Preoperative Predictors of Failure of Microsurgical Spermatic Cord Denervation for Men with Chronic Orchialgia.
Parviz K. Kavoussi, M.D., Brady T. West, P.h.D., G. Luke Machen, M.D.
Published Nov 27, 2020
Objective
To evaluate predictors of failure of microsurgical spermatic cord denervation (MSCD) for men with chronic orchialgia.
One hundred and five men underwent MSCD, and of those, 38 were bilateral, for a total of 143 testicular units.
The mean pre-operative visual analog scale was 6.8 ± 2 and the mean duration of pain prior to MSCD was 62.5 ± 100 months.
PVPS is an etiology associated with a higher risk of failure to respond to MSCD than idiopathic chronic orchialgia or chronic orchialgia subsequent to scrotal/inguinal surgery.
Chronic orchialgia has traditionally been a challenging entity to diagnose and treat despite being one of the most frequent complaints seen in the urologist’s office
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The men must have failed to respond to conservative therapy for at least three months, at a minimum including non-steroidal anti-inflammatory drugs (NSAIDs), heat, and scrotal elevation.
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Consideration of candidacy for MSCD included that all men underwent a diagnostic spermatic cord block in the clinic and must have demonstrated at least a 50% improvement in VAS score from baseline to following the nerve block.
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Between September 2011 and March 2019, 105 men met candidacy requirements and underwent MSCD for chronic orchialgia by a single fellowship-trained microsurgeon (PKK).
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The identifiable inciting etiologies of pain per testicular unit included previous scrotal/inguinal surgery prior to the onset of pain 17/143 (11.9%), post-vasectomy pain syndrome (PVPS) 30/143 (21%), infectious epididymitis 9/143 (6.3%2, trauma 15/143 (10.5%), and idiopathic 72/143 (50.3%).
https://www.goldjournal.net/article/S0090-4295(20)31420-5/fulltext
Summary and comments from /u/postvasectomy:
Summary of causes of pain:
| Cause of pain | Number | Percent |
|---|---|---|
| Scrotal/inguinal surgery | 17 | 12% |
| PVPS | 30 | 21% |
| Infection | 9 | 6% |
| Trauma | 15 | 10% |
| Idiopathic | 72 | 50% |
Note that only 10% of men get vasectomy, the only elective situation in the above list. If 100% of men got vasectomy, presumably the PVP numbers would be 10 times higher in studies like this. So a typical composition might look more like this:
| Cause of pain | Number | Percent |
|---|---|---|
| Scrotal/inguinal surgery | 17 | 4% |
| PVPS | 300 | 73% |
| Infection | 9 | 2% |
| Trauma | 15 | 4% |
| Idiopathic | 72 | 17% |
Average Visual Analog Score for pain ranged from 4.8 to 8.8
Of 143 testicles:
- 97 (68%) Success = Had complete resolution of pain
- 27 (27%) Partial Success = Had at least 50% improvement
- 19 (13%) Failure = Less than 50% improvement
Overall failure rate = 13%
Failure rate by cause of pain:
| Cause of pain | Attempts | Failures | Percent Failed |
|---|---|---|---|
| Scrotal/inguinal surgery | 17 | 1 | 6% |
| PVPS | 30 | 8 | 27% |
| Infection | 9 | 1 | 11% |
| Trauma | 15 | 4 | 27% |
| Idiopathic | 72 | 5 | 7% |
Compare these numbers with the video from Dr. Kelli Gross, recently linked in the postvasectomypain subreddit:
Typically one thing that we offer that is a pretty helpful surgery, you see people definitely have a big response after the surgery, is the micro-surgical spermatic cord denervation. That’s where we divide pretty much all of the nerves around the spermatic cord to the testicle, and it really works quite well. So we’ll get 70-80% of men that will have a complete response, so no pain after the spermatic cord denervation. About 10-20% will have a partial response, or will have improvement but won’t be 100% better.
Based on the information from Dr. Gross, one might expect Success + Partial Success rates to range from 70 + 10 = 80% to 80 + 20 = 100%. So failure rate range is 0% to 20%
But Dr. Gross does MSCD for all categories of men, not just PVPS guys. Because so few men get vasectomy, overall failure of MSCD was 13%, which fits in the range expressed by Dr. Gross. But if you are trying MSCD to treat PVPS, you might expect a failure rate that is twice as high – 8 failure out of 30, or 26.6%.