Successful Vasovasostomy Research Articles

MP74-05 PRACTICE PATTERNS IN SURGICAL STERILIZATION: AN ANALYSIS OF US UROLOGIST SURGICAL LOGS

INTRODUCTION AND OBJECTIVES: To consider the feasible surgical options and increase patients’ willingness to seek vasectomy reversal. We report on the techniques for simple and ambulatory miniincision supermicrosurgical vasovasostomy(3-4 layer anastomosis by 9-0 or/and 10-0 nylon with >10x magnification) using a double-ringed clamp (Moon’s clamp), which makes use of dilators, approximators, and background material unnecessary. We also report the results METHODS: Ambulatory mini-incision supermicrosurgical vasovasostomy was conducted on 263 patients who satisfied surgical eligibility requirements for vasovasostomy and safety criteria for local anesthesia. We recorded and retrospectively analysed the operation time, postoperative recovery, and the results of postoperative semen analysis. RESULTS: A mean time of 25.5 min was spent isolating the bilateral vas deferens. All patients were discharged on the day of surgery and returned to their ordinary activities 24e48 h after surgery. No hematoma or infection occurred, except in one patient. Postoperative semen analysis showed that the surgery was successful in 182 patients (96.8%). CONCLUSIONS: Simple ambulatory mini-incision microsurgical vasectomy reversal using Moon’s clamp under local anaesthesia could be a surgically feasible option, with the advantages of a low-risk operation and the achievement of successful vasovasostomy without other accessory devices, for patients who wish to return to their daily activities quickly with minimal complications. Source of Funding: none

MP74-04 A SIMPLE AMBULATORY MINI-INCISION SUPERMICROSURGICAL VASOVASOSTOMY UNDER LOCAL ANESTHESIA : USING A SPECIALLY DESIGNED DOUBLE-RINGED CLAMP WITHOUT ANY ACCESSORY DEVICES

INTRODUCTION AND OBJECTIVES: To consider the feasible surgical options and increase patients’ willingness to seek vasectomy reversal. We report on the techniques for simple and ambulatory miniincision supermicrosurgical vasovasostomy(3-4 layer anastomosis by 9-0 or/and 10-0 nylon with >10x magnification) using a double-ringed clamp (Moon’s clamp), which makes use of dilators, approximators, and background material unnecessary. We also report the results METHODS: Ambulatory mini-incision supermicrosurgical vasovasostomy was conducted on 263 patients who satisfied surgical eligibility requirements for vasovasostomy and safety criteria for local anesthesia. We recorded and retrospectively analysed the operation time, postoperative recovery, and the results of postoperative semen analysis. RESULTS: A mean time of 25.5 min was spent isolating the bilateral vas deferens. All patients were discharged on the day of surgery and returned to their ordinary activities 24e48 h after surgery. No hematoma or infection occurred, except in one patient. Postoperative semen analysis showed that the surgery was successful in 182 patients (96.8%). CONCLUSIONS: Simple ambulatory mini-incision microsurgical vasectomy reversal using Moon’s clamp under local anaesthesia could be a surgically feasible option, with the advantages of a low-risk operation and the achievement of successful vasovasostomy without other accessory devices, for patients who wish to return to their daily activities quickly with minimal complications. Source of Funding: none

A feasible ambulatory mini-incision microsurgical vasovasostomy under local anaesthesia using a specially designed double-ringed clamp that simplifies surgery.

In line with the effort to evaluate feasible surgical options for vasectomy reversal and to increase patients' willingness to undergo the procedure, this study reported on a technique for ambulatory mini-incision microsurgical vasovasostomy using a double-ringed clamp (i.e. Moon's clamp). This technique does not require the use of dilators, approximators and other accessory devices. Ambulatory mini-incision microsurgical vasovasostomy was conducted on 263 patients who satisfied the surgical eligibility requirements for vasovasostomy and the safety criteria for local anaesthesia. The operation time, details on postoperative recovery and results of the postoperative semen analysis were recorded and retrospectively analysed. The mean time used to isolate the bilateral vas deferens was 25.5 minutes. All patients were discharged on the day of surgery and all patients returned to their normal activities within 24-48 hours after surgery. No haematoma or infection occurred except in one patient. Postoperative semen analysis showed that the surgery was successful in 182 (96.8%) of the 188 patients who complied with the postoperative patient instructions. Ambulatory mini-incision microsurgical vasectomy reversal using Moon's clamp and under local anaesthesia is a surgically feasible option that offers the advantages of a low-risk operation. It also achieves successful vasovasostomy without other accessory devices and allows patients to return to their daily activities quickly with minimal complications.

Gene Expression in the Epididymis of Normal and Vasectomized Men: What Can We Learn About Human Sperm Maturation?

