Retentissement sur la sexualité et la fertilité des douleurs pelvipérinéales chroniques

Hydrodissection for improved microsurgical denervation of the spermatic cord: prospective blinded randomized control trial in a rat model

Microsurgical denervation of the spermatic cord (MDSC) can provide up to an 86% improvement in pain in patients with chronic orchialgia (CO) who have failed conservative management. Failures in MDSC could be due to small diameter nerves (≤1 mm) left behind on the spermatic cord. The objective of this study was to assess if hydrodissection (HD) of the spermatic cord after MDSC could decrease the number of residual nerve fibers without compromising blood flow. Prospective blinded randomized control trial: bilateral MDSC was performed on 22 adult rats (44 cords). HD of the spermatic cord was performed on one side of each rat (side randomized) using the ERBEJET2. The contralateral cord (no HD) was the control for each animal. Blood flow through the vessels was monitored using a micro-Doppler probe. After completion a cross-section of the residual cord was sent to pathology (blinded to technique) to assess for small diameter nerves and signs of damage in vascular integrity. Blood flow had been maintained in the vessels when the ERBEJET2 was set to 6 bar (87 psi). The cord where HD had been performed had a significantly lower total median residual nerve count of 5 (0-10), compared to 8 (2-12) on the non-HD side (p = 0.007). No structural damage was seen in the vessels in the spermatic cord that had undergone HD (gross exam and histology). HD of the spermatic cord significantly decreases residual nerve density without compromising vascular integrity in a rat model.

Prospective control trial: flexible CO2 laser vs. monopolar electrocautery for robotic microsurgical denervation of the spermatic cord

Microsurgical denervation of the spermatic cord (MDSC) is a treatment option in patients with chronic orchialgia. This procedure requires precise care to avoid any thermal damage to crucial adjacent tissues (arteries, veins, and lymphatics). Monopolar electrocautery is the standard ligation energy source, but may cause extensive collateral damage to the tissues. However, CO₂ laser is known to produce a very predictable tissue penetration and minimal collateral spread. The goal of this study was to compare the extent of collateral thermal damage in both monopolar electrocautery and CO₂ laser ablation in the spermatic cord during a robotic assisted MDSC (RMDSC) procedure as well as the feasibility for utilizing the flexible fiber-optic CO₂ laser probe after "RMDSC" procedure. RMDSC was performed using standard monopolar electrocautery on the spermatic cord of one side of a fresh human male cadaver (randomly selected) and then compared to RMDSC using the CO₂ laser on the contralateral spermatic cord. Nine histological cross-sections from each cord were measured for depth of collateral thermal/cautery injury. The mean collateral thermal injury with CO₂ laser was 0.17 ± 0.031 mm (range: 0.15-0.25 mm), and with standard electrocautery 0.72 ± 0.046 mm (range: 0.60-0.75 mm). CO₂ laser resulted significantly less collateral thermal injury than standard electrocautery (p < 0.0001). The CO₂ laser probe was easy to manipulate with the Black Diamond micro-forceps (Intuitive Surgical, CA) and allowed for convenient tissue plane dissection. Human cadaveric targeted RMDSC using a flexible CO₂ laser energy results in significantly decreased collateral thermal injury compared to standard monopolar electrocautery. These initial findings suggest potential advantages of the CO₂ laser over traditional monopolar cautery in cases requiring minimal collateral tissue damage. Future studies are needed to assess its clinical potential in microsurgery.