First Vasectomy Procedure Successfully Performed on a Southern African Male Giraffe (Giraffa camelopardalis giraffa).

Vasectomy is by far the most reliable method of birth control. It is the contraceptive method of choice in 4–15% of couples in Thailand, Korea, Canada, the Netherlands and New Zealand.1,2 The increasing popularity of vasectomy as a method of birth control has also led to an increased demand for reversal. As a consequence, vasectomy is the second most common cause of infertility, the leading cause being ductal obstruction. In 1915, the first vasovasostomy was performed on a man requesting restoration of fertility after vasectomy. Since then, numerous procedures have been described that attempt to achieve restoration of sperm in the ejaculate of men who have undergone vasectomy. In this paper, surgical skills, surgical outcomes and potential predictors for treatment results of vasovasostomy are presented along with clinical experiences. In particular, treatment options when previous vasectomy reversal has failed in the era of intracytoplasmic sperm injection (ICSI) will be discussed. Light general or regional anesthesia (usually spinal anesthesia) is preferable, and surgery can be performed on an out-patient basis under local anesthesia with sedation. Currently, I usually perform microsurgical two-layer vasovasostomy under local anesthesia, if the patient is cooperative. Slight movements are greatly magnified by the operating microscope and can disturb the performance of the anastomosis. Therefore, pre-operative and intra-operative sedation is used for patients undergoing vasovasostomy with local anesthesia. Fentanyl is injected intravenously, with blood pressure and electrocardiogram monitoring. A mixture of equal parts of 1% plain lidocaine and 0.5% marcaine (for its long duration of action), without epinephrine, is used for the local anesthetic agents. The local anesthetic may be injected throughout the spermatic cord at the level of the pubic tubercle, or in the uppermost portion of the scrotum. It should be noted that there is a small risk of inadvertent injury to the testicular artery during local anesthesia and cord block.3 Bilateral high vertical scrotal incisions provide the most direct access to the obstructed site in cases of vasectomy reversal. These incisions should be high because the abdominal portion of the vas deferens is difficult to render tension-free, whereas the testicle can be easily moved upward, freeing any tension on the testicular portion of the vas deferens. Usually, the site of the previous vasectomy can be palpated and the ends of the vas simply externalized. If this cannot be performed easily, the scrotal contents can be extruded in an extravaginal fashion. Preferably, one should not enter the tunica vaginalis during this procedure because if an epididymovasostomy is required later, the dissection will be difficult. If the vasal gap is large or the vasectomy site is high, this incision can easily be extended inguinally towards the external ring. When the vasal gap is extremely large, additional length can be achieved by dissecting the entire convoluted vas deferens free of its attachments to the epididymal tunic, allowing the testis to drop upside down. These maneuvers can provide an additional 4–6 cm of length. In order to maintain the integrity of the vasal vessels, this dissection is best performed using magnifying loupes or the operation microscope.4 In men with suspected obstruction of the inguinal vas deferens from prior herniorrhaphy or orchiopexy, an inguinal incision is the preferred approach. The vas deferens is grasped above and below the site of obstruction with two Allis clamps. Although there is a rich network of vessels on the outer vas deferens, care must be taken with the bipolar cautery to avoid excessive cauterization or stripping. The bipolar coagulation causes less tissue damage, can be used under irrigation, and causes only minimal coagulation of the parent blood vessels. The vas deferens is mobilized enough to allow a tension-free anastomosis including the vasal vessels and periadventitial sheath. After the vas deferentia have been freed, the testicular end of each vas deferens is transected with a microsurgical knife or a razor blade, with a piece of a wooden tongue blade placed beneath the vas deferentia for countertraction. The cut surface of the testicular end of the vas deferens is inspected using magnification. A healthy white mucosal ring that springs back immediately after gentle dilation should be seen. The muscularis should be smooth and soft, not gritty. If the blood supply is poor or the muscularis is gritty, the vas deferens should be recut until healthy tissue is found. The vasal artery and vein should then be clamped and ligated.4 Once a patent lumen has been established on the testicular end, the vas deferens is milked and a clean glass slide is touched to its surface. Gentle insertion of 24-guage angiocatheter sheath may be helpful in achieving capillary action. The vas deferens fluid is immediately mixed with a drop of saline and preserved under a coverslip for microscopic examination. As sperm have a reactive effect on the surrounding tissue, the field should be continuously irrigated. Microscopic examination of the vas deferens fluid for sperm from the testicular end is particularly important. The possibility of an epididymal blowout and secondary obstruction must be considered in patients with a long-term occlusion, whenever there is little or no fluid or thick, pasty fluid devoid of sperm. Although there is no hard and fast rule for every instance, it is appropriate for the surgeon dealing with a long-term obstruction to be prepared and capable of performing the more surgically demanding epididymovasostomy.5 The abdominal end of the vas deferens is prepared in a similar manner. Upon transecting the abdominal end of the vas deferens, it is examined and dilated gently with a microvessel dilator. Patency of the distal vas may be tested with a 2-0 nylon suture passed upon the lumen, or by injection of 2–3 mL of saline with a 24-guage angiocatheter sheath. Prior to the 1970s, vasovasostomy was done either without magnification or with magnification of 2–8 times normal size using ocular loupes. With minimal magnification, precise placement of the mucosal suture is not possible. Without precise mucosal observation, mucosal alignment may not be achieved and anastomotic stricture is more likely to occur. In general, the results of non-magnified and loupe-magnified vasovasostomy are about 10–15% inferior to the results obtained with microsurgical techniques. Because of the superior results, most practitioners of vasovasostomy use the operating microscope with either a modified one-layer or two-layer anastomosis. Both of these methods have proved to be equally effective with regard to patency and later pregnancy.6 Modified one-layer anastomosis is ideal when the vasovasostomy is performed in the straight portion of the vas deferens and the discrepancy in lumen size is minimal. On the other hand, the two-layer technique offers great precision in observation of the lumen at each end of the vas deferens, particularly when there is a significant discrepancy in size or when performing the anastomosis at the level of the convoluted vas deferens, where there is less muscle surrounding the lumen and the lumen may be offset. I routinely perform the two-layer anastomotic technique in all vasovasostomy cases. In my opinion, specialized microsurgeons dealing with male infertility should perform two-layer anastomosis to develop and maintain the microsurgical skills required to perform epididymovasostomy, which is still a difficult procedure requiring considerable microsurgical skill. Between 1987 and 1998 (11 years), I have performed 997 vasectomy reversals using microscopic two-layer vasovasostomy. When a decision has been made to perform a vasovasostomy, the distal lumen may be gently dilated with the tips of a microvessel dilator. I always perform the whole procedure sitting on the patient’s left side. From this position, the proximal lumen leading to the testicle is to the left. In my opinion, anastomosis can be facilitated from this position due to the dilated lumen of the proximal end of the vas deferens. Most surgeons use the vas deferens approximating clamps (V Mueller, ASSI and Edward Weck & Co., USA). These clamps prevent movement of the ends of the vas deferens through the clamp. Some surgeons have modified the approximating clamps for more convenience.7,8 A sterile piece of blue plastic material may be cut from a surgical drape or any other inexpensive material and placed under the two ends of the vas deferens. This provides an excellent