Anatomically, the human epididymis is unusual when compared with the excurrent duct of other eutherian mammals. Furthermore, clinical observations suggest that it may not be as important for sperm maturation as is the case for laboratory animals. In contrast, hierarchical clustering of microarray data of epididymides from normal men revealed 2274 modulated qualifiers between the epididymal segments, 1184, 713, and 269 of them being highly expressed in the caput, corpus, and cauda, respectively. The organization of qualifiers according to their similarities by gene ontology indicated that caput transcripts are dedicated to cell-cell adhesion, whereas the corpus is characterized by genes involved in response to other organisms (ie, defense mechanisms) and the cauda transcriptome is specialized in muscle contraction and establishment of localization. A region-specific gene expression pattern thus characterizes the human epididymis as in animal models. In humans, vasectomies have consequences on the epididymal transcriptome. Cluster analysis revealed that 1363 genes are expressed in both normal and vasectomized epididymides, whereas 911 and 660 of them are specifically expressed in normal and vasectomized epididymides, respectively. Three of the affected genes are particularly interesting because of their involvement in sperm biochemical remodeling during epididymal transit: dicarbonyl/l-xylulose reductase, Niemann-Pick disease, type C2, and cysteine-rich secretory protein 1. In some vasovasostomized men, these modifications in gene expression induced by vasectomy are irreversible, thus affecting the biochemical parameters, and potentially, the function of their ejaculated sperm. This may explain the discrepancies between a surgically successful vasovasostomy and fertility recovery.

Outcome of surgical treatment for obstructive azoospermia.

The efficacy of reanastomosis was evaluated in 30 patients with obstructive azoospermia, including 19 postvasectomy cases; 7 cases complicating inguinal herniorrhaphy; 2 cases with a characterized isolated congenital anomaly; 1 case of Young's syndrome; and 1 case with an unknown, possibly congenital cause. In the postvasectomy group. successful vasovasostomy was achieved in 15 of 18 cases (83.3%; 1 postvasectomy patient dropped out of the study prior to analysis). Duration of obstruction in the 3 cases where anastomosis failed was 6, 9, and 20 years. In the group where obstruction followed inguinal herniorrhaphy, unilateral vasovasostomy was performed in 6 cases, and transepididymovasostomy was performed in 1 case. Success was achieved in 3 of 6 cases (50%; 1 case was not included because failure of spermatogenesis was detected postoperatively). In all 4 remaining cases, microsurgical epididymovasostomy or transepididymovasostomy was performed, but success was achieved only in the case of Young's syndrome. Although mailed questionnaires and telephone interviews indicated occurrence of natural pregnancy in only 4 affected couples, postoperative sperm counts were relatively satisfactory as in previous reports.

Effect of vasovasostomy on contralateral testicular damage associated with unilateral vasectomy in mature and immature Lewis rats

Objective: We sought to determine if laser-assisted vasovasostomy could reverse the contralateral histologic testicular changes associated with unilateral vasectomy. Design: A prospective, randomized, blinded, controlled study. Setting: Animal microsurgical laboratory, St. John’s Mercy Medical Center, St. Louis, Missouri. Patient(s): Twenty mature and 20 immature male Lewis rats. Intervention(s): Ten mature and 10 immature male Lewis rats underwent unilateral vasectomy. At 5 months, testicular biopsy and laser-assisted vasovasostomies were performed followed 2 months later by evaluation of vas patency and repeat testicular biopsy. Control animals consisted of 10 rats in each group, 5 that underwent sham operations and 5 that had halothane anesthesia alone. Result(s): In the immature and mature groups unilateral vasectomy resulted in marked contralateral testicular damage in 30% (3 of 10) and 50% (5 of 10), respectively. Vas patency determined 2 months after vasovasostomy was 80% (8 of 10) in the mature group and 89% (8 of 9) in the immature group. No animal that had contralateral testicular changes after vasectomy and a patent vas after vasovasostomy showed improvement in testicular histology. Conclusion(s): It appears that contralateral testicular damage associated with unilateral vasectomy is not improved 2 months after successful vasovasostomy in mature or immature Lewis rats.

Human Vasal Changes after Vasectomy: In vitro Studies

Failure to impregnate, after successful vasovasostomy, has been attributed to immunologic, testicular, and epididymal factors. To study the effect of vasectomy on human vas innervation and vesicoelastic properties. Vas rings were obtained from 8 healthy males during vasectomy as controls and compared to those of 3 vasovasostomy patients. The active and passive properties were determined and the cumulative blocking effects of phenoxybenzamine, propranolol, atropine and tetrodotoxin were studied. There was significantly higher rigidity in the vasovasostomy group as compared to the control group but there were similar active forces between the two groups up to 100-120% of stretch. In the control group, phenoxybenzamine blocked 33.3%, propranolol blocked 15.8%, and atropine blocked 36.5% but tetrodotoxin had no further effect. In the vasovasostomy group, phenoxybenzamine blocked 33.3% (similar to control), propranolol blocked 2%, atropine blocked 11.7% and tetrodotoxin blocked 37.1%. In vasovasostomy group there was increased rigidity without reduction of the active force. There were also decreased cholinergic and possible existence of nonadrenergic noncholinergic neurotransmitters.

Sperm antibodies in vasectomized men and their effects on fertilization.

