[Construction of a predictive model for postoperative pain relief after microscopic spermatic cord surgery for spermatic cord pain].

OBJECTIVE: To explore the relevant factors affecting the efficacy of microscopic spermatic cord surgery and build a predictive model for postoperative pain relief. METHODS: A retrospective analysis was conducted on the clinical data of 324 patients with spermatic cord pain who visited the Department of Urology at Peking University People's Hospital between October 2015 and April 2023. This cohort included 212 patients with varicocele-related spermatic cord pain and 112 patients with idiopathic spermatic cord pain. All the patients underwent microsurgical procedures: varicocele-related pain was treated with microsurgical varicocelectomy, and idiopathic pain was treated with microsurgical denervation of the spermatic cord. The patients were categorized into effective and ineffective groups based on whether their pain had decreased by more than 50% six months post-surgery compared with pre-surgery levels. Baseline data were preliminarily screened for clinical indicators using t tests and univariate analysis. Clinical predictor variables [age, duration of pain, diameter of varicocele, patient health questionnaire-9 (PHQ-9) score, generalized anxiety disorder-7 (GAD-7) score] were selected using Lasso regression. A clinical prediction model for effective pain relief following microscopic spermatic cord surgery was constructed using Logistic regression and presented as a nomogram. The model's internal validation was performed using the bootstrap method. Its predictive power and clinical utility were evaluated through the concor-dance index, the area under the receiver operating characteristic curve, and calibration plots. RESULTS: Post-microscopic varicocele ligation, 156 patients (73.58%) experienced significant pain relief, as did 94 patients (83.93%) following microscopic denervation. Independent predictors for postoperative outcomes included age, PHQ-9 score, GAD-7 score, chronic pain duration, and varicocele diameter, differing slightly between varicocele-related and idiopathic pain groups. The models demonstrated excellent predictive ability, with areas under the curve of 0.909 and 0.913 for varicocele and idiopathic groups, respectively, and high concordance indices. CONCLUSION: The postoperative efficacy prediction model based on age, pain duration, PHQ-9 score, GAD-7 score, and varicocele diameter has good predictive ability and clinical applicability, and can be used in clinical practice.

Chronic Scrotal Content Pain: a Review of the Literature and Management Schemes.

PURPOSE OF REVIEW: Chronic scrotal content pain (CSCP) is a complex condition with multiple etiologies that requires a thorough understanding of its pathophysiology, workup, and treatment options. We performed a comprehensive and contemporary review to augment our current understanding of CSCP. RECENT FINDINGS: We discuss new advances in CSCP-specific pain questionnaires, modern studies of microscopic spermatic cord denervation and its variations, and novel techniques including electric nerve stimulation and cryoablation in addition to randomized control trials with significant negative findings. We also present literature focusing on the prevention of CSCP secondary to surgical iatrogenic causes. The constantly evolving literature of CSCP has led to the significant evolution in its diagnosis and treatment, from oral medications to salvage options after microscopic spermatic cord denervation. With each advance, we come closer to developing a more thorough, evidence-based algorithm to guide urologists in treatment of CSCP.

Targeted Microsurgical Denervation of the Spermatic Cord for Chronic Orchialgia: the Current Standard of Care.

PURPOSE OF REVIEW: This paper reviews the pathophysiology, current literature, techniques for full microsurgical denervation (MDSC) and targeted microsurgical denervation (TMDSC) of the spermatic cord, and outcomes for these treatment options for patients with chronic scrotal content pain (CSCP) or orchialgia. RECENT FINDINGS: Significant reduction in pain (77-100%) is reported across various studies for CSCP patients with minimal patient morbidity. The testicular atrophy/loss risk is less than 1%. Testosterone levels do not appear to be affected by TMDSC/MDSC. The outcomes between TMDSC and MDSC are comparable (not statistically significantly different). However, TMDSC is significantly more efficient and a lot less tedious to perform. TMSCD had a shorter microsurgical operative time (21 min vs 53 min, P = 0.0001) than MDSC. Targeted or full microsurgical denervation of the spermatic cord is a safe and effective treatment option that is well published across several studies. The targeted MDSC approach is a more efficient and potentially less risky approach with similar outcomes to full MDSC.

