Microsurgical Spermatic Cord Denervation Research Articles

A simplified treatment algorithm for chronic scrotal content pain syndrome

Abstract Background Chronic scrotal content pain (CSCP) is a devastating condition characterized by localized scrotal pain that persists for ≥3 months and interferes with daily activities. Approximately 2.5% of all urology outpatient visits are associated with CSCP. General urologists may have difficulty treating these patients because of uncertainties regarding the etiology and pathophysiology of CSCP. Therefore, we aimed to provide a simplified diagnostic and treatment approach for CSCP by subdividing it into distinct categories. Materials and methods We systematically reviewed the published literature in the PubMed, MEDLINE, and Cochrane databases for all reports on CSCP diagnosis and treatment using the keywords “chronic scrotal content pain,” “testicular pain,” “orchialgia,” “testicular pain syndrome,” “microdenervation of the spermatic cord,” “post-vasectomy pain syndrome,” “post-inguinal hernia repair pain,” “testialgia,” and “pudendal neuralgia.” This review included only CSCP-related articles published in English language. Results We subdivided CSCP syndrome into 5 clinical presentation types, including hyperactive cremasteric reflex, pain localized in the testicles, pain in the testis, spermatic cord, and groin, pain localized in the testicles, spermatic cord, groin, and pubis, and pain in the testicles, spermatic cord/groin, and penis/pelvis. Treatments were adjusted stepwise for each type and section. We included more information regarding the role of pudendal neuroglia in CSCP syndrome and discussed more options for nerve blocks for CSCP. For microsurgical spermatic cord denervation failure, we included treatment options for salvage ultrasound-guided targeted cryoablation, Botox injections, and posterior-inferior scrotal denervation. Conclusions Different CSCP subtypes could help general urologists assess the appropriate diagnostic and treatment approaches for scrotal pain management in daily practice.

Chronic scrotal content pain: the experiences of patients undergoing microsurgical spermatic cord denervation.

Chronic scrotal content pain, sometimes referred to as chronic orchialgia, is a common urological condition that gives rise to persistent and often severe painful stimuli to the scrotum and surrounding structures. Despite its relative commonality, accounting for over 2% of urological visits, chronic scrotal content pain is complex to manage and patients may be required to access multiple providers and undergo invasive procedures, including microsurgical spermatic cord denervation (MSCD) surgery. The objective of this study was to understand the experiences and perspectives of persons with chronic scrotal content pain and accessing MSCD surgery. An exploratory qualitative design, guided by interpretive description and integrated knowledge translation, was adopted. We conducted in-depth qualitative interviews with six patients with chronic scrotal content pain who underwent MSCD surgery in a surgical center in Western Canada. Data were analyzed thematically. Analysis of the study data resulted in three core themes: living with chronic scrotal content pain, quality of life, and MSCD procedure and outcomes. We highlight the debilitating nature of pain and the broad impacts upon health, quality of life, and social functioning. Participants described how MSCD surgery offered an effective solution for persistent and debilitating pain. For the participants, MSCD surgery offered hope and the chance to regain their normality. For those with chronic scrotal content pain, access to a pain specialist, along with the adoption of a biopsychosocial approach to pain and early access to MSCD surgery, may improve patient experiences and outcomes. Considering the high prevalence of urological pain, greater interdisciplinary care is needed in order to support more effective and timely management.

EDITORIAL COMMENT

Chronic orchialgia comprises 2.5% of urology clinic visits with an estimated prevalence of 100,000 men per year.1,2 Considering how common it is, it has been understudied leaving an unmet need in the medical literature for investigations such as this one. Spermatic cord block has been established as an important part of the diagnostic evaluation for men with chronic orchialgia when considering surgical intervention.3-5 The current study suggests that an additional 15%-18% of men may be considered candidates for microsurgical spermatic cord denervation (MSCD) with the reported improved outcome of 88% of men with pain reduction of greater than 50% after MSCD with candidacy based on the modified spermatic cord block vs.

