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Urology/Spermatic cord surgery

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QUESTION: Good morning Doctor,

I had a follow up question regarding this thread

http://www.allexperts.com/user.cgi?m=11&catID=989&expID=46720&qID=5103606

I wrote a follow up to my surgeon, and this was his response:

"It is not the ilioinguinal nerve.  That nerve is not at risk at the place where you were operated on.  I am very sorry you are feeling worse."

What are your thoughts on this? I'm sorry if I'm asking you a lot of follow ups, I just greatly respect your opinion and I am trying to get answers. It seems to me his response does not make sense because he operated on my spermatic cord, which is right next to that nerve.

ANSWER: Tyler:

You described areas of numbness in the area of the scrotum and upper, inner thigh.  This corresponds more or less to the distrubution of the ilioinguinal nerve.  If your surgeon has a better or alternative explanation for your new symptoms since the surgery, I'd like to know what it is.  For example, the genitofemoral nerve also innervates this area.

Iliohypogastric and ilioinguinal nerves Iliohypogastric or ilioinguinal nerve injury may be caused by entrapment by sutures at the lateral poles of transverse fascial incisions for laparotomy, laparoscopic or open hernia surgery, direct trauma, or formation of a neuroma during the normal scarring/healing process. The ilioinguinal nerve seems to be at greatest risk; the iliohypogastric seems to be involved less often, but is often associated with ilioinguinal symptoms.

Here are some reprint info on these two nerves:

A cadaver study described the usual course of these nerves along the abdominal wall [3]:

■Ilioinguinal − 3.1 cm medial and 3.7 cm inferior to the anterior superior iliac spine to 2.7 cm lateral to the midline and 1.7 cm superior to pubic symphysis
■Iliohypogastric − 2.1 cm medial and 0.9 cm inferior to the anterior superior iliac spine to 3.7 cm lateral to the midline and 5.2 cm superior to pubic symphysis

Trauma to these nerves is characterized by a triad of symptoms [8]:

■Sharp, burning, lancinating pain radiating from the incision to the suprapubic area, labia/scrotum, or thigh
■Paresthesia over these areas
■Pain relief after infiltration with a local anesthetic

Symptoms may occur soon after surgery, or months to years later. Symptoms are aggravated by stretching, coughing/sneezing, and Valsalva maneuver. Examination may reveal trigger points, which cause lancinating pain when touched. If nerve block produces complete or substantial decrease in pain, neurectomy should be considered. More than 90 percent of patients had resolution of pain after neurectomy and excision of the involved nerve. Postoperative side effects were persistent numbness below the resected nerve [9].


Genitofemoral and lateral femoral cutaneous nerves The genitofemoral and lateral femoral cutaneous nerves lie on the belly of the psoas muscle, lateral to the external iliac vessels. They are at risk of compression from retractor blades, which should be elevated away from this area to protect the nerves, and at risk of transection during dissection of the external iliac lymph nodes, mobilization of the iliac vessels or removal of a large pelvic mass adherent to the pelvic sidewall.

Injury to the genitofemoral nerve causes anesthesia or paresthesia of the labia/scrotum and upper medial thigh without motor deficits.

Injury to the lateral femoral cutaneous nerve results in paresthesias and pain that radiate down the anterior and posterior-lateral aspect of the thigh toward the knee (as in meralgia paresthetica) [16]. A substantial decrease in pain after L1 and L2 nerve blocks supports the diagnosis. Genitofemoral neurectomy should be considered, since most patients get complete pain relief with anesthesia in the nerve distribution as a minor side effect [17].

If uncorrected, sensory loss in the area of the anterior and lateral thigh may occur.