background for observation, and puncturing this sheet with a fine needle at multiple sites allows the blood and irrigating fluid to drain, thus maintaining a clear surgical field.5 Previously, I developed a new blue plastic plate from an easily available plastic sheet. The ends of the vas deferens are fastened to the plate with two sutures through four punctures which have been made in the plate. The plate and the sutures prevent movement of the ends of the vas deferens, facilitate the approximation of the vas deferens and provide a good surgical background. The initial suture is placed through the mucosa at the zero-degree position with 10-0 nylon. A second suture is placed, tied and cut at the 180-degree position. The properly placed mucosal layer suture includes both the mucosa and approximately the inner fourth of the muscular layer. ‘Through stitches’ that catch the mucosa of the opposite side of the vas deferens must be avoided. Goldstein uses a double-armed fishhook-shaped needle.4 The double-armed sutures allow inside-out placement, eliminating the need for manipulation or dilation of the mucosa and the possibility of back-walling. I use the single-armed needle and tie and cut the 10-0 nylon immediately after suturing. ‘Dog ears’ of the mucosal edges are easily prevented by accurate spacing of the mucosal sutures. Recently, Goldstein et al. described a ‘microdot’ technique that uses an extra fine tip skin marker to map the location of placement of eight mucosal sutures.9 After completion of mucosal sutures on one half side of the lumen, muscular sutures are started with 9-0 nylon at 30-degrees and ended at 150-degrees. This maneuver is helpful in order that the mucosal sutures are not disturbed on the opposite side. Then the vas deferens is rotated 180-degrees and two or three additional mucosal sutures are placed and tied. After completion of the mucosal layer, more muscular sutures are placed. I generally use six to eight mucosal and nine to eleven muscular sutures, depending on size. The anastomosis is finished by approximation of vasal sheath with 9-0 nylon sutures. 1. Accurate mucosa to mucosa approximation. 2. Leakproof anastomosis. 3. Tension-free anastomosis. 4. Good blood supply. 5. Healthy mucosa and muscularis. 6. Good atraumatic anastomotic technique. Vasovasostomy performed in the convoluted portion of the vas deferens is technically more demanding than anastomosis in the straight portion. The risk of cutting back into the convoluted vas deferens in order to obtain healthy tissues may cause surgeons to complete an anastomosis in the straight portion when the testicular end of the vas deferens has poor blood supply, unhealthy or friable mucosa, or gritty fibrotic muscularis. Adherence to the following principles can facilitate anastomosis in the convoluted vas deferens to succeed equally as often as those in the straight portion. 1. A perfect transverse cut yielding a round ring of mucosa and a lumen directed straight down is essential. 2. The convoluted vas deferens should not be unraveled. 3. The sheath of the convoluted vas deferens may be carefully dissected free of its attachments to the epididymal tunic. 4. Care must be taken to avoid taking large pieces of the muscularis and adventitial layers on the convoluted side in order to prevent inadvertent perforation of the adjacent convolutions. 5. Reinforce the anastomosis by approximating the vasal sheath of the straight portion of the vas deferens to the sheath of the convoluted portion to remove all tension from the anastomosis. As previously mentioned, the results of non-magnified and loupe-magnified vasovasostomy are about 10–15% less effective than the results obtained with microsurgical techniques. Because of the superior results, most practitioners of vasovasostomy use the operating microscope either using a modified one-layer or two-layer anastomosis. Both of these methods have proved to be equally effective with regard to patency and later pregnancy.6 A summary of a microsurgical vasovasostomy series, which included a relatively large number of subjects, is presented in Table 1. Overall, microsurgical vasectomy reversal has proved to be a highly successful procedure with a patency rate of approximately 90% and a subsequent pregnancy rate of approximately 50%. In my early clinical experience of 97 subjects,12 the anatomical success rate of the two-layer microscopic vasovasostomy was 90.7% and the subsequent pregnancy rate was 67%, superior rates in comparison to the 89% and 50%, respectively, of the one-layer microscopic vasovasostomy previously done at my institute.2 Several factors may influence the outcome of the vasovasostomy. The pregnancy rate after vasectomy reversal is inversely related to the duration of the obstruction interval. It had been reported that men with obstruction intervals of 5 years or less had a better chance for fertility than those with obstruction intervals of 6–10 years, and those with intervals of 10 years or more had a very poor chance of fertility after vasectomy reversal.13 The Vasovasostomy Study Group (VSG)6 reported that there were specific time intervals for postoperative rates of patency and pregnancy, according to the obstruction intervals (< 3, 3–8 years, 9–14, ≥ 15 years). Although a sperm granuloma at the vasectomy site is associated with better sperm quality in the intra-operative vas deferens fluid, the VSG found that a sperm granuloma was not associated with better surgical outcomes.6 The presence of sperm in the vas deferens fluid during a vasovasostomy is also known to have a significant prognostic value. Silber’s grading system of sperm quality in the vas deferens fluid is useful prognostically.14 Data from The VSG reveal that the sperm content of the vas deferens fluid cannot be judged by the fluid’s gross appearance. 15 If no sperm are present in the vas deferens fluid, the cause could be back-pressure induced sperm granuloma in the epididymis,16 in which case epididymovasostomy is recommended. The VSG reported that if sperm are absent from the vas deferens fluid during planned vasovasostomy, the absence is related to the obstruction interval.17 Later, the VSG also examined the relationship between bilateral vas deferens fluid sperm absence during bilateral vasovasostomy and the result of vasovasostomy.6 Of 1247 patients undergoing vasovasostomy, only 84 had no sperm in the vas deferentia fluid on either side and had fluid of identical appearance on both sides. Of 73 patients available for follow-up, 41 (56%) either had sperm in the semen or were able to achieve a pregnancy in their partner, postoperatively. This suggested that when sperm are absent from the vas deferens fluid, the thicker the appearance of the fluid, the less likely it is that sperm will be present in the semen following a vasovasostomy, and the more likely it is that the surgeon must consider epididymovasostomy. Sharlip performed an interesting analysis of the best pregnancy rate that may be expected after a vasectomy reversal.18 Of the 95 patients who consistently had a postoperative sperm concentration of 20 million per mL or more and sperm motility of 50% or more, 58 (61%) achieved a pregnancy. Allowing for later pregnancies after the study was completed, he concluded that the maximum pregnancy probability after vasectomy reversal is 67%. Despite the excellent results of vasectomy reversal with the advent of microsurgical reconstruction, those patients whose vasectomy reversals fail to achieve patency and pregnancy are faced with the need to choose from available treatment options such as repeat vasal reconstruction. With increasing numbers of men undergoing vasectomy reversal procedures, it is important for the surgeon to be prepared to properly advise patients about the management of a failed procedure. It has been generally accepted that repeat microscopic reconstruction is worthwhile in failed vasectomy reversal cases.19,20 However, the choice between a vasovasostomy and an epididymovasostomy is still controversial, but the latter may be required when sperm are absent from the intra-operative vas deferens fluid at the testicular end of the vas deferens. In cases of repeat microsurgical vasectomy reversal, most surgeons perform an epididymovasostomy if no sperm are found after microscopic analysis of the testicular end of the vas deferens.21,22 However, I think that an obstruction at the previous anastomosis site is the cause of failed vasectomy reversal in most cases. The surgical situations in the failed vasectomy reversal cases are probably similar to those in initial vasectomy cases, except for the fact that previous vasectomy reversal has been performed. Therefore, I have repeated a vasovasostomy using microsurgical