Eugene F. Fuchs

Results of 1,469 Microsurgical Vasectomy Reversals by the Vasovasostomy Study Group

During a 9-year period, 1469 men who underwent microsurgical vasectomy reversal procedures were studied at five institutions. Of 1247 men who had first-time procedures, sperm were present in the semen in 865 of 1012 men (86%) who had postoperative semen analyses, and pregnancy occurred in 421 of 810 couples (52%) for whom information regarding conception was available. Rates of patency (return of sperm to the semen) and pregnancy varied depending on the time interval between the vasectomy and its reversal. If the interval was shorter than 3 years, the patency rate was 97% and the pregnancy rate was 76%; for intervals of 3 to 8 years the rates were 88% and 53%; for 9 to 14 years, 79% and 44%; and for 15 years or more, 71% and 30%. The patency and pregnancy rates were no better after 2-layer microsurgical vasovasostomy than after modified 1-layer microsurgical procedures, and they were statistically the same for all patients regardless of the surgeon. When sperm was absent from the intraoperative vas fluid bilaterally and the patient underwent bilateral vasovasostomy rather than vasoepididymostomy, patency occurred in 50 of 83 patients (60%) and pregnancy in 20 of 65 couples (31%). Neither presence nor absence of a sperm granuloma at the vasectomy site nor type of anesthesia affected results. Repeat microsurgical reversal procedures were less successful. A total of 222 repeat operations produced patency in 150 of 199 patients (75%) who had semen analyses, and pregnancy was reported in 52 of 120 couples (43%).

Herniorrhaphy with polypropylene mesh causing inguinal vasal obstruction: a preventable cause of obstructive azoospermia.

Objective:To report a multiinstitutional experience of men presenting with infertility secondary to inguinal hernia repair using polypropylene mesh. Summary Background Data:An estimated 80% of inguinal hernia operations involve placement of a knitted polypropylene mesh to form a “tension-free” herniorrhaphy. The prosthetic mesh induces a chronic foreign-body fibroblastic response creating scar tissue that imparts strength to the floor and leads to fewer recurrences. However, little is known about the long-term effects of the polypropylene mesh on the vas deferens, especially with regard to fertility. Methods:Eight institutions in the United States reported a total of 14 cases of azoospermia secondary to inguinal vasal obstruction related to previous polypropylene mesh herniorrhaphy. Patient characteristics and operative findings were forwarded to 1 center for tabulation of data. Results:Mean patient age was 35.5 years with an average duration of infertility of 1.8 years. Mean number of years between urologic evaluation and herniorrhaphy was 6.3 years. Types of inguinal hernia repair previously performed were: open (10), laparoscopic (2), or both (2). Nine patients had bilateral obstruction and 5 patients had unilateral obstruction with contralateral testicular atrophy or epididymal obstruction. Surgical exploration revealed a dense fibroblastic response encompassing the polypropylene mesh with either trapped or obliterated vas in all patients. Surgical reconstruction was performed in 8 of 14 men (57%). Conclusion:Reconstruction to restore fertility can be difficult secondary to fibrotic reaction. Before undergoing polypropylene mesh herniorrhaphy, men, especially of young reproductive age or with a solitary testicle, need to be carefully advised of potential obstruction and compromise to future fertility.

Vasectomy reversal performed 15 years or more after vasectomy: correlation of pregnancy outcome with partner age and with pregnancy results of in vitro fertilization with intracytoplasmic sperm injection

OBJECTIVE To document a contemporary series of vasectomy reversals performed in men 15 years or more after vasectomy and to correlate the results with spousal age and results of ICSI for obstructive azoospermia. SETTING University referral center for male infertility. DESIGN Retrospective analysis of a single surgeons experience compared with reported ICSI results. PARTICIPANT(S) One hundred seventy-three men who had vasectomy reversal 15 years or more after vasectomy. INTERVENTION(S) Reversal of vasectomy by vasovasostomy or epididymovasostomy. MAIN OUTCOME MEASURE(S) Correlation of pregnancy results after vasectomy reversal with spousal age and published ICSI results. RESULT(S) Pregnancy rates for the intervals of 15-19 years, 20-25 years, and >25 years after vasectomy were 49%, 39%, and 25%, respectively. For spousal age <30 years, 30--35 years, 36-40 years, and >40 years, pregnancy rates were 64%, 49%, 32%, and 28%, respectively. The overall pregnancy rate was 43%, which is similar to the pregnancy rate of 40% for ICSI in obstructive azoospermia. Sixty-two percent of the men required a unilateral or bilateral epididymovasostomy. CONCLUSION(S) Spousal age is an important predictive factor after vasectomy reversal among men who have reversal 15 years or more after vasectomy. Pregnancy rates after vasectomy reversal compare favorably with those obtained with ICSI.