V07-12 INDOCYANINE GREEN ANGIOGRAPHY FOR USE IN ROBOTIC SPERMATIC CORD DENERVATION

You have accessJournal of UrologySexual Dysfunction & Transgender (V07)1 Sep 2021V07-12 INDOCYANINE GREEN ANGIOGRAPHY FOR USE IN ROBOTIC SPERMATIC CORD DENERVATION Alan Makedon, Jeffrey Morrison, and Granville Lloyd Alan MakedonAlan Makedon More articles by this author , Jeffrey MorrisonJeffrey Morrison More articles by this author , and Granville LloydGranville Lloyd More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002034.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Chronic orchialgia continues to be a challenge for urologists to treat and for patients to live with. Currently, conservative treatment (rest, anti-inflammatory drugs, physical therapy, antidepressants) is the first line therapy for men struggling with chronic orchialgia. However, when these approaches fail, alternative therapies are required. Before resorting to orchiectomy, microsurgical spermatic cord denervation (MSCD) has been shown to significantly decrease pain with few side effects for the correctly-selected patient. Accurate microsurgical technique and especially avoidance of arterial injury is critical, especially for novice surgeons as well as in cases with aberrant anatomy. In this video presentation, we describe the novel use of indocyanine green (ICG) angiography in correlation with Doppler during robotic MSCD for the purpose of arterial localization and verification of preservation. METHODS: Robotic MSCD was performed in 10 cases of chronic orchialgia following failed conservative treatment and after a successful anesthetic cord block in the office. The procedure consists of a few distinct steps: division of the cremasteric muscle, isolation of the vas deferens and division of the central adipose tissue. ICG was injected twice in each procedure: to identify the testicular artery during central dissection and to confirm preservation of the artery at conclusion. Micro-doppler was used adjunctly to confirm findings. RESULTS: In all 10 patients, ICG angiography successfully identified the location and course of the testicular artery, including in cases of aberrant and re-operative anatomy. Doppler assessment confirmed this. CONCLUSIONS: ICG angiography during robotic MSCD is a novel technique to clarify spermatic cord arterial anatomy and is especially useful in the setting of prior surgery and developmental abnormality. This technique is a valuable adjunct to this procedure for novice surgeons, as well as producing visual documentation of successful arterial preservation, without adding significant time or complication. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e554-e554 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alan Makedon More articles by this author Jeffrey Morrison More articles by this author Granville Lloyd More articles by this author Expand All Advertisement Loading ...

Indocyanine Green Angiography for Use in Robotic Spermatic Cord Denervation

Introduction: Chronic orchialgia continues to be a challenge for urologists to treat and for patients to live with. Currently, conservative treatment (rest, anti-inflammatory drugs, physical therapy, and antidepressants) is the first-line therapy for men struggling with chronic orchialgia.1 However, when these approaches fail, alternative therapies are required. Before resorting to orchiectomy, microsurgical spermatic cord denervation (MSCD) has been shown to significantly decrease pain with few side effects for the correctly selected patient.2 Accurate microsurgical technique and especially avoidance of arterial injury is critical, especially for novice surgeons as well as in cases with aberrant anatomy. In this video presentation, we describe the novel use of indocyanine green (ICG) angiography in correlation with Doppler during robotic MSCD for the purpose of arterial localization and verification of preservation. Methods: Robotic MSCD was performed in 10 cases of chronic orchialgia after failed conservative treatment and after an effective anesthetic cord block in the office. The procedure consists of a few distinct steps: division of the cremasteric muscle, isolation of the vas deferens and division of the central adipose tissue. ICG was injected twice in each procedure: to identify the testicular artery during central dissection and to confirm preservation of the artery at conclusion. Micro-Doppler was used adjunctly to confirm findings. Results: In all 10 patients, ICG angiography identified the location and course of the testicular artery, including in cases of aberrant and reoperative anatomy. Doppler assessment confirmed this. Conclusion: ICG angiography during robotic MSCD is a novel technique to clarify spermatic cord arterial anatomy and is especially useful in the setting of prior surgery and developmental abnormality. This technique is a valuable adjunct to this procedure for novice surgeons, as well as producing visual documentation of arterial preservation, without adding significant time or complication. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. No funding was received for this article. No competing financial interests exist. Runtime of video: 7 mins and 53 secs

Robotic microsurgical spermatic cord denervation for chronic orchialgia: a case series.

