Types of surgery on the testicular appendage: peculiarities of their performance

Men usually take very good care of their male health, because the instinct of procreation is no less inherent in them than in women. But at some point, a man's health may falter, which he will be reminded of by pain in the scrotum of the genital organ. The causes of such pain may be different, and some of them require surgical intervention. If the problem cannot be solved with the help of conservative treatment methods, the doctor may prescribe an operation on the appendage of the testicle.

Indications for the procedure

The epididymis is an important organ of the male reproductive system, responsible for the ability of sperm to fertilize an egg. These small, mobile creatures that give rise to new life are formed in the testicles, and then, over the course of two weeks, gradually moving along the epididymis (its length is about 0.7 cm), they mature and acquire important functions.

The appendage itself (also known as the epididymis), which is directly adjacent to the testicles (testicles), consists of a wide, rounded head, a narrow, elongated body, and a tail ending in the vas deferens. The organ is covered along its entire length by the vaginal membrane of the testicle.

What pathologies can serve as a reason for prescribing surgery on the epididymis:

• Injuries to the testicles and their appendages with damage to the vaginal membrane (in this case, the operation is usually simple and consists of excision of damaged tissue and suturing of the edges of the wound, but in case of crushing of testicular tissue and the onset of necrosis, resection of the affected testicle together with the appendage may be prescribed),
• Torsion of the spermatic cord of the testicle, which occurs as a result of trauma (in this case, there is a disruption in the blood supply to the organ, which subsequently leads to necrotic changes and requires removal of the damaged testicle).
• Testicular oncology (most often cancer affects one part of the paired organ, and to prevent relapses, doctors insist on the complete removal of the diseased testicle).
• Varicocele or varicose veins of the spermatic cord, which impedes venous outflow and leads to swelling of the testicle, its overheating and disruption of reproductive function (in the most popular Marmara operation, under local anesthesia, the scrotum is opened and the damaged vein is ligated and removed under the control of a microsurgical microscope, after which a suture about 2 cm long remains in the groin area).
• Epididymis cyst. A cyst is a benign round neoplasm that contains liquid serous, hemorrhagic or purulent contents. Small cysts in the head of the epididymis are discovered by chance and do not require surgical treatment. A man is referred for surgery to remove the neoplasm if:

• the cyst has reached a large size and has become the cause of pain and discomfort in the scrotum, especially when walking,
• the neoplasm caused a disruption in the blood supply to the testicles,
• hormonal imbalances such as increased hair growth in the groin, on the face and body are noted,
• There is a violation of sexual and reproductive functions.

• Epididymitis or inflammation of the epididymis, accompanied by its swelling and significant increase in size. The disease itself can be treated with conservative methods, but in some cases such a complication as suppuration of the epididymis is possible, and if its opening and drainage do not give a positive result, removal of the epididymis (epididymectomy) may be prescribed.

Other indications for such surgery may include:

• chronic epididymitis with frequent relapses,
• the formation of dense infiltrates in the tissues of the appendage, causing pain,
• tuberculous epididymitis, i.e. inflammation of the appendage caused by the tuberculosis pathogen (both with an accurate diagnosis and with a suspicion of this type of pathology).

As we can see, different surgical treatment methods are used for different pathologies. In mild cases, only damaged tissues, vessels and cysts are removed, in severe cases – the appendage and testicle.

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Preparation

The disease in a man can be detected long before its first symptoms appear, namely: pain and swelling. Thus, a cyst on the appendage can grow for several years without reminding of itself in any way, but as it grows, it begins to squeeze nearby organs and tissues, causing an increase in the scrotum on one side and pain when walking. In most cases, the neoplasm is detected during a urological examination and is subsequently only observed until it begins to grow and cause discomfort.

Inflammation of the appendage, on the contrary, can debut with acute symptoms: a rise in temperature, severe pain in the scrotum, its swelling and redness. But obvious manifestations of the disease, even without treatment, go away in 3-5 days, after which a lull sets in, characteristic of remission. Now the disease becomes chronic and can periodically remind of itself with pain, an enlarged testicle, palpable seals, a decrease in the fertilizing ability of sperm.

