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- Clinical Experience -
Outpatient varicocelectomy performed under local anesthesia
Geng-Long Hsu1, Pei-Ying Ling1, Cheng-Hsing Hsieh1, Chii-Jye Wang1, Cheng-Wen Chen1, Hsien-Sheng Wen1, Hsiu-Mei Huang1, E. Ferdinand Einhorn1, Guo-Fang Tseng2
1Microsurgical Potency Reconstruction and Research Center, Taiwan Adventist Hospital, Taipei Medical University, Taipei 110, Taiwan, China
2Department of Anatomy and Cell Biology, College of Medicine, National Taiwan University, Taipei 100, Taiwan, China
Abstract
Aim: To report a series of varicocelectomy performed under pure local
anesthesia. Methods: From July 1988 to June 2003, a total of 575 patients, aged between 15 and 73 years, underwent high ligation of the internal spermatic
vein for treatment of a varicocele testis under a regional block in which a precise injection of 0.8 % lidocaine solution
was delivered to involved tissues after exact anatomical references were made. A 100-mm visual analog scale (VAS)
was used to assess whether the pain level was
acceptable. Results: The surgeries were bilateral in 52 cases, and
unilateral in 523 cases. All were successfully performed on an outpatient basis except in the case of two patients, who
were hospitalized because their surgeries required general anesthesia. Overall, 98.6 % (567/575) of men could go
back to work by the end of the first post-operative week and only 8 (1.4 %) men reported feeling physical discomfort
on the eighth day. The VAS scores varied from 11 mm to 41 mm with an average of (18.5 ± 11.3) mm that was
regarded as tolerable. Conclusion: This study has shown varicocelectomy under local anesthesia to be possible,
simple, effective, reliable and reproducible, and a safe method with minimal complications. It offers the advantages
of more privacy, lower morbidity, with no notable adverse effects resulting from anesthesia, and a more rapid return
to regular physical activity with minor complications.
(Asian J Androl 2005 Dec; 7: 439-444)
Keywords: anterior superior iliac spine; spermatic cord; aponeurosis; umbilicus; pubic symphysis; varicocelectomy; anesthesia
Correspondence to: Dr Geng-Long Hsu, M.D., Microsurgical
Potency Reconstruction and Research Center, Taiwan Adventist
Hospital, 424, Pa Te Road, Sec. 2, Taipei 105, Taiwan, China.
Tel: +886-2-2570-3385, Fax: +886-2-2570-1890
E-mail: glhsu@tahsda.org.tw
Received 2005-01-06 Accepted 2005-06-23
DOI: 10.1111/j.1745-7262.2005.00080.x
1 Introduction
Varicocelectomy is a well-accepted and well-described
procedure [1], and its indications [2, 3] and
methodology [4, 5] have long been established. The most
common anesthetic method for high ligation of the internal
spermatic vein (ISV) is general or spinal anesthesia [6].
Although local anesthesia with an adjuvant intravenous
injection of sedatives has been reported [7],in this report we introduced a regional blockage technique using only
local anesthetics for varicocelectomy on an outpatient
basis, developed after repeated cadaveric studies and past
clinical applications.
2 Meterials and methods
2.1 Patient population
From July 1988 to June 2003, a total of 575 patients,
aged between 15 and 73 years, underwent high ligation
of the ISV for treatment of varicocele testis. Their
complaints included 285 patients with testicular discomfort,
191 with infertility, 62 with a palpable mass and 37 with
testicular dragging sensation. Scrotal ultrasonography
was used to confirm varicocele in all cases. All
procedures were performed under a regional block for which
an exact anatomical reference was made.
