Epididymectomy

KHALID ALRABEEAH

PETER CHAN

With the advances in medical imaging to evaluate the nature of most scrotal masses along with the availability of broadspectrum antimicrobials to control infection of scrotal organs, surgical removal of all or part of the epididymis is done infrequently. Nonetheless, when conservative management fails, epididymectomy, although invasive with potential risks of ultimately requiring an orchiectomy and compromising fertility, can be effective in managing defined epididymal pathologies or chronic scrotal pain in carefully selected patients. Because complete and partial epididymectomy is infrequently performed, most urologists have variable levels of experience in these procedures. This further highlights the importance of having a thorough understanding of the various issues related to epididymectomy ranging from preoperative counseling to anatomic details to the variation of surgical techniques so that in the rare event that calls for such a procedure, one can aim not only to minimize any potential complications and risks of compromising the fertility status of the patients but also to maximize long-term satisfaction of the patients particularly in relation to chronic scrotal pain control.

INDICATIONS

The indications of epididymectomy include scrotal pain localized to the epididymis (e.g., postvasectomy), chronic epididymitis, painful large/complex epididymal cystic disease, trauma, tuberculous epididymitis, and schistosomal epididymitis. Epididymectomy for other less common epididymal pathologies such as benign epididymal adenoma, sarcoidosis, and epididymal malignancies (primary and metastatic) have also been described in the literature. Postvasectomy scrotal pain, chronic epididymitis, and painful epididymal cysts or spermatoceles are the most common indications for epididymectomy (Table 54.1), as shown by a series of recent studies on epididymectomy (1,2,3,4,5,6,7,8,9,10,11,12,13).

COUNSELING ISSUES

Patients with chronic scrotal pain syndrome are challenging to manage. No single treatment modality can guarantee effective alleviation of the pain; hence, the logic is to begin with conservative treatment such as reassurance, warm, local compresses, sitz baths, scrotal supports, massotherapy, exercise, and relaxation followed by medical treatments ranging from analgesic, anti-inflammatory, antibiotics, antioxidants, anxiolytic, alphablockers, anticholinergics to narcotics, and neuroleptic drugs. Additional adjunctive treatments with physiotherapy, biofeedback, psychotherapy, regional anesthesia, and acupuncture may also be considered. Invasive and irreversible treatment such as surgery should only be considered as the last resort and the patients should always be informed, in addition to any potential complications, that the pain may not be fully relieved and may even worsen. Thus, just like any patients suffering from chronic pain such as chronic pelvic pain syndrome, men with chronic scrotal pain syndrome are best managed with a multidisciplinary approach involving, in addition to urologists, general surgeons, pain specialists/anesthetists, psychologists, sexologists, physiotherapists, infectious disease specialists, radiologists, reproductive medicine specialists, and acupuncturists.

Proper preoperative counseling for invasive surgery such as epididymectomy in the absence of clear epididymal pathologies such as solid or cystic mass, chronic inflammation, or infection is particularly important. Although epididymectomy is usually performed unilaterally, the surgeon must disclose its potential negative impact on fertility, particularly if there is any indication on history and physical examination that suggests impaired testicular function or the integrity of the excurrent ductal system on the contralateral testis. In the case of partial epididymectomy for resection of localized epididymal lesion, simultaneous microsurgical vasoepididymostomy should be offered in an attempt to maximize the quantity of sperm in semen for preservation of fertility. Likewise, sperm banking by cryopreservation prior to surgery, the potential needs of simultaneous surgical sperm extraction for use with in vitro fertilization/intracytoplasmic sperm injection in the future should also be part of the
discussion and preoperative counseling in addition to surgical risks and complications.

TABLE 54.1 INDICATION OF EPIDIDYMECTOMY

Indication	% of epididymectomy according to indication
Postvasectomy scrotal pain	44
Chronic epididymitis/chronic scrotal pain	37
Painful epididymal cyst	17
Trauma	rare
Tuberculous epididymitis	rare
Schistosomal epididymitis	rare
Leiomyoma of the epididymis	rare
Adenomatoid tumor of the epididymis	rare
Leiomyosarcoma of the epididymis	rare
Epididymal sarcoidosis	rare

Chronic pain is a common presentation in men undergoing epididymectomy and can have a significant psychosocial impact on the individual’s quality of life. At the same time, chronic scrotal pain can also be caused by psychosocial factors, making surgical management or medications such as anti-inflammatory and analgesics ineffective in relieving the pain. As in patient with chronic orchialgia undergoing surgical denervation procedure, we advocate for all patients requiring epididymectomy specifically for chronic pain to undergo multiple sessions of nerve block with local anesthesia or “sham nerve block” with a small amount (<1 mL) of saline to the spermatic cord (with the patient blinded). If pain persists despite properly performed nerve block, surgery with denervation or epididymectomy may not adequately resolve the pain postoperatively. On the other hand, if the pain resolves with a sham nerve block, then psychosomatic factor may play a significant role in the etiology of the chronic pain in the subject. We feel that this information can help surgeon inform patients to have a realistic expectation of the outcomes of surgery. Men with pain and tenderness clearly and specifically localized to the epididymis are the best candidates for epididymectomy.

SURGICAL TECHNIQUES

Anatomic Consideration

Detailed knowledge of epididymal anatomy is essential before undertaking surgery of this delicate structure. The epididymis is blessed with a rich blood supply derived from the testicular vessels superiorly and the deferential vessels inferiorly. With this extensive interconnections between these branches, either the testicular or the deferential branches (but not both) to the epididymis may be divided without compromising epididymal viability. This is particularly important when performing partial epididymectomy (see the following text). Another important piece of anatomic details of the blood supply of the epididymis is that because the epididymal branches of the testicular artery are medial to and separate from the main testicular artery and veins, epididymectomy may be performed on the epididymis without compromising testicular blood supply.