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

A careful history and evaluation of men with chronic orchialgia elucidates the aetiology in some men to be a hyperactive cremaster muscle reflex with testicular retraction as the cause. The objective is to evaluate outcomes in men who underwent microsurgical subinguinal cremaster muscle release (MSCMR) with a retrospective chart review between September 2011 and April 2019. Nineteen men with hyperactive cremaster muscle reflex in 25 spermatic cord units underwent MSCMR, six bilateral and thirteen unilateral. Candidacy for MSCMR included answering yes to the question: "at times of testicular pain, does the testicle retract up in the groin to the extent that you have to milk it back down to the scrotum?", normal digital rectal examinations, negative urinalyses, negative scrotal Doppler ultrasounds, vigorous retraction of testis with Valsalva on examination and pain without an anatomic or pathologically identifiable aetiology except testicular retraction. Of the men who underwent MSCMR, 100% (25/25) of spermatic cord units had resolution of testicular retraction and 92% (23/25) of spermatic cord units had complete resolution of orchialgia. There was one complication, a small scrotal hematoma which resolved. MSCMR is an effective option for men with orchialgia secondary to testicular retraction due to a hyperactive cremaster muscle reflex.

A Clinical Study on Microsurgical Denervation of Spermatic Cord for Refractory Chronic Orchialgia.

OBJECTIVES: Microsurgical denervation of the spermatic cord (MDSC) is a treatment option for chronic orchialgia (CO) refractory to conservative treatment. Studies showed specific nerve fibers as the possible cause of CO. We aimed to present the outcomes of ligation of these nerves using targeted MDSC. METHODS: We retrospectively reviewed 30 cases who underwent targeted MDSC from August 2014 to February 2018. Patients included were under strict criteria. Pain was assessed preoperatively and postoperatively using a subjective visual analog scale (VAS) and objectively with the standardized and validated Pain Impact Questionnaire-6 (PIQ-6) score. RESULTS: Data were available on 28 cases at repercussion. During a median follow-up of 12 months (range 10-29), 25 cases (89.2%) showed a significant reduction in pain and 3 (9.8%) had no change in pain by subjective VAS scoring. Of cases with a significant reduction in pain, 15 (53.5%) had complete resolution and 19 (67.9%) had a 50% or greater reduction. Objective PIQ-6 analysis showed a significant reduction in pain in 78.6% of patients at 6 months postoperatively, in 82.1% at 1 year, in 82.1% at 2 years. CONCLUSIONS: Targeted MDSC is an effective, minimally invasive approach with potential long-term durability in patients with refractory CO.

Targeted Robotic Assisted Microsurgical Denervation of the Spermatic Cord for the Treatment of Chronic Orchialgia or Groin Pain: A Single Center, Large Series Review.

PURPOSE: Microsurgical denervation of the spermatic cord is a treatment option for chronic orchialgia refractory to conservative treatment. A recent study showed specific nerve fibers as the possible cause of chronic orchialgia. Our goal was to present the outcomes of ligation of these nerves using a technique of targeted robotic assisted microsurgical denervation of the spermatic cord. MATERIALS AND METHODS: We retrospectively reviewed the records of 772 patients who underwent targeted robotic assisted microsurgical denervation of the spermatic cord from October 2007 to July 2016. Selection criteria were chronic testicular pain more than 3 months in duration, failed conservative treatments, negative neurological and urological workup, and temporary resolution of pain with a local anesthetic spermatic cord block. Targeted robotic assisted microsurgical denervation of the spermatic cord was performed. Pain was assessed preoperatively and postoperatively using a subjective visual analog scale and objectively with the standardized and validated PIQ-6 (Pain Impact Questionnaire-6) score. RESULTS: Followup data were available on 860 cases. During a median followup of 24 months (range 1 to 70) 718 cases (83%) showed a significant reduction in pain and 142 (17%) had no change in pain by subjective visual analog scale scoring. Of cases with a significant reduction in pain 426 (49%) had complete resolution and 292 (34%) had a 50% or greater reduction. Objective PIQ-6 analysis showed a significant reduction in pain in 67% of patients 6 months postoperatively, in 68% at 1 year, in 77% at 2 years, in 86% at 3 years and in 83% at 4 years. CONCLUSIONS: Targeted robotic assisted microsurgical denervation of the spermatic cord is an effective, minimally invasive approach with potential long-term durability in patients with refractory chronic orchialgia.

Microdenervation of the spermatic cord for post-vasectomy pain syndrome.

