Vasectomy reversal with ultrasonography-guided spermatic cord block

Authors


Frédéric D. Birkhäuser, University Hospital of Bern – Urology, 3010 Inselspital Bern, Switzerland. e-mail: frederic.birkhaeuser@insel.ch

Abstract

Study Type – Therapy (case series)

Level of Evidence 4

What's known on the subject? and What does the study add?

Vasectomy reversal is often performed in general or neuraxial anaesthesia. Even though the site of vasectomy reversal is easily amenable to regional/local anaesthesia, spermatic cord blocks are rarely applied because of their risk of vascular damage within the spermatic cord. Recently, we described the technique of ultrasonography (US)-guided spermatic cord block for scrotal surgery, which, thanks to the US guidance, at the same time avoids the risk of vascular damage of blindly performed injections and the risks of general and neuraxial anaesthesia.

Vasectomy reversal can easily be done in regional anaesthesia with the newly described technique of US-guided spermatic cord block without the risks of vascular damage by a blindly performed injection and the risks of standard general and neuraxial anaesthesia. In addition, this technique grants long-lasting postoperative pain relief and patients recover more quickly. Microsurgical conditions are excellent and patient satisfaction is high. Thanks to these advantages, more patients undergoing vasectomy reversal might avoid general or neuraxial anaesthesia.

OBJECTIVE

  • • To assess the success rate, microsurgical conditions, postoperative recovery, complications and patient satisfaction of ultrasonography (US)-guided spermatic cord block in patients undergoing microscopic vasectomy reversal and to compare them to a control group with general or neuraxial anaesthesia.

PATIENTS AND METHODS

  • • The present study comprised a prospective series of 10 consecutive patients undergoing US-guided spermatic cord block for microscopic vasectomy reversal.
  • • The cohort was compared with 10 patients in a historical control group with general or neuraxial anaesthesia.

RESULTS

  • • Nineteen of 20 (95%) blocks were successful, defined as no pain >3 on the Visual Analogue Scale (VAS), no additional analgesics and/or no conversion to general anaesthesia. Median pain was 0 on the VAS (range 0–5). Additional analgesics were requested in one (5%) block, and there was no conversion to general anaesthesia.
  • • Microsurgical conditions were excellent.
  • • In the spermatic cord block vs general/neuraxial anaesthesia groups, median times (range) between surgery and first postoperative analgesics, alimentation, mobilization and hospital discharge were 12 (2–14) vs 3 (1–6), 1 (0.25–3) vs 4 (3–6), 2 (1–3) vs 6 (3–10), and 4 (3–11) vs 8.5 (6–22) h, respectively.
  • • No complications were reported after the spermatic cord block.
  • • Patient satisfaction was excellent.

CONCLUSIONS

  • • US-guided spermatic cord block for microscopic vasectomy reversal is highly successful and provides long-lasting perioperative analgesia.
  • • Times to alimentation, mobilization and hospital discharge are shorter under US-guided spermatic cord block than under general/neuraxial anaesthesia.
  • • Additional anaesthetic pain management might, however, be required unexpectedly with US-guided spermatic cord block.
Abbreviations
PONV

postoperative nausea and vomiting

US

ultrasonography

VAS

Visual Analogue Scale

INTRODUCTION

Vasectomy reversal is mostly performed with general or neuraxial anaesthesia. Alternatively, regional anaesthesia in the form of a spermatic cord block can be offered, avoiding the potential risks of general and neuraxial anaesthesia and providing long-lasting postoperative analgesia [1–4]. Complications of a blindly performed spermatic cord block include vascular damage of the testicular arteries, which can seriously jeopardize the testicle [5]. The use of an ultrasonography (US)-guided spermatic cord block could improve the success rate of anaesthesia as well as the safety of the procedure.

The aim of the present study was to compare the effects of the newly developed US-guided spermatic cord block [6] with the historical standard of general or neuraxial anaesthesia for microscopic vasectomy reversal.

PATIENTS AND METHODS

We compared data of a prospective consecutive series of 10 patients scheduled for bilateral microscopic vasectomy reversal under US-guided spermatic cord block with data of a retrospective consecutive series of 10 patients who underwent the procedure with general or neuraxial anaesthesia. This prospective study was approved by the ethics committee of the Canton of Bern, and the retrospective analysis was approved by the internal review board of the University of Bern. All patients gave written informed consent. Data from eight scrotal block patients in the present study were also included in our first feasibility study of US-guided spermatic cord block [6]. The exclusion criteria were refusal of regional anaesthesia, a body mass index (BMI) >40 kg/m2, known bleeding disorders, and blood coagulation abnormalities such as international normalized ratio (INR) > 1.5 or platelet count < 100 000/µL.

