Document 6481039

2010 THE AUTHORS. JOURNAL COMPILATION
Original Articles
2010 BJU INTERNATIONAL
SUPERFICIAL DORSAL PENILE VEIN THROMBOSIS AFTER SUBINGUINAL VARICOCELECTOMYARANGO
ET AL.
BJUI
Superficial dorsal penile vein thrombosis:
a little-known complication of
subinguinal varicocelectomy
BJU INTERNATIONAL
Octavio Arango, José A. Lorente, Gloria Nohales, Enrique Rijo and Oscar Bielsa
Department of Urology, Hospital del Mar, Barcelona, Spain
Accepted for publication 18 February 2010
Study Type – Therapy (case series)
Level of Evidence 4
OBJECTIVE
To describe the symptomatology, diagnosis
and treatment of superficial thrombosis of
the dorsal penile vein – the most common
complication of subinguinal varicocelectomy
– and analyse the possible mechanisms
involved in the development of the condition.
PATIENTS AND METHODS
The clinical records of 326 patients who
underwent varicocele repair during the last
10 years was reviewed. The technique used
was subinguinal varicocelectomy with
arterial preservation. A mini-Doppler probe
was used during surgery for artery
identification. We report on the postoperative
complications of varicocelectomy, with
special attention to superficial dorsal penile
vein thrombosis, and provide a detailed
description of the anatomy of the superficial
venous system of the penis.
This study provides the description of a new surgical complication in the subinguinal
varicocelectomy: SDPVT. We analysed the pathophisiology and the management of this
entity.
RESULTS
Complications usually associated with
varicocele surgery occurred in less than 1%
of patients. However, the most common
complication in our series was superficial
dorsal penile vein thrombosis, which
occurred in 2.1% of patients. The use of the
mini-Doppler probe allowed us to identify
and preserve the arteries in all 326 patients.
Varicoceles are the most common correctable
cause of male infertility. Subinguinal
microsurgical varicocelectomy with arterial
preservation is the technique most frequently
used to treat this condition, and the one
with the best results and lowest rate of
complications [1–6].
The aim of the present study was to describe
superficial dorsal penile vein thrombosis as a
complication associated with subinguinal
varicocelectomy and to analyse the
possible mechanisms responsible for this
rapid and safe technique. The outcomes
and complications are similar to those
reported for subinguinal microscopic
varicocelectomy. Superficial dorsal penile
vein thrombosis is a benign self-limited
condition whose association with
subinguinal varicocelectomy has not been
previously reported.
KEYWORDS
CONCLUSION
Subinguinal varicocelectomy with intraoperative use of a mini-Doppler probe is a
complication, to which we found no previous
reference in the literature.
INTRODUCTION
©
What’s known on the subject? and What does the study add?
The superficial dorsal penile vein thrombosis (SDPVT) has been described in connection
with different medical and surgical conditions but never in subinguinal varicocelectomy.
PATIENTS AND METHODS
varicocelectomy, complications,
thrombophlebitis, superficial dorsal penile
vein, mini-Doppler
database we collected all the data related to
the complications associated with varicocele
surgery, paying special attention to superficial
dorsal penile vein thrombosis.
COHORT
SURGERY
We retrospectively reviewed the clinical
records of 326 patients who had undergone
varicocele repair in our department over the
last 10 years. Most of these patients had
consulted for infertility. All patients had
undergone examination using scrotal Doppler
ultrasonography (US) to exclude the presence
of contralateral varicocele. From the hospital’s
The surgical technique used was subinguinal
varicocelectomy with arterial preservation.
The procedure was performed through an
oblique incision 3–4 cm long below the
external inguinal ring. For artery identification
during the procedure we used a mini-Doppler
probe with an 8–10 MHz transducer. Each of
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A R A N G O ET AL.
the vascular elements of the spermatic cord
were separated and examined individually
with the mini-Doppler probe. Any vessel in
which no arterial pulse was detected was
ligated and excised.
FIG. 1.
Diagram of the superficial venous
system of the penis in 70% of
men, consisting of a single vein
terminating on the left side. 1,
femoral vein; 2, great saphenous
vein; 3, superficial dorsal penile
vein; 4, subcutaneous abdominal
veins; 5, spermatic cord; 6,
external inguinal ring; 7, the
dotted line indicates the usual
incision site in subinguinal
varicocelectomy.
CLINICAL PRESENTATION
Superficial dorsal penile thrombosis after
subinguinal varicocelectomy usually presents
in subacute form between the first and
second week after surgery, generally
coinciding with the patient’s resumption of
sexual activity. It manifests clinically as a
cord-like induration on the dorsal region of
the penile shaft and is usually painless,
although it is occasionally accompanied by
signs of local inflammation and mild pain on
palpation. On physical examination the
thrombosed vein feels like a hard, thick rope
located on the proximal two-thirds of the
penile shaft, just below the skin. Pulling the
penis outwards by the glans shows the
affected vein as a tense indurated cord that is
easily palpable beneath the skin. While the
process is benign and self-limited, it usually
generates considerable anxiety and
psychological stress in the patient. The
patient’s clinical history and the physical
examination are usually sufficient to establish
the diagnosis. Certain imaging techniques,
such as penile Doppler US and MRI, which
make it possible to view the thickened vein
walls and the occluded light, confirm the
diagnosis [7,8]. Treatment of superficial dorsal
penile vein thrombosis is usually conservative,
and aggressive therapeutic measures are not
required. It is important to first reassure the
patient and recommend suspending sexual
activity until the symptoms have completely
resolved. The administration of oral NSAIDs
and topical treatment with heparin ointment
speed up resolution. Antibiotics and systemic
anticoagulants are usually unnecessary. In
most patients, the condition resolves
completely within 3–6 weeks, with recanalization of the thrombosed vein occurring
around the week 8 [8–10].