two-layer anastomosis if surgically possible, regardless of the presence of sperm in the intra-operative vas deferens fluid.23 Between 1992 and 1998, 459 patients underwent microsurgical vasectomy reversal in this series, and 70 (15.3%) were identified with previous failure of one or more attempts at vasectomy reversal. Patency and pregnancy follow-up data were available in 62 and 42 patients, respectively. In our study of 62 cases, which underwent microsurgical vasovasostomy at least on one side, the overall patency and pregnancy rate proved to be 91.9% and 57.1%, respectively. Increase in partner’s age was a negative prognostic factor for pregnancy (P = 0.018). Other factors, including intra-operative detection of sperm, obstruction interval, type of reconstruction, site of anastomosis, age of patient and postoperative semen parameters, did not influence the surgical outcome. There are limited numbers of reports about the surgical outcome of repeat vasectomy reversal. A summary of the surgical outcome of a repeat vasectomy reversal series and an analysis of the results according to reconstruction type are shown in Table 2. The overall mean patency and pregnancy rates after repeat vasectomy reversals are 73.8% (range, 63.6–79%) and 41.3% (range, 26.6–44.4%), respectively. The patency and pregnancy rates after repeated vasectomy reversals seemed to be lower than those after a first reversal. In our study of 62 patients, who underwent (repeated) microsurgical vasovasostomy on minimal one side, the overall patency and pregnancy rate was 91.9% and 57.1%, respectively. The difference in surgical method may have brought about these superior results in this study. A surgeon’s choice between a vasovasostomy or an epididymovasostomy is based on the presence or absence of sperm in the intravasal fluid during the operation. Consequently, most surgeons perform epididymovasostomy in order to bypass an epididymal obstruction.6,20–22 However, the principle of this surgical decision is based on limited knowledge, according to Silber.16 In Silber’s study, microscopic epididymal exploration was performed in men undergoing vasectomy reversal who were found to have no sperm in the proximal vas deferens fluid. From these examinations, he concluded that persistent azoospermia after an accurate microscopic vasovasostomy resulted from the secondary epididymal obstruction induced by rupture of the epididymal duct, due to the pressure increase after the vasectomy. Previous series of repeat vasectomy reversals have shown results that include elevated epididymovasostomy rates, which occurred in from 33 to 73% of total reconstructions (Table 2). However, only 4% of procedures performed at the initial vasectomy reversal were epididymovasostomies. In the current series, sperm were observed bilaterally in 23 out of 62 cases (37.1%). Therefore, epididymovasostomy should be required in 62.9% of our cases according to the aforementioned surgical principle. However, microsurgical two-layer vasovasostomy was attempted in all failed vasovasostomy cases if surgically possible, regardless of the findings in the intravasal fluid. Epididymovasostomy combined with contralateral vasovasostomy was required in only two cases. The reason for performing epididymovasostomy was not the absence of sperm in the vasal fluid, but due to the difficulty in tension-free vasovasostomy. An inability to find sperm in the intra-operative vas deferens fluid does not necessarily indicate the presence of epididymal obstruction, and that it is therefore not mandatory to perform epididymovasostomy in such situations. It is unlikely that so much epididymal blowout has occurred after initial vasectomy reversals. Factors other than epididymal obstruction must play a role in causing the intra-operative absence of sperm in the vasal fluid, for example, reversible abnormalities of sperm transport mechanisms and/or epididymal anatomy and functions. Sharlip reported that vasovasostomy in ten cases with bilateral intra-operative sperm absence resulted in recovery of normal sperm counts in six patients and subsequent pregnancy in five of the patient’s partners.24 The VSG also examined the relationship between bilateral vas deferens fluid sperm absence during bilateral vasovasostomy and the result of vasovasostomy.6 Despite the absence of sperm in the intravasal fluid, 60.2% (50 / 83) of these men had sperm in the postoperative ejaculate and 30.8% (20 / 65) achieved pregnancy. In my series, 29 out of 62 (46.8%) men showed a bilateral absence of sperm in the intravasal fluid during the operation. The rate of patency and pregnancy in these patients was 86.2% (25 / 29) and 55.0% (11 / 20). This result suggests that there is no difference in surgical outcome according to the presence of sperm in the intravasal fluid. Although there is a possibility of a false-negative reading of vas deferens fluid all of these results that the absence of sperm in the vasal fluid is not always an that an epididymovasostomy is In our series, five cases showed persistent azoospermia the initial follow-up semen of these patients were cases with bilateral absence of sperm in the intra-operative vas deferens fluid. In these four cases, epididymal obstruction is likely to be the cause of intravasal azoospermia during the and reported that the 23 patients who had a vasectomy reversal that failed to their there was a secondary epididymal obstruction in only four cases The of secondary epididymal obstruction be much less than was previously The results of our study When failed the ends are found to be The cause of this is likely to be due to anastomotic tension during the first procedure. of a length of the testicular end and the abdominal end of the vas deferens, that successful can be performed without when long of the vas deferens are during the previous procedure. our vasovasostomy cases, the anastomotic sites were on the convoluted vas deferens in cases Although a anastomosis has been reported to results similar to that of a two-layer anastomosis accurate has been out under microscopic a two-layer anastomosis is likely to achieve a more approximation without or possibility of as out by The two-layer anastomosis can be performed as in the convoluted as the straight parts of the vas deferens, and this is important in failed vasectomy reversal cases. If azoospermia is due to epididymal epididymovasostomy must be obstruction of the is very difficult to advise that the following factors enter into the decision to perform vasovasostomy or epididymovasostomy when sperm are absent from the vas deferens fluid at the time of vasectomy time from vasectomy until its available vas deferens gross appearance of vas deferens of the for of and the surgeon’s to perform an epididymovasostomy. are to for epididymovasostomy in repeat vasectomy reversal cases. Because are more common at repeat vasectomy reversal than initial vasectomy reversal, the lower patency and pregnancy rates observed for repeat vasectomy reversal probably an increased epididymovasostomy vasovasostomy on at least one side has led to a towards who underwent vasovasostomy on at least one side had patency and pregnancy rates of and respectively, whereas those undergoing epididymovasostomy had rates of and (Table 2). Since the of the microsurgical anastomosis technique by in the success rate of epididymovasostomy has However, epididymovasostomy is still a difficult procedure requiring considerable microsurgical and the fertility outcomes are not The of intracytoplasmic sperm injection (ICSI) has the management of male Because of the of it is to this treatment to all cases of male is a treatment for failed vasectomy reversals. However, the rate following is about reports from This is not a outcome with the results expected from a series of repeat vasectomy reversals performed by when one the additional and the possibility of repeated surgery in order to obtain sperm from microscopic epididymal sperm or testicular sperm it has been shown that these cannot repeat vasectomy reversal in the management of failed vasectomy reversal et al. the of repeat vasectomy reversal to that for combined and that the per by was times the per obtained through repeat vasectomy In to the of there are about a to the of techniques. In cases of failed vasectomy reversal, there is a specific and successful for the man that does not the to these pregnancy by is more likely after repeat vasectomy reversal. sperm injection in is still and there is a need to and results for these As sperm are by the is using In this era of by the role of repeat vasectomy reversal is important. In cases of failed vasectomy reversal, and should not to repeat vasectomy reversal of a sperm procedure combined with

