| Background and ObjectiveSpermatic cord is soft round cord-like structure from the deep inguinal ring to the top of a pair of testicles only for male.The internal spermatic vessels which travel in spermatic cord are important blood supply security and return path for testicular.Its nerves play a vital role in maintaining testicular function,position fixation and the protection.Diseases,such as varicocele,associated with spermatic cord have higher incidence in adult males.Recent years,with microsurgical techniques widely used in urology and andrology,the micro-structure anatomy of the spermatic cord becomes important objective basis and foundation on microscopic surgery.Clinical varicoceles are found to be present in approximately 15%of the male population and 13.7%～16.2%in adolescent population,in up to 35%of men with primary infertility and more than 80%of men with secondary infertility.Varicocele is closely related to male infertility.Varicocele is mainly treated by surgery.Since microsurgical varicocelectomy(MV)was firstly introduced on basis of conventional surgery in 1985,then was modified by Goldstein et al in 1992.Microsurgical varicocelectomy has been considered as the gold-standard technique for varicoceles due to its lower postoperative recurrence(0%-1.5%)and complication rates(hydrocele 0%-0.44%,orchiatrophy 1%),more effective protection for artery and vas deferens than conventional and laparoscopy surgery.For now,many studies have focused on the issues like the approach of operation,the number of vessels and lymphatic,operation time and its complications,but the micro-anatomy of sperm cord is rarely touched upon.Being inaccurate and confusing in its anatomical terminology,the sperm cord itself has been misunderstood in the areas of its compartments and content arrangement.Few literature reviews have dealt with the micro-surgical technique.Some views on surgical procedure are often controversial,for instance,the location of vas deferens and surgical approach.There are two approaches of microsurgical varicocelectomy:high inguinal microsurgical varicocelectomy(MHIV)and subinguinal microsurgical varicocelectomy(MSIV).Different scholars have different research results on anatomical structures of two approach.Some studies reveal that there are more internal spermatic veins(diameter<2mm)through subinguinal approach.Internal spermatic artery is firmly wrapped by complicated reticular veins in 95%subinguinal operations and in 30%inguinal operations.These data show it is more difficult to operate and increases the risk of injuring arteries through subinguinal approach by using microsurgical technique.However,other reports suggested that there is no significant difference on the number of internal and external spermatic veins and spermatic arteries between inguinal and subinguinal approach and argue that it can reduce the pain and shorten the recovery time after operation.So it will not increase the operation difficulty by selecting MSIV.All the previous data derived from observed on operation and the research results from America and Turkey is different,which implies the spermatic vessels and micro-anatomical structure may exist regional,ethnic differences.Therefore,the objective micro-anatomy research of spermatic cord tissue and structure can provide precise number of blood vessels,the exact relationship between blood vessels and fascia of the Chinese male populations,it will also provide a anatomic basis for the standardized varicocele ligation under the microscope.Intractable orchialgia is another disease associated with the spermatic cord,its intermittent or persistent testicular pain and discomfort seriously affect the patient’s daily life.Potential causes of intractable orchialgia include infection,tumors,inguinal hernia,hydrocele,spermatocele,varicocele,referred pain,trauma,surgery and so on.However,about 25%of patients with refractory orchialgia can not find a clear cause.Microscopic orchioneurectomy gradually been widely used in the treatment of patients with refractory orchialgia with unknown cause.The main purpose of this surgery is to ligate the testicular nerves,especially in the spermatic cord.Classical dissection methods,generally based on macroscopic observation,fail to reveal small internal organizational structure,especially that of adjacent links,and can not guide the corresponding operation procedure.In recent years,with the continuous development of computer hardware and software,computer-aided three-dimensional reconstruction techniques get the increasingly wide range of applications in the medical field,the most current applications of multi-dimensional reconstruction are often obtained two-dimensional images based imaging methods(including CT and MRI),these images are easy to obtain,when collected automatically locate and match,so easy to rebuild.However,these images can only reach a maximum level of millimeters,it is difficult to obtain finer micro structure information.A combination of continuous biopsy and computer-assisted anatomic dissection(CAAD)is often applied to overcome the limits of traditional anatomy by magnifying the microstructure and displaying a more objective entity through three-dimensional way.It is feasible to apply CAAD on microsurgical anatomy