Donald J. Mehan

Laparoscopic Varicocelectomy: Preliminary Report of a New Technique

The use of varicocelectomy for the treatment of subfertility seems to be incontrovertible. However, there is a difference of opinion as to the proper surgical method of varicocele ablation. The inguinal and high retroperitoneal approaches are the most commonly accepted methods to date. However, significant postoperative morbidity is common and return to normal activity often is prolonged. Also, bilateral operations are being performed more commonly. These considerations have prompted many to search for alternative techniques. We developed a laparoscopic procedure that is as simple and effective as more traditional methods. In addition, it offers lower morbidity, allows for microscopic dissection with preservation of the spermatic artery and is amenable to bilateral ligation without a second incision. Ten patients 16 to 54 years old underwent laparoscopic ligation of the spermatic veins at the internal inguinal ring. The diagnosis was based on physical examination. Indications for the operation were infertility with a stress sperm pattern in 5 patients, testicular atrophy in 4 and scrotal pain in 1. Four patients underwent bilateral ligation. Preliminary followup showed resolution of the varicocele in all patients and disappearance of pain in the patient treated for this symptom. No morbidity related to this procedure has been encountered and all patients resumed normal activity within 2 days. We believe that this new method is a viable alternative for varicocelectomy.

Complications of Laparoscopic Urological Surgery: Experience at St. Louis University

A total of 221 patients underwent laparoscopic surgery at our institution. An outcome analysis with regard to type of procedure, success and complications was done. Overall, 216 of 221 procedures (97.7%) were performed as originally planned. One operation was converted to an open procedure. Complications producing morbidity occurred in 33 of 217 patients (15.2%). There was no associated mortality. Most complications occurred early in the participating surgeons experience. Of the complications 11 (5.0%) were considered major and included formation of symptomatic lymphoceles (4 patients), vascular injury (1), ureteral transection (1), bladder perforation (1), bowel obstruction (1), cecal perforation (1) and cerebrovascular accident (1). One patient had an idiopathic reaction to the inhalation anesthetic. Of the 11 major complications 9 occurred among 98 patients undergoing pelvic lymphadenectomy and 7 of these occurred among a subset of 15 patients undergoing an extended dissection. Adjuvant surgical intervention was necessary in 13 patients: celiotomy in 5, laparoscopic techniques in 4 and minor surgical procedures or percutaneous techniques in 4. Our experience suggests that urological laparoscopic surgery is safe and offers a shorter convalescence. However, the technique must be regarded as major surgery, associated with a steep learning curve.

Testicular biopsies in 101 cases of varicocele.

Testicular biopsies were done on 101 patients who underwent ligation of the internal spermatic vein as primary treatment for infertility. Retrospective analysis included evaluation of tubular thickening, Leydig cell hyperplasia, premature sloughing, maturation arrest and decreased spermatogenesis. A comparison was made of biopsy profiles, sperm counts and pregnancies in an attempt to determine further the value of testicular biopsy in the subfertile man. The pregnancy rate was 40 per cent over-all, with 32 per cent of the patients with tubular thickening reporting pregnancies. There was only 1 pregnancy in patients with Leydig cell hyperplasia. The controversial finding of premature sloughing had no consistent relationship to results.

Chorionic Gonadotropins in the Treatment of the Subfertile Male

Sixty-four men with idiopathic subfertility were given human chorionic gonadotropin, 50,000 units in 10 divided doses. Sixty-nine per cent of the men demonstrated significant improvement in semen quality in response to the medication, and thirty-six per cent achieved a pregnancy. Eight patients have achieved a second pregnancy without additional therapy.

Adenocarcinoma of rete testis

Adenocarcinoma of the rete testis is a very rare malignant neoplasm originating in the epithelium of the rete testis. Histologically, it appears as a papillary adenocarcinoma. The first case was reported in the literature in 1853 and since that time only 16 additional cases have been reported. This report represents the eighteenth case.

A Clinical Evaluation of a New Silastic Seminal Fluid Collection Device

A new Silastic seminal fluid collection device has been tested clinically and comparison studies have been made with both the polyethylene sheath and commercial latex condoms. In a series of 100 patients, the Silastic seminal fluid device has been found to be superior to the polyethylene sheath with regard to patient comfort and also has had greater reliability. In comparison with the latex device, the Silastic seminal fluid collection device is nearly as comfortable and has been found to be far more reliable.

Human Chorionic Gonadotropin in the Treatment of the Infertile Man

We have treated 128 men with proved infertility with human chorionic gonadotropin. Excellent results were obtained in the patients who underwent varicocelectomy but who did not respond to the operation. Good results were obtained in the idiopathic oligospermic men, that is with sperm density less than 20 million. Indeterminate results were obtained in patients with sperm values more than 20 million. However, therapy was deemed inappropriate in those patients who either had elevation of follicle-stimulating hormone, an untreated varicocele or biopsy findings of hyalinization, or atrophy, which would preclude success of therapy.

Laparoscopic internal spermatic vein ligation : report of a new technique

Over the past 22 months, 51 laparoscopic internal vein ligations have been performed to determine its application and practicality in treating the infertile male with varicoceles. Of the 33 cases available for a follow-up of greater than 6 months, 16 pregnancies are reported. Five patients reporting pregnancies refused to submit a postoperative semenogram. Of the reportable series, 17 of 33 had significant improvement in sperm density (51%), 15 of 33 (45%) in sperm viability, and 15 of 33 (45%) in sperm motility. No major complications were seen and minor complications were few and transient. Morbidity was extremely low. Laparoscopic internal spermatic vein ligations would appear to be a reasonable, practical, and effective method to correct varicoceles.

Urethral duplication With associated agenesis of left kidney and right ureteral ectopia

We report an unusual case of an accessory or duplicated urethra. This case is unique because of its association with multiple urologic anomalies which made management and diagnosis of this condition unusual. The unusual combination of right ectopic ureter and left renal and ureteral agenesis in association with the accessory urethra is presented, along with the diagnostic and surgical management particular to this case.

Congenital megalourethra: report of a unique case.

Abstract Congenital megalourethra is a rare clinical entity of mesodermal origin. A unique case is presented, which demonstrates features of a fusiform and scaphoid megalourethra.