Chemical immobilization is a key aspect of wildlife management. To minimize dose-dependent adverse effects, immobilization protocols often include two or more synergistic agents, which allows for reductions in individual drug dosages. Free-ranging bighorn sheep ( Ovis canadensis) in Canada ( n = 74) were remotely injected with a combination of medetomidine (0.16 ± 0.04 mg/kg) and ketamine (4.0 ± 1.4 mg/kg) (MK), or combination of medetomidine (0.14 ± 0.06 mg/kg), azaperone (0.21 ± 0.11 mg/kg), and alfaxalone (0.45 ± 0.21 mg/kg) (MAA). Once recumbency was achieved, arterial blood samples were collected and immediately analyzed for blood gas and acid-base status. Rectal temperature, heart rate, and respiratory rate were recorded upon recumbency and throughout anesthesia at 5-15 min intervals. At conclusion of the procedures, medetomidine was reversed by intramuscular atipamezole at five times the medetomidine dose. Induction times (mean ± standard deviation) of animals that became immobilized with one dart (8.7 ± 3.2 min, 7.3 ± 3.9 min) and recovery times of all animals (3.4 ± 1.5 min, 3.9 ± 1.6 min) were not significantly different between MK and MAA groups, respectively. Both MK and MAA groups experienced severe hypoxemia (PaO2 42 ± 9 mmHg, 40 ± 10 mmHg, respectively). PaCO2 was significantly higher ( P = 0.0248) in the MK group (median 54 mmHg) than the MAA group (median 48 mmHg) with a trend towards lower pH (7.40 vs 7.42, respectively, P = 0.07). Initially, MK animals had higher heart rates than MAA animals (median 49 vs 40 beats/min), which decreased over time. In bighorn sheep, both MK and MAA produced reliable, reversible immobilization with smooth inductions and recoveries. However, less respiratory depression was seen with MAA than MK.

