Inguino-Scrotal Surgery

, Amr Abdel Raheem^{2, 3} and D. Ralph²

(1)

Department of Andrology, University College London, London, UK

(2)

Department of Urology, University College Hospitals, London, UK

(3)

Department of Andrology, Cairo University, Cairo, Egypt

Introduction

Microscopic Sub-inguinal Varicocelectomy

Radical Inguinal Orchidectomy

Micro Denervation of the Spermatic Cord (MDSC)

References

Introduction

In this chapter we will be discussing several benign conditions affecting the groin and scrotum which andrologist may be involved in managing. Knowledge of the anatomy of this area and potential complications is very important. The rich vascular supply to the scrotum means that any surgical procedure must involve meticulous haemostasis . The scrotum obtains its blood supply from two different directions: transversely and longitudinally. This means that the scrotal wall is usually a very forgiving structure with good healing following both trauma and surgery. The midline raphe incision is utilised in most procedures as it is associated with the best cosmesis. In surgery on or near the epididymis it’s important to be aware of the location of the rete testis with its terminal blood supply to the testis. The rete testis is also the only connection between the testis and the epididymis. This means that epididymal surgery may result in compromise of the blood supply to the testis and epididymis as well as cause epididymal obstruction .

All the procedures in this section require careful counselling of the patients. This must include management of patient expectations especially if the primary aim for surgery is resolution of pain. In addition, a full explanation of possible complications is vital. We often advise scrotal support for 24 h, scrotal elevation for several days and that the patient undertakes minimal exertion for up to a week following surgery.

Microscopic Sub-inguinal Varicocelectomy

A varicocele is an abnormal dilatation of the pampiniform plexus which classically results in a dragging sensation in the scrotum. It may also be associated with delayed growth of the associated testis, and hypogonadism. Its role in infertility remains controversial although there is good evidence that it significantly improves semen parameters and IVF outcomes [1, 2]. The prevalence in the general population is estimated to be 15%; 35% in infertile men [1, 2]. The presence of a new onset varicocele especially in later life should raise the suspicion of a possible renal tumour (secondary varicocele) and so imaging of the renal tract should be performed in these circumstances. On lying supine, the varicocele may empty which helps to differentiate a primary from a secondary varicocele.

Varicoceles are graded as follows:

Grade 1 (small): palpable only with Valsalva.
Grade 2 (medium): palpable without Valsalva.
Grade 3 (large): Visible through the scrotal skin.

The common approaches to varicocelectomy are illustrated in Table 16.1 [3]. We perform a microscopic subinguinal varicocele ligation and we have described the approach below. This has the lowest complication rates and best outcomes.

Table 16.1

Common approaches to varicocelectomy

Radiological retrograde embolization

Inguinal ligation

High retroperitoneal ligation

Microscopic subinguinal ligation

Laparoscopic/robotic assisted ligation

Surgical steps

Subinguinal incision.
- One fingers breadth above pubic tubercle and don’t cross medial border of penis.
Deepen incision through scarpa’s fascia until the superficial inguinal ring is exposed.
Identify the cord and pull up with a Babcock. Free the cord further posteriorly using a peanut swab.
Place a damp swab behind the cord and remove the Babcock.
Identify any cremasteric vessels outside the cord (often observed at the corner of the scrotal neck).
- Ligate the veins using 3–0 vicryl.
Open the cord under the microscopic vision.
Place fingers behind the cord and identify all structures’ systematically from medial to lateral.
- Mobilise veins carefully and sloop.
- Identify and preserve the vas and its vessels.
- The artery is usually between two veins and often within fatty tissue.
Ensure vessels are veins prior to ligating with 3–0 vicryl by applying papaverine and observing for pulsation and by the use of a Doppler.
Deliver testis and ligate any gubernaculum veins.
Return the testis to the scrotum.
Close in layers:
- 3–0 vicryl to fascia.
- 3–0 monocryl to skin.

Risks:

Hydrocele .
Recurrence.
Testicular infarction/atrophy [1–3].

Radical Inguinal Orchidectomy

The presentation of a testis tumour is usually as a painless scrotal mass. The patient should be assessed for metastatic disease or signs of androgenisation i.e. gynaecomastia [3]. Alternative diagnoses should be excluded such as hydrocele, epididymal cyst, hernia and delayed testicular torsion [3]. Initial management includes tumour markers, testis ultrasound and cryopreservation of sperm.

Surgical steps

3–5 cm inguinal incision, 2 cm above the pubic tubercle.
Deepen the incision to expose scarpa’s fascia and divide using monopolar diathermy.
Incise the aponeurosis of the external oblique in the line of its fibres to the superficial inguinal ring.
Identify and preserve the ilioinguinal nerve as it exits the ring laterally.
Elevate the cord and dissect it free from the cremasteric fascia.
Apply a clamp to the proximal end of the cord at the deep ring.
Deliver the testis and divide the gubernaculum.
Divide the cord between two clamps.
Transfix the proximal cord stump with 0-vicryl twice.
Close the groin incision in layers:
- 2–0 vicryl to fascial layers.
- 3–0 monocryl to skin.

Risks

Scrotal and retroperitoneal haematoma.
Wound infection.
Ilio-inguinal nerve injury.
Hernia [3]

Vasectomy

This is an effective form of male sterilisation . The number of vasectomies being performed is falling and it is now mainly done by non-urologists. The aim is to remove a segment of the vas and closure of the proximal and distal ends separately. It may be performed under local or general anaesthesia . This is one of the most litigious areas of Urology which makes careful and detailed counselling vitally important (see Table 16.2). The procedure should be described and a decision made with the patient regarding how whether it should be performed under local or general anaesthesia. Alternative contraceptives will be required until a negative semen analysis is obtained 12 weeks (or 16 weeks) post-procedure [4]. Special clearance may be given if the patient has two semen samples with less than 100,000 non-motile sperm taken 3–6 months apart [4]. Although the procedure is reversible, patients should consider it irreversible. Reversal is usually not available on the NHS and its success rates diminish with increasing time after the vasectomy.

Table 16.2

Checklist for vasectomy counselling