If a man consults a doctor about pain and enlargement of the scrotum, in addition to a visual examination, study of the anamnesis and palpation of the diseased organ, in order to establish an accurate diagnosis, he is prescribed an ultrasound examination, which will help differentiate the usual inflammation of the testicles and their appendages from neoplasms and vascular disorders in this area and Doppler ultrasound.

Sometimes, already during the diagnosis, the doctor makes a decision about the appointment of the operation, its type and volume of work. But in most cases, they try to treat the disease with conservative methods, and only if they are ineffective, they resort to the help of a surgeon who will perform an operation on the epididymis.

In preparation for the operation, the patient will have to undergo a series of laboratory tests that will help assess the functioning of internal organs, the risk of bleeding during surgery and the possibility of using anesthesia:

• clinical blood test,
• blood clotting test (coagulogram),
• the Wasserman reaction in combination with blood tests for HIV infection and hepatitis,
• blood type and Rh factor test (necessary if a blood transfusion is required),
• general urine analysis,
• examination of penile discharge,
• biopsy and histological examination of biomaterial if oncology is suspected.

Additionally, an electrocardiogram may be prescribed to assess the condition of the heart and a chest X-ray, as well as consultations with doctors in connection with existing concomitant pathologies. These points are relevant for performing surgery under general anesthesia, the possibility of which is discussed at the stage of preparation for the operation with clarification of the tolerance of individual anesthetics.

In case of malignant neoplasms and tuberculous epididymitis, chemotherapy sessions are carried out for a month before surgery.

If it is a planned operation, the patient is asked to shave the hair in the groin area beforehand. In the preoperative room, he is given sedatives.

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Technique testicular appendage surgery

In connection with male diseases, the doctor may prescribe 2 options for surgery on the epididymis:

• removal of a testicular cyst (spermocelectomy), which is performed in a similar way to surgical treatment of varicocele,
• removal of the epididymis itself (with or without the testicle).

Surgery to remove a testicular cyst can currently be performed using different methods, but all of them involve access to the neoplasm through an incision in the tissues of the scrotum. Usually, such an incision is made on the side, depending on the location and size of the cyst, and it is necessary to remove the epididymis together with the cyst to the outside or to access them with special microsurgical equipment.

To avoid severe bleeding at the sites of tissue incision, the doctor cauterizes (coagulates) the damaged vessels, and only after that is he able to get closer to the base of the cyst (its stalk). The operation consists of carefully separating the neoplasm from the head and body of the appendage, applying a ligature (clamps) to the stalk of the cyst (and the vessels feeding the cyst) and its excision, after which the wound is sutured layer by layer, using self-absorbable materials.

If the cyst is large, the laparoscopic method and laser treatment are more relevant. In the first case, a tube is inserted through a micro-incision, through which carbon dioxide and surgical micro-instruments are supplied to the scrotum cavity. The doctor controls the instruments remotely, monitoring the progress of the operation on a computer monitor. After cutting off the cyst stalk and crushing its tissues, everything is sucked out of the organ cavity.

Laser treatment is an innovative method of cyst removal that does not require large incisions. A laser diode is inserted through a needle into a micro-incision in the tissues of the scrotum. The beam melts the cyst tissue, which is then sucked out, as in laparoscopic treatment.

Each method has its own advantages and disadvantages. Open surgery and laparoscopy can be performed under either general or local anesthesia (depending on the scope of the surgery and the anesthesiologist's verdict, based on the patient's wishes and health condition). Local anesthesia with lidocaine, novocaine or ultracaine is sufficient for laser cyst removal, since the surgery itself is virtually painless. However, a disadvantage of laser treatment is the impossibility of taking a tissue sample from the cyst for histological examination, which is necessary to refute or confirm its belonging to cancerous neoplasms.

Removal of the epididymis is a more technically complex operation, which, nevertheless, in some cases is simply necessary to prevent necrotic processes.

As in the case of removal of the epididymis cyst, the patient is placed on the operating table on his back and anesthesia is administered. It is also possible to perform the procedure under local anesthesia, which involves pain relief of the incision site and infiltration of the spermatic cord with anesthetics, which contains nerve fibers and provides sensitivity to the testicles and their appendages.