Standard continuous patient monitoring included electrocardiography, heart rate, non-invasive blood pressure and oxygen saturation measurement. A peripheral i.v. line was placed. Nasal oxygen (2 L/min) was administered. Before surgery, an i.v. bolus of midazolam (0.01–0.03 mg/kg; Roche Pharma, Reinach, Switzerland) was injected. The groin region was shaved and disinfected with Betaseptic® (Mundipharm Medical Company, Hamilton, Bermuda). No perioperative transurethral catheter was placed.

For the US-guided spermatic cord block, the spermatic cord and its contents, namely the main testicular artery and smaller arteries and the deferent duct, were visualized by US (M-Turbo, SonoSite Inc., Bothell, WA, USA) using a linear array transducer (L25x, 13-6 MHz, 25 mm broadband linear array) at the inguino-scrotal junction distal to the external inguinal ring on both sides. The probe was covered with a sterile dressing and using sterile US gel. Fifteen minutes before surgery, first on one side and then on the other, a 23G Microlance® sharp needle (Becton Dickinson AG, Fraga, Spain) was inserted under US guidance and directed towards the deferent duct, contralaterally to the main testicular artery. Around the deferent duct a mixture of 5 mL short-acting mepivacaine 2% (Institute of Pharmacology, University Hospital, Bern, Switzerland) and 5 mL long-acting ropivacaine 0.75% (AstraZeneca AG, Zug, Switzerland) was injected. The injection of the block took 2–3 min on each side (Fig. 1).

Figure 1.

Images showing the technique of the US-guided spermatic cord block. (A) The spermatic cord (SC) is grabbed with two fingers and gently lifted by the assistant. With one hand, the surgeon holds the US transducer transversally just distally of the superficial inguinal ring representing the morphological structures of the spermatic cord. (B) With his other hand, he injects the local anaesthetic, avoiding vascular structures.

For the microscopic vasectomy reversal, local anaesthesia of the scrotal skin was done with 1–3 mL of the same anaesthetic mixture as for the block immediately before surgery. Bilateral longitudinal scrotal skin incisions of 2–3 cm each were made, and the spermatic cord was exposed through the incision. Preparation and anastomosis of both stumps of the deferent duct were performed microscopically in a modified one-layer technique using a non-absorbable polypropylene suture, Prolene® 9-0 (Ethicon GmbH, Neuenburg, Switzerland) [7]. The skin was sutured with individual single sutures using Vicryl® rapid 3-0. All operations were done by the same principal surgeon (F.B.).

A retrospective consecutive series comprising 10 patients who underwent microscopic vasectomy reversal with general or neuraxial anaesthesia just before the prospective study started served as a historical control group. Microscopic vasectomy reversal was done technically identically as described earlier.

The primary endpoint in the US-guided spermatic cord block group was the success rate of the blocks, which was defined as surgery with no or light pains according to the Visual Analogue Scale (VAS ≤ 3; 0 = no pain, 10 = worst imaginable pain) without any substitution of opioids, additional local anaesthetics or conversion to general anaesthesia. In the control group, no pain (VAS = 0) was assumed.

Secondary endpoints were as follows:

  • • Microsurgical conditions, evaluated by the surgeon according to a scale of 1 to 5 (1 = very bad with frequent/strong movements, surgery impossible; 2 = bad with frequent movements/trembling; 3 = good with occasional sudden movements; 4 = very good with occasional slow movements; 5 = excellent without movements). In the retrospective group microsurgical conditions were assumed to be 5 on this scale.
  • • Time between end of surgery and first request of analgesic, alimentation, mobilization and hospital discharge.
  • • Complications until 30 d after surgery.
  • • Patient satisfaction assessed 7 d after surgery by telephone (1 = very unsatisfactory; 2 = unsatisfactory; 3 = indifferent; 4 = satisfactory; 5 = very satisfactory).

For the statistical analysis, the non-parametric Mann–Whitney test with a two-sided exactly derived P value was used to compare the variables in two independent groups [8]. The median difference of the two groups was derived with the Hodges–Lehmann estimator, together with its 95% confidence interval [9]. A two-sided P value <0.05 is considered to indicate statistical significance. Statistical analyses were performed by the Institute of Mathematical Statistics and Actuarial Science of the University of Bern, Switzerland, using the statistical software StatXact-8.

RESULTS

Patient characteristics were similar in both groups as presented in Table 1

Table 1.  Patient characteristics. Data are medians (ranges)
Patient characteristicsUS-guidedGeneral/neuraxial
spermatic cord blockanaesthesia
  1. ASA, American Society of Anesthesiologists score.

