Scrotal Surgery Research Articles

A narrative review on the performance and outcomes of penile and scrotal surgery in the ambulatory setting.

Following the COVID-19 pandemic, surgical wait times have surged, creating a backlog in elective urological procedures. This review aims to address the need to explore ambulatory care for penile and scrotal surgeries, which can offer benefits by shifting these procedures away from traditional inpatient settings. Recent studies confirm the safety and efficacy of performing penile and scrotal procedures in an ambulatory setting using local anesthesia (LA) or loco-sedative techniques. Of 616 reviewed cases, over 90% of patients expressed high satisfaction with LA and reported minimal postoperative complications. Pain management advancements, particularly the use of liposomal bupivacaine, reduced the need for opioids postoperatively. Importantly, no intraoperative complications or hospital admissions were reported, and adverse events were managed conservatively. The data highlighted in this review supports a move towards outpatient surgeries as a safe alternative to inpatient care for select cases. This review highlights the strong potential for ambulatory urological surgeries to alleviate surgical backlogs significantly, while reducing strain on hospital resources, and maintaining high levels of patient satisfaction. As evidence continues to grow on the safety, feasibility, and effectiveness of LA in office-based procedures, expanding ambulatory urological will be quintessential in modernizing patient care and reducing healthcare burdens.

The effect of intraoperative methadone on postoperative opioid requirements in children undergoing orchiopexy: A randomized clinical trial.

Children undergoing outpatient surgery are at risk of inadequate postoperative pain control. Methadone has a long duration of action and an intraoperative dose may provide stable analgesia throughout the postoperative period. Intraoperative methadone has been shown to improve pain control in adolescents but its use for postoperative pain in pediatric patients undergoing outpatient surgery has not been studied before. Therefore, we conducted a double-blind randomized placebo-controlled trial to investigate the effects of a single dose of intraoperative methadone in children aged less than 5 years undergoing orchiopexy for undescended testis. A total of 68 children were randomized to receive either methadone (0.1 mg/kg) or isotonic saline following induction of anesthesia. Exclusion criteria included preterm birth, previous scrotal surgery, and parents' inability to consent. Primary outcomes were opioid requirements (first primary outcome) and pain intensity in the post-anesthesia care unit. Secondary outcomes included episodes of desaturation and time until readiness to discharge from the post-anesthesia care unit, sleep on the first postoperative night, pain intensity, and opioid requirements at home until the evening on the first postoperative day. Follow-up was 4 days. Sixty children completed the study (age, mean ± SD, 26.2 ± 13.9 months), 29 children received methadone, and 31 children received placebo. Eighteen children required opioids in the post-anesthesia care unit, five children in the methadone group (proportion = 0.17, 95% confidence interval (CI): 0.07, 0.36) compared to thirteen patients in the placebo group (0.42, 95% CI: 0.26, 0.60) (mean difference = -0.24 and 95% CI: -0.03, -0.47) (p = 0.037). Five children in the methadone group (0.17, 95% CI: 0.03, 0.31) versus ten in the placebo group (0.32, 95% CI: 0.16, 0.49) had a face, legs, activity, cry, consolability score of ≥5 in the post-anesthesia care unit (mean difference = -0.15, 95% CI: -0.36, 0.06) (p = .179). More children in the placebo group woke up due to pain the first night following surgery (seven children vs. one child). The methadone group had a longer stay in the post-anesthesia care unit. There were no differences between the two groups regarding the other secondary outcomes. A single dose of intraoperative methadone reduces short-term postoperative opioid requirements in children after orchiopexy for nondescended testes but prolongs the duration of their stay in the post-anesthesia care unit.

Utilizing Local Anesthesia Only for Penile and Scrotal Urologic Surgery: A Prospective Study on Patient Tolerability and Surgical Outcomes for a Sedation-free Option

ObjectiveTo prospectively assess surgical outcomes, complications, and patient-reported tolerability of invasive scrotal surgeries under local anesthesia (LA) alone, without sedation, compared to tolerability of penile procedures commonly performed in this manner. MethodsAdult patients undergoing penile and scrotal surgeries under LA only were enrolled from August 2022 to June 2023 (NCT05617261). Demographics, surgeon-perceived and patient-reported pain, and surgical variables were collected. Tolerability to the procedures and future anesthetic choice for a repeat procedure was assessed on follow-up. Complication data was collected, including recurrence, infection, excessive pain, and emergency room and family physician visits. Results107 patients were enrolled with a mean age ± SD of 42.2 ± 16.4 years. There was a 100% procedural success rate and no cases of perioperative complications or escalation of anesthetic. 92.4% (n=97) of patients indicated they would opt for LA only for a hypothetical repeat procedure. Of the minority opting for general anesthetic, most indicated discomfort or preferring an element of amnesia. No differences between intraoperative pain or tolerability scores of invasive scrotal procedures compared to penile procedures were observed. On univariate analysis, longer procedure duration (p=0.003), cannabis use (p=0.01), and higher intra-operative pain (p=0.005) was associated with lower tolerability. ConclusionLA alone in an office-based setting is promising for scrotal surgeries. It offers similarly high patient tolerability compared to procedures that are routinely performed under LA, with the preservation of outcomes. Adopting this method has the potential for substantial cost savings, reduced wait times, enhanced accessibility, and improved surgical efficiency.

