Minimally invasive accesses in surgery have developed rapidly over the past decade. Today, it is easier to name the organs and systems of the human body that are not yet examined by endoscopy.

The advantages of endovideosurgical technologies over open surgical procedures are well known and include minimization of surgical aggression, virtually eliminating the catabolic phase of the body's response to surgical trauma, and a significant improvement in visualization of the examined organs due to optical magnification and displaying the image on a monitor. These advantages have created convincing prerequisites for implementation of endovideosurgical access and endovideosurgical technologies in new anatomical areas - retroperitoneal surgery, extraperitoneal pelvic surgery, arthroscopic surgery, etc. From our point of view, all this fully applies to the scrotal cavity.

Recently, there have been reports on the use of scrotoscopy for the diagnosis and treatment of diseases of the scrotal organs [1-3]. One of the first reports emphasizes the high diagnostic significance of scrotoscopy and the possibility to perform biopsy with minimal traumatization [4].

In 2015, we developed a method of scrotal organ revision (patent RU 2568767 C2). However, this method is still far from being perfect and the search for its development is urgent.

The aim of the study is to reduce traumatism and increase the efficiency of diagnosis and treatment of patients with diseases of the scrotal organs by developing endovideosurgical intrascrotal access and introducing the method into clinical practice.

Material and methods

A Karl Storz (Germany) rigid endoscope with HOPKINS II optics, 4 mm in diameter, 13 cm in length, 30° optical axis angle and 80° viewing angle were used for intrascrotal video surgical interventions.

The choice of access for introducing an endoscope into the scrotal cavity was developed on anatomical preparations taking into account topographic and anatomical features of the scrotal organs.

The analysis showed that the optimal place of instrument insertion was near the testicular equator on the anterolateral surface in the nonvascular zone. This allowed good visualization of the testicular poles with the head and tail of the appendage, as well as revision of the posterolateral space behind the appendage.

To perform a high-quality endovideosurgical revision of the scrotal organs, it was necessary to form a cavity of sufficient volume. This problem was solved by creating an artificial hydrocele.

Endoscopic revision of the scrotal organs was performed as follows. Under intravenous general anesthesia, after preparing the surgical field, the scrotal skin above the middle segment of the testis on the anterolateral surface was grasped with two clamps, between which a needle with a 20 ml syringe filled with saline was inserted obliquely into the scrotal wall, The testicular vaginal cavity was punctured, then an artificial hydrocele was formed using physiological solution, after which a trocar was inserted into the created cavity, through which an optical instrument with a diameter of 4 mm and a 30° angle of optics, connected to an illuminator and a video complex monitor, was passed.

Sufficiently detailed panoramic examination of the scrotal organs was possible from a distance of 23 mm. We assessed the condition of the testis and its appendage, the nature and localization of the pathological process, identified the causes of testicular appendage obstruction (cystic fibrosis in the area of its head, the level of strangulation of the latter by adhesions, the localization and extent of spermiogranuloma in the appendage tissue, the level of prestenotic dilation in the appendage), severity of varicose changes in the appendicular vein, severity of testicular venous hyperemia, degree of deformation of appendage by seminal cyst (spermatoceles), assessed individual features of surgical geometry of scrotal organs and their landmarks, determined indications and technical possibility of performing necessary diagnostic or treatment steps using the obtained data.

After all stages of the intervention, fluid was removed from the scrotal cavity, and a single suture was applied to the puncture wound. The wound was treated with an antiseptic solution, and an aseptic dressing with suspension was applied for 1 day.

Results

The method of scrotal organ revision was introduced into clinical practice in two medical institutions after approval by the ethical committee.

18 endovideosurgical examinations of the scrotal organs before MicroTESE and 10 biopsies of testicular tissue under visual control were performed in 11 patients with azoospermia of different origin at the urology department of the West Siberian Center of FMBA of Russia.

In the children's urological department of the City Children's Clinical Hospital No.3 of the Omsk region, a 12-year-old child's hydatid was removed in an emergency procedure under artificial hydrocele with a good result in its torsion.

All patients gave voluntary informed written consent for scrotoscopy according to the developed method.

Discussion

Diseases of the scrotal organs are quite common. Some of them require surgical treatment. Currently, all operations on the scrotal organs are performed with open surgical access.

The traumatic nature of open surgical access to the scrotal organs is well known and is associated with postoperative lymphostasis of the scrotal organs and in some cases with the development of adhesive adhesions causing compression and deformation of the appendage, with the possible occurrence of obstructive infertility of the operated testis. To diagnose the obstructive forms of male infertility and to identify the level of obstruction of the seminal tracts it is often necessary to resort to scrotal revision. A transverse suprapubic incision connecting the exit openings of both inguinal canals and allowing the left and right sides of the testicle and its appendage to be inspected from the same access was used for bilateral revision. The entrance to the scrotum was widened along the course of the spermatic cord, and both testicles were removed from the scrotum into the surgical wound. Such accesses are quite traumatic, create a high risk of various complications, as well as technical difficulties when repeated intervention on the testis and appendage is required for sperm retrieval. Therefore, the development and use of minimally invasive methods of scrotal organ revision will significantly reduce the consequences of traditional surgical accesses.

Conclusion

The developed method of endoscopic revision of scrotal organs significantly reduced the trauma of this operation due to mini-invasive access, optical magnification of the endoscope and displaying the image on the monitor screen, improved visualization of organs and detection of tissue changes, facilitated targeted biopsy of testicular organs.

It should be noted that the developed method showed sufficient informativity and clinical efficacy. There were no complications during the manipulations.

The study was not sponsored.

The authors declare no conflicts of interest.