After the anesthesia is administered, the scrotal tissue is stretched and a longitudinal incision is made along the suture slightly to the side. The edges of the wound are held in place with special holders. The testicle and the appendage attached to it are removed, for which an incision is first made in the vaginal membrane. If the operation is prescribed due to tuberculous epididymitis, the incision will reach the vas deferens, which must be removed.

In the sinus area, an anesthetic solution is injected under the head and body of the appendage (infiltration anesthesia). After this, the anterior ligament of the appendage is first cut off, having previously stitched its head, and then scissors are inserted into the space between the appendage and its shell, trying to extract it without damaging the capsule and nearby testicular vessels. Now the doctor can cut off the tail of the appendage and a small section of the vas deferens adjacent to it (about 2 cm). The remaining section of the vas deferens closer to the groin is clamped with ligatures and cut off.

When the epididymis tissue is separated from the testicle, the capsule is sutured, closing the defect formed as a result of the epididymis removal. The testicle is repositioned into the membrane and the wound is sutured layer by layer. If a necrotic process is detected in the testicular tissue by means of an express biopsy, the testicle should also be removed.

The inflammatory process in the appendage can cause overstretching of the scrotum tissue. In this case, excess tissue is removed, and the rest is sutured in such a way as to give the organ its original appearance. After the appendage is removed and the wound is sutured, an aseptic pressure bandage is applied to the scrotum, lifting the organ upward.

Both types of surgery involve the introduction into the internal structures of the male body, so they must be carried out strictly in sterile conditions after careful treatment of the incision site with antiseptics. If necessary, the operation site is drained to remove elements that may subsequently cause a purulent-inflammatory process.

The operation to remove a cyst of the epididymis takes 30-40 minutes, and excision of the epididymis takes about 1 hour, because it requires special care due to the risk of damage to the blood vessels of the testicle, after which the patient is left for several more hours under the supervision of a doctor.

Contraindications to the procedure

Since the operation to remove a cyst or the epididymis itself can be performed under local anesthesia, there are not many contraindications to its implementation. However, they are typical for any non-bloodless operations.

A serious obstacle to performing an operation on the epididymis, which requires tissue incision, is a violation of blood clotting, although the risk of severe bleeding is prevented by timely coagulation of the vessels. With laser therapy, this occurs naturally under the influence of laser radiation, which cauterizes tissue and vessels directly during the removal of the cyst.

If the decrease in blood viscosity occurred as a result of taking special medications (anticoagulants), the operation may be postponed for a while if it is possible to refuse taking such medications.

Relative contraindications to surgery are also considered:

• the presence of foci of skin diseases in the scrotum area,
• acute inflammatory processes in the testicles and appendages,
• acute systemic infectious diseases,
• severe physical and mental condition of the patient.

The doctor cannot refuse the operation, but he can postpone the procedure until the period of complete recovery or remission of the disease. If the patient's general condition is severe, the operation can be performed after the condition has stabilized.

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Consequences after the procedure

Surgery on the appendix is not considered a complex surgical procedure, so in most cases it ends successfully. After removal of the cyst on the appendix, more than 95% of men report the disappearance of pain and discomfort in the scrotum. The rest reported minor pain during the next 3 months after the operation, after which the discomfort disappeared completely. At the same time, the affected reproductive function in men was restored in most cases.

Doctors do not prescribe the removal of the epididymis or even the entire testicle with the epididymis very often. However, there is no need to be afraid of the operation. The risk of becoming infertile is higher if nothing is done. And after the removal of the epididymis or one of the testicles, the other testicle begins to function for two, which gives the man the opportunity to become the father of his own child. The operation also has virtually no effect on potency and orgasm, but pain and discomfort, which significantly worsen the patient's quality of life, go away.

It is clear that, like any other operation, there is a certain risk of complications arising after surgical manipulations. The most common complications are considered to be the formation of hematomas due to subcutaneous bleeding, as well as tissue suppuration due to the accumulation of blood in them or infection during surgery.