OBJECTIVE: To evaluate the outcomes of patients who underwent microdenervation of the spermatic cord (MDSC) for post-vasectomy pain syndrome (PVPS) at our institution. METHODS: A retrospective study of all patients who underwent MDSC for PVPS by a single surgeon between March 2002 and October 2016 was performed. Pain was documented using the numerical rating scale (NRS). Spermatic cord block (SCB) was performed on all patients, and success was defined as NRS score ≤1 for >4 h. All patients had failed medical therapy prior to MDSC. All previous procedures for PVPS had been performed elsewhere. Surgical success was defined as a postoperative NRS score of ≤1. RESULTS: A total of 27 patients with 28 scrotal units underwent MDSC for PVPS. The median (1st quartile; 3rd quartile) follow-up was 10 (2; 16.5) months. The median (range) duration of pain prior to surgery was 57 (8-468) months. Pain was bilateral in 14 (52%), left-sided in eight (30%) and right-sided in five patients (19%). Data on SCB were available for 23 patients, with a success rate of 96%. The median (range) preoperative pain NRS score was 7 (2-10). The median (range) pain score after SCB on the NRS scale was 0 (0-5). The median (range) postoperative pain score on the NRS was 0 (0-9). Overall success was achieved in 20 of 28 testicular units (71%). Patients with involvement of multiple structures in the scrotum (i.e. testis, epididymis, spermatic cord) had a success rate of 81% and were more likely to have a successful surgery (P < 0.001). Five patients had failed a prior epididymectomy and three had failed a vaso-vasostomy for PVPS; this had no correlation with the success of MDSC (P = 0.89). CONCLUSION: The MDSC procedure is a reasonably successful, durable and valuable approach for PVPS, especially when pain involves multiple structures in the scrotum (testis, epididymis, spermatic cord). MDSC was equally efficacious in patients who had previously failed a procedure for PVPS. No patient had a worsening NRS score after MDSC. This is the largest study to date evaluating MDSC for the treatment of PVPS.

Chronic Scrotal Pain.

PURPOSE OF REVIEW: Chronic scrotal pain (CSP) is a common yet poorly understood condition, with significant impacts on overall quality of life. Many patients will have sought evaluation and management from multiple providers in an attempt to find a solution for their pain. RECENT FINDINGS: Despite many emerging treatments for CSP and further understanding of the potential etiologies and pathophysiological basis of the condition, its natural history is poorly understood. It is also important to recognize the psychosocial impact of CSP and consider formal referral for psychological evaluation and treatment if the patient endorses significant psychiatric responses to pain. It is important to also recognize the neuropathic component of pain that may arise in patients with CSP. Neuropathic medications show promise as a narcotic-sparing pharmacological intervention. There are promising surgical options for CSP including microsurgical denervation of the spermatic cord. This article highlights the current best practice recommendations on the evaluation and management of chronic scrotal pain.

Microsurgical Anatomy of the Spermatic Cord and Spermatic Fascia: Distribution of Lymphatics, and Sensory and Autonomic Nerves.

PURPOSE: An understanding of the microsurgical anatomy of the spermatic cord and spermatic fascia is important for surgeons during microsurgical varicocelectomy and denervation. We examined the distribution of the lymphatics, and the sensory and autonomic nerves of the spermatic cord. MATERIALS AND METHODS: We collected spermatic cords from 11 men undergoing orchiectomy for localized testicular tumors and we biopsied a third of the spermatic fascia from 36 men undergoing microsurgical varicocelectomy. Immunohistochemical staining of the pan-neuronal marker PGP 9.5 (protein gene product 9.5), the sensory nociceptor marker CPRP (calcitonin gene-related peptide), the sympathetic marker TH (tyrosine hydroxylase), the parasympathetic marker VIP (vasoactive intestinal polypeptide) and the lymphatic marker D2-40 was performed. We counted the number of nerves and lymphatics. RESULTS: PGP 9.5 staining revealed dense nerve distributions in the spermatic cord and fascia. Sensory and autonomic nerve fibers were basically co-localized in the same nerve. Of the nerves 50% were identified near the vas deferens and 20% were identified in the spermatic fascia. Sensory and sympathetic nerve fibers represented most of the nerves but a few parasympathetic nerve fibers were observed. Of the lymphatics 36 per patient were identified in the spermatic cord but only a few were identified in the spermatic fascia. CONCLUSIONS: Sensory and sympathetic nerves accounted for the majority of the nerves. Although the functional aspects of the nerves remain undetermined, information on the distribution of nerves and lymphatics is useful when dealing with nerves and preserving lymphatics during microsurgical varicocelectomy or denervation.