Diagnosis and management of ureteroiliac artery fistula: value of provocative arteriography followed by common iliac artery embolization and extraanatomic arterial bypass grafting.

PURPOSE We describe an effective multidisciplinary approach to the diagnosis and management of ureteroarterial fistulas that reduces morbidity and mortality. MATERIALS AND METHODS Five ureteroarterial fistulas in 4 patients were studied with standard and provocative arteriography (arteriography combined with ureteral manipulation). After establishing the diagnosis, each lesion was treated with percutaneous embolic occlusion of the common iliac artery followed by extraanatomic arterial bypass grafting. All patients had chronic ureteral stenting, prior pelvic irradiation, prior pelvic surgery and intrapelvic malignancy, and all fistulas presented with urinary tract hemorrhage. RESULTS Standard arteriography was nondiagnostic but provocative arteriography demonstrated the fistula in each case. Successful embolization of the common iliac artery followed by extraanatomic arterial bypass grafting precluded the need for laparotomy and preserved ipsilateral renal function. CONCLUSIONS Provocative arteriography followed by arteriographic common iliac artery embolization and extraanatomic bypass grafting was successful for the diagnosis and treatment of ureteroarterial fistulas. There was no mortality, limb loss or renal loss.

Immunologic considerations before and after vasovasostomy

A prospective study has been completed to determine the incidence and significance of antisperm antibodies in 160 men undergoing vasovasostomy to relieve obstruction of the vas deferens due to vasectomy. Preoperatively, serum sperm-agglutinating antibody (SSAA), serum sperm-immobilizing antibody (SSIA), and seminal plasma sperm-agglutinating antibody (SPSAA) were found in 63%, 37%, and 3%, respectively. When they were postoperatively studied, 92 of the same men demonstrated no significant change in the incidence or the absolute level of SSAA or SSIA. The SPSAA was found in 7% of 120 men preoperatively; however, 16% of 51 men studied postoperatively exhibited SPSAA. Significant differences in pregnancy rates have been documented between the spouses of men with detectable levels of agglutinating and immobilizing antibody and the spouses of men with no evidence of antibody formation.

Vasectomy Reversal for Treatment of the Post-Vasectomy Pain Syndrome

PURPOSE The post-vasectomy pain syndrome is a rare but troublesome complication of vasectomy. We report our experience with 32 patients who underwent vasectomy reversal for relief of the post-vasectomy pain syndrome. MATERIALS AND METHODS The records of 32 patients undergoing vasovasostomy or epididymovasostomy for the post-vasectomy pain syndrome were evaluated for characteristics of symptoms, previous therapy, interval from vasectomy, success of surgery and duration of relief. RESULTS Of 32 men who underwent vasectomy reversal for the post-vasectomy pain syndrome between 1980 and 1994, 24 had relief of symptoms after the initial procedure. Of 8 men with recurrent pain 6 underwent a second reversal procedure, and 3 of them subsequently had relief of symptoms. Overall, 27 of 32 men had resolution of pain. CONCLUSIONS In our experience vasectomy reversal has a high rate of success for relief of the post-vasectomy pain syndrome. It does not preclude other forms of surgical therapy and it should be considered in the treatment of the post-vasectomy pain syndrome.