Efficacy of EMLA for Office-based Andrology Procedures Under Local Anesthesia: A Randomized Control Trial

ObjectiveTo evaluate the effectiveness of Eutectic Mixture of Local Anesthetic (EMLA), a topical anesthetic cream, in office-based invasive andrological procedures such as hydrocelectomy, spermatocelectomy, and others, aimed at minimizing pain perception and enhancing the overall patient experience. MethodsA double-blinded randomized controlled trial was conducted for patients undergoing scrotal andrology surgeries under LA. Power calculation was performed with an estimated sample size of 72. Participants were randomly assigned in a 1:1 ratio to topical EMLA + LA vs LA alone. In the post-operative recovery area, patient will be asked to complete a VAS questionnaire rating pain with LA administration and pain with procedure. Analysis comparing VAS pain scores of both groups was performed using the independent sample t-test method. Results72 patients were included in our analysis, with 36 in the control and 36 in the intervention arm. For patient pain with administration of LA, the control arm reported an average VAS pain score of 4.31, compared to 3.72 in the intervention arm (p=0.319). For patient pain with procedure, patients in the control arm reported a median VAS pain score of 3.47 compared to 3.03 (p=0.432) in the intervention arm. Overall, 86% (62/72) of patients reported that they would either be “very likely” (4/5) or “highly likely” (5/5) to undergo future procedures under local anesthetic. ConclusionsWhile performing scrotal surgeries under LA appears to be well tolerated and a feasible option, the application of EMLA cream does not appear to significantly alter patient-reported outcomes.

Gabapentin for Postoperative Pain Control and Opioid Reduction in Scrotal Surgery: A Randomized Controlled Clinical Trial: Erratum

Gabapentin for Postoperative Pain Control and Opioid Reduction in Scrotal Surgery: A Randomized Controlled Clinical Trial: Erratum

Stripping versus ligation of vas deferens in microscopic denervation of spermatic cord in men with chronic orchialgia: A multicenter study.

Microdenervation of the spermatic cord (MSCD) is an effective treatment modality for men with intractable scrotal content pain. For patients not interested in preserving fertility, some centers advocate ligation of the vas during denervation, while others prefer stripping of the vas deferens to preserve the vasal artery, hence preserving vasculature to the testis and possibly decreasing post-operative congestion pain. To compare outcomes of patients with chronic orchialgia, who underwent MSCD by either stripping or ligating the vas deferens. A retrospective chart review of 85 patients who underwent MSCD from 2017-2023 was performed. Patients' demographics including history of prior surgical procedures were recorded. Response to surgery was evaluated as either complete resolution of pain, partial resolution of pain, or no improvement in pain. Eighty-five patients underwent MSCD with a median (interquartile range, IQR) age of 36 (25.5-46.5) years and median duration of pain of 16 (6-31) months. Thirty-seven patients underwent stripping of vas, while 48 underwent ligation of vas during MSCD. Median follow up was 12 months. Twenty-one (43.5%) patients had prior inguinal scrotal surgery in the ligation group compared to 5 (13.5%) in the stripping group, p=0.003. The etiology of pain was similar between the groups. The response to MSCD between the two groups was similar, 67.6% of patients who underwent stripping had complete resolution of pain versus 66.7% of those who had ligation (p=0.968), with similar rates of post-operative complications (p-value=0.132). In men with intractable chronic scrotal content pain with no interest in preserving fertility, ligation, or stripping of the vas deferens yields similar outcomes with regard to pain resolution. Both techniques are safe with no reports of any testicular atrophy.

(130) Multicenter Study Comparing Stripping vs Ligation of Vas Deferens During Microscopic Denervation of Spermatic Cord in Men with Chronic Orchialgia Across the US