Chronic orchialgia is a frustrating urologic condition that is commonly refractory to conservative modes of therapy. Microscopic spermatic cord denervation is a proven solution for patients who do not achieve relief from nonsurgical treatments. However, current widely used techniques require additional training in microsurgery. To describe an adaptation and improvement of spermatic cord microdenervation technique that leveraged the robotic surgical training common for new urologists and is also accessible for urologists not specifically trained in microsurgery. Robotic-assisted microdenervation of the spermatic cord was performed in three patients using a fluorescence vascular imaging tool to improve visualization of vascular structures (Firefly™; Innovative Surgical, Sunnyvale, CA, USA), along with a tissue matrix allograft to allow for better healing (AminoFix™; MiMedx®, Marietta, GA, USA). All three patients (100%) experienced postoperative resolution of their chronic orchialgia, and none reported any new pain. Utilization of robotic-assisted surgery offers more urologists the ability to use familiar techniques to treat chronic orchialgia when conservative measures are unsuccessful.

Preoperative Predictors of Failure of Microsurgical Spermatic Cord Denervation for Men With Chronic Orchialgia

ObjectiveTo evaluate predictors of failure of microsurgical spermatic cord denervation (MSCD) for men with chronic orchialgia. MethodsRetrospective chart review of men who underwent MSCD. Outcomes were recorded with potential preoperative predictors of failure. ResultsOne hundred and five men underwent MSCD, and of those, 38 were bilateral for a total of 143 testicular units. Overall, 97 of 143 (67.8%) had complete resolution of pain, 27 of 143 (18.9%) had improvement of pain, and 19 of 143 (13.3%) were considered failures with either no improvement or less than 50% improvement in pain after MSCD with a 1-year follow-up period. Overall, 59 of 143 (41%) presented with intermittent orchialgia while 84 of 143 (59%) presented with constant pain. The mean preoperative visual analog scale was 6.8 ± 2 and the mean duration of pain prior to MSCD was 62.5 ± 100 months. Potential etiologies of pain per testicular unit included previous scrotal/inguinal surgery 17 of 143 (11.9%), postvasectomy pain syndrome (PVPS) 30 of 143 (21%), infectious epididymitis 9 of 143 (6.3%), trauma 15/143 (10.5%), and idiopathic 72/143 (50.3%). The only pre-operative predictor having an association with predicting failure was the etiology of orchialgia. Relative to men who had idiopathic orchialgia or prior scrotal/inguinal surgery inciting orchialgia, men with PVPS had increased odds of failure with MSCD. ConclusionPVPS is an etiology associated with a higher risk of failure to respond to MSCD than idiopathic chronic orchialgia or chronic orchialgia subsequent to scrotal/inguinal surgery.

Dorsal Root Ganglion Stimulation for the Treatment of Bilateral Intractable Chronic Testicular Pain

Chronic testicular pain can be idiopathic or as a consequence of injury, infection or surgical Interventions. It can manifest as intermittent or constant, dull or throbbing pain which can radiate to the ipsilateral inner thigh and the perineum. It can be spontaneous or exacerbated by physical activity and local pressure. It is usually associated with depression, reduced libido, and sexual dysfunction. It has a detrimental effect on patients’ quality of life ( 1. Granitsiotis P Kirk D. Chronic testicular pain: an overview. Eur Urol. 2004; 45: 430-436 Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar ). Nerve blocks, pulsed radiofrequency, as well as dorsal column spinal cord stimulation (SCS) have been described for the treatment of chronic testicular pain. Surgical interventions include microsurgical denervation of the spermatic cord, epididymectomy in selected cases and orchiectomy which has also been described and is currently considered as a last treatment resort ( 2. Cassidy DJ. Early experience with microsurgical spermatic cord denervation for chronic orchialgia at a Canadian centre. Can Urol Assoc J. 2015; 9: e72-e74 Crossref PubMed Scopus (13) Google Scholar ).

