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  • Robotic Assisted Microsurgical Targeted Denervation of the Spermatic Cord

    Authors

    Jamin Brahmbhatt, MD

    Jamin Brahmbhatt MD on Urologybook.com

    Dr. Jamin Brahmbhatt was a Clinical Assistant Professor in the department of urology at the University of Florida and Winter Haven Hospital.  He is currently co director of Personalized Urology & Robotics – at South Lake Hospital, in Clermont, Florida. He received his undergraduate training at Boston University in Boston, MA, where he graduated Magna Cum Laude.  He underwent his medical training at Boston University School of Medicine and residency in urology from University of Tennessee Health Science Center in Memphis, TN.  He completed a one-year clinical fellowship in robotic microsurgery and male infertility with University of Florida and Winter Haven Hospital.  His clinical and research interests include male sexual function, hypogonadism, male-factor infertility, and chronic groin and testicular pain.

    Ahmet Gudeloglu, MD

    Ahmet Gudeloglu on Urologybook.com

    Ahmet Gudeloglu, MD, FEBU, was a research fellow at the Winter Haven Hospital & University of Florida Robotics Institute and Center for Urology. He is currently at Memorial Ankara Hospital in Turkey.

    He is a board certified urologist through the European Board of Urology. Dr. Gudeloglu earned his medical degree from 19 Mayis University in Samsun/Turkey in 2005 and completed a residency in urology at Hacettepe University in Ankara/Turkey in 2011. Dr. Gudeloglu was an active researcher in the field of robotic microsurgery, reproductive urology and chronic testicular pain.  He was also an instructor at Polk State College for their robotic nursing program and summer medical high school academy. He had joined the Cochrane Prostatic Diseases & Urologic Cancers Group.

    Sijo Parekattil, MD

    Sijo Parekattil MD

    Dr. Sijo Parekattil was the Director of Urology & Robotic Surgery at Winter Haven Hospital, University of Florida. He is currently co director of Personalized Urology & Robotics – at South Lake Hospital, in Clermont, Florida.  He was an Electrical Engineer (University of Michigan) prior to his medical training and thus has interests in surgical techniques incorporating technology, robotics and microsurgery. He completed his urology residency training at Albany Medical Center and then went onto complete dual fellowship training from the Cleveland Clinic Foundation, Cleveland in Laparoscopy/Robotic Surgery and Microsurgery/Male Infertility.

    Dr. Parekattil has received numerous awards including the Golden Garland Award in Medicine in 2012. He is a co-editor of a comprehensive textbook on Male Infertility and a surgical textbook on Robotic Microsurgery. He has performed some pioneering work in the arena of robotic microsurgery and has now performed over 1000 such procedures. He has developed a multi-disciplinary program dedicated to the treatment of male infertility and groin/testicular pain.

    Authors’ Website (link)

    Chronic Groin and Scrotal Content Pain

    Chronic groin or scrotal content pain (CGSCP) is defined as unilateral or bilateral, intermittent or constant pain and lasts more than 3 months(1-3). Since the symptoms can originate from the inguinal canal, spermatic cord, testis or paratesticular structures such as the epididymis the term “chronic scrotal content pain” is preferred over chronic orchialgia or testicular pain(2). The pain can also originate from the groin and therefore the term CGSCP is used to cover the entire disease entity (4).

    Possible Mechanisms of Chronic Scrotal Content Pain

    Potential etiologies of CGSCP include vasectomy, varicocele, trauma, hernia repair, and inguinal or scrotal surgery. In most patients the exact trigger cannot be identified (3, 5-8). In these patients neuropathic pain is a potential etiology. (8, 9).  The International Association for the Study of Pain defines neuropathic pain as “pain caused by a lesion or disease of the somatosensory system”(10). In this scenario any disease that causes pain hypersensitivity and/or lesions derived from prior surgery or trauma affecting the ilioinguinal and/or genitofemoral nerves can disturb the somatosensory system and cause neuropathic CGSCP. Pain hypersensitivity can be explained through neuronal plasticity in primary sensory neurons where alterations in nociceptor thresholds cause chronic pain. These alterations are not only at the peripheral nociceptor level but also at the central nervous system level associated with central sensitization(9). It has been determined that neuronal plasticity plays an important role in the pathophysiology of chronic pain(11). Furthermore it is well described that inflammatory processes play an important role in neuronal plasticity pathways(11, 12). Recently, we reported that patients who undergo microsurgical denervation of the spermatic cord (MDSC) have significantly more Wallerian degeneration in their peripheral nerve fibers(13). This study supports the theory that inflammatory processes including Wallerian degeneration within the spermatic cord nerve fibers play a key role in CGSCP.

    Incidence

    CGSCP can develop in over 100,000 men annually(1, 14-17). 1-2% of vasectomized patients and 6-11% of inguinal hernia repair patients suffer from CGSCP(3, 18, 19). A significant amount of CGSCP patients do not have any identifiable etiology.

