IN T R A T U N IC A L I N S T I L L A T I O N O F B U P I V A C A I N E A N D
M E T H Y L P R E D N I S O L O N E F O R R E L IE F O F
S C R O T A L P A I N A N D S W E L L IN G F R O M TE S E O R M E S A
T i b e t E r d o g r u , M .D .* / M u s t a f a B a h ç e c i, M .D .* * / E s ra A k y o l , M .D .* *
S u le y m a n T o s u n , M .D .* * / N u m a n B a y a z i t , M .D .* *
*
D e p a r t m e n t o f U r o l o g y , T h e G e r m a n H o s p i t a l , I s t a n b u l , T u r k e y .**
D e p a r t m e n t o f I V F a n d E n d o s c o p i c G y n e c o l o g y , T h e G e r m a n H o s p i t a l , I s t a n b u l , T u r k e y .A B S T R A C T
Objective:
Scrotal pain and swelling due to
surgical sperm retrieval procedures and
peritesticular fibrosis, as a problem of late term,
create significant morbidity in the postoperative
life of patients and affect possible future sperm
retrieval procedures.
Methods:
Thirty-one patients received NSAIDS
postoperatively by IM (intramuscular) route
without
local
anaesthetic
agent
and/or
corticosteroid instillation around the testicles
before closure of the tunica vaginalis-control
group-. No NSAIDS were given to the remaining
34 patients in whom 2.5 ml of 0.5% bupivacaine
combined with 10 mg/ml. methylprednisolone
were introduced before closing of the tunica
vaginalis. The mean pain scale scores and
duration of painless period after surgery between
the two groups were evaluated.
Results:
The mean pain score difference was
not statistically significant just after surgery
between the two groups (p>0.05), while the
differences were significant for 2 and 4 hours
after surgery (p<0.05 and p<0.01). The mean
duration of pain free interval (hours) after the
procedure was 47.8 ± 16.9 (12-72) hours in the
intratunical instillated group patients, and 10
(29%) and 23 (67%) of them were completely
free of pain and had no scrotal swelling,
respectively. Meanwhile, in the control group, the
mean painless period was 9.9 ± 3.6 (4-20) hours,
after second NSAID, and 30 of them (97%) had
scrotal swelling, postoperatively.
Conclusion:
This study confirms that direct
intratunical Instillation of bupivacaine and
methylprednisolone around the testis reduces
postoperative pain, scrotal swelling and
peritesticular fibrosis. Controlling of post surgical
scrotal pain and edema results in more rapid
return to daily activities and work.
K e y W o r d s :
ICSI, Pain, Scrotum, Surgical
sperm retrieval, Testis
I N T R O D U C T I O N
Testicular sperm extraction (TESE) and
microepididymal sperm aspiration (MESA) have
become important sperm harvesting procedures
during intracytoplasmic sperm injection (ICSI) in
azoospermic male patients. These scrotal
procedures are usually performed in the
outpatient setting, which can be distressing for
the patient and also his spouse who could be a
(Accepted 10 October, 2000) Marmara Medical Journal 2001 ;14(1 ):12-15
12
Bupivacaine and méthylprednisolone for relief of scrotal pain and swelling from TESE or MESA
candidate for embryo transfer in 48 to 72 hours.
Secondly, in spite of analgesic therapy, severe
scrotal pain after this procedure may delay
discharging the patient from the ambulatory care
unit. Finally, scrotal pain and swelling which
depend upon the surgical intervention (more
tunical incisions are required for severe
hypospermatogenesis) may continue for 5 to 7
days postoperatively affecting the quality of life
and creating significant morbidity at home.