Age, years44 (34–65)44 (35–55)
BMI, kg/m226 (21–28)26 (23–31)
ASA1 (1–1)1 (1–2)
Time between vasectomy and vasectomy reversal, months7 (2–20)9.5 (5–15)

In all 10 patients in the spermatic cord block group, an US-guided spermatic cord block was placed on both sides. A vasovasostomy was carried out on 19 sides, but on one side no vasectomy reversal was performed because of an unexpected lack of proximal and distal deferent duct. On 19 of 20 sides (95%), the US-guided spermatic cord block was successful. In the case of the one unsuccessful block, short-lasting testicular pain of VAS 5 was reported, while the scrotal cavity had to be explored meticulously because of missing vas deferens stumps (Table 2). The administration of a single dose of 250 µg alfentanil i.v. enabled surgery to be finished without further pain. In none of the patients was conversion to general anaesthesia necessary. During the US-guided injection of the block, there was no vascular puncture or bleeding inside the spermatic cord. Anaesthetic monitoring was uneventful in all patients. Intraoperative microsurgical conditions were classified as excellent with a median (range) of 5 (4–5). The first postoperative analgesic was requested a median (range) of 12 (2–14) h after surgery. In accordance with a previous in-house guideline, two patients received fix analgesic (diclofenac) 2 h after surgery. Seven patients (70%) did not request any medication until hospital discharge. The median (range) times to first alimentation and to first mobilization were 1 (0.25–3) and 2 (1–3) h, respectively. Hospital discharge took place a median (range) of 4 (3–11) h after surgery; two patients (20%) stayed overnight. No complications were noted. Seven days after surgery, patients' satisfaction was excellent with a median (range) score of 5 (4–5) on a scale of 5 (Table 3).

Table 2.  Results of the US-guided spermatic cord block group. Pain analysis is according to the VAS, ranging from 0 (no pain) to 10 (worst imaginable pain).
 VAS score
Baselinebefore surgeryInjectionof blockSurgery (min after beginning)
154575105135165195
  • *

    Administration of a single dose of 250 µg alfentanil i.v.

Patient 101–20000End  
Patient 20100000End 
Patient 301000003End
Patient 400.5000001End
Patient 50200000End 
Patient 6010000End  
Patient 702–300005*00
Patient 8011111End  
Patient 905000003End
Patient 1002003000End
Table 3.  Results of both the US-guided spermatic cord block group and the control group under general or neuraxial anaesthesia
 US-guided spermatic cord block [n (%) or median (range)]General or neuraxial anaesthesia [n (%) or median (range)] P value
Patients included1010 
Vasovasostomy performed (sides)1919 
Epididymovasostomy performed (sides)01 
No vasectomy reversal performed (sides)10 
Duration of surgery, min155 (110–195)173 (135–210) 
General anaesthesia performed06 (60) 
 Intubation05 
 Larynx mask01 
Neuraxial anaesthesia performed04 (40) 
 Epidural04 
 Peridural00 
Perioperative transurethral catheter05 
Postoperative urinary retention01 
PONV01 
Postoperative prostatitis01 
Time to first postoperative analgesia, h12 (2–14)3 (1–6)n/a
Time to first postoperative alimentation, h1 (0.25–3)4 (3–6)0.002
Time to first postoperative mobilization, h2 (1–3)6 (3–10)0.087
Time between end of surgery and hospital discharge, h4 (3–11)8.5 (6–22)0.007
Stay at hospital overnight24 

In the general/neuraxial anaesthesia control group, on 19 sides a vasovasostomy and on one side an epididymovasostomy was performed. A perioperative transurethral catheter was placed in five (50%) patients. Median (range) time to the first postoperative analgesics was 3 (1–6) h. First postoperative alimentation took place a median (range) of 4 (3–6) h after surgery, while first mobilization took place a median (range) of 6 (3–10) h after surgery. Median (range) time until hospital discharge was 8.5 (6–22) h; four patients (40%) stayed overnight. After surgery, one patient had urinary retention and requested transurethral catheterization and one had an episode of postoperative nausea and vomiting (PONV), which was treated by i.v. antiemetics. Seven days after surgery, one patient, who had a perioperative transurethral catheter, developed acute prostatitis and was treated conservatively according to the guidelines (Table 3).

The comparison of the two study groups revealed a significantly shorter time to first postoperative alimentation (median difference −2.875, 95% CI: −3.5 to −2, P= 0.002) and a significantly earlier hospital discharge (median difference −5, 95% CI: −15 to −3, P= 0.007) in the US-guided spermatic cord block group. However, the time to first mobilization was similar in both groups (median difference −3, 95% CI: −5 to −0, P= 0.087).