    Treatment

    Management of CGSCP starts with ruling out all possible causes such as ureteral stones, infection (orchitis or epididymitis) or back problems (lumbar disk hernia) with history, physical exam, and imaging. Then medical treatment such as analgesics, anti-inflammatories and anticonvulsants are started(2, 20). A spermatic cord nerve block can also be attempted. If pain relief cannot be achieved with these non-invasive options, MDSC is then offered as a minimally invasive surgical option(2, 8). Orchiectomy and epididymectomy can be attempted but not recommended surgical modalities due to their low success rates(15, 21, 22).

    MDSC is comprised of ligation of these spermatic cord nerve fibers that carry pain sensation. Today MDSC is a postulated minimal invasive surgical option for CGSCP and it is demonstrated that MDSC has better outcomes over conservative surgical options such as epididymectomy(2, 8, 23). Recently, we determined the density, pathology (Wallerian Degeneration) and distribution (cremasteric muscle, peri-vasal tissue and peri-arterial/posterior lipomatous tissue) of these nerves within the spermatic cord(13). A representative illustration is provided of the pertinent anatomy

    Anatomy of Spermatic Cord During Robotic Selective Cord Denervation For Scrotal Pain
    (Image provided to Urologybook.com By Dr. Sijo Parekattil)

    Our group further refined this technique by incorporating the da Vinci robotic platform (Intuitive Surgical, Inc., Sunnyvale, CA) and targeting these three specific areas of the spermatic cord (23).

    Surgical Technique

    The robotic assisted MDSC (RMDSC) surgical technique begins with 1 to 2 cm sub-inguinal incision. Once Camper’s and Scarpa’s fascia are passed collateral branches of ilioinguinal and genitofemoral nerve fibers are ligated. Then the spermatic cord is brought up and a wooden tongue depressor is placed underneath for stabilization. The robot is now brought in from the right of the patient. Black Diamond micro-forceps x 2 and Maryland bipolar forceps are used for the right, third and the left arm, respectively. Flexible fiber optic CO2 laser probe (OmniGuide Inc., Cambridge, MA) is held on the third arm to assist with microdissection. First, cremaster muscle is cut circumferentially and then peri-vasal and posterior per-arterial lipomatous complex are ligated based on our previous study showing nerve distribution within spermatic cord(13). For the ligation of the nerves we prefer CO2 laser energy to decrease thermal injury to the adjacent tissues(24). The vas deferens is washed with high-pressure water-jet using a hydrodissector (ERBE Inc., Atlanta, GA) to reduce residual nerve fibers(25). Finally the cord is wrapped with a bio-inert matrix material called Axoguard (Axogen Inc., Gainesville,FL) to reduce neuroma formation(26). The spermatic cord is then released and the sub-inguinal incision is closed.

    Outcomes

    We performed 508 RMDSC procedures in patients who did not response to standard medical therapy from October 2008 to May 2013. For the pain assessment we use the pain impact questionnaire (PIQ-6, QualityMetric Inc., Lincoln, RI). Pain assessments are performed preoperatively and post-operatively at 1, 3, 6 and 12 months using PIQ-6.

    Median robotic microsurgical operative duration of our serial was 15 minutes (5 minutes – 150 minutes). 86% (437/508) of the patients had a significant decrease in their pain by 6 months post-op: 72 % had complete elimination of pain and an additional 14% had a greater than 50% reduction in the pain score.

    Potential Complications

    Delayed complications were 2 wound infections, 1 testicular ischemia, 9 hematomas and 2 seromas. Intra-op complications were 2 testicular artery and 1 vasal injury – all repaired intra-op with robotic assisted microsurgical techniques without any further sequela.

    Conclusion

    Targeted robotic assisted microsurgical denervation of the spermatic cord appears to be safe and feasible.  The outcomes appear promising. The 4th arm allowed the surgeon to control one additional instrument leading to less reliance on the microsurgical assistant.

     References:

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    2.           Levine L. Chronic orchialgia: evaluation and discussion of treatment options. Therapeutic advances in urology. 2010;2(5-06):209-14. Epub 2011/07/27.

    3.           Alfieri S, Amid PK, Campanelli G, Izard G, Kehlet H, Wijsmuller AR, et al. International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery. Hernia : the journal of hernias and abdominal wall surgery. 2011;15(3):239-49. Epub 2011/03/03.

    4.           Cunningham J, Temple WJ, Mitchell P, Nixon JA, Preshaw RM, Hagen NA. Cooperative hernia study. Pain in the postrepair patient. Ann Surg. 1996;224(5):598-602. Epub 1996/11/01.

    5.           Tandon S, Sabanegh E, Jr. Chronic pain after vasectomy: a diagnostic and treatment dilemma. BJU international. 2008;102(2):166-9. Epub 2008/03/08.

