Microsurgical Denervation of the Spermatic Cord: A Surgical Alternative in the Treatment of Chronic Orchialgia

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THE JOURNAL OF UROLOGY

Vol. 155, 1005-1007. March 1996 Printed in LISA

Copyright 0 1996 by AMERICAN UROLOOICAL ASS~CIATION, hc.

Urologists At Work MICROSURGICAL DENERVATION OF THE SPERMATIC CORD: A SURGICAL ALTERNATrVE IN THE TREATMENT OF CHRONIC ORCHIALGIA LAURENCE A. LEVINE,* THOMAS G. MATKOV AND TIMOTHY R. LUBENOW From the Departments of Urology and Anesthesia (Rush Pain Center),Rush-Presbyterian-St. Luke’s Medical Center, Chicago, Illinois

ABSTRACT

Purpose: We demonstrated effective treatment of chronic orchialgia by microsurgical denervation of the spermatic cord. Materials and Methods: Seven men with a history of chronic orchialgia (mean duration 16.6 months) underwent this surgical procedure a h r conservative treatment failed. A bupivacaine spermatic cord block resulted in temporary pain relief. Results: There was an excellent correlation between the response to preoperative temporary cord nerve block and the surgical result. Six men had complete and permanent pain relief aRer surgery. One patient with bilateral orchialgia had complete unilateral relief and partial relief on the contralateral side. There was no complaint of postoperative regional hypoesthesia. Conclusions: Microsurgical denervation of the spermatic cord is an effective testicular sparing surgical alternative for the treatment of chronic orchialgia. Key Worn: testis; pain, intractable; denervation; spermatic cord

Chronic orchialgia has been defined as intermittent or constant testicular pain lasting 3 months or longer, which interferes with normal daily activities.’ Although testicular pain is associated with various etiologies, such as infection, trauma, hydrocele, varicocele and testicular tumor, nearly 25% of these cases are of unknown origin, making diagnosis and management a frustrating clinical problem.2 It is generally agreed in the literature that the initial course of action should be nonsurgical and conservative.2.3 However, when conservative measures, such as antibiotics, analgesics, antiinflammatory agents or regional nerve blocks, fail to provide sufficient pain relief, the next course of therapy is no longer unanimous. Davis and Noble noted that inguinal orchiectomy was the most successful surgical option with 75% of their patients reporting complete relief of pain.2 In contrast, Costabile et a1 observed that 80% of their patients continued to have significant pain even after orchie~tomy.~ This variability in the response to orchiectomy only adds to the ther-

apeutic dilemma. Denervation of the spermatic cord was previously described as a surgical treatment for orchialgia in 2 patienta.4 We report our findings in 7 men who underwent microsurgical denervation of the spermatic cord in an attempt to relieve testicular pain while preserving the testicle. MATERIALS AND METHODS

Patient population. Six patients with chronic unilateral and 1 with bilateral orchialgia (mean age 45.6 years, range 36 to 59)were seen between June 1991 and September 1994. The duration of orchialgia ranged from 10 to 237 months (mean 85,see table). All 7 patients were referred for further consultation and therapy after conservative treatment with antibiotic therapy, analgesics and anti-inflammatory agents failed. In addition, 5 patients had been evaluated at a pain center and had not obtained permanent relief by an ilioinguinal, genitofemoral, caudal or hypogastric plexus nerve block, or cryoablation. Diagnostic scrotal ultrasound failed to identify a structural abnormality in any patient while psychological evaluation in 4 revealed no primary psychogenic Accepted for publication July 14, 1995. etiology for the pain. Various etiologies and symptomatola* Re uesta for reprints: Department of Urology, Rmh-Presbyteri- gies were noted, including previous inguinal or scrotal surm-St.Euke’s Medical Center, 1653 West Congress Pky., ChiCagO, gery (see table). Illinois 60612. Patient churacteristies, and results of cord block and surgical denemation Pt. Age No.4vrs.)

Mos. Pain

Etiology

1-36 2-44

12 24 237 24 10 120 (bilat.) 168

After vasectomy After inguinal hernia repair ARer vaaectamy

3-48 4-59

W 6 6-39 7-57

Outcomes Cord Block . -~

MOS.