The nerve supply to the testis and the tunica
albuginea is derived from the sympathetic
autonomic plexus via the T10-12 nerve roots,
which is difficult to interrupt with regional block
(1). In addition, scrotal surgery usually results in
moderate to severe scrotal swelling. The edema
may take in a couple of weeks to resolve in spite
of anti-inflammatory medication. On the other
hand, peritesticular fibrosis, usually observed in
patients after even minimal scrotal surgery and
even with improved quality of suture materials
has negative effects for further TESE or MESA
procedures. Thus we determined the effect of
local instillation of a combination of bupivacaine
and méthylprednisolone into the tunical vaginal
space surrounding one or two testicles in patients
undergoing uni-or bi-lateral testicular sperm
extraction or epididymal sperm aspiration.
M A T E R I A L A N D M E T H O D S
A total of 65 azoospermie male patients (mean
age: 34.87 ± 4.23 years) enrolled in this study
who underwent scrotal exploration with uni-or bi
lateral TESE or MESA. Standard general
anaesthetic technique was used in all patients.
Thirty-one
patients
received
NSAIDS
postoperatively by IM (intramuscular) route
without
local
anaesthetic
agent
and/or
corticosteroid instillation around the testicles
before closure of the tunica vaginalis-control
group-. No NSAIDS were given to the remaining
34 patients in whom 2.5 ml of 0,5% bupivacaine
combined with 10mg/ml. méthylprednisolone
were introduced before closing of the tunica
vaginalis.Non-absorbable suture (5/0 prolene)
was used for tunica albuginea and tunica
vaginalis repair during the TESE procedure.
Absorbable suture material (4/0 chromic catgut)
was used for closing the subcutaneous fascia
and skin in both group patients.
The degree of postoperative pain was evaluated
in all patients in both groups using a visual
analogue pain score, with a recording of the
location and description of pain (range from 0 to
a maximum of 10). The assessment was
performed in the immediate postoperative period
as soon as the patient could respond to
questioning, and repeated 2 and 4 hours later.
The degree and duration of scrotal pain was
determined
on
postoperative
controls
(postoperative 2nd and 7th days). If there was
severe pain after 4th hours, we performed a
second dose of NSAID with IM route. Scrotal
swelling and wound healing were noted during
this period, as well. Informed consent was
obtained before procedure from all participants in
whom intratunical instillations were performed.
Men unwilling or unable to give informed consent
were included in the plain per- and post-operative
pain treatment group as control patients. Men
were excluded from the study who had taken an
experimental drug less than six weeks before
undergoing surgery or had a history of
orchioepididymitis or had had previous scrotal
surgery.
A student's-t test was performed between the two
groups for statistical analysis to observe the
mean pain scale scores and duration of painless
period after surgery.
R E S U L T S
The mean pain scores in control group patients
were 1.87 ± 0.99, 4.48 ± 0.96 and 5.03 ± 0.79 for
immediately after, 2 and 4 hours after surgery,
whereas these scores were 1.03 ± 0.67, 1.18 ±
0.76 and 2.05 ± 0.85 in the intratunical instillated
group, respectively (Fig 1). The mean pain score
difference was not statistically significant just
after surgery between the two groups (p>0.05)
while the differences were significant for 2 and 4
hours after surgery (p<0.05 and p<0.01). The
mean duration of pain free interval (hours) after
the procedure was 47.8 ± 16.9 (12-72) hours in
the intratunical instillated group of patients, and
10 (29%) and 23 (67%) patients were completely
free of pain and had no scrotal swelling,
respectively. Meanwhile, in the control group, all
patients required a second dose of NSAID
injection due to increased pain score. The mean
painless period was 9.9 ± 3.6 (4-20) hours, after
Tibet Erdogru, et al
F i g . l s The mean values of “Visual Analogue Pain Score” of each group immediately, 2nd and 4th hours after surgery.
second dose, and 30 p a tie n ts (97% ) had scrotal s w e llin g , p o s to p e ra tiv e ly . T h e p o s to p e ra tiv e painless period w as s ig n ific a n tly lo n g e r in the intratunical instillated g ro u p than controls. (Fig. 2) N either w o und in fe ctio n n o r o rc h ie p id id y m itis w as observed o v e r long term fo llo w -u p (1 to 3 m onths posto p e ra tive ly) in both g roups. T here w as no w ound healing p ro b le m in any of the p a tie n ts , e s p e c ia lly in in tra tu n ic a l m éth ylp re d n iso lo n e in stilla te d patients.
