Types of surgery on the epididymis: the features of their operation

Men usually watch their male health very carefully, because the instinct of procreation is inherent to them no less than to women. But at some point the health of a man can be shaken, which he will be reminded of 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 can not be solved with the help of conservative methods of treatment, the doctor can be prescribed an operation on the epididymis.

Indications for the procedure

Adherence of the testicle is an important organ of the reproductive system in men, which is responsible for the ability of sperm to fertilize the egg. These small mobile creatures that give rise to a new life are formed in the testicles, and then for two weeks gradually moving along the appendage (its length is of the order of 0.7 cm), mature and acquire important functions.

The appendage (epididymis itself), which adjoins directly to the testicles (testicles) consists of a wide, rounded head, a narrow elongated body and tail terminating in the vas deferens. Through its entire length the body is covered with the vaginal envelope of the testicle.

What pathologies can serve as the reason for the appointment of surgery on the epididymis:

• Injuries of the testicles and their appendages with damage to the vaginal membrane (in this case, the operation is usually carried out uncomplicated and consists in excision of damaged tissues and suturing the edges of the wound, but with crushing of the testicles and beginning necrosis, a resection of the affected testis together with the appendage can be prescribed)
• Torsion of the testicle of the testicle, which occurs as a result of trauma (in this case there is a violation of the blood supply to the organ, which subsequently leads to necrotic changes and requires removal of the damaged testicle).
• Oncology of the testicles (most often cancer affects one part of the paired organ, and to prevent relapse, doctors insist on the complete removal of the affected testicle).
• Varicocele or varicose veins of the spermatic cord, which complicates venous outflow and leads to oedematous edema, overheating and disruption of reproductive function (in the most popular Marmara operation under local anesthesia, the scrotum is opened and the damaged vein is bandaged and removed under the control of a microsurgical microscope, after which groin remains a seam length of about 2 cm).
• Cyst of epididymis. The cyst is a benign, rounded neoplasm, inside of which is a liquid content of serous, hemorrhagic or purulent nature. Small cysts in the head of the epididymis are detected by chance, and do not require surgical treatment. The man is sent to the operation to remove the tumor, if:

• the cyst reached a large size and caused pain and discomfort in the scrotum, especially during walking,
• the neoplasm caused a violation of the blood supply to the testicles,
• there are such hormonal failures as increased growth of hair in the groin, on the face and body,
• there is a violation of sexual and reproductive functions.

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

Other indications for such an operation may include:

• chronic epididymitis with frequent relapses,
• formation in the tissues of the appendage of dense infiltrates, causing painful sensations,
• tuberculous epididymitis, i.e. Inflammation of the appendage caused by the causative agent of tuberculosis (both with an accurate diagnosis and with a suspected pathology).

As we can see, with different pathologies various methods of operative treatment are used. In mild cases, only the damaged tissues, vessels and cysts are removed, in the heavy - the epididymis and the testicle.

[1], [2], [3], [4]

Preparation

Disease in a man can be identified long before its first symptoms appear, namely: pain and swelling. So the cyst on the epididymis can grow for several years, not reminiscent of itself, but as it grows, it begins to squeeze the nearby organs and tissues, cause the scrotal enlargement on one side and pain during walking. In most cases, a neoplasm is detected during a urological examination and 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 manifest manifestations of the disease even in the absence of treatment go away for 3-5 days, after which there comes a lull, characteristic for remission. Now the disease turns into a chronic form and can periodically remind oneself of pain, enlargement of the testicle, palpable seals, a decrease in the fertilizing capacity of the sperm.

If a man seeks a doctor for pain and scrotal enlargement, in addition to visual examination, examination of anamnesis and palpation of the diseased organ, an ultrasound examination is prescribed for an accurate diagnosis, which will help to differentiate the usual inflammation of the testicles and their appendages from tumors and vascular disorders in this area and Doppler.

Sometimes already during the diagnosis the doctor makes a decision about the purpose of the operation, its type and amount of work. But in most cases, the disease is treated with conservative methods, and only when they are ineffective resorted to the help of a surgeon who will perform an operation on the epididymis.

As a preparation for the operation, the patient will have to pass a number of laboratory tests that will help assess the performance of internal organs, the risk of bleeding during surgery and the possibility of using anesthesia:

• clinical blood test,
• blood clotting assay (coagulogram),
• Wasserman's reaction in combination with blood tests for HIV infection and hepatitis,
• analysis for the determination of blood type and Rh factor (necessary in case of need of blood transfusion),
• general urine analysis,
• study of discharge from the penis,
• biopsy and histological study of biomaterial for suspected oncology.

