Microsurgical denervation of the spermatic cord

A 30 year old gentleman came with orchalgia on left side.He underwent multiple tests and took multiple medications but without any benefit.He had consumed several antibiotics including anti-tubercular drugs,hetrazan course,painkillers,nerve modulators,anti-epileptics but the pain persisted. 

We find several such patients in practice and the general view amongst the consultants about chronic idiopathic orchalgia has been very pessimistic.

There is even one joke circulating amongst doctors that the best revenge that a doctor can take over his  adversary is by referring a case of chronic orchalgia to him.But jokes apart; the treatment has been less fruitful and the patients agony continues while he visits multiple doctors.They even try alternative medicines  like acupressure,naturotherapy etc etc.

There is a recent interest in microsurgical denervation of the spermatic cord in refractory orchalgia.

We routinely do this microsurgical denervation in refractory cases with reasonable success.

Anatomic considerations:

 The classic and memorable description of the contents of spermatic cord in the male are:

• 3 arteries: cremasteric artery, deferential artery, testicular artery;
• 3 nerves: genital branch of the genitofemoral nerve (L1/2), autonomic and visceral afferent fibres, ilioinguinal nerve (N.B. outside spermatic cord but travels next to it)
• 3 fascial layers: external spermatic, cremasteric, and internal spermatic fascia;
• 3 other structures: pampiniform plexus, vas deferens (ductus deferens), testicular lymphatics

Pathophysiology behind orchalgia:

Orchalgia can occur because of plasticity of nerves...ilioinguinal,genitofemoral nerves or other nerves embedded in the fasciae surrounding the structures in the spermatic cord.There is a chonic upregulation of the central and peripheral nervous pathways .There is an altered function,gene expression,chemical receptors profiles and the structure leading to orchalgia.Its similar to pain syndromes like trigeminal neuralgia,interstitial cystitis etc.

Various reasons are flouted..

like chronic orchalgia from infection can lead to neuralgia even after the eradication of the infective pathology and nerve entrapment either due to previous surgical scars.or hernia.

How we go about it:

We routinely give a spermatic cord block with bupivacaine to see whether the pain eases off.If the pain subsides to a significant amount then we assume that the permanent denervation is going to be succeeded.

 

How is the procedure to be performed?

We use microsurgical method.The incision is inguinal or subinguinal but prefer inguinal as the anatomy of the cord is easier to understand.

The magnification that we use is 10-15 x.The cord is isolated over a penrose drain.We classically carry out " stripping of the spermatic cord".

All structures...vas deferens,testicular arteries,lymphatics are preserved.The rest of the structures .. all fasciae,nerves and even the adventitia of the vas are stripped.All these structures are denuded and the final structure should appear as the one containing one or two arteries and vas only.