2.2 Anesthesia
Using a marker pen, an isosceles triangle (Figure 1
Left) was drawn between the anterior superior iliac spine
(A), umbilicus (B), and mid-penopubic fold symphysis
pubis (C). The point on the skin, one fingerbreadth
perpendicular to the mid-point of A and C, corresponded to
the underlying spermatic cord. A 23-gauge, 3.18-cm
disposable needle connected to a 10-mL syringe was used
to inject the local anesthetic, which was prepared as
follows: 50 mL of 0.8 % lidocaine solution in an aseptic
bowl that was pre-filled with 0.1 mL of a 1 : 200 000
epinephrine solution [8, 9]. Initially, the injection was given
superficially, relative to the aponeurosis of the external
oblique muscle (Figure 1 Right). Subsequent injections
were given into a deeper layer whenever necessary. The
total lidocaine consumption ranged from 120 mg to 320 mg
(15 mL-40 mL), with an average of (177.6 ± 16.8) mg.
2.3 Surgical procedure
The intersection (Figure 1) of the transverse
abdominal crease and the lateral margin of the rectus abdominis
muscle were marked. This position corresponded to the
underlying spermatic cord. When determining the point
using palpation, it was very helpful to have the patient
contract the muscles of the lower abdomen. A
rectangular region of approximately 5 cm × 1 cm, centered at
the point, was infiltrated with 5 mL-7 mL of lidocaine
solution using a 10-mL syringe. A 3.5-cm wound was
made after the anesthetic effect was ascertained by
pinching the skin with toothed forceps. The circumflex branch
of the external pudendal vein was preserved if
encoun-tered. The wound was deepened to Scarpa¡¯s fascia,
which was opened, using hemostats, after the area was
anesthetized. The aponeurosis of the external oblique
muscle was clearly identified, and local infiltration,
with the injection needle beneath the fascia, was performed. A
feather-like appearance of the lateral portion of the
aponeurosis denotes the exact position, and a slit wound
(Figure 1Right) was made in the direction of its fibers
with a surgical scalpel, followed by an extension on both
ends using a pair of scissors. The cut margin was held
by hemostat in order to apply a US Army retractor to
expose the underlying muscle. Fatty tissue positioned
caudally with a yellowish appearance (Figure 2A,
A¡¯), delineated by muscle tissue located cranially with a
reddish color, could be well identified. A rectangular area of
approximately 3 cm × 1 cm on the muscle, located
0.5 cm cranial to the above delineation, was infiltrated with
4 mL-5 mL of lidocaine solution, and care was taken not to
puncture into more deeply seated vessels. Therefore,
aspiration by syringe was required before attempting any
injection. The muscle layer was gently separated with a
pair of retractors through the external oblique, the
internal oblique and the transversus abdominis muscles until
the whitish paravesical fat was encountered.
The spermatic cord (Figure 2B, B¡¯), with its
accompanying vas deference, was hooked and pulled out
cranially to the internal ring of the inguinal canal with right
angle hemostats (Figure 2C, C¡¯). The cord could
occasionally be pulled laterally if the blade of the retractor
was positioned too deeply. If the retractor is withdrawn,
the inferior epigastric artery and vein can be clearly seen
and the superficial-lateral neighboring cord can be easily
managed. A deeper-blade retractor may be applied
cranially which limits the abdominal content and enables the
cord to be clearly identified. When managing the cord, it
is unnecessary and unwise to separate any tissue to avoid
causing any pain to the patient. The entire cord was
hung out with cured-prong hemostats. Three to four
veins were meticulously dissected and identified in this
process. A loupe (Designs for Vision, Ronkonkoma, NY,
USA) was routinely applied during this procedure. A
squeezing maneuver was applied to the pampiniform plexus to facilitate visibility of the vein whenever
necessary. The transparent lymphatic vessel and a
pulsatile, more pinkish in color or rather erect artery could
be readily identified. In the management of larger veins,
a 3-cm segment was removed, and the proximal stump
was tied 0.5 cm proximally from its end. The distal stump
was allowed to remain open for drainage of the blood
pooled in the pampiniform plexus and was freely tied
afterwards. Finally, the two stumps were tied together
with two knots separated by at least 0.2 cm. This
reinforces the strength of the entire spermatic cord as well
as preventing the veins from being re-canalized
post-operatively. The muscle layer was approximated, using
3-0 or 4-0 silk sutures with adequate tightness after the
cord was returned to its normal position. Likewise, the
aponeurosis, Scarpa¡¯s fascia, and the subcutaneous layer
were subsequently closed layer by layer with 4-0 silk.