Additionally, an electrocardiogram for assessing the condition of the heart and a chest x-ray can be prescribed, as well as consultations of physicians in connection with the existing concomitant pathologies. These moments are relevant for conducting an operation under general anesthesia, the possibility of which is discussed at the stage of preparation for surgery with the specification of tolerability of individual anesthetics.

With malignant neoplasms and tuberculous epididymitis, chemotherapy sessions are performed for a month before the operation.

If it is a question of the planned operation of the patient, they are asked to shave their hair in the groin area. In the preoperative he is administered sedatives.

[5], [6], [7], [8]

Technique of the operations on the epididymis

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

• removal of the testicle cyst (spermocelectomy), which is carried out by analogy with the surgical treatment of varicocele,
• the removal of the epididymis directly (with or without the testicle).

The operation to remove the testicle cyst  can now be performed by different methods, but all of them imply access to the neoplasm through the incision in the scrotum tissues. Usually such an incision is made laterally, depending on the localization and size of the cyst, and it is necessary to remove the epididymis along with the cyst outwards or access to them special microsurgical equipment.

To avoid severe bleeding at the tissue cutting sites, the doctor cauterizes (coagulates) the damaged vessels, and only after that he gets the opportunity to get closer to the base of the cyst (its pedicle). The operation consists in carefully separating the neoplasm from the head and body of the epididymis, applying cysts (and feeding the cyst vessels) of the ligature (clamps) and excising it, after which layer wound suturing is carried out, for which the bioresorbable materials are used.

With a large cyst size, laparoscopic and laser treatment are more relevant. In the first case, a tube is inserted through the microradia through which carbon dioxide and surgical microinstruments are fed into the scrotum cavity. The doctor controls the instruments remotely, monitoring the progress of the operation on the computer monitor. After cutting off the cyst's leg and chopping its tissues, it is all sucked from the body cavity.

Laser treatment is an innovative method of removing cysts that does not require large incisions. The laser diode is inserted by means of a needle into the microcut on the scrotum tissues. The beam melts the tissue of the cyst, which is subsequently aspirated, as in laparoscopic treatment.

Each of the methods has its advantages and disadvantages. The open-label procedure and laparoscopy can be performed both under general and under local anesthesia (depending on the scope of the operation and the anesthesiologist's verdict based on the wishes of the patient and the state of his health). For the removal of cysts by laser, local anesthesia with lidocaine, novocaine or ultracaine is sufficient, since the operation itself is practically painless. But the lack of laser treatment can be considered the impossibility of taking a sample of cyst tissues for a histological examination necessary to refute or confirm its belonging to cancerous growths.

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

As in the case of removal of the epididymal cyst, the patient is placed on the operating table on the back and anesthesia is injected. It is also possible to perform the procedure under local anesthesia, which involves anesthetizing the incision site and anesthetic infiltration of the spermatic cord, which contains nerve fibers and provides sensitivity to the testicles and their appendages.

After the introduction of anesthesia, the scrotum tissues are stretched and made in them a longitudinal incision along the seam a little to the side of it. The edges of the wound are held by special holders. The testicle and the appendage attached to it are removed outside, for which a cut in the vaginal membrane is previously made. If the operation is scheduled in connection with tuberculous epididymitis the incision will reach the seed duct, which should be removed.

In the area of the sinus, an anesthetic solution (infiltration anesthesia) is inserted under the head and body of the appendage. After this, first cut off the anterior ligament of the epididymis, pre-piercing its head, and then insert the scissors into the space between the appendage and its shell, trying to extract it without damaging the capsule and the nearby testicles. Now the doctor can cut off the tail of the epididymis and a small segment of the ductal duct adjacent to it (about 2 cm). The rest of the vas deferens is closer to the groin and is ligated and cut off.

When the appendage tissues are separated from the testicle, the capsule is sutured, closing the defect resulting from the removal of epididymis. The testicles are placed in a shell and layer wound. If a necrotic process was detected in the testicle tissues by express biopsy, the testis should also be removed.

Inflammatory process in the appendage can cause overgrowth of the scrotum tissues. In this case, excess tissues are removed, and the rest are sutured in such a way as to give the organ an original appearance. After the appendage is removed and the wound is sutured, an aseptic pressing bandage is applied to the scrotum, lifting the organ upward.

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

Surgery to remove the cyst of the epididymis takes about 30-40 minutes, and the epididymal incision requires about 1 hour, because it requires special care because of the risk of damage to the testicles, 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 the cyst or the epididymis itself can be carried out under local anesthesia, there are not very many contraindications to its conduct. In this case, they are typical for any non-bloodless operations.

