2
LAPAROSCOPIC TESTICULAR DENERVATION 735 vaginalis are innervated by the genital branch of the genito- femoral nerve while nociceptive fibers from the testicle, vas deferens and epididymis course within the sympathetic nerve supply of each organ. Therefore, testicular nociceptive fibers course in the svmrJathetic plexus (T10 to T12). investing the CONCLUSIONS Laparoscopic testicular denemation provides significant pain relief in the majority of patients with chronic orchialgia. This procedure appears to be a reasonable option to orchiec- . testicular artery and vein,-while deferential and epidid-pal nociceptive fibers course with sympathetic fibers through the pelvic plexus (T10 to L1) and along the vas defer en^.^ Inguinal testicular denervation allows one to divide all 3 pathways while sparing the gonadal artery and at least 1 vein. This procedure requires meticulous dissection and di- vision of the periadventitial fibers enveloping the artery without compromising vessel integrity. Unfortunately, with- out dividing the artery and veins completely, one cannot ensure that all of the testicular pain fibers have been divided completely. Furthermore, in the setting of prior scrotal or inguinal surgery, including vasectomy, the integrity of the collateral testicular circulation is circumspect, which in- creases the risk of testicular atrophy after inguinal cord dissection. Finally, a successful procedure demands expert microsurgical skills, and general or regional anesthesia be- cause of the lengthy operative time. We have used laparoscopic testicular denervation as a testis sparing, minimally invasive alternative. By dividing the gonadal artery, vein and perivascular tissue completely, interruption of the autonomic and nociceptive innervation of the testis is guaranteed. However, since fibers to the tunica vaginalis, vas deferens and epididymis are spared, one would not expect complete scrotal denervation or universal success, despite a successful preoperative cord block. Our 78% suc- cess rate (greater than 10-point reduction in pain score) reflects this supposition. On the other hand, one may hypoth- esize that in cases with prior spermatic cord surgery the tunica vaginalis or deferential nociceptive fibers are probably compromised to some degree. Therefore, the likelihood that the orchialgia is mediated by testicular fibers in these cases is increased. In addition to definitive division of the nociceptive inner- vation of the testis, laparoscopic testicular denervation pro- vides another potential advantage compared to inguinal de- nervation in patients with prior spermatic cord surgery (vasectomy), that is a less technically challenging means of preserving arterial flow to the testis. In contrast to the in- guinal approach in these patients, when preserving the integrity of the testicular artery is essential for testis viabil- ity, laparoscopic testicular denervation allows for simple di- vision of the artery and vein. This division is possible since it occurs proximal to vessel confluence with the vas deferens. As a result, distal gonadal artery flow in laparoscopic testic- ular denervation can be safely reconstituted via collaterals from the proximal deferential artery, even in the case of prior vasectomy, which is supported by the fact that no testicular atrophy developed in our patients, although 8 of 9 had un- dergone prior spermatic cord surgery. Finally, both proce- dures have similar general anesthetic requirements while the operative time for laparoscopic testicular denervation is likely comparable to if not shorter than microsurgical ingui- nal denervation (no data published to our knowledge). Our preliminary evaluation of laparoscopic testicular de- nervation indicates that this technique may offer the major- ity of patients (78%) with refractory chronic orchialgia a significant reduction in or elimination of pain (71% reduction in pain score) with minimal morbidity. Furthermore, if this organ preserving alternative fails, one may still proceed to orchiectomy as advocated by others.'.2 This study is limited in its retrospective, nonrandomized design as well as small sample size. In particular, measures of testicular atrophy, and the pain and activity analog scales were administered retrospectively in a nonblinded fashion. Therefore, the valid- ity of this approach requires verification with a larger blinded, randomized series. tomyin select patients after all nonsurgical modalities have failed. Larger prospective series are necessary to evaluate better the efficacy of this procedure. 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 orchialgia. AUA Update Series, 11: 10,1992. 3. Holland, J. M., Feldman, J. L. and Gilbert, H. C.: Phantom orchialgia. J. Urol., 162 2291,1994. 4. Kursh, E. D. and Schover, L. R.: The dilemma of chronic genital pain. AUA Update Series, 16 290,1997. 5. Chen, T. and Ball, R.: Epididymectomyfor post-vasectomy pain: histological review. Brit. J. Urol., 68: 407, 1991. 6. Myers, S. A,, Mershon, C. E. and Fuchs, E. F.: Vasectomy rever- sal for treatment of the post-vasectomy pain syndrome. J. Urol., 151: 518,1997. 7. Choa, R. G. and Swami, K S.: Testicular denervation. A new surgical procedure for intractable testicular pain. Brit. J. Urol., 70 417,1992. 8. Brooks, J. D., Moore, R. G. and Kavoussi, L. R.: Laparoscopic management of testicular pain after embolotherapy of varico- cele. J. Endourol., 8: 361,1994. 9. Vest, S. A: Infections and diseases of the scrotum and its contents. In: Principles of Urology; An Introductory Textbook to the Diseases of the Urogenital Tract. Edited by M. F. Campbell. Philadelphia: W. B. Saunders Co., pp. 666-727,1957. EDITORIAL COMMENT The authors describe an interesting surgical procedure and the results sound promising. However, it has a few major flaws, of which the most serious is that patients were asked to make retrospective ratings of preoperative pain improvement by the surgeon. Both fac- tors introduced potential positive bias into the findings. The princi- ple of cognitive dissonance states that when one undergoes a painful procedure, one is more likely to value the outcome. Also, if one is grateful to a physician, one is likely to rate satisfactionwith services more highly when asked for an evaluation by that physician. To my knowledge the study did not use any of several well validated pain questionnaires but instead just asked patients to rate pain and activity on 2 scales created by the physicians. Another problem is in the description of the patients. The authors concede that no physical findings could explain these pain syn- dromes and claim that all conservative measures for pain relief were attempted before these men were considered surgical candidates.Yet only 2 of 9 men tried antidepressants and only 3 consulted a pain management program. Whether any of the men were screened by a mental health professional before surgery is not mentioned. Further- more, 3 had already undergone epididymal surgery, presumably unsuccessful procedures performed for pain relief, and 3 had under- gone varicocelectomy but the reason (pain relief versus correction of infertility) was not given. These are hardly "virgin" surgical patients. It is possible that screening by a mental health professional could have resulted in better selection of surgical candidates and that failure in 2 of 9 patients (22%) is not only due to incomplete dener- vation expected from the procedure, but also to the fact that a surgical procedure was performed for a somatoform pain disorder. The management of chronic unexplained genital pain remains a perplexing problem and difficult challenge for the patient and health care professional. There is increasing evidence that psychological factors have an important role in genital pain with no identifiable organic cause, with the most consistent features being somatization disorder, major depression, anxiety, difficulty establishing relation- ships, sexual anxiety and sexual dysfunction. Some have described a condition involving the pelvic floor muscles or areas of attachment which may be responsible for discomfort in some men with chronic genital pain. Sin& et al described a condi- tion called pelvic floor tension myalgia which is characterized by continuous habitual contraction of the muscles of the pelvic We have coined the term n e u r o m d a r pelvic floor d9-a