Thiafentanil oxalate, previously known as A-3080, is a synthetic opioid used for chemical immobilization of a variety of nondomestic hoofstock species. This study compared the combination of thiafentanil oxalate, medetomidine, and ketamine (TMK; 0.09 +/- 0.02 mg/kg, 0.01 +/- 0.003 mg/kg, and 1.36 +/- 0.33 mg/kg, respectively) with the combination of medetomidine and ketamine (MK; 0.09 +/- 0.02 mg/kg and 3.48 +/- 0.55 mg/kg, respectively) for anesthetization of 17 captive male axis deer (Axis axis) for vasectomy. Nine deer received TMK and eight deer received MK via projectile syringe during the months of January and February, 2005. Mean induction and arousal times, vital signs, and arterial blood gas values were monitored and compared. All animals received supplemental oxygen during the surgical procedure. Animals receiving TMK were reversed with naltrexone (100 mg/mg thiafentanil) and atipamazole (5 mg/mg medetomidine). Animals receiving MK were reversed with atipamazole (5 mg/mg medetomidine). Two MK animals and three TMK animals required supplementation with ketamine i.v. immediately upon handling. Six of the nine animals immobilized with TMK required intubation for positive-pressure ventilation. Two of these six animals also required isoflurane to maintain anesthesia. Mean induction time was 3.5 +/- 2.0 min in the TMK group, and 9.8 +/- 6.7 min in the MK group. Despite shorter mean induction times, animals anesthetized with TMK experienced unpredictable inductions, apnea, muscle rigidity, limb movement, and significant respiratory and metabolic lactic acidosis. MK resulted in smoother inductions, better respiratory function, and less adverse metabolic disturbances, and thus was considered superior to TMK for anesthesia in captive axis deer at the dosages tested.