Denemation

Complete Complete Complete Complete Complete Complete unknown Complete Complete Aftmvaseetomy Complete Complete ARer vasectomy Lt. complete, rt. partid Lt. complete, rt. partial ARer inguinalhernia repair Complete Complete

1005

Complications

‘ 0 ’ 0 ~ ~

36

30 24 8 8

7 3

None None None Teatidaratrophy None Lt.seroma, rt. hydmcele None

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MICROSURGICAL DENERVATION OF SPERMATIC CORD

An in-office spermatic cord block was performed in all patients using 10 cc 0.5% bupivacaine. After successful temporary relief of pain microsurgical spermatic cord denervation was suggested as a more permanent solution. Patients were clearly informed of the possible benefits but understood that partial relief or complete failure was possible. In addition, they were informed of risks, such as testicular atrophy, hydrocele and increased pain. One patient subsequently underwent unilateral orchiectomy. Procedure. Microsurgical denervation of the spermatic cord was performed with the patient under regional or general anesthesia. The approach was via a low inguinal incision canied down to the level of the external inguinal ring with isolation of the spermatic cord. The ilioinguinal nerve and its branches emerging from the external ring were clearly identified and divided. The proximal end of the ilioinguinal nerve was buried in the external oblique fascia to reduce the likelihood of n e m m a formation. The spermatic cord was then elevated and supported over the wound by a Penrose drain (fig. 1). When the 8 to 14X operating microscope was brought into the field, all fascia and cremasteric fibers within the cord were divided by electrocautery. To preserve the testicular artery early identification and isolation are recommended. This process may be facilitated with an intraoperative Doppler ultrasound probe. If the testicular artery is injured or not identified, then the deferential artery should be preserved. Patients who previously underwent vasectomy w i l l likely not have a patent deferential artery. The internal spermatic veins were doubly ligated and divided. Typically, several large lymphatic vessels were identified of which 1 or 2 were spared. In patients who had not undergone vasectomy the vas deferens was divided to eradicate the sympathetic innervation of this structure, which may contribute a reflex sympathetic dystrophy component to orchialgia. At the end of the procedure a testicular artery andfor deferential artery with 1 or 2 lymphatic vessels remained while all other tissue was divided (fig. 2). The cord was carefully placed back into its bed with hemostasis obtained. A 10 cc dose of 0.5% bupivacaine was injected into the proximal cord region for postoperative pain relief and the wound was closed in layers.

FIG.2. At conclusion of denervation procedure testicdar artery and lymphatic vessel remain,and all other structures are divided.

pain, experienced unilateral relief from the cord block and surgical procedure. Interestingly he had partial pain relief from the cord block only on the contralateral (right) side and a similar degree of relief after denervation. A small hydrocele developed on the side of continued pain. Ultimately he elected right inguinal orchiectomy, which resulted in complete bilateral pain relief. Followup ranged from 3 to 36 months (mean 16.6). In 1 patient the testis atrophied secondary to ischemia. ARer several weeks of testicular swelling and discomfort the pain subsided. There were no complaints due to hypoesthesia of the scrota& penile shaft,inguinal or medial thigh skin. One patient also had a seroma, which spontaneously drained and healed without sequelae. No other hydroceles were observed. DISCUSSION

When conservative treatment of chronic orchialgia fails, the next appropriate step is generally accepted to be surgery. RESULTS Six patients with unilateral testicular pain received ap- Epididymectomy,scrotal or inguinal orchiectomy, vasovasosproximately 4 to 6 hours of pain relief from the spermatic tomy and orchiopexy have been performed to relieve intractWith up to 76% success inguinal orcord block. Following denervation of the spermatic cord they able testicular pain.2~~ chiectomy is currently considered the treatment of choice.2 In reported continued complete relief of pain. The remaining patient, who initially presented with bilateral testicular our opinion testicular sacrifice as initial surgical treatment is neither necessary nor desirable. In addition, it should be noted that in 80% of patients in 1 series pain persisted after orchiectomy.3 Although denervation of the spermatic cord risks possible hydrocele formation, testicular atrophy and increased pain, these risks do not outweigh the consequences of orchiectomy. Furthermore, the psychological repercussions of genital injury leading to castration anxiety have been well documented and certainly may contribute to heightened attention to perceived pain in this area.s It makes empirical sense that all efforts should be made to spare the testicle for psychological and potentially physiological reasons. Although the surgical procedure as described may require slightly more operative time than simple orchiectomy,the possible psychologicalbenefits of preserving the testicle seem readily appreciated. Testicular pain may arise h m mtd and spermatic branches of the genitofemoral and i l i o i n m a l nerves. Theoretically, if pain is truly testicular and not referred, division of these fibers should interrupt the pathway of pain sensation. If a temporary spermatic cord block is successfulin relieving pain, surgical denervation of the cord is the next logical step. The FIG.1. LeR spermaticwrd is freed h m bed and supported over importanCe of the initial cord block must not be underestimated inguinal incision by Penrose drain. not only in verifying the diagnosisthat pain is testicular and not

