Validation of targeted microsurgical spermatic cord denervation: comparison of outcomes to traditional complete microsurgical spermatic cord denervation

Abstract

The aim of this study was to validate the effectiveness of targeted microsurgical spermatic cord denervation (MSCD) of the trifecta nerve complex in comparison to traditional full MSCD with complete skeletonization of the spermatic cord in men with chronic orchialgia. Retrospective chart review was performed by a single fellowship-trained microsurgeon between 2011 and 2016. Patients had follow-ups at 6 weeks, 6 months, and 1 year postoperatively. Thirty-nine men with chronic orchialgia underwent full MSCD between 2011 and 2013. In July 2013, after the publication of an anatomic study with identification of Wallerian degeneration of the trifecta nerve complex in men with chronic orchialgia, the technique was changed to targeted MSCD. From July 2013 to March 2016, 43 men underwent targeted MSCD. When comparing the full MSCD group to the targeted MSCD group, there was no significant difference in resolution of pain (66.7% vs 69.8%, P = 0.88), no difference in partial relief of pain (17.9% vs 23.3%, P = 0.55), and no difference in failure to respond rates (15.4% vs 7.0%, P = 0.22) between the two groups. There was no difference in mean change of visual analog pain scale scores between the two groups ( P = 0.27). Targeted MSCD had a shorter operative time (53 min vs 21 min, P = 0.0001). Targeted MSCD offers patients comparable outcomes to traditional full MSCD, with a shorter operative time, a less technically challenging surgery, and potentially less risk to cord structures which should be preserved.

Preoperative Predictors of Failure of Microsurgical Spermatic Cord Denervation for Men With Chronic Orchialgia

“…5 The same microsurgeon that performed these MSCDs previously published a study revealing that both surgical techniques resulted in comparable outcomes. 6 There was not a significant difference in outcomes based on preoperative VAS scores, so the severity of pain preoperatively was not relevant to success with MSCD. The group that failed to respond to MSCD had a mean preoperative VAS score of 7.4 § 2.7 versus 6.7 § 2.1 in the group who responded successfully to MSCD (Pvalue .1958).…”

“…In the available previous literature, good response rates have been reported with MSCD in men with chronic orchialgia without an anatomic, infectious, or pathologic etiology; however, there is always a failure rate reported, typically of approximately 15% in most series, which leaves clinicians and patients frustrated. 3,4,[6][7][8][9][10][11][12][13][14][15][16] To our knowledge, this is the first study examining the potential reasons for failure of MSCD in carefully selected surgical patients. Therefore, the aim of this study was to identify potential predictors of failure to counsel patients on preoperatively and potentially help understand failure postoperatively.…”

“…Both surgical techniques have been previously described and have been shown to have comparable outcomes. [4][5][6] St. David's Healthcare Institutional Review Board (Austin, USA) exemption was obtained due to the deidentification of the data.…”

“…This technique has been shown to provide equivalent outcomes for patients with chronic orchialgia as the traditional skeletonization technique while reducing operative time and potential risks. 5,6 Regardless of the surgical technique used to treat chronic orchialgia, all approaches typically report an approximately 15% failure rate, where patients fail to have an adequate response to MSCD, defined as a less than 50% improvement in preoperative VAS score following MSCD. [6][7][8] No prior studies have identified preoperative predictors of the failure of MSCD, which has important implications for counseling patients appropriately.…”

Microsurgical subinguinal cremaster muscle release for chronic orchialgia secondary to hyperactive cremaster muscle reflex in adults

“…Surgical intervention for chronic orchialgia was advanced with the use of the operative microscope in the 1970s to perform microsurgical spermatic cord denervation (MSCD; Devine & Schellhammer, ). Although MSCD has progressed from a full skeletonisation of the spermatic cord to a more targeted approach to MSCD, a retractile testis secondary to a hyperactive cremaster muscle reflex as the clear cause of orchialgia can even further simplify the surgical approach (Kavoussi, ; Levine, Matkov, & Lubenow, ; Parekattil et al, ). A careful history and physical examination may elicit testicular retraction secondary to a hyperactive cremaster muscle as the aetiology for orchialgia which allows for a less complex and less time‐consuming surgical procedure with favourable outcomes, which essentially avoids risk to important microsurgical anatomic structures within the spermatic cord such as lymphatic channels, gonadal arteries and the vas deferens.…”