A Superior Spermatic Cord Denervation Technique?: A Meta‐Analysis

INTRODUCTION: Chronic orchialgia is a common condition encompassing about 2.5%-5% of urology consults in the United States each year. When conservative treatments fail, spermatic cord denervation is often pursued after a diagnostic cord block. A standard total denervation (SD) of the spermatic cord has been considered the gold standard, targeting all nerves while preserving arteries. Recently, newer methods like targeted complex denervation (TD) and robotic-assisted denervation (RD) have emerged. OBJECTIVES: This study systematically evaluates whether these methods provide improved pain relief over the traditional approach. METHODS: A systematic review evaluating pain improvement in men with chronic orchialgia following SD, TD, and RD was conducted, PROSPERO database (Registration No.: CRD42024540544). A comprehensive literature search was performed using MEDLINE, EMBASE, Cochrane Library, Scopus, ClinicalTrials.gov, WHO ICTRP, Global Index Medicus, and Web of Science in May 2024. Articles were evaluated by two independent screeners. Data was analyzed and summarized using odds ratios (ORs) and confidence intervals (CIs) for complete (100%) or significant (> 50%) pain resolution, and continuous variables were compared using inverse-variance weighted means and corresponding 95% CI. Study quality was assessed using the Newcastle-Ottawa Scale (NOS). RESULTS: Twenty-three studies were included: 17 on SD, 5 on RD, and 4 on TD. SD was performed on 675 testicular units, RD on 947, and TD on 992. Complete pain resolution was found in 65.8%, 48.6%, and 51.4% of testicular units undergoing SD, TD, and RD, respectively. Significant (> 50%) pain resolution was experienced by 84.9%, 83.8%, and 83.3% of testicular units after SD, TD, and RD, respectively. SD had 1.86-fold higher odds of complete pain relief (OR: 1.86; 95% CI: 1.51-2.29; p < 0.001) and no difference in the odds of significant (> 50%) pain relief (OR: 0.94; 95% CI: 0.72-1.24; p = 0.68) compared to TD. SD had 1.68-fold higher odds of complete pain relief (OR: 1.68; 95% CI: 1.36-2.07; p < 0.001) and no difference in the odds of significant (> 50%) pain relief (OR: 0.98; 95% CI: 0.74-1.28; p = 0.86) when compared to RD. Average operative times were 71.50, 20.89, and 21.25 min per testicular unit for SD, TD, and RD, respectively. Complication rates were similar with 6.1%, 7.0%, and 7.6% for standard, targeted, and robotic approaches, respectively. Of all included and scored studies, 55% (12/22) were categorized as having a NOS score < 7. CONCLUSION: SD offers the highest odds of complete pain resolution, although all approaches have similar chances of achieving > 50% pain reduction. The ORs suggest that SD had higher odds of complete pain resolution, but the lack of well-designed comparative studies limits adequate comparison of efficacy.