If the wound was not properly cared for in the postoperative period, inflammation and suppuration of tissues in this area are possible. To prevent this from happening, the wound should be regularly treated with antiseptic solutions when changing dressings. Subsequently, rough scars may form at the site of inflammation and a feeling of tissue constriction may appear.

The following symptoms will indicate that the operation was not without complications:

• intense increasing pain after 3 days after surgery,
• the release of blood, ichor or pus at the site of the sutures,
• pain and discomfort in the groin several months after surgery,
• swelling and redness of the scrotal tissue observed for several days after removal of a cyst or epididymis,
• a sudden increase in body temperature, indicating the development of an inflammatory process in the body.

Recurrence of the cyst and infertility can hardly be called complications after surgery. Rather, it is the result of the lack of proper treatment of the underlying disease. Although sometimes, due to carelessness, the doctor may still damage the vas deferens during cyst removal, which will disrupt its patency, but with a normally functioning second testicle, the man remains capable of conceiving. So there is no direct connection between infertility and surgery.

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Care after the procedure

Despite the apparent complexity of the operation on the appendix of the testicle, the rehabilitation period after it is short. After the operation, an aseptic bandage and cold are applied to the scrotum. After a couple of hours, if there is no pronounced pain syndrome and bleeding from the wound, the patient can already leave the clinic, although doctors sometimes insist that the man stay in the hospital for a couple of days, after which he is discharged home for outpatient treatment.

In case of epidimectomy, the first dressing is applied the day after the operation. If a rubber bleeder was left in the wound, it is removed immediately.

Outpatient treatment involves taking antibiotics for 5-7 days. This is necessary to prevent inflammatory complications caused by an infectious factor. Additionally, therapy for the underlying disease that caused inflammation of the epididymis, cyst formation, or vascular pathologies may be prescribed.

In the first days after the operation, a man should stay in bed and move less, which will prevent damage to the wound tissue, bleeding and swelling of the scrotum. During rehabilitation after the operation (and this is 2-3 weeks), doctors recommend abstaining from sexual contact and sexual arousal during self-satisfaction, limiting physical activity, avoiding heavy physical labor and lifting weights, visiting baths and saunas.

After the removal of the epididymis, pain medications may be prescribed for the first three days. If it is oncology or tuberculosis inflammation, then a course of chemotherapy follows.

Surface sutures can be made of non-absorbable materials. In this case, they will need to be removed 7-10 days after the operation. Until then, it is recommended to use a suspensory - a special supporting bandage for the scrotum, preventing stretching of its tissues and divergence of the sutures. Then you will need to wear briefs for some time, which provide good fixation of the scrotum.

To assess the treatment, the patient should come to the urologist for a follow-up examination 10 days after the operation. This will help to identify possible postoperative complications in time and take measures to eliminate them.

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Reviews

Diseases of the male reproductive system and their treatment are a delicate topic that the stronger sex does not seek to discuss in the media. But men quite actively share their feelings with doctors and note the disappearance of pain and discomfort that tormented them before, which could not be dealt with by the previously administered medication and physiotherapy.

Doctors consider the operation on the appendix of the testicle as one of the effective methods of treating some of the diseases we mentioned above. And they insist that this procedure helps not only to improve the quality of life of patients, but also helps to preserve the ability to continue the family line. By postponing the operation when the size of the scrotum increases on the right or left and the testicles are noticeably painful, a man risks remaining infertile much more than when performing an operation to remove the cause of reproductive dysfunction.

In general, according to statistics available to treating physicians, patients tolerate the operation well and are satisfied with its results. Negative reviews are mainly due to the fact that some men end any treatment with the operation, not realizing the need for antibiotic therapy and taking other drugs that help prevent inflammation and the appearance of a recurrent cyst.

Doctors do not hide the fact that there is a risk of infertility after surgery on the appendix of the testicle, which they warn patients about in advance. But this risk, if the surgery is performed professionally and the requirements of the rehabilitation period are met, is still less than that associated with the growth of the cyst, ischemia of the testicular tissue, recurrent inflammation, and especially oncology, which threatens not only the reproductive function, but also the life of a person. However, any surgery is performed only with the consent of the patient, so the man takes full responsibility for its consequences.