A serious obstacle to surgery on the epididymis, which requires the cutting of tissues, is a violation of blood coagulability, although the risk of developing severe bleeding is prevented by timely vascular coagulation. In laser therapy, this happens naturally through the action of laser radiation, which cauterizes tissues and blood vessels directly during the removal of the cyst.

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

Relative contraindications for surgery are also considered:

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

To refuse surgery the doctor can not, but in his power to postpone the procedure for a period of complete cure or remission of diseases. In severe general patient condition, surgery can be performed after stabilization of the condition.

[9]

Consequences after the procedure

Surgery on the epididymis is not considered a complicated surgical procedure, so in most cases it ends well. After removal of the cyst on the appendage, the disappearance of pain and discomfort in the scrotum is noted by more than 95% of men. The rest indicated minor pain during the next 3 months after the operation, after which the discomfort left completely. In this case, the affected reproductive function in men in most cases was restored.

Removal of the appendage of the testicle by doctors or even the entire testis with an appendage is prescribed by doctors not so often. Nevertheless, to be afraid of operation it is not necessary. The risk of becoming sterile is higher if nothing is done. And so, after removing the epididymis or one of their testicles, another testicle starts functioning for two, which enables a man to become the father of his own child. On the potency and orgasm, the operation is also not actually reflected, but the pain and discomfort that significantly worsen the patient's quality of life go away.

It is clear that, like any other operation, there is some risk of complications arising after surgical manipulation. The most common complications are 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 in the postoperative period the wound was not properly treated, inflammation and suppuration of tissues in this area is possible. To prevent this from happening, with a change of dressings, the wound should be treated regularly with antiseptic solutions. Subsequently, on the site of inflammation, rough scars can form and there may appear sensations of constriction of the tissues.

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

• intensive pain after 3 days after the operation,
• allocation on the spot of blood, sutures or pus,
• pain unpleasant sensations in the groin a few months after the operation,
• edema and redness of the scrotum tissues, observed for several days after removal of the cyst or epididymis,
• sudden increase in body temperature, indicating the development of the inflammatory process in the body.

Recurrence of cysts and infertility can hardly be called complications after surgery. This is more the result of a lack of proper treatment of the underlying disease. Although sometimes by carelessness the doctor during the removal of the cyst can still damage the vas deferens, which will violate his passableness, but with a normally functioning second testicle, the man remains capable of conceiving. So there is no direct connection between infertility and surgery.

[10], [11], [12], [13], [14], [15]

Care after the procedure

Despite the apparent complexity of the operation on the epididymis, the rehabilitation period after it is small. After the operation, an aseptic bandage and cold are applied to the scrotum. After a couple of hours in the absence of severe pain 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.

When the epididymectomy, the first day after the operation, the first dressing is performed. If a rubber graduate of the contents was left in the wound, it is immediately removed.

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

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

After removal of the epididymis during the first three days, medications for pain relief may be prescribed. If it comes to oncology or tubercular inflammation, then a course of chemotherapy follows.

Surface joints can be made of non-absorbable materials. In this case, they need to be removed after 7-10 days after the operation. Until then, it is recommended to use a suspensions - a special supporting bandage for the scrotum, preventing the stretching of its tissues and divergence of the joints. Next it will be necessary for some time to wear panties in the form of swimming trunks, which provide a good fixation of the scrotum.

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

[16]

Reviews

Diseases of the male sexual sphere and their treatment is a delicate topic that the strong sex does not seek to discuss in the media. But with the doctors, the men quite actively share their feelings and note the disappearance of the pains and discomfort that tormented them before, the medical and physiotherapy that could not be performed earlier could not cope with it.

Doctors surgery on the epididymis is considered as one of the effective methods of treating certain diseases, which we mentioned above. And insist that this procedure helps not only improve the quality of life of patients, but also helps to maintain the ability to procreate. Postponing the operation with an increase in the size of the scrotum to the right or left and a noticeable tenderness of the testes, a man risks remaining barren much more than when performing an operation to remove the cause of reproductive harm.

In general, according to statistics, which is available to the treating doctors, the operation is tolerated by the patients well and the results are satisfied. Negative reviews are associated mainly with the fact that some men complete any treatment with surgery, without realizing the need for antibiotic therapy and taking other medications that help prevent inflammation and the appearance of a repeated cyst.

Do not hide the doctors and the fact that the risk of infertility after surgery on the epididymis still exists, which they warn patients in advance. But this risk in a professionally performed operation and compliance with the requirements of the rehabilitation period is still less than that due to the growth of the cyst, ischemia of the testicles, a recurrent inflammatory process, and especially oncology, which threatens not only the reproductive function but also human life. Nevertheless, any operation is carried out only with the consent of the patient himself, therefore, the man takes all responsibility for its consequences.