Effects of streptozotocin-induced diabetes and insulin on calcium responsiveness of the rat vas deferens

Dear Editor: In the article ‘‘Long-term follow-up after Lichtenstein hernioplasty in a general surgical unit’’ Verstraete and Swannet noted a fairly high level of chronic and occasional discomfort in patients following Lichtenstein hernia repairs. They suggested that further studies to prevent or cure chronic pain and occasional discomfort following a Lichtenstein hernioplasty are necessary, since the frequency of these complications is higher than the prevalence of recurrence. They went on to propose a theory that the origin of the chronic pain in their patients could be attributed to central neuroplasticity. They also stated that the dysjaculation that they observed in their patients could not be due to obstruction of the sperm core due to foreign-body reaction, since their patients were not sterile after the operation. Before attributing chronic and intermittent postoperative pain to central nervous system dysfunction, we should consider some simple facts and the craftsmanship that a surgeon should display. Dr. Robert Bendavid has shown us that dysejaculation pain is caused by kinking of the vas deferens. We also know that having one patient vas deferens is certainly sufficient to father a child. The physicians at the Shouldice Hospital have always stressed division of the genital branch of the genitofemoral nerve to prevent the development of chronic postoperative pain. The Lichtenstein hernia repair, as it is usually done, places mesh directly on top of this nerve. The vas deferens is frequently lying on top of the mesh. Whether mesh is used in an opened hernia repair or not, division of the genital branch of the genitofemoral nerve is an important aspect of opened inguinal hernia repairs which is often overlooked. In my own practice, I have frequently operated (using local anesthesia) on patients referred to me for chronic inguinal pain after hernia repair only to find the genital branch of the genitofemoral nerve involved in scarring wither from direct suturing or from mesh being placed on top of the nerve. It should be emphasized (especially at a teaching institution) that hernia repairs should be performed using local anesthesia. It is widely felt that hernia repairs done under local anesthesia have a much lower rate of chronic pain. This is understandable, since patients complain when a nerve whose presence is not appreciated by the surgeon is inadvertently incorporated into a repair. The surgeon can then adjust the placement of his suture, thus, saving the patient postoperative discomfort. Those who teach hernia repair should stress the pertinent anatomy of the groin and a meticulous technique using local anesthesia and including division of the genital branch of the genitofemoral nerve. In addition, transposition of the spermatic cord above the aponeurosis of the external oblique muscle (as Dr. E. Trabucco has suggested) would prevent adherence of the vas deferens and the spermatic vessels to any mesh placed on the floor of Hesselbach’s triangle.

Report on evaluation of the azoospermic male

Introduction The Sealed Vasectomy Procedure (SVP) is a new bipolar radiofrequency sealing tool for transdermal vasectomy in hopes of making the procedure a faster, simpler, and safer office procedure. Initial human results indicated a good safety and efficacy profile. Here we present our final data from the initial human trial. Objective Evaluate the safety and effectiveness of the SVP in a successful vasectomy. Methods After FDA and IRB approval, 8 male patients were enrolled in the trial, as per FDA mandate. Pre-procedure semen analysis was performed to ensure sperm present for each participant. Each then underwent office-based, minimally invasive vasectomy using Signati Separo device, with treatment occurring outside of the scrotum/skin. They were then followed for 6 months post-procedure to collect safety and efficacy data. Subjects only provided a 6 month post-vasectomy semen analysis (PVSA) if the 3 month was not either negative or rare non-motile sperm. Results All 8 patients have undergone sealed vasectomy procedure with either zero sperm or &amp;lt;100, 000 non-motile sperm seen on PVSA. Mean procedure time was 18 minutes 44 seconds while mean sealing time was 3.57 seconds per vas deferens. All patients had sealing and separation of each vas deferens as confirmed by the treating provider. Only one 30 day pain score was greater than zero (1). No patient experienced an adverse event. All 8 patients had a pathology confirmed result of either complete transection (1/8) or obliterated lumen (7/8) of the vas deferens. Conclusions After the first human study, Signati sealed vasectomy procedure appears to be safe and effective in performing vasectomies in humans. Disclosure Yes, this is sponsored by industry/sponsor: Signati Medical Clarification: Industry funding only - investigator initiated and executed study Any of the authors act as a consultant, employee or shareholder of an industry for: Signati Medical