[Updated diagnosis and management of chronic orchialgia].

Chronic orchialgia (CO) is a common complaint in urology or andrology. Due to its complicated pathogenesis, the diagnosis and treatment of CO are quite challenging. Based on different etiologies, CO can be idiopathic or secondary. Idiopathic CO accounts for approximately 50% of the cases and is probably associated with Wallerian degeneration in the spermatic cord nerves and peripheral sensitization. Secondary CO can be attributed to direct causes and its treatment focuses on the pathologic condition identified. The main methods for the treatment of CO include conservative and surgical strategies, among which microsurgical spermatic cord denervation ( MSCD) is an effective and minimally invasive option, while orchiectomy is but the last alternative when no other means is left.

Microsurgical Spermatic Cord Denervation as a Treatment for Chronic Scrotal Content Pain: A Multicenter Open Label Trial.

PURPOSE: We prospectively evaluated the results of microsurgical spermatic cord denervation in a series of patients with chronic scrotal content pain in a multicenter study, including 1 center in Germany and 3 centers in Chile. MATERIALS AND METHODS: A total of 50 patients with chronic scrotal content pain more than 3 months in duration were prospectively selected for standardized operative microsurgical spermatic cord denervation as pain treatment. In all patients preoperative management included a positive response to a spermatic cord block test with local anesthesia. Pain severity was assessed using an analog visual pain scale (range 0 to 10) for 30 consecutive days. A total of 52 testicular units were operated on using a subinguinal approach. In all cases a surgical microscope was used to identify the arteria testicularis. RESULTS: No intraoperative complications were observed and no testicular units were lost. Two reoperations were performed, including 1 for hematocele and 1 for hydrocele. Six months after surgery 40 patients (80%) were completely pain-free. In 6 patients (12%) intermittent testicular discomfort persisted, which could be managed by acetaminophen on demand. Four patients (8%) had no change in pain severity after surgery. CONCLUSIONS: After proper selection of patients microsurgical spermatic cord denervation seems to be a safe and efficient procedure to treat chronic scrotal content pain. Considering the limitations of the study, a randomized, controlled trial with longer followup is highly warranted.

Microsurgical denervation of rat spermatic cord: safety and efficacy data.

OBJECTIVE: To describe a microsurgical technique for denervation of the spermatic cord and use of multiphoton microscopy (MPM) laser to identify and ablate residual nerves after microsurgical denervation. To evaluate structural and functional changes in the rat testis and vas deferens after denervation. MATERIALS AND METHODS: Nine Sprague-Dawley rats were divided into three experimental groups: sham, microsurgical denervation of the spermatic cord (MDSC), and MDSC immediately followed by laser ablation with MPM. At 2 months after surgery, we assessed testicular volume, functional circulation of the testicular artery with Doppler, patency of the vas deferens, and histology of the testis and vas deferens. RESULTS: There was a significant decrease in the median number of nerves remaining around the vas deferens with MDSC alone (3.5 nerves) or MDSC with MPM (1.5 nerves) compared with sham rats (15.5 nerves) (P = 0.003). Although, MDSC with MPM resulted in the fewest remaining nerves, this result was similar to MDSC alone (P = 0.29). No deleterious effects on spermatogenesis or vas patency were seen in the experimental groups when compared with the sham rats. CONCLUSION: A microsurgical approach can be used to effectively and safely denervate the rat spermatic cord with minimal changes to structure and function of the testis and vas deferens. MPM can be used as an adjunct to identify and ablate residual nerves after MDSC.

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.

Trifecta nerve complex: potential anatomical basis for microsurgical denervation of the spermatic cord for chronic orchialgia.

