BJUI
Vasectomy reversal with ultrasonographyguided spermatic cord block
BJU INTERNATIONAL
Frédéric D. Birkhäuser, Marius Wipfli*, Urs Eichenberger*, Cédric Luyet*,
Robert Greif* and George N. Thalmann
Department of Urology and *Department of Anaesthesiology and Pain Therapy, University of Bern, Switzerland
Accepted for publication 10 November 2011
Study Type – Therapy (case series)
Level of Evidence 4
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.
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
1796
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.
• 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.
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.
KEYWORDS
CONCLUSIONS
• US-guided spermatic cord block for
microscopic vasectomy reversal is highly
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
regional anaesthesia, ultrasonographyguided spermatic cord block, vasectomy
reversal, vasovasostomy
(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
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BJU INTERNATIONAL
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2012 THE AUTHORS
2 0 1 2 B J U I N T E R N A T I O N A L | 11 0 , 1 7 9 6 – 1 8 0 0 | doi:10.1111/j.1464-410X.2012.11099.x
VASECTOMY REVERSAL WITH US-GUIDED SPERMATIC CORD BLOCK
FIG. 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.
A
SC
SC
B
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 shortacting 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).
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.).
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 nonparametric 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
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
Patient characteristics were similar in both
groups as presented in Table 1
In all 10 patients in the spermatic cord block
group, an US-guided spermatic cord block
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BIRKHÄUSER ET AL.
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).
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
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TABLE 1 Patient characteristics. Data are medians (ranges)
US-guided
spermatic cord block
44 (34–65)
26 (21–28)
1 (1–1)
7 (2–20)
Patient characteristics
Age, years
BMI, kg/m2
ASA
Time between vasectomy and vasectomy
reversal, months
General/neuraxial
anaesthesia
44 (35–55)
26 (23–31)
1 (1–2)
9.5 (5–15)
ASA, American Society of Anesthesiologists score.
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).
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Patient 6
Patient 7
Patient 8
Patient 9
Patient 10
VAS score
Baseline
before surgery
0
0
0
0
0
0
0
0
0
0
Injection
of block
1–2
1
1
0.5
2
1
2–3
1
5
2
Surgery (min after beginning)
15
45
75
105
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
1
1
0
0
0
0
0
0
3
0
135
End
0
0
0
0
End
5*
End
0
0
165
195
End
3
1
End
End
End
0
0
3
0
End
End
*Administration of a single dose of 250 μg alfentanil i.v.
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.
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VASECTOMY REVERSAL WITH US-GUIDED SPERMATIC CORD BLOCK
TABLE 3 Results of both the US-guided spermatic cord block group and the control group under
general or neuraxial anaesthesia
Patients included
Vasovasostomy performed (sides)
Epididymovasostomy performed (sides)
No vasectomy reversal performed (sides)
Duration of surgery, min
General anaesthesia performed
Intubation
Larynx mask
Neuraxial anaesthesia performed
Epidural
Peridural
Perioperative transurethral catheter
Postoperative urinary retention
PONV
Postoperative prostatitis
Time to first postoperative analgesia, h
Time to first postoperative alimentation, h
Time to first postoperative mobilization, h
Time between end of surgery and hospital
discharge, h
Stay at hospital overnight
US-guided spermatic
cord block [n (%) or
median (range)]
10
19
0
1
155 (110–195)
0
0
0
0
0
0
0
0
0
0
12 (2–14)
1 (0.25–3)
2 (1–3)
4 (3–11)
2
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.
©
General or neuraxial
anaesthesia [n (%)
or median (range)]
10
19
1
0
173 (135–210)
6 (60)
5
1
4 (40)
4
0
5
1
1
1
3 (1–6)
4 (3–6)
6 (3–10)
8.5 (6–22)
P
value
n/a
0.002
0.087
0.007
4
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.
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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.
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Correspondence: Frédéric D. Birkhäuser,
University Hospital of Bern – Urology, 3010
Inselspital Bern, Switzerland.
e-mail: frederic.birkhaeuser@insel.ch
Abbreviations: PONV, postoperative nausea
and vomiting; US, ultrasonography; VAS,
Visual Analogue Scale.
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