The endocannabinoid system plays important roles in various systems, including the genitourinary system; however, its mechanism of action is not fully understood. This study aimed to investigate the direct relaxant effects of anandamide and its possible mechanisms in isolated rat bladder and vas deferens tissues. Twenty-one adult male Wistar albino rats were used. Bladder and vas deferens (prostatic and epididymal portions) tissues were mounted in 10 mL of organ baths. Relaxation responses to anandamide were recorded at 3 and 10 μM concentrations. After the rest period, the procedures were repeated in the presence of cannabinoid (CB) and vanilloid receptor antagonists, various potassium channel blockers, cyclo-oxygenase, and nitric oxide synthase inhibitors. In different tissues to investigate the Ca2+-channel antagonistic effect of anandamide, concentration-response curves to CaCl2 were obtained in the absence and presence of anandamide. Anandamide caused a significant relaxation response in the bladder and epididymal vas deferens tissues, but not in the prostatic portion. The effect of anandamide was antagonized in the presence of the CB1 antagonist AM251 or the non-selective potassium channel blocker tetraethylammonium in bladder tissue. In the epididymal vas deferens, anandamide significantly inhibited the calcium contraction responses, especially at high concentrations. The CB2 antagonist AM630 reversed this inhibition. The results show that anandamide has a direct relaxant effect on the isolated rat bladder and epididymal vas deferens. Anandamide triggers different mechanisms in different types of tissues, and further studies are needed to elucidate the mechanism of action of anandamide.

Vasectomy and Vasovasostomy

Introduction The Sealed Vasectomy Procedure (SVP) is a new bipolar radiofrequency sealing tool for transdermal vasectomy in hopes of making the procedure a faster, simpler, and safer office procedure. Testing has been successful in rabbits with excellent wound healing, complete vas occlusion on histology, and no sperm in post procedural semen analysis. Further studies in larger animals were then done in canine, porcine and human vas deferens that showed good sealing of the vas deferens. FDA-approval are needed before its application in humans. The next step in FDA approval process is a FDA prescribed Good Laboratory Practices (GLP) animal study. Objective Evaluate the effectiveness of the SVP in sealing the vas deferens in rabbit, canine, porcine and in humans. Now presenting the FDA prescribed GLP study. Methods Rabbit studies have been previously described including AUA22 best video award. We preformed microscopic evaluation of the vas deferens tissues from canines treated with the SVP at either 40 or 60 watts, euthanized at 14 days post-treatment under the conditions of this study. Human vas deferens specimens after removal from the patient were then immediately treated with SVP tool on benchtop. Porcine vas deferens samples were procured and underwent benchtop testing. The GLP study was done at Charles River in Kalamazoo, Michigan. The GLP study was on 6 canines: 3 with the outside the skin method and 3 canines with the transdermal method. All were terminal after a period of healing of up to 28 days. Results 9 canine, 6 human, and 20 porcine vas deferens were included in SVP testing. Human, porcine, and canine specimens demonstrated tissue coagulation and fibrosis in the treated vasa deferentia by Pathology. (See Figure 1 Human and 2 Canine) For the FDA GLP prescribed study, all 6 dogs survived and were euthanized at 28 days post-treatment. Pathology for the GLP study was done by Charles River. Conclusions SVP is a potentially exciting novel vasectomy procedure that appears to provide good sealing of the vas deferens in the rabbit &amp; canine animal model and on benchtop for the human &amp; porcine vas deferens. The FDA GLP study is done and awaits FDA submission. FDA-approval is still needed before use in humans. Disclosure Yes, this is sponsored by industry/sponsor: Signati. Clarification: Industry initiated, executed and funded study. Any of the authors act as a consultant, employee or shareholder of an industry for: Signati.

