose delivered for each patient. The discrepancy between planned and delivered doses was compared for the maximum dose to the superior and inferior cord, mean dose to the larynx, larynx V50 and D60. Results: The group mean error, systematic error, and random error of the larynx centroid positions were 0.12cm, 0.06cm, and 0.08cm, laterally, and 0.15cm, 0.06cm, and 0.08cm in the anterior‐posterior direction. The lateral values for the superior cord were 0.04cm, 0.01cm, and 0.03cm, and for the inferior cord were 0.17cm, 0.06cm, and 0.12cm. Lateral and anterior‐posterior margins were 0.22cm and 0.20cm (larynx), 0.05cm and 0.08cm (superior cord), and 0.22cm and 0.35cm (inferior cord). Maximum cord dose was 43.8Gy. The average change in maximum dose was 0.3Gy (max=1.8Gy) for the superior cord, and −0.6Gy (max=1.2Gy) for the inferior cord. The increases in larynx mean dose, V50, and D60 averaged 1.6Gy (SD=2.5Gy), 3.24% (SD=3.52%), and 4.7Gy (SD=6.1Gy). Conclusions: While the inferior cord demonstrated the largest motion, it remained within the cord block. The increase in maximum cord dose and mean larynx dose were no more than 1.8Gy and 5.1Gy, respectively. The split‐field technique remains clinically viable.Funding provided by the University of Texas Graduate School of Biomedical Sciences at Houston.

Treatment of Debilitating Cremasteric Synkinesia With Intracremasteric Botulinum-A Toxin Injections

To describe the surgical technique of botulinum-A toxin injection into the cremasteric muscles of a 26-year-old male with bilateral cremasteric muscle spasms causing significant pain and limitation of activity. This pain has been refractory to multiple previous therapies, including inguinal nerve blocks and bilateral orchidopexies with cremasteric muscle lysis. Multiple imaging modalities revealed no obvious pathology for this significant bilateral pain. Genitourinary examination revealed hyper-retractile testes with changes consistent with bilateral orchidopexies and was otherwise normal. The patient has undergone 3 outpatient staged injections of botulinum-A toxin into the bilateral cremasteric muscles after spermatic cord block with 1% lidocaine. One hundred units of botulinum-A toxin mixed into 10 mL of sterile normal saline were used for each injection staged 6 weeks apart. The patient tolerated all injections without apparent side effects. After the first injection into his left side, his baseline pain scores were reduced from 8 out of 10 to 3 out of 10 on a standard 10-point pain scale. He reported maximal efficacy 2 weeks after each injection, with dissipation over 4-6 weeks. After 2 left-sided and 1 right-sided injections, his baseline pain was 2 to 4 of 10, equal bilaterally, and he was back to rigorous activity with some limitations. Direct injection of botulinum-A toxin into the cremasteric muscle is a viable treatment option for the rare patient with debilitating and painful cremasteric spasms refractory to other therapies.