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LAPAROSCOPIC TESTICULAR DENERVATION 735

vaginalis are innervated by the genital branch of the genito- femoral nerve while nociceptive fibers from the testicle, vas deferens and epididymis course within the sympathetic nerve supply of each organ. Therefore, testicular nociceptive fibers course in the svmrJathetic plexus (T10 to T12). investing the

CONCLUSIONS

Laparoscopic testicular denemation provides significant pain relief in the majority of patients with chronic orchialgia. This procedure appears to be a reasonable option to orchiec- .

testicular artery and vein,-while deferential and epidid-pal nociceptive fibers course with sympathetic fibers through the pelvic plexus (T10 to L1) and along the vas defer en^.^

Inguinal testicular denervation allows one to divide all 3 pathways while sparing the gonadal artery and at least 1 vein. This procedure requires meticulous dissection and di- vision of the periadventitial fibers enveloping the artery without compromising vessel integrity. Unfortunately, with- out dividing the artery and veins completely, one cannot ensure that all of the testicular pain fibers have been divided completely. Furthermore, in the setting of prior scrotal or inguinal surgery, including vasectomy, the integrity of the collateral testicular circulation is circumspect, which in- creases the risk of testicular atrophy after inguinal cord dissection. Finally, a successful procedure demands expert microsurgical skills, and general or regional anesthesia be- cause of the lengthy operative time.