SUMMARY AND RECOMMENDATIONS

■Entrapment, compression, transection, or stretching of nerves can result in postoperative neuropathy. The most common neuropathies associated with pelvic surgery involve the femoral, ilioinguinal, iliohypogastric, genitofemoral, lateral femoral cutaneous, obturator, and pudendal nerves. (See 'Introduction' above and 'Anatomy' above.)
■Longitudinal (also called vertical) incisions are associated with a low risk of nerve injury. (See 'Longitudinal incisions' above.)
■Transverse incisions that extend beyond the rectus abdominis, involve extensive dissection of the anterior rectus sheath, or are too near the symphysis pubis are more likely to result in neuropathy.
■Injury of iliohypogastric or ilioinguinal nerves may occur from entrapment of the nerves by sutures at the lateral poles of transverse fascial incisions, direct nerve trauma, neuroma formation, or from neural constriction caused by the normal scarring/healing process. The characteristic triad of symptoms is (1) sharp, burning, lancinating pain radiating from the incision to the suprapubic area, labia/scrotum, or thigh, (2) paresthesia over these areas, and (3) pain relief after infiltration with a local anesthetic.
■A neuroma should be suspected in a patient with pain and burning at the incision site, sensory impairment in the area of nerve distribution, referred pain to the groin or along the distribution of the nerve's sensory distribution, and pain elicited by percussion over the neuroma.
■Injury to the genitofemoral nerve results in anesthesia or paresthesia of the labia majora/scrotum and upper medial thigh, without motor deficits. Injury to the lateral femoral cutaneous nerve results in paresthesias and pain that radiate down the anterior and posterior-lateral aspect of the thigh toward the knee. If uncorrected, sensory loss in the area of the anterior and lateral thigh may occur





---------- FOLLOW-UP ----------

QUESTION: Thank you Dr.   I wrote him a follow up message asking how the ilioinguinal nerve could not be at risk since it runs along the spermatic cord. This is his response:

"The nerve does not run along that part of the cord.  It is at risk during a hernia repair, with a higher-up inguinal incision.  We'll talk more about this when you come in."

Thoughts? (I'm sorry for taking so much of your time, I just feel that I need another expert opinion on what he is telling me.)

ANSWER: Tyler:

Your surgeon will know the details of the surgery and may have an explanation that I cannot predict from the available info.  Good luck.

---------- FOLLOW-UP ----------

QUESTION: Good morning Doctor. Not sure if this helps at all, but here is the operation report from my surgery:

"The patient was given a general anesthetic and placed in the supine position where he was prepped with Betadine and draped in sterile fashion. A transverse right inguinal incision was made just above the pubic tuercle and the right spermatic cord was identified just below the external inguinal ring. A Penrose was placed under the spermatic cord. Electrocautery was used to divide internal spermatic fascia and cremasteric muscle fibers in a circumferential fashion. Smaller spermatic veins were ligated with silk and divided. Care was taken to avoid damage to the vas deferens and vasal artery and to a moderate-sized internal spermatic vein. Scarpa's fascia was closed with interrupted 3-0 Vicryl suture. Skin edges were reapproximated with running subcuticular 3-0 Monocryl. A total of 8 mL of 0.25% plain Marcaine was used for local anethesia. Dermabond was placed in the incision. The patient tolerated the procedure well. He was awakened from anethesia and transported to the recovery room in stable condition."

Answer
Tyler:

The description sounds like the inguinal canal was not entered. From that location, it would not be expected that any of the nerves described are likely to be involved, but both the ilioinguinal and the genital branch of the genitofemoral nerve do pass through so there is at least an outside chance that one or both could have been injured.  Here is a reference:

"The superficial inguinal ring (subcutaneous inguinal ring or external inguinal ring) is an anatomical structure in the anterior wall of the mammalian abdomen. It is a triangular opening that forms the exit of the inguinal canal, which houses the ilioinguinal nerve, the genital branch of the genitofemoral nerve, and the spermatic cord (in men)."

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Stephen W. Leslie, MD

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Questions concerning erectile dysfunction, kidney stones and prostate disorders including prostate cancer. I have a special interest in kidney stone disease prevention.

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Full time practicing urologist with 30 years experience. Associate Professor of Surgery and Chief of Urology at Creighton University Medical Center. Editor in Chief of eMedicine Urology internet textbook. Author of only NIH approved book written for patients by a urologist on the subject of kidney stones "The Kidney Stones Handbook". Inventor of the "Parachute" and "Escape" kidney stone baskets and the "Calculus" stone prevention analysis computer program.

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American Urological Association, Ohio State Medical Association, Sexual Medicine Society

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Men's Health, Journal of Urology, Urology, Healthwatch Magazine, Emergency Medicine Monthly, eMedicine, "The Kidney Stones Handbook", and numerous articles in various newspapers. He is also the editor of the Urology Board Review by McGraw-Hill used by urologists to study for their Board Certification Examinations.

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Graduate of New York Medical College with residencies completed at Metropolitan Hospital New York, Albany Medical Center and University of Wisconsin-Madison.

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Thirlby Award of the American Urological Association. Rated as one the country's Best Urologists by the Independent Consumer's Research Institute

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