Men undergoing laparoscopic nephrectomy should be warned that they might develop testicular pain postoperatively.
To confirm their clinical impression that testicular pain occurred in a significant proportion of men after laparoscopic renal or adrenal gland surgery, the researchers analyzed prospectively collected data from 64 male patients operated on between January 2006 and February 2007. The surgery was unilateral in 60 men and bilateral in four men, for a total of 68 sides.
Testicular pain developed in 14 patients (21%) and was consistently ipsilateral to the side of their surgery. Eleven different procedures were represented in the series, but all men who developed testicular pain had undergone donor or radical nephrectomy. The rate of development of testicular pain was 55% in the donor nephrectomy subgroup and 20% among men undergoing radical nephrectomy.
"Our experience is that some men who develop testicular pain report it only when directly questioned," said Dr. Gjertson, who presented the findings at the 2007 AUA annual meeting in Anaheim, CA. "We believe this problem is something that has been under-recognized and under-reported. Although there appear to be no significant sequelae, we believe a risk of testicular pain as well as of hydrocele are elements that should be included in the informed consent for patients undergoing laparoscopic nephrectomy."
Surgeries performed in the series included hand-assisted and standard laparoscopic radical, simple, and donor nephrectomy, adrenalectomy, pyeloplasty, nephroureterectomy, renal cyst decortication, retroperitoneal radical and simple nephrectomy, and cryoablation of renal tumor. Forty of the procedures were left-sided; 28 were right-sided.
Time to discharge ranged from 1 to 7 days (median, 2 days), and no patient had pain while in the hospital. Onset of pain ranged from 5 to 7 days after surgery.
Men were asked to rate their pain using a 10-point analog pain scale. Their responses showed a range in severity, with scores between 1 and 8 and a mean of 3.9. Persistence of pain was also variable, ranging from 1 week to almost 4 months, with an average of about 1 month.
What influences pain?
Analyses also were performed to determine whether any factors influenced the risk of pain. Prospectively collected parameters investigated included patient demographic features, operative time, blood loss, side of the operation, length of stay, and the dissection and/or ligation of the gonadal vein.
Men who developed pain were significantly younger than their counterparts who did not (42 vs. 52 years old, respectively). Otherwise, only sacrifice of the gonadal vein seemed to be associated with the risk. Among 39 men in whom the gonadal vein was sacrificed, 33% developed testicular pain compared with only 3.4% of the 29 patients whose gonadal vein was preserved.
"Our analyses are based on a relatively small series of patients in a single-center study," Dr. Gjertson explained. "We are continuing to follow more men to better understand risk factors and etiology of the pain. We also analyzed our complication rate and found it was within the range of that reported in large retrospective series, and so we do not believe the development of testicular pain is related to any departure from standard surgical technique."
Because the etiology of the pain is unclear, it is not possible to identify preventive strategies. One hypothesis regarding the cause of the pain is that it may be related to vascular congestion following ligation of the gonadal vein or lymphatic vessels.
"However, sparing the lymphatics or the gonadal vein is difficult, especially in a left-sided donor nephrectomy," Dr. Gjertson noted.