Abstract Introduction Microdenervation of the spermatic cord (MSCD) is an effective treatment modality for men with intractable scrotal content pain. For patients not interested in preserving fertility, some centers advocate ligation of the vas during denervation while others perfer stripping of the Vas deferens to preserve the vasal artery, hence preserving vasculature to testis and possibly decreasing post operative congestion pain. Objective This multicenter study analyzes outcomes of patients that underwent MSCD by either stripping or ligating the vas deferens. Methods A retrospective chart review of 85 patients who underwent MSCD from 2020–2023 was performed. Patients’ demographics including history of prior surgical procedures was recorded. Response to surgery was evaluated as either complete resolution of pain, partial resolution of pain or no improvement in pain. Results 85 patients underwent MSCD with a median (IQR) age of 36 (25.5–46.5) years and median duration of pain of 16 months. 37 patients underwent stripping of vas while 48 underwent ligation of vas during MSCD. Median follow up was 12 months. 21(43.5%) patients had prior inguinal scrotal surgery in ligation group compared to 5 (13.5%) in the stripping group p=0.003. The etiology of pain was similar between the groups. The response to MSCD between the 2 groups was similar (p=0.968), with similar post op complications (Table 1). Conclusions In men with intractable chronic scrotal content with no interest in preserving fertility, ligation or stripping of the vas deferens yields similar outcomes with regards to pain resolution. Both techniques are safe with no reports of any testicular atrophy. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Advisory board and speaker for Coloplast; consultant for Cynosure; advisory board and speaker for Halozyme; intellectual property with Masimo; advisory board for Promescent; consultant for Sprout; advisory board for Xialla.

(131) Microsurgical Denervation of the Spermatic Cord for Chronic Scrotal Pain: Results from a Prospective Case Series

Abstract Introduction Microsurgical spermatic cord denervation (MSCD) is one of the lines of management of chronic scrotal pain refractory to conservative lines of therapy, however, it has not been fully adopted by different centres. Other procedures such as epididymectomy, orchidectomy and vasectomy reversal are being offered instead. Objective To evaluate the safety and efficacy of microsurgical denervation of the spermatic cord in the management of chronic scrotal pain refractory to conservative lines of therapy. Methods Twenty consecutive patients were prospectively enrolled for MSCD over a 24-month period. These patients underwent MSCD after exclusion of any correctable cause of chronic scrotal pain (CSP) and/or poor response to medical treatment. Efficacy of the technique was evaluated by the degree of pain improvement using the Visual Analogue Scale (VAS). Safety was assessed by reporting any intra- or post-operative complications. Results The mean age of the studied population was 51.7 (36–78) years. The mean pain duration was 4.2 (1–20) years. In 8 patients (40%), the aetiology of the chronic pain was idiopathic, 5 patients (25%) the pain occurred after previous scrotal surgery (vasectomy in 2 patients, AUS in 2 and an epididymal cyst excision in 1 patient), 4 patients (20%) post scrotal trauma and 3 patients (15%) post epididymo-orchitis. Ten patients (50%) had complete pain resolution, 8 (40%) had a partial resolution of their pain, the pain remained the same in a one patient (5%), and one patient (5%) had resolution of the scrotal pain but developed pain at the incision site following MSCD. The VAS pain score significantly improved from a mean of 9.7 to 3.7 postoperatively. (p=0.0029). No significant complications have been encountered in this case series. Conclusions Microsurgical denervation of the spermatic cord is a safe and reliable option that should be more widely adopted to treat men with chronic scrotal pain refractory to conservative treatment. Disclosure No.

(040) Local Anesthesia Only for Penile and Scrotal Procedures: A Prospective Analysis of Patient Tolerability as an Alternative to Sedation

Abstract Introduction Traditionally, urological procedures utilize general or spinal anesthesia (GA) in an operating room (OR) to achieve adequate periprocedural pain relief. However, this approach presents various obstacles, including high OR related expenses, difficulties in accessing healthcare in rural areas, higher risk of anesthetic related complications and long wait times for patients due to limited OR space. This is particularly evident in penile and scrotal procedures, which often receive non-urgent treatment and result in wait times exceeding six months in Canada. The use of local anesthesia (LA) only is an appealing approach that has been gaining more traction in recent literature – however, no study to date has evaluated patient-reported tolerability to procedures conducted in this manner. Objective To investigate the surgical outcomes and patient-reported tolerability of penile and scrotal urologic procedures performed solely under LA. Additionally, information regarding complications is collected to provide data regarding the safety of this method, offering a viable alternative without the need for sedation. Methods This prospective study is registered as a clinical trial NCT05617261. Adult patients undergoing penile or scrotal surgery under LA only have been enrolled since August 2022, and is ongoing until August 2023. Procedures of interest include hydrocelectomies, spermatocelectomies, epididymectomies, testicular biopsies, circumcisions and frenulectomies. For scrotal procedures LA is administered along the median raphe along with a spermatic cord block, and for penile procedures a subcutaneous ring and dorsal penile block is utilized. Demographics, surgeon- and patient-reported visual analogue pain scores (VAS), and surgical variables are collected. Patient tolerability to the procedure and future anesthetic choice for a hypothetical repeat procedure are assessed at a follow-up appointment as our primary outcome. Complication data is also collected including recurrence (if applicable), emergency room visits, excess pain, hematoma & infection. Statistical tests include analyses to determine associations between demographic or surgical variables and patient-reported outcomes. Results Thus far, 215 patients are enrolled with complete follow-up data and statistical analysis on 72 patients. The mean age ± SD is 42.2 ± 16.4 years and there has been a 100% success rate with no perioperative complications or conversions to sedation or general anesthetic. Table 1 highlights the current patient demographic differences between those who do or do not recommend LA. Table 2 describes VAS at each point in time. On follow-up, 93.1% of patients indicated they would opt for LA for a hypothetical repeat procedure, with Figure 1 illustrating this by procedure type. Of the minority opting for GA, only 2 patients did so due to excess pain – highlighting that patient tolerability is not a limiting factor; instead, a desire to have no memory of the procedure is prevalent in this small cohort. Conclusions LA only is a promising technique for various scrotal and penile urologic procedures with high levels of patient tolerability. As we continue our analysis, we anticipate minimal complication rates similar to existing literature and data highlighting cost savings to our public health care system with a substantial reduction in patient wait times and surgical and recovery times – allowing for increased surgical efficiency and accessibility. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific.