PURPOSE: We identified structural abnormalities in the spermatic cord nerves that may explain how microsurgical denervation of the spermatic cord provides pain relief in patients with chronic orchialgia. MATERIALS AND METHODS: We retrospectively reviewed a prospective database to compare spermatic cord biopsy specimens from 56 men treated with a total of 57 procedures for microsurgical denervation of the spermatic cord for chronic orchialgia vs a control group of men without pain treated with cord surgery, including varicocelectomy in 4 and radical orchiectomy in 6. Tissue biopsies were obtained from mapped regions of the spermatic cord in all cases. Biopsies stained with hematoxylin and eosin were examined by an independent pathologist. Three human cadaveric spermatic cords were dissected to confirm localization of the nerve distribution identified on pathological mapping. RESULTS: We identified a median of 25 small diameter (less than 1 mm) nerve fibers in the spermatic cord. Of the 57 procedures for orchialgia 48 (84%) showed wallerian degeneration in 1 or more of these nerves but only 2 of 10 controls (20%) had such degeneration (p = 0.0008). In decreasing order of nerve density the 3 primary sites (trifecta nerve complex) of these changes were the cremasteric muscle fibers (19 nerves per patient), perivasal tissues and vasal sheath (9 nerves per patient), and posterior cord lipomatous/perivessel tissues (3 nerves per patient). Cord nerve distribution mapped by the biopsies was confirmed by cadaveric dissection. CONCLUSIONS: In men with chronic orchialgia there appears to be wallerian degeneration in reproducible patterns in the spermatic cord nerve fibers. Transection of these nerves may explain the effect of the denervation procedure.

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.

Multiphoton imaging and laser ablation of rodent spermatic cord nerves: potential treatment for patients with chronic orchialgia.

PURPOSE: Microsurgical denervation of the spermatic cord has been done to treat chronic orchialgia. However, identifying the site of spermatic cord nerves is not feasible with an operating microscope or robotic stereoscope. We used multiphoton microscopy, a novel laser imaging technology, to identify and selectively ablate spermatic cord nerves in the rat. MATERIALS AND METHODS: The spermatic cords of adult male Sprague-Dawley® rats were initially imaged in vivo under a low power multiphoton microscopy laser. After assessing the number, diameter and site (vasal vs perivasal) of the nerves a higher power laser using the same objective was used to ablate the nerves. The precision of nerve ablation and the preservation of surrounding structures were determined by histological analysis. We assessed the heterogeneity of the number of nerves with the Wilcoxon signed rank test. RESULTS: The average number of nerves per spermatic cord was 10, which was similar bilaterally (p = 0.13). The vas and perivasal structures had a similar number of nerves (p = 0.4). The median diameter of all nerves was 32 µm. Confirmation of nerve ablation, and preservation of the vas deferens and vasculature were anatomically validated by histological analysis. CONCLUSIONS: Multiphoton microscopy can identify and ablate nerves selectively in vivo in the rat. It can potentially be used for spermatic cord denervation to treat chronic orchialgia. Such imaging may increase the efficacy of nerve ablation and can avoid the potential risks of testicular atrophy and hydrocele associated with spermatic cord microsurgical denervation.

Vasectomy reversal with ultrasonography-guided spermatic cord block.

UNLABELLED: Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Vasectomy reversal is often performed in general or neuraxial anaesthesia. Even though the site of vasectomy reversal is easily amenable to regional/local anaesthesia, spermatic cord blocks are rarely applied because of their risk of vascular damage within the spermatic cord. Recently, we described the technique of ultrasonography (US)-guided spermatic cord block for scrotal surgery, which, thanks to the US guidance, at the same time avoids the risk of vascular damage of blindly performed injections and the risks of general and neuraxial anaesthesia. Vasectomy reversal can easily be done in regional anaesthesia with the newly described technique of US-guided spermatic cord block without the risks of vascular damage by a blindly performed injection and the risks of standard general and neuraxial anaesthesia. In addition, this technique grants long-lasting postoperative pain relief and patients recover more quickly. Microsurgical conditions are excellent and patient satisfaction is high. Thanks to these advantages, more patients undergoing vasectomy reversal might avoid general or neuraxial anaesthesia. OBJECTIVE: • To assess the success rate, microsurgical conditions, postoperative recovery, complications and patient satisfaction of ultrasonography (US)-guided spermatic cord block in patients undergoing microscopic vasectomy reversal and to compare them to a control group with general or neuraxial anaesthesia. PATIENTS AND METHODS: • The present study comprised a prospective series of 10 consecutive patients undergoing US-guided spermatic cord block for microscopic vasectomy reversal. • The cohort was compared with 10 patients in a historical control group with general or neuraxial anaesthesia. RESULTS: • Nineteen of 20 (95%) blocks were successful, defined as no pain >3 on the Visual Analogue Scale (VAS), no additional analgesics and/or no conversion to general anaesthesia. Median pain was 0 on the VAS (range 0-5). Additional analgesics were requested in one (5%) block, and there was no conversion to general anaesthesia. • Microsurgical conditions were excellent. • In the spermatic cord block vs general/neuraxial anaesthesia groups, median times (range) between surgery and first postoperative analgesics, alimentation, mobilization and hospital discharge were 12 (2-14) vs 3 (1-6), 1 (0.25-3) vs 4 (3-6), 2 (1-3) vs 6 (3-10), and 4 (3-11) vs 8.5 (6-22) h, respectively. • No complications were reported after the spermatic cord block. • Patient satisfaction was excellent. CONCLUSIONS: • US-guided spermatic cord block for microscopic vasectomy reversal is highly successful and provides long-lasting perioperative analgesia. • Times to alimentation, mobilization and hospital discharge are shorter under US-guided spermatic cord block than under general/neuraxial anaesthesia. • Additional anaesthetic pain management might, however, be required unexpectedly with US-guided spermatic cord block.

