Cord denervation: Surgeons describe microsurgical techniques in men with scrotal pain

Orchalgia, also known as “ball pain,” can be the bane of general urologists’ existence. In our practice, most of these patients end up in our Men’s Health Center. Here we provide three videos on microsurgical cord denervation (MSCD), which, when done properly, we have found to be very effective in providing nearly instant pain relief to men with orchalgia. MSCD is a very satisfying operation, and we find that these men are some of our most grateful patients. The videos below each represent a different approach to this complex microsurgical procedure. The surgeons all demonstrate meticulous hemostasis and clear definition of tissue planes, which is critical to the success of these surgeries.
-James M. Hotaling, MD, MS, Section Editor

Commentary on the videos is provided by James Craig, MD, a men's health and reconstructive urology fellow at the University of Utah, and by 'Y'tube Section Editor James M. Hotaling, MD, MS, assistant professor of surgery (urology) at the Center for Reconstructive Urology and Men's Health, University of Utah, Salt Lake City.

Continue to the next page to watch the videos.

Microscopic spermatic cord denervation - James Craig, MD, and James M. Hotaling, MD, MS

We demonstrate the technique we use at our Men’s Health Center in Utah for optimal cord denervation. Like many others, we use a small subinguinal incision. However, we improve our exposure in obese patients by using the hooks from a Lone Star retractor to facilitate exposure. Here, Dr. Craig begins by identifying the lymphatics and preserving these with vessel loops. He uses a micro needle driver for much of the fine dissection to preserve fragile tissue planes and identify the artery, which he then places a vessel loop around. We transect the vas deferens in all men who are done having children. At the end of the procedure, we have only three lymphatics and the artery. Although we do not demonstrate it in this video, we also use Amniofix (a technique learned from Dr. Shridharani) and have found that our success rates have gone from 80% to 90% since use of this adjunct.

Microsurgical denervation of the spermatic cord for testicular pain - Daniel H. Williams, IV, MD

Dr. Williams performs a microsurgical denervation of the spermatic cord in a patient with severe testicular pain that was refractory to medical therapy. This is an outpatient, same-day procedure. A small subinguinal incision is made. Using the operating microscope and a micro-doppler ultrasound, critical structures including testicular arteries and lymphatics are preserved. Venous drainage occurs via the gubernacular veins. All other structures are ligated to provide anesthesia and durable pain relief to the affected testicle.

Dr. Craig: The surgeon demonstrates his method of spermatic cord denervation. Highlights of his video include performing this through a subinguinal location with a small and concealable incision, identification and preservation of the testicular artery with the assistance of a micro-doppler, preservation of lymphatic channels, and transection of the vas deferens as well as the vasal packet-a prime location for a large volume of neural tissue.

Dr. Hotaling: Dr. Williams performs a radical neurolysis here, preserving only the testicular artery and a few lymphatic channels. We have found that preservation of a few of these channels is critical to prevent hydrocele formation. This dissection leaves only the critical structures behind and, in expert hands, offers outstanding success rates of 75% to 90%.

Microsurgical spermatic cord deneveration, with and without sparing of the vas - Anand Shridharani, MD

Dr. Craig: The surgeons demonstrate the importance of targeting and dividing structures of the spermatic cord, which contain a high volume of neural tissue. They demonstrate a more limited dissection and fewer number of transected structures compared to Dr. Williams’ technique, with a good response rate postoperatively. They also illustrate the ability to perform this type of procedure while preserving the vas deferens and therefore fertility.

Dr. Hotaling: Dr. Shridharani elegantly demonstrates a nice use of vessel loops both to isolate the cremasteric fibers for ligation but also to provide exposure for dissection of delicate cord structures. In contrast to other videos, his team performs a less radical neurolysis but does demonstrate good outcomes. Their choice of removing 2 cm of the perivasal tissue is novel and could likely be easily incorporated into a vassal-sparing denervation. One advantage of their less extensive dissection is the lack of risk of a hydrocele due to the preservation of numerous lymphatic channels around the testicular artery. The use of Amniofix for improving postoperative pain relief is another novel technique that we. at the University of Utah Center for Men’s Health & Reconstructive Urology, have found to improve our success rates significantly.

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