(379) The Effect of 5-α Reductase Inhibitor on Male Reproductive Function

Abstract Introduction 5α-reductase inhibitor (5-ARI) such as finasteride or dutasteride has been approved to treat benign prostatic hyperplasia and androgenic alopecia (male pattern hair loss), which blocks the conversion of testosterone to dihydrotestosterone. With expanding usage among young men, concerns exist regarding potential negative influence of this hormonal agent on male reproductive function. Objective We investigated the effect of 5-ARI usage on the sexual and reproductive function in men of reproductive age. Methods This study included healthy males of reproductive age who visited single fertility center. We compared the sexual and reproductive function between those who take 5-ARI for androgenic alopecia (n=40) and no medication group (n=48). Erectile function was surveyed using IIEF-5 questionnaire. In addition to basic fertility evaluation, semen parameters and serum reproductive hormone were compared between groups. Semen samples were collected with abstinence period of more than 48 hours. Patients with chronic medical disease, previous scrotal surgery or exposure to gonadotoxic agents were excluded. Results The mean duration of 5-ARI intake was 54.2 months and there was no significant difference in IIEF-5 score between the two groups (5-ARI group vs. control group). There was no significant difference in semen parameters; sperm concentration ([101.5 ± 68.7]×10^6/mL vs. [97.5 ± 65.5]×10^6/mL, p=0.783), sperm motility (39.8% ± 9.0% vs. 42.0% ± 8.5%, p=0.224), sperm progressive motility (37.4% ± 9.4% vs. 39.0% ± 9.0%, p=0.404), sperm morphology (normal forms: 4.5% ± 1.4% vs. 4.8% ± 1.1%, p=0.308), except smaller semen volume in 5-ARI group (2.3 ± 0.9 mL vs. 3.4 ± 1.4 mL, p<0.001). Serum testosterone and FSH were higher in 5-ARI group. Two patients experienced adverse events while taking 5-ARI. Conclusions Our study suggests that administration of 5-ARI does not significantly affect male reproductive function. However, a prudent approach is recommended in men with oligospermia or ejaculatory dysfunction. Disclosure No.

(079) Stripping vs Ligation of Vas Deferens in Microscopic Denervation of Spermatic Cord in Men with Chronic Orchialgia: A Multicenter Study

Abstract Introduction Microdenervation of the spermatic cord (MSCD) is an effective treatment modality for men with intractable scrotal content pain. For patients not interested in preserving fertility, some centers advocate ligation of the vas during denervation while others perfer stripping of the Vas deferens to preserve the vasal artery, hence preserving vasculature to testis and possibly decreasing post operative congestion pain. Objective This multicenter study analyzes outcomes of patients that underwent MSCD by either stripping or ligating the vas deferens Methods A retrospective chart review of 85 patients who underwent MSCD from 2020-2023 was performed. Patients’ demographics including history of prior surgical procedures was recorded. Response to surgery was evaluated as either complete resolution of pain, partial resolution of pain or no improvement in pain. Results 85 patients underwent MSCD with a median (IQR) age of 36 (25.5-46.5) years and median duration of pain of 16 months. 37 patients underwent stripping of vas while 48 underwent ligation of vas during MSCD. Median follow up was 12 months. 21(43.5%) patients had prior inguinal scrotal surgery in ligation group compared to 5 (13.5%) in the stripping group p=0.003. The etiology of pain was similar between the groups. The response to MSCD between the 2 groups was similar (p=0.968), with similar post op complications (Table 1). Conclusions In men with intractable chronic scrotal content with no interest in preserving fertility, ligation or stripping of the vas deferens yields similar outcomes with regards to pain resolution. Both techniques are safe with no reports of any testicular atrophy. Disclosure No.

