Microsurgical denervation of the spermatic cord with tunica vaginalis fenestration: results of a case series with a review of the literature

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Microsurgical denervation of the spermatic cord with tunica vaginalis fenestration: results of a case series with a review of the literature

https://doi.org/10.21203/rs.3.rs-3406057/v1

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Microsurgical denervation of the spermatic cord (MDSC) is one of the lines of management of chronic orchialgia, but it has not been fully adopted by different centers. This article reviews a case series experience with a review of the literature. Eighteen patients (18 testicular units) with chronic orchialgia, unresponsive to medical treatment were prospectively enrolled in this study. All underwent unilateral MDSC with a slight modification in the technique (tunica vaginalis fenestration). Efficacy of the technique was evaluated by the degree of pain improvement using the Visual Analogue Scale (VAS) which was done preoperatively and 6 months postoperatively. Safety was assessed by reporting any intra- or post-operative complications. Available literature was reviewed looking at safety and efficacy of the technique. Six patients had complete pain resolution, 11 had partial but significant resolution of their pain and the pain remained the same in one patient following MDSC. The VAS pain score significantly improved from a median (IQR) of 8(7.25-9) to 2(2-4.75) postoperatively (p=0.0029). No significant complications have been encountered in this study. So, MDSC seems to be a safe and efficacious surgical option for the treatment of resistant chronic scrotal pain (CSP) and should be more widely adopted by specialized centers.

Health sciences/Diseases/Urogenital diseases

Health sciences/Diseases/Urogenital diseases/Sexual dysfunction

chronic scrotal pain

chronic orchialgia

microsurgical denervation of the spermatic cord.

Chronic scrotal pain (CSP) is defined as intermittent or persistent unilateral or bilateral scrotal pain lasting for more than 3 months and negatively affecting patient’s daily activities and his sense of wellbeing. The prevalence and possible causes of CSP have never been clearly addressed in the literature. However, it represents a challenging problem for both patients and physicians. [1, 2]

It could be attributed to varicocele, testicular lesions, infection, torsion and detorsion, trauma, vasectomy among other causes. However, 25–50% of cases would be idiopathic and frustrating as there is no clear treatment approach. [3, 4]

Patients with CSP should be systematically evaluated by: accurate history taking; thorough examination; ruling out possible causes by urine culture; scrotal and renal tract scans for local causes; and referred pain from ureters, prostate or lumbar spine. [3, 4]

The pathophysiology of CSP is still poorly understood. Any damage to any of the scrotal contents; following the above-mentioned possible causes, could lead to peripheral neural injury and Wallerian degeneration and nerve sensitization. [5, 6]

The initial treatment strategy should be conservative in the form of treatment of the cause if applicable, analgesics, antibiotic trials and alpha blockers. If the response is not satisfactory, the surgical option including the (Microsurgical denervation of the spermatic cord) MDSC could then be considered. [7]

Some authors have reported on the outcome of the MDSC. [8–18] However, the technique is still not adequately adopted in many centers. Herein; we report on a case series of MDSC; the initial outcome, description of the technique with a review of the literature.

The study was conducted as an audit over 24-month period, starting from June 2021 at one centre. Twenty one patients with chronic unilateral scrotal pain more than 6 months and refractory to conservative lines of therapy who underwent MDSC; were initially included. Patients were evaluated by complete history taking, general and local genital examination. We performed urine analysis and culture, semen analyses and culture and pelvi-abdominal and scrotal ultrasonography to exclude any treatable cause of their CSP. Pain was assessed using the visual analogue pain score (VAS) which was completed by all patients. All patients included in the study signed informed, written consent that have been approved by a local ethics committee.

All MDSC procedures (Fig. 1) were performed by one surgeon (AR), the technique utilized entailed the delivery of the cord through a small 2-cm subinguinal skin incision. A 2cm segment of the cremasteric muscle was then excised all around the cord. The fascia covering the cord was then opened, ligated and divided. Using the surgical microscope, the fascia covering the vas was opened and stripped over a 2cm segment with the sparing of the vasal vessels. The internal spermatic veins were ligated and divided with a 2cm segment excised, the tissue in between was also divided with a 2cm segment excised. At the end of the procedure the testicular artery, with its immediate surrounding veins, a few lymphatics, the vas and vasal vessels were spared. All other cord structures were ligated and divided with a 2cm segment excised. We have added a modification to the technique whereby at the end of the procedure the testis was delivered through the same incision, the tunica vaginalis was opened and 2x2cm piece of tunica was excised with under-running of the edges in order to avoid postoperative hydrocele (prophylactic mini-hydrocelectomy).