Interestingly, anatomic studies using immunohistochemistry indicated that innervation of the epididymis is denser than that of testis (14). Indeed, there is an extensive sympathetic nerve network innervating the cauda epididymis and vas deferens (15) controlled by the abdominal and pelvic sympathetic nervous system to generate transport of spermatozoa from the epididymis through the vas deferens. Human epididymis is densely innervated by nerve fibers immunoreactive to a wide range of neuropeptides including tyrosine hydroxylase, neuropeptide Y, vasoactive intestinal polypeptide, calcitonin gene-related peptide, galanin, peptide histidine isoleucine, and substance P (14). Besides regulation of smooth musculature function, some of these neuropeptides (most notably substance P and calcitonin gene-related peptide) have been shown to take part in the processing of pain (16,17).

A recent histologic study reported a reproducible, distinct anatomic distribution of nerves in the spermatic cord that is commonly found to have pathologic condition such as wallerian degeneration in men with chronic orchialgia. In decreasing order of nerve density, the three primary sites of this trifecta nerve complex are localized in (a) cremasteric muscle fibers, (b) perivasal tissues and vasal sheath, and (c) posterior cord lipomatous/perivessel tissues (18). Targeting these specific abnormal nerves may enhance the efficacy of pain control during surgical denervation or epididymectomy in patients with chronic orchialgia.

In human, distal caput, corpus, and cauda epididymis is a single, tightly coiled, 5- to 7-m long tubule. When refractory chronic pain due to obstruction of the outflow of the excurrent ductal system (such as postvasectomy) can be localized to a specific area such as cauda epididymis, partial epididymectomy may alleviate the pain. However, one must keep in mind that effectively, the surgery allows the point of obstruction to be migrated more proximally along the epididymis and there is a potential risk that similar pain may recur proximally. Even with complete epididymectomy for chronic pain due to obstruction, there is a risk that obstruction and pressure may build up postoperatively at the level of the testis leading to chronic orchialgia. Thus, prior to undertaking epididymectomy for pain control, the patient must receive proper counseling of the potential risks of recurrence of ipsilateral chronic pain.

Anesthesia

Simple epididymectomy can be completed within 1 hour, thus the choices of anesthesia including general, regional, and, in motivated patient, local anesthesia are all reasonable options. However, in complicated cases such as those with extensive inflammation that may require complicated dissection or if additional procedures such as microsurgical reconstruction with vasoepididymostomy and/or epididymal or testicular sperm retrieval are planned with a partial epididymectomy, general or long-acting regional anesthesia is preferred.

After induction of appropriate anesthesia, intravenous administration of antimicrobial drugs should be considered in cases when infectious causes of epididymitis are suspected.

Incision

For unilateral epididymectomy due to chronic pain secondary to inflammatory/infectious or obstructive causes, an ipsilateral transverse or midline scrotal incision can be used. A high scrotal incision should be considered if there is extensive inflammation that may require dissection and resection of the vas deferens in the subinguinal region or if a simultaneous vasoepididymostomy is planned during a partial epididymectomy. These incisions can also be used in most cases when the indication of epididymectomy is epididymal mass, as the great majority of these masses are benign adenomatoid tumors. However, when there is a history of rapid growth of an epididymal mass that is solid and hypervascular on sonography, the lesion may represent malignant epididymal tumor. In these extremely rare cases, an inguinal incision, as in radical orchiectomy for testicular tumor, should be used to allow early control of the spermatic cord and associated vasculature and lymphatics.

When scrotal incision is used, it should be large enough to allow delivery of the testis and epididymis. The tunica vaginalis can be exposed by developing the plane between it
and the dartos muscle layers with a combination of sharp and blunt dissection. The use of electrocautery can provide excellent hemostasis. Alternatively, after the skin incision, some surgeons advocate to gather the successive layers with a suture placed at either end or in an Allis clamps to facilitate wound closure at the end of the procedure. In either approaches, one should attempt to deliver the intravaginal contents with the tunica vaginalis intact to allow for closure separate from the more superficial scrotal layers.

Handling of the Vas Deferens

Prior to opening the tunica vaginalis, in cases of inflammatory or infectious epididymitis, one should dissect superiorly along the spermatic cord toward the external inguinal ring to allow inspection for any sinus openings. If infectious epididymitis is suspected, appropriate culture of a swab of the operative field or any suspicious fluid should be performed followed by copious irrigation of the field. If the extent of inflammation involves more proximally along vas deferens and the spermatic cord, the incision may need to be extended or new incision made subinguinally to allow for adequate exposure for complete removal of inflammatory tissues. When epididymectomy is performed for postvasectomy pain, dissection along the spermatic cord should be performed to expose the vasectomy site to allow the testicular end of the vas deferens and any associated sperm granuloma to be resected.

In epididymectomy for other indications, the vas deferens may be divided and ligated at the junction of the convoluted and straight vas. This is particularly important if a partial epididymectomy for a benign focal lesion is planned and a simultaneous vasoepididymostomy is to be performed as it will allow the straight vas to be used for the vasoepididymostomy. Ligation of the vas can be done using absorbable sutures. Titanium clips should be avoided in patients with pain as the primary presentation.

In patient with pain as the chief complaint, microsurgical denervation can be considered simultaneously during epididymectomy. A formal denervation (see Chapter 54 on denervation) can achieve satisfactory results for pain alleviation but may inadvertently lead to decreased scrotal and penile skin sensation. Relief of chronic severe pain localized to the epididymis may be better achieved, in addition to epididymectomy, by denervating the perivasal nerve fibers (18) using a microbipolar forceps. Care should be taken during the procedure, as it may inadvertently damage the vas deferens.

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