We have used laparoscopic testicular denervation as a testis sparing, minimally invasive alternative. By dividing the gonadal artery, vein and perivascular tissue completely, interruption of the autonomic and nociceptive innervation of the testis is guaranteed. However, since fibers to the tunica vaginalis, vas deferens and epididymis are spared, one would not expect complete scrotal denervation or universal success, despite a successful preoperative cord block. Our 78% suc- cess rate (greater than 10-point reduction in pain score) reflects this supposition. On the other hand, one may hypoth- esize that in cases with prior spermatic cord surgery the tunica vaginalis or deferential nociceptive fibers are probably compromised to some degree. Therefore, the likelihood that the orchialgia is mediated by testicular fibers in these cases is increased.

In addition to definitive division of the nociceptive inner- vation of the testis, laparoscopic testicular denervation pro- vides another potential advantage compared to inguinal de- nervation in patients with prior spermatic cord surgery (vasectomy), that is a less technically challenging means of preserving arterial flow to the testis. In contrast to the in- guinal approach in these patients, when preserving the integrity of the testicular artery is essential for testis viabil- ity, laparoscopic testicular denervation allows for simple di- vision of the artery and vein. This division is possible since it occurs proximal to vessel confluence with the vas deferens. As a result, distal gonadal artery flow in laparoscopic testic- ular denervation can be safely reconstituted via collaterals from the proximal deferential artery, even in the case of prior vasectomy, which is supported by the fact that no testicular atrophy developed in our patients, although 8 of 9 had un- dergone prior spermatic cord surgery. Finally, both proce- dures have similar general anesthetic requirements while the operative time for laparoscopic testicular denervation is likely comparable to if not shorter than microsurgical ingui- nal denervation (no data published to our knowledge).

Our preliminary evaluation of laparoscopic testicular de- nervation indicates that this technique may offer the major- ity of patients (78%) with refractory chronic orchialgia a significant reduction in or elimination of pain (71% reduction in pain score) with minimal morbidity. Furthermore, if this organ preserving alternative fails, one may still proceed to orchiectomy as advocated by others.'.2 This study is limited in its retrospective, nonrandomized design as well as small sample size. In particular, measures of testicular atrophy, and the pain and activity analog scales were administered retrospectively in a nonblinded fashion. Therefore, the valid- ity of this approach requires verification with a larger blinded, randomized series.

tomyin select patients after all nonsurgical modalities have failed. Larger prospective series are necessary to evaluate better the efficacy of this procedure.

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 orchialgia. AUA Update Series, 11: 10, 1992.

3. Holland, J. M., Feldman, J. L. and Gilbert, H. C.: Phantom orchialgia. J. Urol., 162 2291, 1994.

4. Kursh, E. D. and Schover, L. R.: The dilemma of chronic genital pain. AUA Update Series, 1 6 290, 1997.

5. Chen, T. and Ball, R.: Epididymectomy for post-vasectomy pain: histological review. Brit. J. Urol., 68: 407, 1991.

6. Myers, S. A,, Mershon, C. E. and Fuchs, E. F.: Vasectomy rever- sal for treatment of the post-vasectomy pain syndrome. J. Urol., 151: 518, 1997.

7. Choa, R. G. and Swami, K S.: Testicular denervation. A new surgical procedure for intractable testicular pain. Brit. J. Urol., 70 417, 1992.

8. Brooks, J. D., Moore, R. G. and Kavoussi, L. R.: Laparoscopic management of testicular pain after embolotherapy of varico- cele. J. Endourol., 8: 361, 1994.