All patients were asked to fill in VAS 6 months postoperatively. We adopted the conclusion of Kelly AM who defined the minimum clinically significant difference (MCSD) in VAS pain score as the mean difference between current and baseline scores when pain is reported as a little better or a little worse. [19]

Differences in MCSD of less than 9 mm were unlikely to have clinical significance even if they were statistically significant. Moreover, Intra and postoperative complications were retrieved from patients’ records.

Twenty one patients with unilateral CSP, not responding to medical treatment were enrolled in the study. However, 3 lost in follow up and a total of 18 completed the study. Pain was purely testicular in 3, purely epididymal in 3 and in the other 12 cases, pain originated from both the testis and the epididymis. The median (IQR) age of the studied population was 43.5 (33.2–71.2) years. The median (IQR) pain duration was 3 (2-6.75) years. Previous scrotal surgery was the cause of pain in 5 patients (vasectomy, 2 patients; artificial urinary sphincter surgery, 2 patients; epididymal cyst excision, 1 patient). Pain occurred following epididymitis in 3, trauma in 3 cases while the remaining 7 had no obvious cause (idiopathic).

Six patients showed complete pain remission, 11 patients showed partial but statistically and clinically significant improvement in their pain perception (p = 0.0029) [19] and no pain relief was noticed in a single patient. On further analysis of pain improvement of the 17 patients, the VAS pain score improved from a median (IQR) of 8(7.25-9) to 2(2-4.75) postoperatively. (p = 0.0029) (Fig. 2) This reflects not only statistically significant improvement, but also clinically significant improvement according to the MCSD as it was more than 9mm on the VAS scale in every patient of the 17 who improved. [19] Complications were encountered in 3 patients (16.66%) in the form of a small scrotal haematoma which developed postoperatively and was successfully managed conservatively. Another patient developed small hydrocele and the third experienced incision site neuralgia.

Chronic scrotal pain is a condition that causes significant bother to patients and can be quite frustrating to urologists because of the lack of clear management guidelines and the fact that it is idiopathic in up to half of the cases.[3, 4] The exact prevalence is not known but it may account to 2.5% of the urology outpatient clinic visits. [20]

Patients should be fully assessed by history taking, physical examination, imaging, urine and semen cultures in order to rule out treatable causes for the pain such as varicocele, chronic urogenital infection or causes of referred pain such as renal calculi. If no treatable cause is identified, initial management includes anti-inflammatory drugs, analgesics, empirical antibiotics and alpha blockers. [7]

Surgery is only considered after failure of conservative lines of therapy. Surgical options include; vasectomy reversal and/or excision of sperm granuloma in post vasectomy pain, epididymectomy, orchidectomy and MDSC.

Vasectomy reversal has a success rate of 69–84%. [21] However, it will restore the patient’s fertility which is not a convenient option to those who originally chose to have a vasectomy as a male contraceptive method. Epididymectomy has a success rate of 10–80% but will only be useful if the pain is confined to the epididymis. [22] Epididymectomy will also impair the fertility potential and this may not be a good option for younger patients who haven’t completed their family. Orchidectomy is effective in 20–80% of cases but will impair both fertility and testosterone production in addition to the aesthetic and psychological drawbacks. [13, 23]

Microsurgical denervation of the spermatic cord is another surgical option that can be considered in CSP cases not responding to medical treatment. This technique was first described in 1978 by Devine and Schellhammer. [24] It has the advantage of not affecting fertility or testosterone production in addition to having a better outcome for pain control. [25]