DISCUSSION

With 19/20 (95%) successfully operated sides, the success rate of US-guided spermatic cord blocks for microscopic vasectomy reversal was excellent. To the best of our knowledge, no studies comparing US-guided spermatic cord blocks with general or neuraxial anaesthesia in microscopic vasectomy reversal have been published as yet. As the standard procedure until now, spermatic cord blocks were usually performed blindly in the conventional anatomical landmark-based method [1–4,10–13]. Success rates of up to 100% have been published for blindly injected spermatic cord blocks allowing eventual injections of additional analgesics during surgery [3,4,12]. The comparison of success rates between the US-guided and blind techniques is biased by the variety of study methods, namely the type and volume of local anaesthetics. However, for an anaesthetic procedure, the success rate of the US-guided technique is very high, especially when considering that the study population consisted of young, sensitive male patients.

Unexpected testicle pain can arise intraoperatively as a result of an ineffective spermatic cord block and require potent analgetic response, such as systemically applied analgetics (opioids). Alternatively, additional local anaesthetics injected into the spermatic cord under visual control can relieve testicle pain. However, this manoeuvre would compromise the effort of US-guided injection to avoid the risks of vascular damage of the testicular arteries when blindly performed [5]. Moreover, this manoeuvre usually doesn't ensure immediate pain relief. In cases where there is persistent pain, conversion to general anaesthesia should be considered. In their recently published review, Lipshultz et al. [7] concluded that an expected surgery length of more than 3 h could represent a potential limitation of regional anaesthesia. In our series, length of surgery of up to 3 h did not impair quality of analgesia or patient satisfaction. However, an expected long and/or complicated surgery with probable extensive mobilization could signify a potential limitation of regional anaesthesia and should be discussed carefully with the patient. Thus, patients should always be informed before surgery and give corresponding written informed consent for possible conversion to general anaesthesia. In the series in the present study, however, no conversion to general anaesthesia was necessary.

Because of the presence of multiple blood vessels in the spermatic cord, namely testicular arteries and the pampiniform plexus, blindly performed injections carry the risk of intravasal injection of local anaesthetics with subsequent danger of systemic intoxication [14]. Another feared complication, especially in young patients undergoing vasectomy reversal, is damage to a testicular artery with consecutive bleeding and/or ischaemia of the testicle [5]. However, by ultrasonic visualization of the testicular arteries and placing the needle tip accurately next to the deferent duct, vascular punctures can be avoided [6].

Optimal intraoperative conditions are crucial to obtaining the best possible microsurgical results. In our experience, occasional slow relaxing movements of the legs or trunk did not disturb the surgical process. Similarly to the optimal surgical conditions under general or neuraxial anaesthesia, microsurgical conditions were evaluated as excellent mostly without any movements.

The US-guided spermatic cord block assured long-lasting postoperative pain relief for a median (range) of 12 (2–14) h. Seven patients (70%) did not request any postoperative analgesic treatment until hospital discharge. Similar to the results of the present study, Burden et al.[15] described reduced postoperative pain after a blindly injected spermatic cord block in a randomized, double-blind controlled study. In accordance with our guidelines, all patients in our retrospective control group received a fixed pain medication once surgery was terminated, which is why a comparison with the prospective group is not legitimate. Still, both first postoperative alimentation and, as a consequence of the faster recovery, hospital discharge took place significantly earlier in the US-guided spermatic cord block group than in the control group in general/neuraxial anaesthesia. The time to first mobilization was not statistically different in both groups, probably because of the small number of patients.

There were no complications in the spermatic cord block group, whereas there was one case of postoperative urinary retention and one of UTI in the control group. Similarly, Nordin et al.[16] reported a lower risk of complications for groin surgery under local anaesthesia than under regional and general anaesthesia. The risk of UTI is likely to be reduced as a consequence of the lack of a perioperative transurethral catheterization. Furthermore, there were no cases of PONV in the spermatic cord block group, compared with one case in the general anaesthesia group. In the literature, the incidence of PONV after general anaesthesia is reported to be up to 30% [17].

Seven days after surgery, patient's satisfaction was excellent with a median (range) score of 5 (4–5) on a scale of 5. Similar rates of satisfaction were reported by Ezeh et al.[10] in patients undergoing testicular sperm extraction surgery with regional anaesthesia.

There were several potential limitations regarding the present study. All vasectomy reversals were performed by the same principal surgeon. However, although this could be a limitation, it also represents a strength in that we have followed consistent surgical technique and experience. An additional potential limitation is that only vasovasostomies were performed under US-guided spermatic cord block, not the more time-consuming and complicated epididymovasostomies.

In conclusion, bilateral US-guided spermatic cord block is highly successful in vasectomy reversal surgery with excellent patient satisfaction. It allows not only for excellent microsurgical conditions but also ensures long-lasting postoperative analgesia, which results in a faster postoperative recovery.

CONFLICT OF INTEREST

None declared.

Ancillary