ABSTRACT
OBJECTIVE: To evaluate the effectiveness of Eutectic Mixture of Local Anesthetic (EMLA), a topical anesthetic cream, in office-based invasive andrological procedures such as hydrocelectomy, spermatocelectomy, and others, aimed at minimizing pain perception and enhancing the overall patient experience. METHODS: A double-blinded randomized controlled trial was conducted for patients undergoing scrotal andrology surgeries under LA. Power calculation was performed with an estimated sample size of 72. Participants were randomly assigned in a 1:1 ratio to topical EMLA + LA vs LA alone. In the post-operative recovery area, patient will be asked to complete a VAS questionnaire rating pain with LA administration and pain with procedure. Analysis comparing VAS pain scores of both groups was performed using the independent sample t-test method. RESULTS: 72 patients were included in our analysis, with 36 in the control and 36 in the intervention arm. For patient pain with administration of LA, the control arm reported an average VAS pain score of 4.31, compared to 3.72 in the intervention arm (p=0.319). For patient pain with procedure, patients in the control arm reported a median VAS pain score of 3.47 compared to 3.03 (p=0.432) in the intervention arm. Overall, 86% (62/72) of patients reported that they would either be "very likely" (4/5) or "highly likely" (5/5) to undergo future procedures under local anesthetic. CONCLUSIONS: While performing scrotal surgeries under LA appears to be well tolerated and a feasible option, the application of EMLA cream does not appear to significantly alter patient-reported outcomes.
ABSTRACT
INTRODUCTION: We aimed to investigate the surgical outcomes following inguinal and subinguinal urological procedures under deep intravenous sedation (DIVS) with multimodal local anesthesia (LA). METHODS: We conducted a retrospective cohort study from September 2022 to December 2023 including adult patients deemed eligible for day surgery (American Society of Anesthesiologist score 1-3) undergoing radical orchiectomy (RO), microscopic varicocelectomy (MV), or microscopic denervation of spermatic cords (MDSC). All procedures were performed at a single urologic ambulatory surgical center and outpatient clinic, and by a single surgeon (PP). Procedures were performed through a subinguinal or inguinal approach with DIVS and adjunctive multimodal LA. We evaluated intraoperative complications and relevant surgical outcomes and parameters. RESULTS: A total of 103 patients were included in the analysis with a mean age ± standard deviation of 37.3±9.6. This included 25 patients who underwent RO, 54 patients who underwent MV, and 24 patients who underwent MDSC. All procedures were completed successfully without intraoperative complications. Oncologic outcomes were preserved, fertility outcomes improved, and pain scores reduced similar to the expected rates in the literature. CONCLUSIONS: Our preliminary results demonstrate the safety, effectiveness, and feasibility of performing inguinal and subinguinal urologic procedures under DIVS with LA. These findings suggest that this technique preserves high-quality care while avoiding unnecessary risks of general or spinal anesthesia, representing an opportunity to transfer these cases outside of hospitals' operating rooms into outpatient ambulatory centers.
ABSTRACT
INTRODUCTION: Despite being a commonly encountered urologic condition, there remains a paucity of understanding and literature on the management and natural history of isolated epididymal pain. Typically, patients who do not respond to conservative management undergo an epididymectomy; however, the literature on its efficacy is also scarce, with success rates varying from 10-90%. Our goal was to better describe the etiology and natural history of isolated epididymal pain and to describe the rates of success associated with epididymectomy. METHODS: A retrospective, case-control study was conducted at the Manitoba Men's Health Clinic, with the approval of the University of Manitoba Research Ethics Board. All patients presenting with chronic epididymitis, defined as discomfort or pain localized to the epididymis for at least three months, were identified. Information regarding patient demographics, past medical and surgical history, duration of pain, localization of pain, findings on previous ultrasounds, prior conservative therapies trialed, and response rates, as well as response rates to surgical therapy were collected. RESULTS: From April 2022 to April 2023, a total of 275 patients with chronic orchialgia were identified; among them, 74 patients presented with chronic isolated epididymal pain. On average, 22.9% of patients experienced symptoms for 3-6 months, 10% for 6-12 months, and 67.1% for over 12 months; 13.5% (n=10) had associated ejaculatory pain, 8.1% (n=6) had lower urinary tract symptoms, and 4.1% (n=3) had erectile dysfunction. Ultrasound findings were observed in 68.9% of patients, with 31.1% having an epididymal cyst, 27.1% having a varicocele, 5.4% having a spermatocele, and 4.1% having a hydrocele. Among those who underwent conservative therapy, only 36.2% of patients reported a positive response. Surgical intervention was performed on 23 patients, including 16 who underwent epididymectomy, three who underwent cord denervation, and two who underwent vasovasostomy and spermatocelectomy each. Most (81.3%, n=13) patients who underwent epididymectomy had a positive response to the surgical intervention, defined as no pain on followup, while all patients undergoing other surgical interventions experienced a positive response. CONCLUSIONS: Chronic epididymal pain is a condition with limited data surrounding its management. Prior to referral, a large proportion of patients did not undergo any conservative treatment, and of those that did, there was limited response. For those who underwent surgical intervention, all were pain-free on followup, except three patients who underwent epididymectomy.