Finally, the skin layer was repaired with 4-0 or 6-0 nylon
sutures.
2.4 Follow-up
Oral acetaminophen, 500 mg four times per day, was
prescribed for 5 days, and diclofenac 50 mg was taken
once or twice daily, depending on the patients¡¯
perception of pain. Patients were instructed to apply a clenched
fist to compress the wound whenever they sneezed or
coughed. Physical daily activity, however, was not limited.
The pain level was assessed with a 100-mm visual
analog scale (VAS) at 2 h, 4 h, 8 h, 12 h and 24 h
post-surgery. Scrotal ultrasonography was again used to
confirm residual varicocele if suspected clinically.
3 Results
The procedure was performed on an outpatient basis on 575 patients whose surgeries were bilateral in 52
cases and unilateral in 523 cases. Two patients were
hospitalized because their obesity and anxiety required
general anesthesia. Their operation had been attempted
on an outpatient basis without success. However, their
operative courses were uneventful and resulted in a 30 %
increase to their medical expenditure. One patient
sustained a stitch abscess which was cured after a skin
revision was performed.
The VAS scores varied from 11 mm to 41 mm with
an average of (18.5 ± 11.3) mm. Subsequently, 98.6 %
(567/575) of the patients could go back to work by the
end of the first postoperative week. The numbers of
patients who returned to work on postoperative day 1,
2, 3, 4, 5, 6 and 7 were 173 (30.1 %), 191 (33.2 %), 83
(14.4 %), 48 (8.3 %), 41 (7.1 %), 23 (4.0 %) and 8
(1.4 %), respectively. Only 8 (1.4 %) men reported feeling
physical discomfort on the day 8. Of the 575 patients, 569
(99.0 %) regarded this treatment modality as a worthy
one. Although 6 (1.0 %) men complained of
symptomatic indifference, only 4 (0.7 %), in fact, had a confirmed
postoperative recurrence after evaluation with scrotal
ultrasonography.
4 Discussion
The surface markings of the lower abdomen and the
inguinal region have been previously described in
anatomical texts, which were exclusively derived from
human cadavers [10]. In the surgeon¡¯s practice, however,
an attempt to directly apply that anatomical knowledge
may not be practical until a proper recognition of these
viable tissue markings is given. During the entire
procedure described in our study, neither a Bovie nor a
suction apparatus was applied on any patients, as no
excessive blood was noted. All vessel stumps could be readily
identified and ligated with a 6-0 nylon suture. Likewise,
a drain tube was not routinely necessary because vessel
trauma could be avoided. Of the 575 patients
undergoing the operation, 11 were chronically ingesting aspirin
for coronary artery disease, and two patients were
taking Coumadin daily because of their valvular replacement.
They all underwent this surgery after discontinuation of
their medication had been requested 5 days preoperatively,
and they required no special efforts or care after the
operation.
An injection may be expected to be painful in this
sensitive region. In reality, however, a slow injection as
well as a quick puncture through the skin was
acceptable [11] to almost all the patients. A wheal produced as
a result of a subcutaneous injection should be avoided to
prevent any further pain or anxiety to the patient. Some
investigators advise against the use of adrenaline as a
local anesthetic [12] because of ischemia, but this
concern was not applicable to any of the patients in our study
because there were none with actual ischemia. We found
that this agent was not only good for prolonging the an
esthesia time [13], but may also be helpful to a physician
in managing a type of challenging surgery [8, 9].