Chronic scrotal pain is mediated by the spermatic and scrotal branches of the genital branch of genitofemoral nerve, ilioinguinal nerve and sympathetic fibers around testicular arteries. The rationale of the MDSC technique can be justified by the study of Parekattil et al, who found that 84% of the nerve fibers of the spermatic cord in men with CSP showed Wallerian degeneration. Moreover, they described the density of these pathological nerves to be higher within the cremasteric muscle fibers, followed by peri-vasal tissues and least in lipomatous and perivascular tissues (trifecta nerve complex). Thus, cutting the afferent pain pathway signals may lead to down-regulation of the central pain receptors and eventually pain perception control. [26]

After a Medline search, we found 12 studies reporting the outcome of MDSC (Table 1). MSDC was done to 707 patients complaining of chronic testicular pain in the 12 reviewed studies. Studies showed that MDSC is effective in 71–96% of the cases and has a complication rate of 0-8.9%. Reported complications include testicular atrophy, hydrocele, haematocele, wound infection and haematoma. [8–18]

In the current case series, the technique was effective in 17/18 patients and complications encountered were minor in nature (small scrotal heamatoma, small hydrocele and wound neuralgia; all were conservatively managed). The extra time and effort taken in sparing some of the lymphatic vessels; in addition to making a fenestration in the tunica vaginalis, which is a modification that we have added to the original technique prevents hydrocele formation. Most experienced microsurgeons should be able to identify and spare the testicular artery however it is important to spare a few veins in order to prevent venous ischaemia. In our technique we spared the veins immediately surrounding the testicular artery which are usually 1–2 veins.

Conventional MDSC is performed with surgical microscopes, however, other methods have also been tested. Caddedu et al used a laparoscopic approach while Parekattil and Gudeloglu used a robot-assisted approach on a series of 9 and 401 patients respectively with pain improvement in 77.8 and 86% of the cases respectively.[9, 15]

The limitations of this study are the small sample size and the absence of validated questionnaires to assess the changes in the quality of life. However, it represents our initial experience with MDSC with full description of the modified technique, which is not yet fully adopted by specialists as a surgical option to CSP refractory to conservative lines of therapy. Our experience suggests that MDSC is a safe and effective surgical option for those patients and should be used instead of the other surgeries performed for those cases, namely: vasectomy reversal, epididymectomy and orchidectomy.

MDSC is a safe and efficacious option for men with chronic scrotal pain refractory to conservative lines of therapy. Tunica vaginalis fenestration is a modification of the technique which can prevent post operative hydrocele formation. Further studies are warranted to consolidate these initial results.

Competing interests: nothing to be declared.

Funding: none.

Authors' contributions: All authors have read and approved the manuscript. AR and KA suggested the idea and performed the surgeries, TR & IA retrieved the data, AM did the statistical analysis, AR, TA, IA and KA wrote the draft and all the authors reviewed the drafts until the final manuscript was reached.

Acknowledgements: none

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Table1: reports on the outcome of MSCD.

Study	Design	Number of testis units	Mean follow up in months	Efficacy (complete/ partial/ no response)	Complications
Choa et al, 1992	Prospective	4	18.5	100/0/0	None
Cadeddu JA et al, 1999	Retrospective	9	25.1	0/77.8/22.2	None
Levine et al, 1996	Prospective	7	16.6	85.7/0/14.3	None
Levine LA &Matkov TG, 2001	Prospective	33	20	76/9.1/15	None
Heidenreich et al 2002	Prospective	25	31.5	96/0/1	None
Strom KH & Levine LA 2008	Prospective	95	20.3	71/17/12	8.9% Testicular atrophy 2, wound inf 2, hydrocele 2, incision hematoma 1
Oliviera et al 2009	Prospective	10	24m	70/20/0	None
Parekattil and Gudeloglu, 2013	Prospective	401	23	72/14/14	3% 1 atrophy, 9 hematoma, 2 seroma
Cassidy et al, 2015	Prospective	9	3-9	77/22 /1	None
Marconi et al 2015	Multicenter open label prospective trial	52	6	80/12/8	4% 1 haematocele, 1 hydrocele
Chaudhari et al 2019	Prospective	62	48	81.6/10.5/7.9	superficial wound infection in 3 units, hydrocele in 2 units, seroma in 2 units, and an incisional hematoma in 1 unit

There is NO conflict of interest to disclose.

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Microsurgical denervation of the spermatic cord with tunica vaginalis fenestration: results of a case series with a review of the literature

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