Who are the candidates for microsurgical denervation of the spermatic cord?
Men with persistent and uncomfortable scrotal pain, despite recognized medical treatment (eg. anti-inflammatories). If this is the case, Dr. Marois will evaluate the patient to see if he would be a good candidate for denervation of the spermatic cord. This is done by injecting a local anesthetic into the surrounding cord and nerves. This must be done in advance to validate the testicular or epididymal origin of the pain, via the temporary relief. This infiltration temporarily stops the conduction of pain signals through the inguinal nerves. If this resolves the pain, definitively cutting these nerves will probably also improve the chronic pain. As this is a subjective test, it is important that the patient be honest about the effectiveness of the injection, otherwise the procedure will not work. In contrast, pain that affects areas outside the testis (eg. leg or back pain) that is not relieved by an infiltration, will not respond to this treatment.
Where are the nerves involved in testicular pain?
The nerves involved in testicular pain are not visible, even using an operating microscope. They exist in certain structures around the spermatic cord (the cord that carries the vessels and the vas deferens to the testicle). Studies have shown that most nerves are found in the muscular and fascial layers around the cord, and the rest around the vascular canal and in the fat layers of the cord. There are also nerves outside the spermatic cord that may contribute to pain in some patients.
How does a microsurgical denervation of the spermatic cord with a Doppler, take place?
This procedure can be performed under general anesthesia. However, in the Cliniques Marois, it is performed under local anesthesia with a mild sedation and a spermatic cord block. Microsurgical denervation of the spermatic cord with a Doppler takes about one hour and 30 minutes. A 2-3 cm incision is made just above the scrotum, on the sore side and the spermatic cord is brought through the incision. The spermatic cord is easily exposed and retained outside the skin with instruments. A high-powered operating microscope is then installed and the spermatic cord is opened by incising the muscle and fascia of the spermatic cord with an electrocautery. Dr. Marois also uses a Micro-Doppler to identify the testicular arteries, which will be preserved with the utmost care. The Micro-Doppler greatly reduces the vascular risks of the surgery. Then comes the time of denervation: usually an aggressive dissection gives the patient the best chance of complete resolution of the pain. There is a small chance that this can lead to small areas of numbness on the scrotum. Finally, the skin is closed in different layers with sutures and surgical glue for a better aesthetic result
What are the possible complications of microsurgical denervation of the spermatic cord?
Secondary hydrocele: the risk is very low (less than 1%) since the dissection of the spermatic cord is done under a microscope and the lymphatic tissues are not cut or ligated. This can be corrected later, if necessary.
Bruising (blue skin).
Hematoma. Although rare, it may require drainage.
Infection at the level of the wound. Infected wounds can become hot, swollen, red, and painful, with significant drainage from the incision site. Patients may also develop fever. If the wound becomes infected (usually 3 to 5 days after surgery), antibiotics may be needed.
Testicular Atrophy: It is secondary to testicular ischemia if an arterial branch has been ligated. It is exceptional after DMCS by microscopy and micro-doppler under inguinal.
What is the success rate of microsurgical denervation of the spermatic cord?
Of patients who have a significant response to anesthetic block of the spermatic cord, approximately 70-80% will have a good response after denervation. Moreover, according to recent studies, this effect seems to be sustainable. Those who fail this surgery are usually patients whose pain is not localized mainly to the testis. These patients usually have another condition, such as pelvic muscle spasm or prostatitis, which may contribute to their pain. Late recurrences of pain seem to be rare.
What are the other surgical options for microsurgical denervation of the spermatic cord?
Orchiectomy (complete excision of the testis) and epididymectomy have been described as solutions to treat the problem of chronic scrotal pain. Orchiectomy is rarely performed in view of its aggressive nature without guarantee of complete resolution of chronic scrotal pain. Indeed, clinical experience shows that some patients remain with pain, despite the absence of the testis.
The epididymectomy is performed as a last resort in cases of pain clearly limited to the epididymis.
The success rate for both these surgeries is variable, ranging from 20 to 70%.