SUPERFICIAL VENOUS DRAINAGE OF
THE PENIS
The anatomy of the superficial venous system
of the penis is quite variable. The system is
located in the subcutaneous cellular tissue
above Buck’s fascia and its function is to drain
the blood from the shaft, foreskin and fascial
coverings of the penis. It does not receive
blood from the glans or from the corpus
96
spongiosum and does not communicate with
the deep venous system. In 70–90% of men,
the superficial venous system forms a single
trunk at the base of the penis to which small
subcutaneous veins of the abdomen and
scrotum are joined and that empties into the
femoral vein or the top of the saphenous–
femoral junction of the great saphenous vein
(Fig. 1) In the remaining 10–30%, the
superficial venous system is formed by two or
more veins of unequal calibre, with several
anastomoses between them, which empty
into the saphenous vein on either side. In 70%
of men with a single superficial dorsal vein,
the vein empties into the left saphenous vein;
in the remaining 30%, it empties into the
right saphenous vein [11,12].
RESULTS
Between September 1999 and September
2009, 326 patients underwent subinguinal
varicocele repair in our department. The
varicocele was on the left side in 299 (91.8%)
patients and was bilateral in 27 (8.2%)
patients. The mean duration of the procedure
was 35 min (range 25–50). The procedure was
performed under general anaesthesia in 270
patients and under sedation and local
anaesthesia with mepivacaine in 56 patients.
In 92% of the patients, intra-operative miniDoppler US examination of all the elements of
the spermatic cord allowed us to identify the
three arteries (testicular, deferential and
cremasteric) of the cord present at this level.
In the remaining 8%, two of the three arteries
were identified. The complications usually
associated with varicocele surgery (testicular
artery injury, testicular atrophy, hydrocele and
varicocele recurrence) occurred in fewer than
1% of patients. Early problems of the surgical
wound, such as haematoma or infection,
occurred in five (1.5%) patients. However,
superficial dorsal penile thrombosis occurred
in seven (2.1%) patients, and was thus the
most common postoperative complication in
our series. We observed no link between this
complication and the type of anaesthesia
used, the duration of the procedure or the
bilateral nature of the varicocele.
DISCUSSION
The main mechanisms that favour venous
thrombosis are usually trauma to the vascular
endothelium, slowing of venous flow and
hypercoagulable states due to some systemic
process. We believe the first two of these to be
responsible for the superficial dorsal penile
vein thrombosis inpatients undergoing
subinguinal varicocelectomy that we describe
in the present study. When the subinguinal
incision is oblique, the superficial dorsal vein
often crosses the upper part of the surgical
wound and can be injured inadvertently. Small
traumas to the vascular endothelium, which
act as a starting point for thrombosis, can also
be produced (Fig. 2).
Once venous thrombosis is produced at the
point of the surgical incision, it progresses in
a retrograde direction until the superficial
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2010 BJU INTERNATIONAL
SUPERFICIAL DORSAL PENILE VEIN THROMBOSIS AFTER SUBINGUINAL VARICOCELECTOMY
FIG. 2. Vascular loop holding up the superficial dorsal penile vein that crosses the upper part of the
subinguinal varicocelectomy incision. At this level the vein is sometimes injured during the procedure,
leading to thrombophlebitis.
dorsal penile vein and its branches are
affected. As in all thrombotic processes, a
local inflammatory response is then
generated, resulting in thrombophlebitis of
the superficial venous system of the penis.
The fact that thrombosis occurs only in some
patients and not in others might be
attributable to the great anatomical variability
of the system, which in three-quarters of
patients consists of a single superficial dorsal
vein that empties exclusively into the left
great saphenous vein [13]. For this reason, it is
common in varicocelectomy to encounter
the vein crossing the upper part of the
subinguinal incision. To reduce the incidence
of this distressing complication, we have
modified the direction of the subinguinal
incision and try to make the incision as
transverse as possible, rather than oblique. In
this way, we avoid the situation in which the
superficial dorsal vein crosses the surgical
wound, thus reducing the risk of injury.
Superficial dorsal penile vein thrombosis,
known as Mondor’s phlebitis, has also been
described in connection with prolonged
vigorous sexual activity, tumours of the
genito-urinary tract, tumours of the digestive
tract, infections, trauma, hypercoagulable
©
states, prostate biopsies, inguinal hernia
surgery, long-haul flights and the use of
tadalafil [14–20].
Subinguinal varicocelectomy with artery
identification via the intra-operative use of a
mini-Doppler probe is a rapid and safe
technique. Its complication rates are similar
to those of subinguinal microscopic
varicocelectomy, currently considered the
gold standard for treating varicocele. In the
series considered in the present study, the
most common complication of the procedure
was superficial dorsal penile vein thrombosis,
a benign self-limited condition. A possible
mechanism underlying this complication is
the fact that, in most cases, the superficial
dorsal penile vein terminates on the left side
and often crosses the upper part of the
surgical incision. Superficial dorsal penile
thrombosis has not been previously described
in connection with subinguinal
varicocelectomy.
CONFLICT OF INTEREST
None declared.
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Correspondence: Octavio Arango, Department
of Urology, Andrology Section, Hospital del
Mar, Passeig Maritim 25-29, 08003 Barcelona,
Spain.
e-mail: [email protected]
Abbreviation: US, ultrasonography.
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JOURNAL COMPILATION
©
2010 THE AUTHORS
2010 BJU INTERNATIONAL