Inguinal metastases of testicular cancer. Report of two cases

Case description: We present a series of two cases of patients presenting testicular cancer associated to inguinal masses. First, a 28 year-old male with history of bilateral orchidopexy presenting a right abscessed inguinal mass associated to a left testicular mass. Teratoma was diagnosed by the pathological anatomy. The second case is a 52 year-old male patient with a history of bilateral orchidopexy and right inguinal orchiectomy due to seminoma. A PET scan obtained during follow-up, showed a right inguinal mass with enhanced tracer uptake. A biopsy of such mass was performed, reporting metastasis of seminoma. Relevance: Due to the anatomy of the lymphatic drainage of the testes, retroperitoneal nodes constitute the first station for metastases. However, this drainage is modified in patients with history of inguinal or scrotal surgery, as anastomosis with inguinal vessels are formed. Clinical implication: Even though testicular cancer spreads through the lymphatic system to retroperitoneal nodes, in the rare cases that inguinal masses occur, these are considered as distant metastasis, changing the patient´s stage. Conclusion: Although inguinal metastases in testicular cancer are infrequent, they can be present in patients who underwent scrotal surgery. These should be considered as regional and not distant metastases.

Comparison of Scrotal Hitch Technique and Conventional Scrotal Dressing in Reducing the Postoperative Scrotal Oedema in Inguinoscrotal Surgeries: A Non Randomised Clinical Study

Introduction: Inguinoscrotal swellings, including hernias and hydroceles, are the most common complaints in the surgical outpatient department. Hernioplasty and eversion of the sac are the most common elective procedures for inguinoscrotal swellings. Scrotal oedema is one of the complications following the surgery, which increases the patient’s morbidity. Aim: To evaluate the effectiveness of the scrotal hitch technique in preventing scrotal oedema and postoperative pain after inguinal and scrotal surgeries compared to conventional scrotal dressing. Materials and Methods: This is a non randomised clinical study conducted in the Department of General Surgery at Melmaruvathur Adhiparasakhti Institute of Medical Sciences and Research, Melmaruvathur, Tamil Nadu, India, from September 2021 to December 2023, among 60 patients undergoing inguinoscrotal surgeries. Group-A consists of 30 patients who were given scrotal hitch and 30 patients in Group-B were given conventional scrotal dressing. The outcomes were compared between both groups for scrotal oedema and postoperative pain. Descriptive statistics were presented as mean±Standard Deviation (SD) for continuous variables and frequencies and percentages for categorical variables. Fisher’s-exact test was used as a test of significance for categorical data. Student’s t-test and Mann-Whitney U test were used as tests of significance for continuous data. Results: The mean age of patients in Group-A was 51.7±13.87 years and in Group-B was 53.03±14.22 years. In Group-A, two patients developed scrotal oedema with the scrotal hitch, while in Group-B with scrotal dressing, 11 patients developed scrotal oedema 72 hours postsurgery. In Group-A, the median Visual Analogue Scale (VAS) score at 6, 24, 48 and 72 hours was 6, 3, 1 and 0. In Group-B, the median VAS score was 7, 4, 1 and 0 at 6, 24, 48 and 72 hours. Conclusion: Postoperative pain was found to be lower in the scrotal hitch group compared to patients with conventional scrotal dressing.

Atypical presentation of testicular mesothelioma

Mesothelioma is a rare cancer that generally affects the lining of the lungs. However, in more rare cases, there are extra-pleural involvement of organs that are lined with mesothelial cells, including the testicle. Mesothelioma of the tunica vaginalis of the testicle typically presents with a painless scrotal mass with accompanying hydrocele of the affected side. The most common predisposition to mesothelioma of the tunica vaginalis is previous asbestos exposure, long-standing hydrocele, and previous scrotal surgeries. In this case we present a patient with isolated left tunica vaginalis mesothelioma of the testicle, yet without classic risk factors or other sites of disease. Left radical orchiectomy was performed and subsequent follow-up imaging did not reveal any sites of recurrence or metastasis. Although, mesothelioma of the tunica vaginalis is a rare cancer, it should be seen as a possible differential when evaluating new testicular masses.

Embryological basis of polyorchidism including classification, reproductive potential, and risk of malignancy: A review.

Polyorchidism, a congenital malformation characterized by supernumerary testes (SNTs), is usually revealed incidentally during ultrasound or open scrotal surgery. In the approximately 200 cases so far published in the literature, the left side is affected more often than the right. Despite the rarity of this anomaly, a surgeon must have basic knowledge of its embryological basis and classifications to implement proper treatment and avoid overlooking it, since the consequences could harm the patient. This review summarizes previous classifications. It can be assumed that determining the risk of malignancy, and the level of reproductive potential based on location, vascularization, ductus deferens drainage, and environmental factors (e.g., temperature) affecting the SNTs, indicates the best approach to management. Therefore, we have created a new classification based on previous ones, addressing the aforementioned issues, which will guide the clinician to select the most appropriate treatment.