Validation of targeted microsurgical spermatic cord denervation: comparison of outcomes to traditional complete microsurgical spermatic cord denervation.

The aim of this study was to validate the effectiveness of targeted microsurgical spermatic cord denervation (MSCD) of the trifecta nerve complex in comparison to traditional full MSCD with complete skeletonization of the spermatic cord in men with chronic orchialgia. Retrospective chart review was performed by a single fellowship-trained microsurgeon between 2011 and 2016. Patients had follow-ups at 6 weeks, 6 months, and 1 year postoperatively. Thirty-nine men with chronic orchialgia underwent full MSCD between 2011 and 2013. In July 2013, after the publication of an anatomic study with identification of Wallerian degeneration of the trifecta nerve complex in men with chronic orchialgia, the technique was changed to targeted MSCD. From July 2013 to March 2016, 43 men underwent targeted MSCD. When comparing the full MSCD group to the targeted MSCD group, there was no significant difference in resolution of pain (66.7% vs 69.8%, P = 0.88), no difference in partial relief of pain (17.9% vs 23.3%, P = 0.55), and no difference in failure to respond rates (15.4% vs 7.0%, P = 0.22) between the two groups. There was no difference in mean change of visual analog pain scale scores between the two groups (P = 0.27). Targeted MSCD had a shorter operative time (53 min vs 21 min, P = 0.0001). Targeted MSCD offers patients comparable outcomes to traditional full MSCD, with a shorter operative time, a less technically challenging surgery, and potentially less risk to cord structures which should be preserved.

Spermatic Cord Denervation for Chronic Orchialgia

To review the surgical management of chronic scrotal content pain with microsurgical spermatic cord denervation (MSCD). The data continues to support the use of MSCD for patients with chronic idiopathic scrotal content pain. The use of the robotic approach to this operation is novel but may still be cost-prohibitive and more studies are needed to prove equivalence to the standard microsurgical approach. MSCD has evolved into a very effective treatment for a difficult patient population with few options. It should be considered surgical standard of care for men with persistent chronic scrotal content pain whose symptoms are temporarily resolved with a spermatic cord block.

Chronic scrotal pain and microsurgical spermatic cord denervation: tricks of the trade.

Every practicing urologist encounters patients complaining of chronic scrotal content pain (CSCP). This condition can be equally frustrating for both patients and clinicians as there are no clear treatment guidelines, or pathways, for urologists to follow. As a result, most patients typically seek out multiple providers without improvements in their symptoms. Fortunately, microsurgical spermatic cord denervation (MSCD) is becoming an accepted, reliable and reproducible technique for definitively addressing CSCP in select patients. This manuscript reviews the background, effectiveness and current practice guidelines for scrotal pain in general, and MSCD in particular. Technical insights into how this technique can be performed both safely, and efficaciously, are provided. Finally, the manuscript presents a simple, yet detailed, easy to follow treatment algorithm to aid all urologists in the management of patients presenting with chronic pain.

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 ...

Editorial Comment

No AccessJournal of UrologyAdult Urology1 Jun 2016Editorial Comment Phil Vu Bach and Marc Goldstein Phil Vu BachPhil Vu Bach More articles by this author and Marc GoldsteinMarc Goldstein More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.11.098AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, 195(6), p. 1847 References 1 : Microsurgical denervation of the spermatic cord for chronic orchialgia: long-term results from a single center. J Urol2008; 180: 949. Link, Google Scholar 2 : Microsurgical spermatic cord denervation as a treatment for chronic scrotal content pain: a multi-center open label trial. J Urol2015; 194: 1323. Link, Google Scholar 3 : Open non-microsurgical, laparoscopic or open microsurgical varicocelectomy for male infertility: a meta-analysis of randomized controlled trials. BJU Int2012; 110: 1536. Google Scholar © 2016 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 195Issue 6June 2016Page: 1847 Advertisement Copyright & Permissions© 2016 by American Urological Association Education and Research, Inc.MetricsAuthor Information Phil Vu Bach More articles by this author Marc Goldstein More articles by this author Expand All Advertisement PDF downloadLoading ...