Urologist-Acquired Renal Access for Percutaneous Renal Surgery

OBJECTIVES In most endourology programs an interventional radiologist is employed to acquire renal access for percutaneous renal surgery. Over the last 13 years the senior endourologist at Oregon Health Sciences University has acquired access without employing a radiologist. We report our experience with urologist-acquired renal access for percutaneous renal surgery in 522 cases. METHODS We reviewed the records of all patients at our hospital who underwent percutaneous renal surgery between August 1983 and December 1996 with renal access being obtained in the operating room by a urologist. RESULTS Four hundred fifty-six patients underwent 522 procedures. Indications for percutaneous renal surgery were renal and proximal ureteral calculi (n = 516), retained ureteral stent (n = 3), and intrarenal collecting system tumor (n = 3). We were successful in gaining access to 513 of 522 kidneys (98.3%). Access was obtained via a subcostal approach in 344 procedures, over the 12th rib in 152 procedures, over the 11th rib in 15 procedures, and transabdominally in 2 procedures. Sixty-five patients (12.7%) required a second or multiple sites to facilitate complete removal of calculi. Our overall complication rate was 15.3%. Blood transfusion was required in 5.4% of the cases, ileus developed in 1.9%, pneumothorax in 1.1%, intraoperative hydrothorax in 1.1%, postoperative pleural effusion requiring aspiration in 0.9%, and septic shock in 0.9%. Our overall success rate for stone removal was 94.5%. CONCLUSIONS In our experience, the urologist is able to safely and effectively obtain percutaneous access to the collecting system for percutaneous renal surgery as a one-stage procedure without the aid of interventional radiologists.

The Laboratory Diagnosis of Testosterone Deficiency

The evaluation and treatment of hypogonadal men has become an important part of urologic practice. Fatigue, loss of libido, and erectile dysfunction are commonly reported, but nonspecific symptoms and laboratory verification of low testosterone (T) are an important part of evaluation in addition to a detailed history and physical examination. Significant intraindividual fluctuations in serum T levels, biologic variation of T action on end organs, the wide range of T levels in human serum samples, and technical limitations of currently available assays have led to poor reliability of T measurements in the clinical laboratory setting. There is no universally accepted threshold of T concentration that distinguishes eugonadal from hypogonadal men; thus, laboratory results have to be interpreted in the appropriate clinical setting. This review focuses on clinical, biological, and technological challenges that affect serum T measurements to educate clinicians regarding technological advances and limitations of the currently available laboratory methods to diagnose hypogonadism. A collaborative effort led by the American Urological Association between practicing clinicians, patient advocacy groups, government regulatory agencies, industry, and professional societies is underway to provide optimized assay platforms and evidence-based normal assay ranges to guide clinical decision making. Until such standardization is commonplace in clinical laboratories, the decision to treat should be based on the presence of signs and symptoms in addition to serum T measurements. Rigid interpretation of T ranges should not dictate clinical decision making or define coverage of treatment by third party payers.

The Supracostal Approach for Percutaneous Nephrostolithotomy

Sixty-nine patients underwent percutaneous nephrostolithotomy or ultrasonic lithotripsy through a nephrostomy tract placed over the 12th rib. All procedures were accomplished as a single stage in a standard operating room with patients under general anesthesia. With the exception of a single failed access the targeted calculus was removed in all instances. There were no episodes of postoperative pneumothorax or hydrothorax. One patient suffered delayed postoperative pneumonia and another patient had a delayed pleural effusion. The supracostal approach for percutaneous nephrostolithotomy is an important and safe modification of the traditional percutaneous approach to the kidney for an endourological procedure.

Results in the United States with Sperm Micro-Aspiration Retrieval Techniques and Assisted Reproductive Technologies

AbstractImproved methods of urological microsurgery and of various assisted reproductive technologies have resulted in the ability to achieve pregnancies with sperm aspirated microsurgically from men with bilateral congenital absence of the vasa deferentia or with ductal obstructions that cannot be surgically reconstructed. A survey was conducted of the results of such procedures performed in the United States during approximately 2 years. Female partner ovarian stimulation was initiated in 219 instances at 22 centers. Of the 219 procedures 23 (11%) were terminated without attempting any form of gamete fertilization or insemination of the wife for various reasons (no sperm or too few sperm retrieved, poor to absent sperm motility or poor quality eggs). The etiology of azoospermia in the 219 procedures was congenital absence of the vasa deferentia in 115 cases (52%), other congenital conditions in 15 (7%), failed vasectomy reversal in 37 (17%), infection in 4 (2%), other conditions (mainly ejaculatory dysf...