(284) A Systematic Review of Loco-sedative Anesthesia for Penile and Scrotal Surgery

Abstract Introduction The current standard of care for patients undergoing the majority of scrotal and penile procedures is to administer general or spinal anesthesia. The use of general or spinal anesthesia can lead to several complications, long wait times and is not feasible in many rural and remote areas. Objective The objective of this study is to perform a systematic review of the characteristics and outcomes of conscious sedation and local anesthesia for penile and scrotal urologic procedures. Methods A systematic search was conducted on PubMed, and Scopus databases following PRISMA criteria from inception to August 2021. Articles were included if they were prospective, randomized or non-randomized controlled trials that used local anesthetic or conscious sedation for penile or scrotal interventions. Additionally, included studies provided primary data on the use loco-sedative anesthesia and the efficacy and complications from the procedures. Results Nine articles with 4511 patients were included in the study. Procedures examined included vasectomies, adult circumcisions, varicocelectomies, urethrocutaneous fistula repair, microepididymal sperm aspiration and testicular sperm extraction. Of the studies that reported age, the mean patient age was 29.3 years old. The most common anesthetic and analgesic relief was the use of local anesthetic with 1% lidocaine. Only one study used conscious sedation whereas the rest used local anesthetics. However, there was significant heterogeneity in the type of local or conscious sedation method and whether there was a combination was used. 44.4% of the studies used the visual analog scale (VAS) for their primary endpoint. All the studies reported 100% successful procedures with no sedative complications. Conclusions Given the high efficacy rates, loco-sedative anesthesia is a promising technique for penile and scrotal urologic interventions. However, the current body of literature has limited data on a wider array of procedures. Further controlled studies examining the use of loco-sedative anesthesia for a larger variety of penile and scrotal interventions are recommended. This review also demonstrates the significant heterogeneity on how sedation may be assessed and the variety of local anesthetics that can be used to substitute for general or spinal anesthesia. Disclosure No

(181) Combination Clomiphene Citrate and Anastrozole Therapy Iimproves Semen Parameters in a Multi-institutional Cohort of Men with Idiopathic Infertility

Abstract Introduction Clomiphene citrate (CC), a selective estrogen receptor modulator, and anastrozole, a selective aromatase inhibitor, are common empiric medical therapies for men with idiopathic infertility. The effects of jointly administering these agents are not well understood. Objective The objective of this study is to compare semen parameters in men treated with clomiphene citrate and anastrozole (CC-A) combination therapy to those in men taking anastrozole alone. Methods We performed a multi-center, retrospective cohort study of men with idiopathic infertility prescribed anastrozole at two tertiary referral institutions. Demographic, laboratory, and prescription data were captured. The subset of patients taking CC at the time of anastrozole initiation were identified. Patients with pre-treatment normozoospermia, recent or current exogenous testosterone or human chorionic gonadotropin use, previous orchiectomy, and scrotal surgery during the treatment period were excluded. Outcome measures included changes in World Health Organization sperm concentration category (WHO-SCC) following initiation of anastrozole therapy. Linear and logistic regression models were constructed to evaluate the association of combination therapy with these outcomes. Results 72 men were included in the analysis cohort, including 54 men taking anastrozole alone and 18 men on CC therapy who subsequently started taking anastrozole (CC-A). Men on CC-A relative to anastrozole monotherapy were older (40 vs. 35 years, p=0.03) and had a lower BMI (30 vs. 34 kg/m^2, p=0.05), respectively. Pre-treatment LH levels (5.6 vs. 7.6 IU/L, p=0.25) and testosterone (336 vs 263 ng/dL, p=0.32) were similar. Baseline semen parameters including sperm concentration (3.7 vs. 2.3 M/mL, p=0.26) and motility (41 vs. 36%, p= 0.17) were also comparable. However, post-treatment median sperm concentration (6.9 vs. 3.4M/mL, p=0.02) and the change in mean sperm concentration (17.5 vs. 6.2 M/mL, p=0.03) were significantly higher in the CC-A combination group. Univariate linear regression also revealed an association between the use of CCA combination therapy and increase in sperm concentration (p=0.05). Despite these differences, WHO-SCC upgrade rates between groups were comparable (56 vs. 39%, p=0.22) in the setting of similar post-treatment levels of LH (7.4 vs. 8.6 IU/L, p=0.5), FSH (8.6 vs. 9.4 IU/mL, p=0.19), and testosterone (537 vs. 415 ng/dL, p=0.09). Conclusions Combination therapy with clomiphene citrate and anastrozole was associated with modest benefits in post-treatment sperm concentration when compared to anastrozole monotherapy. Combination empiric medical therapy using clomiphene citrate and anastrozole offers a small, but significant, clinical benefit over anastrozole alone for infertile men Disclosure No

(287) Office-Based Epididymectomy and Spermatocelectomy Under Local Anesthesia – An Excellent Option to Avoid General Anesthesia and Increase Access to Timely Care