S econdary T E S E o r M E S A p ro c e d u re s w e re perform ed in 8 and 10 p a tie n ts from the control g ro u p a nd in tra tu n ic a l in s tilla te d g ro u p , re sp e ctive ly. No in tra tu n ic a l, p e rite s tic u la r or p e rie p id id y m a l fib ro s is w a s o b s e rv e d in the intratunical m é th y lp re d n is o lo n e in stilla te d group. T h e re w a s m o d e ra te p e rite s tic u la r and
75-1 T3 .2 GJ Q. V» </>
£
25-4 7 .8± 16.9 9.9± 3.6 0 Instillated in :3 4 ï Control (n:31^F l g .2 : The mean pain free interval after intratunical instillation and routine analgesic approach.
p e rie p id id ym a l fib ro s is in fo u r p a tie n ts from the control gro u p and slig h t p e ri-in s ic io n a l fib ro s is in the rem aining 4.
DISCUSSION
R ecently, new a p p ro a c h e s fo r scro ta l pain relief have been un d e r in ve stig a tio n , e s p e c ia lly a fte r T E S E and M ESA, p o p u la riz e d p ro c e d u re s as part of ICSI (2). B e cu se th e s e are o u t-p a tie n t p ro c e d u re s , th e pain m a n a g e m e n t b e c o m e s m ore im portant. F u rth e rm o re , pain a ffe ctin g the m ale p a tients m ight p s y c h o lo g ic a lly im p a c t th e ir spouses, ca n d id a te s fo r e m b ryo tra n s fe r w ithin 4 8 -72 hours. O th e r im p o rta n t fa c to rs are scrotal s w e llin g , a nd p e rite s tic u la r an d e p id id y m a l fibrosis that m ay d e v e lo p in the e a rly and late period a fte r scro ta l surgery. T his fib ro s is m ay lead to ch ro n ic scrotal pain and d is c o m fo rt and a ffect fu rth e r T E S E and M E S A p ro c e d u re s d ue to a m ore d iffic u lt d is s e c tio n .lt is th o u g h t that these side e ffects of sperm h a rve stin g p ro c e d u re s in a z o o s p e rm ic m ale p a tie n ts m ig h t be pre ve n te d by using Intratunical instilla tio n of a co m b in a tio n o f local a n a e s th e tic a g e n t and c o rtic o s te ro id around the testis.
To pro vid e p o s ts u rg ic a l pain re lie f fo r a v a rie ty of s u rg ic a l p ro c e d u re s , in s tilla tio n of a n a lg e s ic a g e n ts d ire c tly in to th e o p e ra tiv e s id e is c o m m o n ly used (3-6). R e ce n tly th is app ro a ch has b e co m e p o p u la riz e d in te s tic u la r bio p sie s using in tra tu n ica l (tunica va g in a lis ) b u p iv a c a in e (7). H o w e v e r, in tra tu n ic a l c o rtic o s te ro id in stilla tio n has not been fo u n d in the literature. T h e lite ra tu re in d ica te s th a t using steroid is a s a fe a nd e ffe c tiv e m e a n s o f re d u c in g p o s to p e ra tiv e pain and ede m a . S tu d ie s have show n ste ro id s to d e la y w o u n d healing , inhibit c o lla g e n s y n th e s is a n d th e in c re a s e of p o s to p e ra tiv e infection. B ut there w e re no reports of d e la ye d w o u n d o r bon e healing or in cre a se d in fection rate in p a tie n ts in th e c a se w h e re s te ro id w a s used p e ro p e ra tiv e ly . In re c e n tly p u b lish e d studies, th e m o st c o m m o n reason for th e use of ste ro id s w a s to d e c re a s e e d e m a (8,9). In C ita rd i's s tu d y (10), th e e ffe c tiv e n e s s of in tra s in u s o id a l b e c lo m e th a s o n e in s tilla tio n th e ra p y w a s m e n tio n e d in th e tre a tm e n t of re fra cto ry p o s to p e ra tiv e m u cosal e dem a. A study re p o rte d th a t 4 7 % o f th e m e m b e rs of T h e A m e ric a n S o c ie ty o f M a x illo fa c ia l S u rg e o n s