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.

Early experience with microsurgical spermatic cord denervation for chronic orchialgia at a Canadian centre

Microsurgical spermatic cord denervation (MSCD) is an effective surgical technique to manage chronic orchalgia, but it has not been readily adopted by Canadian urosurgeons. This paper reviews the early experience of a single urosurgeon in Canada. Nine consecutive testicular units underwent MSCD over a 24 month period. These patients underwent MSCD after ruling out reversible causes and after a successful diagnostic spermatic cord block. Of these patients, 77% (7/9) had a complete resolution and 22% (2/9) had a partial resolution of their pain symptoms following MSCD. There were no failures or complications. MSCD is an effective, safe, and reproducible surgical technique that should be included in the treatment armamentarium for chronic orchalgia.

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

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.

Inhibition of Adhesion and Fibrosis Improves the Outcome of Epididymectomy as a Treatment for Chronic Epididymitis: a Multicenter, Randomized Controlled, Single-Blind Study

We measured the effectiveness of inhibition of adhesion and fibrosis on patient outcomes after epididymectomy as a treatment for chronic epididymitis. An initial cohort of 152 patients was treated conservatively for chronic epididymitis. Of these patients 43 did not respond to conservative treatment and following informed consent they were enrolled in the clinical trial. The patients were randomized into 2 groups so that 22 underwent epididymectomy with concurrent administration of the inhibitors of adhesion and fibrosis hyaluronic acid and carboxymethylcellulose (group 1), and 21 underwent epididymectomy only (group 2). Visual analog pain scores and patient satisfaction scores were obtained at postoperative weeks 4, 12 and 24. There were no postoperative complications such as wound infection or hematoma in either group. One patient was lost to followup from group 1 and 2 were lost from group 2. At postoperative week 24, 12 patients (57.1%) from group 1 and 3 (15.8%) from group 2 were pain-free, 6 (28.6%) from group 1 and 6 (31.6%) from group 2 exhibited limited pain relief, 2 (9.5%) from group 1 and 7 (36.8%) from group 2 exhibited no pain relief, and 1 (4.8%) from group 1 and 3 (15.8%) from group 2 exhibited recurrence of pain after initial resolution at earlier followup intervals (p = 0.028). Inhibition of adhesion and fibrosis after epididymectomy as a treatment for chronic epididymitis improves pain relief and patient satisfaction.

Microsurgical Denervation of the Spermatic Cord for Chronic Orchialgia: Long-Term Results From a Single Center

We assessed the long-term efficacy, complications and patient perceptions of microsurgical denervation of the spermatic cord in the treatment of chronic orchialgia. Microsurgical denervation of the spermatic cord was performed on 95 testicular units in 79 men (mean age 40.3 years, mean duration of pain 62 months, 16 bilateral) for chronic orchialgia. Conservative management failed in all, and patients were evaluated with an extensive medical history and physical examination. To be a candidate for microsurgical denervation of the spermatic cord each man would have responded either completely or partially to spermatic cord block (greater than 50% decrease in pain) and had no identifiable reversible etiology. Postoperative pain rating scales (0 to 10) were used to determine efficacy. Mean followup was 20.3 months (range 1 to 102 months) and complete, durable relief was noted in 67 (71%) testicular units, partial relief in 17 (17%), and unchanged in 11 (12%). No patients reported worse pain. Complications included testicular atrophy without hypogonadism in 2 patients, superficial wound infection in 2, hydrocele in 2 and an incisional hematoma in 1. Microsurgical denervation of the spermatic cord is a minimally invasive, effective and durable management option for treatment of chronic orchialgia refractory to medical management, preserving the physiological function and psychological role of the testes.