Sera (vbs, n = 25) and seminal plasma (vsp, n = 21) from vasectomized men (n = 25) were analyzed for cross-reaction with lithium diiodosalicylate (LIS)-solubilized human sperm extract, protamine, and fertilization antigen (FA-1) with an enzyme-linked immunosorbent assay (ELISA). Among the vbs tested, 44% reacted with human sperm extract, 28% reacted with protamine, and 44% reacted with FA-1 for at least one class of antibodies (IgG, IgA, or IgM). In contrast to the sera, the seminal plasma showed minimal reactions. Neither the vbs nor vsp were found to contain immune complexes, indicating that the antibodies were present in free form. Vasectomized sera that reacted with FA-1 showed a significant (p less than 0.0001) inhibition of human sperm penetration of zona-free hamster ova. The immunoabsorption of FA-1-positive sera with purified FA-1 significantly increased the penetration rates. Affinity-purified human immunoglobulins reactive with FA-1 and not those reactive with protamine reduced sperm penetration rates. Thus, antibodies in vbs reactive with FA-1 are relevant to infertility, causing an inhibition of fertilization. These data will have clinical relevance for diagnosis and treatment of infertility after successful vasovasostomy.

Abnormalities of sperm morphology in cases of persistent infertility after vasectomy reversal

Persistent infertility after vasectomy reversal by vasovasostomy may be due to irreversible changes in epididymal physiology, producing morphologic abnormalities of the sperm tail. Specimens from 29 men with persistent infertility following vasectomy reversal were analyzed and sperm motility and morphology were evaluated. the percentage of motile sperm was below normal in 23 specimens. Swimming speed evaluation on 20 specimens showed only 4 were below the normal range. In 19 of the 29 specimens, 10% or more of the sperm cells examined were characterized by a normal head and a coiled or shortened tail. Within this group, the percentage of sperm with tail abnormalities ranged from 2-64%, with a mean of 18.1%. The appearance of sperm tail abnormalities in conjunction with normal or high sperm concentrations suggests a disturbance of epididymal physiology. The epididymal environment is required for the final maturation of spermatazoa and the acquisition of normal motility and fertilizing ability. The study results suggest that these epididymal functions may be impaired in some men after vasectomy. A case report of a 32 year old man who had a vasectomy 7 years prior to referral to the evaluation group, and a successful vasovasostomy 2 years prior, revealed only 20% of the sperm evaluated in the initial specimen had the normal head and tail shape. His semen volume was 3.5 ml with a sperm concentration of 250 million/ml. 25% of the sperm were motile. Reexamination of the semen 8 times during the next year showed no significant changes. The cervical mucus penetration test showed no abnormalities of the sperm-cervical mucus interaction. When the motile sperm were spearated from the immotile cells and incubated with zona-free hamster eggs, all of the eggs were penetrated. Attempts were unsuccessful to isolate sufficient numbers of motile cells for artificial insemination, however, a normal pregnancy was conceived 1 year after the initial evaluation without additional therapy. One other man from the group also produced a pregnancy. It is suggested that the morphologic abnormalities may not confer sterility on the affected individual even when present in the majority of sperm cells, as indicated by the ability of sperm with normal tails to fuse with zona-free hamster eggs in vitro.

Vasectomy in rhesus monkeys III. Light microscopic studies of testicular morphology

Rhesus monkeys were randomly assigned to undergo various surgical procedures. The animals were followed from one to sixty-six weeks postvasectomy, at which time they were sacrificed and their tissues prepared for light and electron microscopy. Vasectomy in the rhesus monkey, as in certain other species, appears to be a procedure not attended with widespread testicular atrophy or histologic evidence of impaired spermatogenic potential utilizing the procedures and postoperative periods studied. Why certain animals exhibited focal degenerative changes is unclear; perhaps a certain population, yet to be defined, is more sensitive to such procedures, resulting in testicular alterations. It is important that such a population and such changes be defined to predict more accurately the possibility of successful vasovasostomy and reestablishment of fertility.

When and Why Does Occlusion of the Vas Deferens Affect the Testis?

The motility of spermatozoa from successive segments of human and animal epididymides was examined under the phase-contrast microscope. The segments were taken from laboratory rodents unilaterally vas ligated for three to five months and from human orchiectomy specimens. Evidence for testicular alteration, caused by epididymal stasis proven by the phase-contrast motility profile, was sought by weight, gross observation, and histologic examination. Two observations were made on the animals: (1) the ligature about the vas seldom resulted in epididymal stasis because the ligature cut through the muscular wall of the vas (permitting a leak);and, (2) when stasis was achieved, gross and microscopic alterations of the testis from the normal were inevitable. The observations of the human material showed that a progressive loss of sperm motility during passage through the epididymis occurred in more than one half the specimens. The motility profile of these epididymides closely resembled that seen in the unilaterally vas-ligated animals. The suggestion is made that senescence of a testicle may be caused by occlusion of its excurrent ducts. These observations seemed to support the hypothesis that faulty sperm transport and faulty maturation, becuase of epididymal rupture and fibrosis (rather than the presence of autoantibodies to sperm) probably cause the unreliability of vasovasostomy. Storage of frozen semen offers more certainty than the possibility of successful vasovasostomy.