Bupivacaine and méthylprednisolone for relief of scrotal pain and swelling from TESE or MESA
u tiliz e s h o rt-te rm , h ig h -d o s e p e rio p e ra tiv e c o rtic o s te ro id s to c o n tro l p o s to p e ra tiv e in fla m m a tio n (11). T he m ost com m o n reason for not using s te ro id s p e rio p e ra tiv e ly w as perceived a lack of lite ra tu re s u p p o rtin g th e ir e ffe ctivene ss (8, 11). W a ta n u ki et al. (12) po in te d out that in tra o p e ra tiv e a d m in is tra tio n o f large d o se s of ste ro id s w a s e ffe ctive not on ly in reducing pain but also in re lieving p o s to p e ra tiv e pyre xia in p a tie n ts w h o u n d e rw e n t total hip jo in t or knee jo in t re p la ce m e n t.
In o u r s e rie s , in tra tu n ic a l in s tilla tio n o f a c o m b in a tio n o f b u p iv a c a in e and m é th y lp re d n is o lo n e s ig n ific a n tly d e c re a s e s p o s to p e ra tiv e s c ro ta l p a in as o p p o s e d to a n a lg e s ic and a n ti-in fla m m a to ry tre a tm e n t (4.48 ± 0.96 and 5.03 ± 0.79 vs 1.18 ± 0.76 and 2.05 ± 0.85 fo r 2 and 4 ho u rs a fte r su rg e ry, re sp e ctive ly; p < 0 .0 5 ). F u rth e rm o re , in s tilla tio n w ith a c o m b in a tio n o f lo c a l a n a e s th e tic and c o rtic o s te ro id w ith in the tu n ic a l ca vity is m ore effe ctive not on ly in p re v e n tin g scro ta l sw elling b u t a ls o p ro lo n g in g p o s to rp e ra tiv e p a in le s s period (47.8 ± 16.9 vs. 9.9 ± 3.6, p<0.01) w ith no a p p a re n t e ffe c t upon w o u n d healing and local in fection rates.
T h is s tu d y c o n firm s th a t d ire c t in tra tu n ic a l in s tilla tio n o f b u p iv a c a in e an d m é th y lp re d n is o lo n e a ro u n d the te stis reduces p o s to p e ra tiv e p a in , s c ro ta l s w e llin g and p e rite s tic u la r fib ro sis. C o n tro llin g of p o st surgical scro ta l pain and e d e m a results in m ore rapid return to d a ily a c tiv itie s and w ork. Intratunical local a n a e s th e tic instilla tio n has been d escribed p re v io u s ly (7), h o w e ve r, w e are the firs t to d e s c rib e in s tillin g of a c o m b in a tio n of local a n a e s th e tic and co rtic o s te ro id into the tunica va g in a lis a ro u n d th e te s tis and epididym is. W e use a do se of 2.5 ml b u p iv a c a in e 0 .5% com bined w ith 1 0 m g /m l. m é th y lp re d n is o lo n e in to the p e rite s tic u la r in tra tu n ic a v a g in a l space. This c o m b in a tio n le ads to a s ig n ific a n t reduction in p o s to p e ra tiv e p a in , s c ro ta l s w e llin g and p e rite s tic u la r fib ro s is a sso cia te d w ith te s tic u la r or e p id id ym a l sperm h a rve stin g procedure s.
Acknow ledgem ent
T he skilful te c h n ic a l and sc ie n tific a ssista n ce of B e n ja m in S p e n c e r (M a s s a c h u s e tts G e n e ra l
H o s p ita l, D e p a rtm e n t o f U ro lo g y ) is kin d ly acknow led ged.