9. Vest, S. A: Infections and diseases of the scrotum and its contents. In: Principles of Urology; An Introductory Textbook to the Diseases of the Urogenital Tract. Edited by M. F. Campbell. Philadelphia: W. B. Saunders Co., pp. 666-727,1957.

EDITORIAL COMMENT The authors describe an interesting surgical procedure and the

results sound promising. However, it has a few major flaws, of which the most serious is that patients were asked to make retrospective ratings of preoperative pain improvement by the surgeon. Both fac- tors introduced potential positive bias into the findings. The princi- ple of cognitive dissonance states that when one undergoes a painful procedure, one is more likely to value the outcome. Also, if one is grateful to a physician, one is likely to rate satisfaction with services more highly when asked for an evaluation by that physician. To my knowledge the study did not use any of several well validated pain questionnaires but instead just asked patients to rate pain and activity on 2 scales created by the physicians.

Another problem is in the description of the patients. The authors concede that no physical findings could explain these pain syn- dromes and claim that all conservative measures for pain relief were attempted before these men were considered surgical candidates. Yet only 2 of 9 men tried antidepressants and only 3 consulted a pain management program. Whether any of the men were screened by a mental health professional before surgery is not mentioned. Further- more, 3 had already undergone epididymal surgery, presumably unsuccessful procedures performed for pain relief, and 3 had under- gone varicocelectomy but the reason (pain relief versus correction of infertility) was not given. These are hardly "virgin" surgical patients. It is possible that screening by a mental health professional could have resulted in better selection of surgical candidates and that failure in 2 of 9 patients (22%) is not only due to incomplete dener- vation expected from the procedure, but also to the fact that a surgical procedure was performed for a somatoform pain disorder.

The management of chronic unexplained genital pain remains a perplexing problem and difficult challenge for the patient and health care professional. There is increasing evidence that psychological factors have an important role in genital pain with no identifiable organic cause, with the most consistent features being somatization disorder, major depression, anxiety, difficulty establishing relation- ships, sexual anxiety and sexual dysfunction.

Some have described a condition involving the pelvic floor muscles or areas of attachment which may be responsible for discomfort in some men with chronic genital pain. Sin& et al described a condi- tion called pelvic floor tension myalgia which is characterized by continuous habitual contraction of the muscles of the pelvic We have coined the term n e u r o m d a r pelvic floor d 9 - a

Page 2: EDITORIAL COMMENT

736 LAPAROSCOPIC TESTICUIAR DENERVATION

encompass these patients (reference 4 in article). Specialists in phys- ical medicine and rehabilitation are familiar with this disorder but the overwhelming number of practicing urologists are not. Physical therapy may have an important role in the management of some of these conditions.

We have adopted a systematic multidisciplinary approach for the management of chronic genital pain. Patients are evaluated and treated by a urologist, mental health professional and physical ther- apist. Although it is too early to know the outcome of this approach, initial experience is promising. Because of the limitations in this report, we do not advocate the general use of testicular denervation for the management of chronic unexplained genital pain. Alterna- tively, we encourage others to adopt a multidisciplinary approach in the evaluation and management of this complex disorder.

Elroy D. Kursch Department of Urology-Lynhurst Cleveland Clinic Foundation Lynhurst, Ohio

1. sin&, M., Merritt, J. L. and Stillwell, G. K.: Tension myalgia of the pelvic floor. Mayo Clii. Proc., 52 717, 1997.

REPLY BY AUTHORS

Chronic orchalgia is a common and perplexing problem for the urologist. It is especially frustrating since many of these patients present with pain following other (nonpain related) urological pro- cedures such as vasectomy. All patients were offered pain clinic referral and treatment either failed or was refused when they were informed of therapies offered. In addition, all patients were seen multiple times by the same urologist who eventually performed the procedure. The evaluation process permitted the development of a good rapport with the patient and an opportunity for the surgeon screen for other psychological factors. The best evaluation of this procedure would be a blinded study but this would be difficult to perform in the given scenario.