Abstract Introduction Epididymectomy is indicated for patients with focal epididymal pain and bothersome epididymal cysts or masses. Similarly, spermatocelectomy is indicated for spermatoceles that have becomes symptomatic due to size or pain. The majority of scrotal surgeries are performed in the operating room (OR) using general or monitored anesthesia. Here, we sought to evaluate our experience with office-based epididymectomy and spermatocelectomy using only local anesthesia. Objective To evaluate post-procedural complications and pain resolution following epididymectomy or spermatocelectomy, comparing procedures performed in the clinic with only local anesthesia, compared to the OR. Methods We identified patients who underwent epididymectomy or spermatocelectomy at our institution from 2018-2021. A chart review was performed to identify pertinent information including whether the procedure was performed in the OR under monitored/general anesthesia versus in the clinic using only local anesthesia. Post-procedural outcomes including pain resolution (if applicable) and 30-day complications were compared between those who underwent epididymectomy or spermatocelectomy in the OR versus the office. Statistical analysis was performed using the chi-squared test. Results A total of 112 patients were identified, including 23 (20.5%) who underwent epididymectomy and 89 (79.5%) who underwent spermatocelectomy. Mean patient follow-up was 14.8 months (SD 11.6). Indications for epididymectomy or spermatocelectomy included pain (n= 50, 44.6%), epididymal cyst/mass (n=6, 5.4%), and mass effect secondary to spermatocele (n=56, 50.0%). Fifty-seven procedures (50.9%) were performed in the office under local anesthesia. Nitrous oxide was used in 21 (36.8%) of these cases. Thirty-four patients (30.3%) were on anticoagulation/antiplatelet therapy prior to surgery including 22 (64.7%) who continued anticoagulation/antiplatelet therapy due to high-risk comorbidities. The adverse event rate within 30 days was similar between patients who underwent surgery in clinic versus OR (p=0.67). Specifically, adverse events occurred in 9 patients (8.0%), of whom 4 had their procedure performed in the clinic (7.0% of clinic procedures) and 5 had their procedure performed in the OR (9.1% of OR procedures). Specific adverse events included postoperative hematoma in 6 patients (66%) and a single case of each of the following: infection, inability to void postoperatively, and intestinal obstruction. Hematoma rates did not differ significantly between those who were or were not on anticoagulation perioperatively (p=0.057). In patients with reported adverse events, 3 (33.3%) required reoperation. Of the 50 patients who underwent epididymectomy or spermatocelectomy for scrotal content pain, 39 had sufficient documentation available to evaluate pain resolution. 82% (n=32) reported 50% improvement in pain. There was no statistically significant difference in the likelihood of reporting significant pain reduction based on the location of the procedure (OR versus clinic). Conclusions Epididymectomy and spermatocelectomy can be successfully carried out in the office using only local anesthesia, including in those patients who are high risk for general anesthesia or require maintenance of anticoagulation perioperatively. Pain improvement may be anticipated in the majority of appropriately selected patients following treatment in either the clinic or OR. Disclosure No

MP62-19 STRIP OR LIGATE THE VAS DEFERENS DURING MICROSCOPIC SPERMATIC CORD DENERVATION FOR CHRONIC SCROTAL CONTENT PAIN? A MULTICENTER STUDY

You have accessJournal of UrologyCME1 Apr 2023MP62-19 STRIP OR LIGATE THE VAS DEFERENS DURING MICROSCOPIC SPERMATIC CORD DENERVATION FOR CHRONIC SCROTAL CONTENT PAIN? A MULTICENTER STUDY Adnan El-Achkar, Muhammed Hammad, David Barham, Charles Loeb, Jake Miller, Lawrence Jenkins, Tung Chin Hsieh, Darshan Patel, Siriam Eleswarapu, Jesse Mills, and Faysal Yafi Adnan El-AchkarAdnan El-Achkar More articles by this author , Muhammed HammadMuhammed Hammad More articles by this author , David BarhamDavid Barham More articles by this author , Charles LoebCharles Loeb More articles by this author , Jake MillerJake Miller More articles by this author , Lawrence JenkinsLawrence Jenkins More articles by this author , Tung Chin HsiehTung Chin Hsieh More articles by this author , Darshan PatelDarshan Patel More articles by this author , Siriam EleswarapuSiriam Eleswarapu More articles by this author , Jesse MillsJesse Mills More articles by this author , and Faysal YafiFaysal Yafi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003320.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Microscopic denervation of the spermatic cord (MSCD) is an effective treatment for men with intractable scrotal content pain (SCP). For patients not interested in preserving fertility, some advocate ligation of the vas deferens during MSCD while others prefer stripping. This multicenter study sought to compare these two techniques in the aim of determining which intervention provides better pain relief. METHODS: A retrospective chart review of 59 patients who underwent MSCD for SCP (> 3 months duration, no structural abnormalities and no history of vasectomy or other scrotal surgery) from 2020-2022 was performed. Patients’ demographics including history of prior surgical procedures was recorded. Response to surgery was evaluated as either complete resolution of pain, partial resolution of pain or no improvement in pain. RESULTS: 59 patients underwent MSCD with a median age of 35 (IQR 25-37) years and median duration of pain of 18 months (IQR 12-32). 37 patients (62%) underwent stripping of the vas while 22 (38%) underwent ligation. Five patients (13%) had prior inguinal surgery in the stripping group compared to 11 (50%) in the ligation group. There was no significant difference between the groups regarding suspected etiology. There was no significant difference in response to MSCD between the 2 groups (stripping: 68% complete and 27% partial response; ligation: 82% complete, 18% partial response, p =0.36). There were no serious post-operative complications in either group (Table 1). CONCLUSIONS: In men with intractable chronic SCP with no interest in preserving fertility, ligation or stripping of the vas deferens seems to yield comparable outcomes with regards to pain resolution. Both techniques are safe with no reports of serious post-operative complications. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e869 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Adnan El-Achkar More articles by this author Muhammed Hammad More articles by this author David Barham More articles by this author Charles Loeb More articles by this author Jake Miller More articles by this author Lawrence Jenkins More articles by this author Tung Chin Hsieh More articles by this author Darshan Patel More articles by this author Siriam Eleswarapu More articles by this author Jesse Mills More articles by this author Faysal Yafi More articles by this author Expand All Advertisement PDF downloadLoading ...