1007

MICROSURGICAL,DENERVATION OF SPERMATIC CORD

referred but also as a prognostic indicator of surgicai mcce88. Although it was not used in our study, inguinal spermatic cord block with saline has been recommended to prognosticate a psychogenic or placebo component.6 This approach may further identify patients who may not benefit from surgery, especially those who notice complete or temporary pain relief after saline injection. In our study the outcome of the spermatic cord block correlated identically with the outcome of surgical spermatic cord denervation. In patient 6 pain wa8 not fully resolved with the cord block or subsequent denervation surgery. Therefore, the spermatic cord block seems essential in determining the appropriateness of this surgical procedure for any given patient. A potential alternative autonomic pathway for testicular efferent and afferent input may exist, which may be responsible for incomplete pain relief after spermatic cord block or denervation surgery. Zorn et al recently reported their experience with a transrectal ultrasound guided pelvic plexus local anesthetic block in men with chronic orchialgia.7 Of their 8 patients 6 (75%) had complete yet temporary relief of pain following this approach. The neuropathic pain associated with reflex sympathetic dystrophy has recently received attention and may be applicableto this population of patients with chronic orchialgia.S.9 The pathophysiology of this condition is poorly understood but pain can be relieved by blocking or dividing the sympathetic nerve fibers.8-1OThe majority of these fibers follow the testicular vessels and vas deferens yet they may also follow alternate routes by traveling with the pudendal vessels or hypogastric plexus. CONCLUSIONS

The goal of complete microsurgical denervation is to divide all nerve fibers, including autonomic and somatic branches

traveling with the spermatic cord. The success of this procedure in relieving chronic orchialgia in our patient population demonstrates that with proper patient selection based on the success of the spermatic cord block testicular pain can be resolved without testicular sacrifice. REFERENCES

1. Davis, B.E.,Noble, M. J., Weigel, J. W., Foret, J. D. and Mebust, W. K: Analysis and management of chronic testicular pain. J. Urol., 143: 936,1990. 2. Davis, B. E. and Noble, M. J.: Analysis and management of chronic orchalgia. AUA Update Series, vol. XI, lesson 10,1992. 3. Costabile, R. A,Habn, M. and McLeod, D. G.: Chronic orchialgia in the pain prone patient the clinical perspective. J. Urol., 146: 1571,1991. 4. Devine, C. J.,Jr. and Schellhammer, P. F.: The use of micmsurgical denervation of the spermatic cord for orchialgia. Trans. Amer. Ass. Genito-Urin. Surg., 10 149,1978. 5. Rangell, L.: Castration. J. h e r . Psychoanalytic Ass., 39: 3, 1991. 6.Jordan,G.: Personal communication. 7. Zorn, B. H.,Rauchenwald, M. and Steers,W. D.: Periprostatic injection of local anesthesia for relief of chronic orchialgia. J. Urol., part 2,151:41M, abstract 735,1994. 8. Schwartzman, R. J. and McLellan, T. L.: Reflex sympathetic dystrophy. A review. Arch. Neurol., 44:555, 1987. 9. Galloway, N. T.,Gabale, D. R. and Irwin, P. P.: Interstitial cystitis or reflex sympathetic dystrophy of the bladder? Sern. Urol., 9 148, 1991. 10. Payne, R.: Sympathetic dystrophy syndrome: diagnosis and treatment. In: Pain Syndromes in Neurology. Edited by H. C. Fields. London: Butterworth., chant. 5. DD. 107-129.1990. ~

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