V1562 A MINIMALLY INVASIVE VASOVASOSTOMY WITH IN LINE VASECTOMY INSTRUMENTS

You have accessJournal of UrologyInfertility, Infection, Erectile Dysfunction & Trauma1 Apr 2011V1562 A MINIMALLY INVASIVE VASOVASOSTOMY WITH IN LINE VASECTOMY INSTRUMENTS Joel Marmar Joel MarmarJoel Marmar Camden, NJ More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1585AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES About 500,000 men have vasectomies in the US each year and 3–5% change their minds and seek more children. In the past, the only option for these men was a vasovasostomy (VV). Now,there is sperm extraction and IVF/ICSI, and these procedures have reduced the number of requests for VVs. Therefore, if urologists hope to remain active in the field of microsurgery, it seems important to develop more minilally invasive percedures. This video will demonstrate a minimally invasive VV with In Line Vasectomy (ILV)instruments that offers several advantages. The procedure may be done with a cord block and minimal local to the skin. The procedure is by open access to the vas, and is applicable to men with thick scrotal skin and re do VVs. A mini tenaculum with teeth can enter the 4 mm opening in the scrotal skin to secure the vas scar which is removed to allow the ends of the vasa greater relaxation during the anastomosis. Post operatively, there is much less swelling than a conventional VV, and the patients return to work in about 3 days. METHODS A cord block is completed with 10 cc of 1% xylocaine, and the scrotal skin is numbed with 0.5 cc over the vas scar. A 0.5mm opening is made with a # 15 blade over the vas scar as it is palpated by the surgeon. The mini tenaculum will secure the vas scar in its teeth while a window is dissected in the mesentary above and below the scar. After a hemostat is positioned thru both windows aqnd behind the mesentary, a cautery tip will burn the area below the vas scar to separate it from the mesentary. The vasal ends are cut sharply on either side of the vas scar, and the scar is removed. The ends are stretched apart to create length. The vas fluid was tested for sperm before these structures are placed in a vas holding clamp for a 2 layer VV. Following the anastomosis, the repaired vas is replaced into the scrotum thru the 4mm opening which is closed with 1 stitch. RESULTS Ten men have had bilateral VVs with this procedure. The mean age was 41.3 years. The interval of obsrtuction ranged between 4–11 years. Post operative swelling and pain was about the same as the vasectomy. The men returned to work in 3 days. Nine of 10 demonstrated motile sperm in the ejaculate, and the mean sperm densities were 19 million sperm/ml. There have been 5 live births. CONCLUSIONS A minimally invasive VV with ILV instruments is an effective out patient proceure, and it can be done with a local anesthetic and minimal post op discomfort. Furthermore, this procedure is more cost effective that IVF/ICSI, and it should be offered to men who seek more children after a vasectomy. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e627 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joel Marmar Camden, NJ More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Ultrasound-guided spermatic cord block for scrotal surgery

BackgroundPerforming spermatic cord block for scrotal surgery avoids the potential risks of neuraxial and general anaesthesia and provides long-lasting postoperative analgesia. A blindly performed block is often inefficient and bears its own potential risks (intravascular injection of local anaesthetics, haematoma formation and perforation of the deferent duct). The use of ultrasound may help to overcome these disadvantages. The aim of this study was to test the feasibility and monitor the success rate of a new ultrasound-guided spermatic cord block. MethodsTwenty consecutive patients undergoing urologic surgery (subcapsular orchiectomy or vaso-vasostomy) were included in this prospective study. Using a linear ultrasound probe, the spermatic cord was identified by locating the spermatic artery and the deferent duct. A 23 G Microlance needle was advanced close to the deferent duct by avoiding vessel perforation, and local anaesthetic was deposited around the deferent duct under direct visualization. The primary outcome was the success rate of the block which was defined as surgery without any substitution of opioids, additional local anaesthetics, or sedatives. ResultsIn 20 patients, 40 blocks were performed with a success rate of 95% (n=38). The failure rate was 5% (n=2) and no conversion to general anaesthesia was needed. The mean duration of the block was 14.1 h (sd 6.9). ConclusionsThe use of ultrasound guidance to perform spermatic cord block is feasible and has a high success rate. Our new approach may become a suitable alternative to neuraxial or general anaesthesia especially in the ambulatory surgical setting.Registry: International Standard Randomised Controlled Trial Number Register; www.controlled-trials.com; Registry Nr.: ISRCTN44647819.

Surgical Treatment of a Patient with Human Tail and Multiple Abnormalities of the Spinal Cord and Column

The dorsal cutaneous appendage, or so-called human tail, is often considered to be a cutaneous marker of underlying occult dysraphism. The authors present a case of human tail occurring in a 9-month-old infant with multiple abnormalities of the spinal cord and spine. Examination revealed unremarkable except for a caudal appendage and a dark pigmentation area in the low back. Neuroradiological scans revealed cleft vertebrae and bifid ribbon, split cord malformations, block vertebrae, and hemivertebra. Surgical excision of the tail and untethering the spinal cord by removal of the septum were performed. The infant had an uneventful postoperative period and was unchanged neurologically for 18 months of followup. To our knowledge, no similar case reports exist in the literature. The specific features in a rare case with a human tail treated surgically are discussed in light of the available literature.