MP62-20 EFFECTS OF ADJUVANT DEXMEDETOMIDINE IN DORSAL PENILE BLOCK FOR PENILE PROSTHESIS IMPLANTATION

You have accessJournal of UrologyCME1 Apr 2023MP62-20 EFFECTS OF ADJUVANT DEXMEDETOMIDINE IN DORSAL PENILE BLOCK FOR PENILE PROSTHESIS IMPLANTATION Kikuye Sugiyama, Amanda Swanton, Tejash Shah, and Ricardo Munarriz Kikuye SugiyamaKikuye Sugiyama More articles by this author , Amanda SwantonAmanda Swanton More articles by this author , Tejash ShahTejash Shah More articles by this author , and Ricardo MunarrizRicardo Munarriz More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003320.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Inflatable penile prosthesis (IPP) surgery is the gold standard treatment for medication-refractory erectile dysfunction. While highly satisfactory, post-operative pain and narcotic requirement remains a concern. Use of intraoperative dorsal penile nerve block with long acting local anesthetic can improve postoperative analgesia. Recent studies in non-urologic fields have demonstrated prolonged analgesia with minimal adverse effects with local nerve blocks containing long acting local anesthetic with either dexamethasone or dexmedetomidine. This study aims to evaluate the analgesic efficacy of these adjuvants in bupivacaine penile nerve block as compared to a bupivacaine-only block during primary IPP surgery. METHODS: This is a retrospective single institution IRB-approved comparative study of patients undergoing primary IPP placement receiving intraoperative dorsal penile nerve block with either 0.25% bupivacaine (2019) versus combination block with 0.25% bupivacaine+70 µg dexmedetomidine+4 mg dexamethasone (2020 - 2021). The primary outcome was pain during the first 24 hours post-operatively (0, 2, 6, 12, 18, and 24 hrs) while secondary outcomes were intra- and postoperative narcotic use, intraoperative hypotension defined here as MAP<60 for more than 5 minutes or requiring intervention, and intraoperative bradycardia defined here as HR<50 for more than a minute. RESULTS: Of 98 the patients included, 32 received bupivacaine only and 66 received the combination block. Mean PACU pain in the first 24 hours at all times (0, 2, 6, 12, 18, 24 hrs) were significantly lower in the combination block group (1.1 vs 3.8, 1.6 vs 3.9, 3.1 vs 4.9, 2.4 vs 4.3, 2.9 vs 5.3, 2.3 vs 4.4; p<0.05). Mean total postoperative narcotics was lower for the combination block (46 vs 65, p<0.05). There was no significant difference in intraoperative narcotics between groups (111 vs 132; p=0.133). Of patients who received the combination block, 4 had intraoperative hypotension of MAP<60 for more than 5 minutes and 114 had bradycardia below 50 but did not require intervention. CONCLUSIONS: Intraoperative dorsal penile nerve block consisting of long acting local anesthetic mixed with dexmedetomidine and dexamethasone can safely enhance immediate post-operative analgesia and decrease opioid consumption in the first 24 hours after surgery. A prospective randomized study is underway to further evaluate outcomes. This type of combination penile nerve block may also be a useful tool for other penile and scrotal surgeries. Source of Funding: Unfunded © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e870 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kikuye Sugiyama More articles by this author Amanda Swanton More articles by this author Tejash Shah More articles by this author Ricardo Munarriz More articles by this author Expand All Advertisement PDF downloadLoading ...