Post-vasectomy pain syndrome: clinical features and treatment options.

INTRODUCTION: Post-vasectomy pain syndrome (PVPS), defined as chronic epididymal pain that is continuous or recurrent in the absence of proven epididymal or testicular infection, has become more common as the number of vasectomies performed rises. With more than four million vasectomies performed annually, the prevention and treatment of this condition becomes more important. Multiple theories have been proposed as a potential etiology of this condition, and along with this have come multiple modalities of treatment. With the uncertainty surrounding the etiology of this syndrome, the aims of treatment are varied and are described and analyzed in this review. MATERIALS AND METHODS: A literature review was conducted to ascertain the various theories explaining the source of the discomfort in this syndrome, along with several treatment modalities, both medical and surgical. CONCLUSIONS: Options for the management of PVPS are rapidly expanding. Among the existing surgical options that include spermatic cord denervation and vasovasostomies, testosterone has emerged as a potential medical therapy with some promising results. Our review of the literature reveals the etiology of PVPS is still uncertain, as multiple theories still prevail. However, progress has been made in the development of additional medical therapies that could provide some relief for patients who are unwilling to accept the risks of surgery. Nevertheless, the importance of counseling patients of the risks of PVPS with vasectomy cannot be overstated. Through review of the pathophysiology of this condition and treatment options including conservative approaches, topical therapies, denervation of the spermatic cord, and surgical approaches, a comprehensive therapeutic approach can be offered to affected patients.

Surgical management of chronic scrotal pain: a review of the current literature.

Chronic scrotal pain (CSP) may be due to an identifiable cause, may be multifactorial, or may be idiopathic. Successful treatment often requires multimodal therapy with a multidisciplinary approach. Conservative options may be offered initially, but if symptoms fail to improve with conservative interventions, more invasive therapies may be required. A nerve block may be attempted and patients who experience improvement in pain following nerve blocks may be good candidates for surgical denervation of the spermatic cord. Alternative surgical treatment options including proximal nerve blocks, neuromodulation, cryoablation, vasectomy reversal, varicocelectomy, and even orchiectomy have been described. The aim of this review is to discuss the treatment options for CSP with a focus on surgical treatment options.

Preoperative Modified Spermatic Cord Block Predicts Success in Candidates for Microscopic Spermatic Cord Denervation.

OBJECTIVE: To examine the utility of a modified spermatic cord block (MSCB) that targets known contributors to refractory chronic scrotal content pain (CSCP) at predicting postoperative pain relief following a microscopic spermatic cord denervation (MSCD). METHODS: A MSCB was performed in all patients with refractory CSCP. This was performed by injecting anesthetic circumferentially around the vas deferens and over the external ring. Patients with >50% pain reduction were offered MSCD. Baseline, post-block, and postoperative pain was assessed. Age, prior groin surgery, and post-block pain free period were recorded. A multivariate linear regression model was used to determine predictors of surgical success. RESULTS: Fifty-two patients underwent a MSCB. Forty-six (88%) had an adequate response and underwent MSCD. All patients saw improvement in pain postoperatively with an average reduction of 80% (4 < 50%; 7 50-69%; 35 ≥ 70%). On multivariate linear regression analysis, pain reduction following MSCD was an independent predictor of postoperative improvement (P < 0.001). No other factors, including post-block pain free period or prior surgery predicted success. CONCLUSIONS: The described MSCB can be utilized as an independent predictor of success following MSCD. Post-block pain free period was not associated with postoperative pain level. The MSCB may help identify candidates for MSCD that would be missed with the traditional block.