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 2010 THE AUTHORS JOURNAL COMPILATION © 2 0 1 0 B J U I N T E R N A T I O N A L | 1 0 7 , 9 5 – 9 8 | doi:10.1111/j.1464-410X.2010.09465.x 95 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 © JOURNAL COMPILATION © 2010 THE AUTHORS 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. REFERENCES Baazeem A, Zini A. Surgery illustratedSurgical Atlas Microsurgical varicocelectomy. BJU Int 2009; 104: 420– 7 2 Goldstein M, Gilbert BR, Dicker AP et al. Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique. J Urol 1992; 148: 1808–11 3 Watanabe M, Nagai A, Kusumi N et al. Minimal invasiveness and effectivity of subinguinal microscopic varicocelectomy: a comparative study with retroperitoneal high and laparoscopic approaches. Int J Urol 2005; 12: 892–8 4 Grober ED, O’Brien J, Jarvi KA et al. 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Mondor’s syndrome. Case review and bibliographic review. Arch Esp Urol 2009; 62: 317–9 17 Alvarez-Garrido H, Garrido-Rios AA, Sanz-Muñoz C et al. Mondor’s disease. Clin Exp Dermatol 2009; 34: 753– 6 18 Horn AS, Pecora A, Chiesa JC et al. Penile thrombophlebitis as a presenting manifestation of pancreatic carcinoma. Am J Gastroenterol 1985; 80: 463– 5 19 Day S, Bingham JS. Mondor’s disease of the penis following a long-haul flight. Int J STD AIDS 2006; 16: 510–1 20 Guarneri C, Guarneri F. Mondor’s phlebitis after using tadalafil. Br J Dermatol 2007; 157: 209–10 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. © JOURNAL COMPILATION © 2010 THE AUTHORS 2010 BJU INTERNATIONAL