    6.           Ribe N, Manasia P, Sarquella J, Grimaldi S, Pomerol JM. Clinical follow-up after subinguinal varicocele ligation to treat pain. Arch Ital Urol Androl. 2002;74(2):51-3. Epub 2002/08/07.

    7.           Granitsiotis P, Kirk D. Chronic testicular pain: an overview. European urology. 2004;45(4):430-6. Epub 2004/03/26.

    8.           Larsen SM, Benson JS, Levine LA. Microdenervation of the spermatic cord for chronic scrotal content pain: single institution review analyzing success rate after prior attempts at surgical correction. The Journal of urology. 2013;189(2):554-8. Epub 2012/12/25.

    9.           Woolf CJ, Salter MW. Neuronal plasticity: increasing the gain in pain. Science. 2000;288(5472):1765-9. Epub 2000/06/10.

    10.         Jensen TS, Baron R, Haanpaa M, Kalso E, Loeser JD, Rice AS, et al. A new definition of neuropathic pain. Pain. 2011;152(10):2204-5. Epub 2011/07/19.

    11.         Puretic MB, Demarin V. Neuroplasticity mechanisms in the pathophysiology of chronic pain. Acta clinica Croatica. 2012;51(3):425-9. Epub 2013/01/22.

    12.         Gaudet AD, Popovich PG, Ramer MS. Wallerian degeneration: gaining perspective on inflammatory events after peripheral nerve injury. Journal of neuroinflammation. 2011;8:110. Epub 2011/09/01.

    13.         Parekattil SJ, Gudeloglu A, Brahmbhatt JV, Priola KB, Vieweg J, Allan RW. Trifecta Nerve Complex – Potential Anatomic Basis for Microsurgical Denervation of the Spermatic Cord for Chronic Orchialgia. The Journal of urology. 2013.

    14.         Parekattil SJ, Cohen MS. Robotic surgery in male infertility and chronic orchialgia. Current opinion in urology. 2010;20(1):75-9. Epub 2009/11/06.

    15.         Costabile RA, Hahn M, McLeod DG. Chronic orchialgia in the pain prone patient: the clinical perspective. The Journal of urology. 1991;146(6):1571-4. Epub 1991/12/01.

    16.         Levine LA. Microsurgical denervation of the spermatic cord. The journal of sexual medicine. 2008;5(3):526-9. Epub 2008/02/29.

    17.         Strom KH, Levine LA. Microsurgical denervation of the spermatic cord for chronic orchialgia: long-term results from a single center. The Journal of urology. 2008;180(3):949-53. Epub 2008/07/22.

    18.         Sharlip ID, Belker AM, Honig S, Labrecque M, Marmar JL, Ross LS, et al. Vasectomy: AUA guideline. The Journal of urology. 2012;188(6 Suppl):2482-91. Epub 2012/10/27.

    19.         Nienhuijs S, Staal E, Strobbe L, Rosman C, Groenewoud H, Bleichrodt R. Chronic pain after mesh repair of inguinal hernia: a systematic review. Am J Surg. 2007;194(3):394-400. Epub 2007/08/19.

    20.         Masarani M, Cox R. The aetiology, pathophysiology and management of chronic orchialgia. BJU international. 2003;91(5):435-7. Epub 2003/02/27.

    21.         Sweeney CA, Oades GM, Fraser M, Palmer M. Does surgery have a role in management of chronic intrascrotal pain? Urology. 2008;71(6):1099-102. Epub 2008/04/26.

    22.         Calleary JG, Masood J, Hill JT. Chronic epididymitis: is epididymectomy a valid surgical treatment? Int J Androl. 2009;32(5):468-72. Epub 2008/04/03.

    23.         Parekattil SJ, Gudeloglu A. Robotic assisted andrological surgery. Asian journal of andrology. 2013;15(1):67-74. Epub 2012/12/18.

    24.         Brahmbhatt J, Gudeloglu A, Parekattil S. Prospective Control Trial: Flexible Fiber-Optic CO2 Laser vs Monopolar Cautery for Robotic Microsurgical Denervation of the Spermatic Cord.  28th Annual Meeting of Engineering and Urology Society San Diego2013.

    25.         Gudeloglu A, Iqbal Z, Parekattil SJ, Groth AC, Priola KB, Allan RW. Hydrodissection For Improved Microsurgical Denervation Of The Spermatic Cord: Prospective Blinded Randomized Control Trial In A Rat Model.
      Fertility and sterility. 2011;96(3, Supplement):S87-8.

    26.         Parekattil SJ, Gudeloglu A, Brahmbhatt J, Priola KB, Cohen MS. Prospective Randomized Control Trial Of A Neuroprotective Wrap For The Spermatic Cord After Denervation For Chronic Orchialgia. Fertility and sterility. 2011;96(3, Supplement):S231.

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