When the spermatic cord is ready to be operated on,
it is positioned immediately above the internal ring of the
inguinal canal, where there is a 0.5-cm allowance. It is,
therefore, unnecessary to dissect any tissue [14]. Thus,
high ligation of the ISV is a relatively painless surgery,
although delicacy of manipulation is mandatory. The
surgery creates a mere 3.0-cm-long opening, making it
possible to use local anesthesia on an outpatient basis, as
the overlying fatty layer is always very thin, even in males
with central obesity. Choosing this operative area has
the advantages of being low enough to apply local anesthesia, and high enough to avoid multiple venous
channels. This type of local anesthesia is, of course,
applicable to a varicocelectomy of a lower kind, although
it may be difficult to perform in a heavily obese patient,
but we have not yet encountered this situation.
We advise physicians to shorten and then enhance
the major ISV after the pooled blood is squeezed out.
The venous trunk is sufficiently strong to sustain
the increased suspension force to the ipsilateral testicle which,
in turn, can solve the problem of testicular ptosis in which
the testicle may touch the ground when the patient squats.
The squeezing manipulation of the pampiniform plexus
used during the operation is very helpful for increasing
the visibility of the smaller veins and expelling the venous
content. It is important that the assistant holds rather
than squeezes the testicle proper, otherwise the patient
may experience intolerable pain.
Postoperative wound pain is likely to be reported by
patients; however, oral intake of analgesic medication
appears to be indispensable in the 24 h postoperatively
and sufficient for pain management. It is unnecessary
to repair the muscle layer too tightly as the purpose of
the muscle layer repair is approximation, otherwise,
postoperative pain can occur as chronic ischemia, which can
lead to fibrosis of these muscles. Some may question
the usage of silk sutures for the closure of the muscle
layer. However, we observed no complications in our
study. Similarly, care should be taken not to encasing or
traumatizing the iliohypogastric or ilioinguinal nerve,
otherwise, iatrogenic numbness over the inguinal region
may be irreversible.
Varicocele was traditionally described as being
disadvantageous to spermatogenesis [15, 16],
characterized by a low sperm count, poor motility and bizarre
morphology. It mostly occurred among fertile young
patients. Therefore, most surgical patients come from
the sterile disease entity. In our practice, however, we
observed that infertile patients accounted for only
33.2 % (191/575) of the study group. This unusually lower
proportion might be a bias resulting from patients¡¯
recommendation in which many patients yearn for this surgery,
but not for fertility reasons. Some investigators
suggested that varicocelectomy may benefit erectile
function [17], but further scientific research is needed to
elucidate this point with prospective randomized trials,
including clinical responses and hormone assays.
The low procedure-related complication rate was
varied in published reports [18]. The low complication
rate in our study seemed to be in accordance with those
of other methodologies such as inguinal and subinguinal
ones [18], although the risks associated with general
anesthesia are unavoidable, particularly in recently
developed laparoscopic operations [19]. Embolization has been
reported, but these procedures were rather experimental
at this point [20]. Meticulous dissection of all tissues
and a precise manipulation of vessels not only made our
procedure possible under local anesthesia on a true
outpatient basis, but also resulted in minimal complications,
such as paucity of hematoma, varicocele recurrence in
only two patients, and hydrocele in one case, which was
conservatively managed. Similarly, inadvertent
traumatization to nearby tissues should be avoided because
patients are only under local anesthesia. Furthermore, a
financial benefit is promising. Savings on medical
expenditure of approximately 30 % and 52 % were observed
in our patients who underwent bilateral and unilateral
varicocelectomy respectively, compared to the traditional
method of anesthesia. However, the financial savings
may be even more because the labor cost-savings were
not estimated in this study.
In conclusion, the procedure of varicocelectomy, as
described above, was shown in this study to be effective,
reliable, reproducible and simple, and a safe method with
minimal complications. It offers the advantages of more
patient privacy, a lower morbidity, no notable adverse
effects resulting from anesthesia, and a more rapid
return to regular physical activity.
Acknowledgement
The authors acknowledge the Geng-Long Hsu Foundation for Microsurgical Potency Research in Houston,
Texas, USA, for its dedicated service and enormous con
tribution towards the solution of the malady of
impotence which has plagued mankind throughout the ages.
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