of the sperm cord.This study aims to discover the micro-structural anatomy of sperm cord with 3D representation of the adjacent relationships.Materials and methodsFor scientific purposes,and in following the authorized necropsy of China’s laws and regulations,we studied the sperm cord(including both left and right)of 13 normal male human cadavers at Southern Medical University.The exact causes of death were unknown,but macroscopic examination showed that the sperm cords and kidneys were free from obvious pathological changes and surgical intervention.All the sperm cords,from the internal ring to the epididymis,were dissected and put in a single block.Tissues were cut into transverse sections after formalin fixation,and each transverse section was divided into multiple blocks for embedding in paraffin.We then cut a series of 5-10um sections at intervals of 200-250um.Sections were stained by three methods,hematoxylin-eosin(HE)staining,silver staining,sirius red staining and immunohistochemical staining.All operations had been carried out by the classical staining procedure。Vessels were counted at inguinal and subinguinal levels.All fascias,arteries,veins,nerves were verified on histologic examination.The quantity of vessels in both right and left sperm cord were counted and statistics analysis.Statistical analysis was performed by SPSS 16.0.We manually operated all the reconstruction steps.Histologic sections were digitized by using stereo microscope(OLYMPUS SZ61-SET,Japan).Histologic images were reassembled with Photoshop software and realigned with a sequential representation.Vessels,fascia and nerve fibers were outlined manually and reconstructed in 3D by using Minics software.ResultsThe presence and location of spermatic fascias were reshaped by histological staining and three-dimensional reconstruction.Two thin and translucent sheaths were found to be respectively wrapping around the internal spermatic vessels,the vas deferens and accompanying vessels inside cremaster.This is different from our classic anatomy.The sheath wrapping around the internal spermatic vessels was defined as the internal spermatic fascia.The sheath wrapping around the vas deferens and accompanying vessels was named vas deferens fascia by this study.Two sheaths were closely cohered together with the two fascias and their contents parallelly running inside of external spermatic fascia and cremaster.In accordance with this knowledge,we can separate sperm cord into three part:external compartment including external spermatic fascias and cremaster,internal spermatic vessels surrounding by internal spermatic fascia,Vas deferens fascia and its contents are generally located at the posterior of internal spermatic fascia and internal spermatic vessels.We counted the vessels and nerve fibers at two level of left and right sperm cord:inguinal and subinguinal.The number of veins was 11.00±2.26(8-15)in left subinguinal,10.00±2.05(7-12)in right subinguinal,9.60±2.22(7-13)in left inguinal and 9.90±2.76(6-14)in right inguinal.There was no difference on the number of spermatic veins between subinguinal and inguinal,left and right.The number of spermatic arteries was 4.10±0.87 in left subinguinal,4.10±0.81 in right subinguinal,3.40±0.84 in left inguinal and 4.00±0.88 in right inguinal.There was no difference on the number of arteries between subinguinal and inguinal,right and left.We found a total of 29.2±6.1 nerves in the spermatic cord of 13 cadaver specimens.According to our demarcation,7.4±1.3 nerves were found in internal spermatic vessels,which mostly course along internal spermatic arteries.11.6±3.4 nerves were identified inside the vas deferens fascia.Nerve fibers are distributed widely in the spermatic cord,according to regional division we delineate above.Generally the distribution of most nerve fibers mainly concentrated around the vas deferens,spermatic artery,cremaster muscle bundles;minority nerve fibers are confirmed around Vas deferens artery and connective t issues which surround pampiniform plexus,a few nerve fibers can be found in adipose tissue,the distribution of nerve fiber bundle is not fixed at one point,but according to the above rules,random distribution in the region.These presentations of micro-anatomy structure provide an objective basis for development and improvement of micro-surgery in male reproductive and male function treatment.Conclusions1.Internal spermatic fascia and vas deferens fascia were found to be respectively wrapping around the internal spermatic vessels,the vas deferens with accompanying vessels inside cremaster.Vas deferens is not inside the internal spermatic fascia.2.There is no difference on the number of spermatic veins,arteries between subinguinal and inguinal,left and right.It will not increase the operation difficulty by selecting MSIV.3.the distribution of most nerve fibers mainly concentrated around the vas deferens,spermatic artery,cremaster muscle bundles;minority nerve fibers are confirmed around Vas deferens artery and connective t issues which surround pampiniform plexus,a few nerve fibers can be found in adipose tissue,the distribution of nerve fiber bundle is not fixed at one point,but random distribution in the region. |
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