Background: Hesperidin is a naturally occurring Bioflavonoid found in citrus fruits. It has anti-inflammatory, antioxidant, antihypertensive, antimicrobial, anti-carcinogenic and vasodilator activities. Hesperidin’s effect on normal behavioral is not clear. Hence the present study is aimed to elucidate the effects of hesperidin on behavioral and biochemical markers of liver and kidney function in Sprague Dawley (SD) rats. Method: Healthy, adult, male SD rats were used for the study. Animals were divided into 5 groups (n = 6) viz., Group I: Control, Group II: Vitamin C(200mg/kg), Group III: Hesperidin (25mg/kg), Group IV: Hesperidin (50mg/kg) and GroupV: Hesperidin (100mg/kg). The standard and test drugs were suspended in 0.5% w/v carboxymethyl cellulose and administered once daily through oral gavage for 28 consecutive days. Throughout the study changes in behavioral functions (locomotor activity, muscular strength, learning and memory) and body weight were monitored at regular intervals. Blood samples were collected from all the experimental rats and used for biochemical parameters analysis. Results: Vitamin C and hesperidin did not show any significant alterations in locomotion, grip strength, muscular strength and spatial memory when compared with normal control. Both vitamin C and hesperidin improved the normal anxiety behavior without affecting regular body weight gain and biochemical markers of liver and kidney function. Conclusion: The experimental rats administered with hesperidin at the dose levels of 25, 50and100 mg/kg did not show any changes in psychomotor behavior and significantly improved their alertness without affecting the biochemical markers of liver and kidney function.

MP01-12 HISTOLOGY APPEARS TO REVEAL GOOD SEALING OF THE HUMAN, PORCINE AND DOG VASECTOMY SPECIMENS USING THE VASECTOMY SEALING PROCEDURE

Introduction The Sealed Vasectomy Procedure (SVP) is a new bipolar radiofrequency sealing tool for transdermal vasectomy in hopes of making the procedure a faster, simpler, and safer office procedure. Testing has been successful in rabbits with excellent wound healing, complete vas occlusion on histology, and no sperm in post-procedural semen analysis. The study data was presented last year as a video submission and subsequently won the AUA 2022’s “Best Video” of the andrology / infertility / sexual dysfunction session. Further studies in larger animals were indicated and FDA approval is needed before its application in humans. The issue of “does the SVP effectively seal the vas deferens in animals larger than a rabbit and in humans?” is a critical one for treating physicians. Objective Evaluate the effectiveness of the SVP in sealing the vas deferens in animals larger than a rabbit and in humans. Methods Animal (rabbit) studies have been previously described. We performed microscopic evaluation of the vas deferens tissues from canines treated with the SVP at either 40 or 60 watts, euthanized at 14 days post-treatment under the conditions of this study. Human vas deferens specimens after removal from the patient were then immediately treated with SVP tool on benchtop. Porcine vas deferens samples were procured and underwent benchtop testing. Specimens were sent for pathologic evaluation by a third-party professional vendor [Crisp County Regional Medical Center in Cordele, Georgia]. Results 4 canine, 6 human, and 26 porcine vas deferens were included in SVP testing. Human, porcine, and canine specimens demonstrated tissue coagulation and fibrosis in the treated vasa deferentia. (See Figure 1 Human and 2 Canine) Conclusions SVP is a potentially exciting novel vasectomy procedure that appears to provide good sealing of the vas deferens in the canine animal model and on benchtop for the human and porcine vas deferens. FDA approval is still needed before use in humans. Disclosure Yes, this is sponsored by industry/sponsor: Signati Medical Clarification Industry initiated, executed and funded study Any of the authors act as a consultant, employee or shareholder of an industry for: Signati Medical.

Infliximab prevents dysfunction of the vas deferens by suppressing inflammation and oxidative stress in rats with chronic stress

Objective To investigate the diagnostic and therapeutic strategies of congenital absence of the vas deferens (CAVD) and the cystic fibrosis transmembrane conductance regulator (CFTR) mutations in the Chinese Han patients. Methods Forty-one cases of CAVD were recruited and analyzed. Genomic DNA from 21 patients’ blood samples was extracted. 5T and F508 alleles polymophyism were detected by polymerase chain reaction (PCR), and the PCR products were sequenced. Results Twenty cases of CAVD were congenital bilateral absence of the vas deferens (CBAVD), while 14 were congenital bilateral partial aplasia of the vas deferens (CPAVD) and 7 were congenital bilateral partial aplasia of the vas deferens (CUAVD). Forty patients obtained sperm by epididymal fluid, testicular biopsy or M-TESE, while 1 failed in sperm extraction was diagnosed as spermatogenic maturation arrest by testicular biopsy. Four CUAVD patients who had strong demand of natural pregnancy underwent micro-vasoepididymostomy (VE) or transseptal crossover VE treatments, all of which found no sperm after 1-6 months follow-up. Twelve cases were treated with ICSI, 7 of which fathered their children, and 2 wives of which were pregnant. About 42.9% (9/21) patients were detected 5T allele in the polythymidine tract of intron 8, while delta F508del mutation was not detected in any patients. Conclusion The combination of clinical features, laboratory tests, ultrasound and other imaging examinations was crucial to diagnose CAVD. Sperm retrieval combined with ICSI was an efficient approach for CAVD. 5T allele mutation was observed in almost half of Chinese Han patients with CAVD. Delta F508del mutation which was common in Caucasian patients was not found. Key words: Congenital absence of the vas deferens (CAVD); Vasoepididymostomy (VE); Assisted reproductive technology (ART); Cystic fibrosis transmembrane conductance regulator (CFTR)