1880 TRIFECTA OF PAIN: ANATOMIC BASIS FOR DENERVATION OF THE SPERMATIC CORD FOR CHRONIC ORCHIALGIA

Robotic assisted andrological surgery

The introduction of the operative microscope for andrological surgery in the 1970s provided enhanced magnification and accuracy, unparalleled to any previous visual loop or magnification techniques. This technology revolutionized techniques for microsurgery in andrology. Today, we may be on the verge of a second such revolution by the incorporation of robotic assisted platforms for microsurgery in andrology. Robotic assisted microsurgery is being utilized to a greater degree in andrology and a number of other microsurgical fields, such as ophthalmology, hand surgery, plastics and reconstructive surgery. The potential advantages of robotic assisted platforms include elimination of tremor, improved stability, surgeon ergonomics, scalability of motion, multi-input visual interphases with up to three simultaneous visual views, enhanced magnification, and the ability to manipulate three surgical instruments and cameras simultaneously. This review paper begins with the historical development of robotic microsurgery. It then provides an in-depth presentation of the technique and outcomes of common robotic microsurgical andrological procedures, such as vasectomy reversal, subinguinal varicocelectomy, targeted spermatic cord denervation (for chronic orchialgia) and robotic assisted microsurgical testicular sperm extraction (microTESE).

Microdenervation of the spermatic cord for chronic scrotal content pain: single institution review analyzing success rate after prior attempts at surgical correction

PURPOSE

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.

MATERIALS AND METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Does a positive response to spermatic cord block predict response to microdenervation of the spermatic cord for chronic scrotal content pain?

INTRODUCTION

Microdenervation of the spermatic cord (MDSC) has been demonstrated to be an effective treatment for men with intractable scrotal content pain.

AIM

This study evaluates the correlation between a positive response to a spermatic cord block with local anesthetic and the subsequent surgical outcome following MDSC.

MAIN OUTCOME MEASURES

Pre- and post-cord block pain and pre- and post-MDSC pain.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Chronic orchialgia: evaluation and discussion of treatment options

Virtually all practicing urologists will encounter patients with a complaint of chronic testicular pain. This can be a frustrating process for both patient and physician, as there is no clearly established effective treatment regimen, nor is there a recognized and accepted standard protocol for evaluation. Many of these patients will see multiple physicians during the course of their evaluation, further increasing their frustration and potentially straining the physician/patient relationship. The etiology of testicular pain is varied and is frequently idiopathic. Easily recognized and reversible causes include spermatocele, tumor, infection, varicocele, and torsion. Chronic orchialgia has been defined as at least 3 months of chronic or intermittent pain. Although the diagnosis of chronic orchialgia is frequently given to these patients, it should be recognized that fairly frequently the patient will not have just testicular pain, but may have pain involving the epididymis, vas deferens, or adjacent paratesticular structures. Therefore a more appropriate term would be chronic scrotal content pain. This article reviews the current understanding of chronic scrotal content pain, reviewing the etiology, evaluation, and then a systematic review of the published literature on treatment. It should be recognized that the majority of the published literature are cohort studies with limited numbers of patients, rarely placebo-controlled, and without a uniform standard evaluation. Microdenervation of the spermatic cord is emerging as a reasonable and effective outpatient surgical technique to resolve chronic scrotal content pain, and successful results appear to be predicted by a temporary but complete response to a spermatic cord block.