Joel L. Marmar

MODIFIED VASOEPIDIDYMOSTOMY WITH SIMULTANEOUS DOUBLE NEEDLE PLACEMENT, TUBULOTOMY AND TUBULAR INVAGINATION

PURPOSE Recently a new technique for vasoepididymostomy was described which included tubular invagination by the triangulation method with a patency rate of 92%. Although these early data were encouraging, some technical problems were noted with the technique. After placing the first suture there was often tubular leakage and collapse. The tubulotomy was difficult and in some cases a suture was inadvertently cut. A modified technique is presented for vasoepididymostomy with tubular invagination, including some methods described in rat models. Only 2 sutures are used with simultaneous double needle placement. MATERIALS AND METHODS The 2-suture technique was used on 19 men who had undergone at least 1 vasoepididymostomy during vasectomy reversal procedures. RESULTS Patency was demonstrated in 7 of 9 men (77.7%) who underwent modified bilateral vasoepididymostomy and 6 of 7 (85.7%) who underwent unilateral vasoepididymostomy and unilateral vasovasostomy. Pregnancies were reported in both groups. The overall operating time for the modified technique was about 35 to 45 minutes per side. CONCLUSIONS Modified vasoepididymostomy with simultaneous needle placement, tubulotomy and invagination resulted in early patency in a high percentage of patients. Tubular invagination may have advantages compared to other conventional methods of vasoepididymostomy but more followup is needed.

Vasectomy: AUA Guideline

PURPOSE The purpose of this guideline is to provide guidance to clinicians who offer vasectomy services. MATERIALS AND METHODS A systematic review of the literature using the search dates January 1949-August 2011 was conducted to identify peer-reviewed publications relevant to vasectomy. The search identified almost 2,000 titles and abstracts. Application of inclusion/exclusion criteria yielded an evidence base of 275 articles. Evidence-based practices for vasectomy were defined when evidence was available. When evidence was insufficient or absent, expert opinion-based practices were defined by Panel consensus. The Panel sought to define the minimum and necessary concepts for pre-vasectomy counseling; optimum methods for anesthesia, vas isolation, vas occlusion and post-vasectomy follow up; and rates of complications of vasectomy. This guideline was peer reviewed by 55 independent experts during the guideline development process. RESULTS Vas isolation should be performed using a minimally-invasive vasectomy technique such as the no-scalpel vasectomy technique. Vas occlusion should be performed by any one of four techniques that are associated with occlusive failure rates consistently below 1%. These are mucosal cautery of both ends of the divided vas without ligation or clips (1) with or (2) without fascial interposition; (3) open testicular end of the divided vas with MC of abdominal end with FI and without ligation or clips; and (4) non-divisional extended electrocautery. Patients may stop using other methods of contraception when one uncentrifuged fresh semen specimen shows azoospermia or ≤ 100,000 non-motile sperm/mL. CONCLUSIONS Vasectomy should be considered for permanent contraception much more frequently than is the current practice in the U.S. and many other nations. The full text of this guideline is available to the public at http://www.auanet.org/content/media/vasectomy.pdf.

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.

Intraurethral Condylomas Acuminata: Management and Review of the Literature

We report 4 cases of intraurethral conylomas, the last one representing the first reported successful management of total urethral and intravesical condylomas in a male patient. The literature is reviewed and recommendations for management based on the modalities available are given.

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...

Transseptal Crossed Vasovasostomy

We examined 11 patients with acquired obstructive azoospermia resulting from irreparable obstruction of 1 vas deferens and severe damage to the contralateral testis. All of the patients underwent transseptal crossed vasovasostomy with no morbidity. Of 8 patients evaluated with postoperative semen analyses 4 (50 per cent) demonstrated total sperm counts of 29 to 205 million and 2 pregnancies (25 per cent) have been reported, with followup ranging from 5 months to 2 years. The etiologies of the vasal obstruction included previous inguinal surgery in 7 patients, vasectomy in 1, ejaculatory duct obstruction in 1, ectopic ureter in 1 and vasal agenesis in 1. Factors leading to loss of the contralateral testis were torsion in 5 patients, mumps orchitis in 2, varicocele in 1, pediatric inguinal herniorrhaphy in 1, epididymal blow out in 1 and unknown in 1. A representative case involving a unilateral ectopic ureter emptying into the seminal vesicle and subsequent contralateral testicular torsion is presented. The results indicate that a transseptal crossed vasovasostomy should be done in patients satisfying the criteria presented.

Urethrography Manifestations of Venereal Warts (Condyloma Acuminata)1

Intraurethral spread of venereal warts is a serious complication. Urethral involvement may be extensive and is associated with severe irritative symptoms. Spread to the bladder is possible. Recurrences are frequent and eradication difficult. We describe the urethrographic appearance of intraurethral verrucae and believe it to be strongly suggestive of the diagnosis. Voiding cystourethrography is recommended, and satisfactory visualization may be obtained with either voiding or retrograde urethrography. Voiding urethrography following intravenously administered contrast (excretory voiding cystourethrography) is particularly advantageous since it avoids the need for urethral instrumentation and, therefore, cannot contribute to retrograde spread of these contagious growths.

Functional Role of Spermagglutinating Antibodies in Men

The presence of spermagglutinating antibodies in blood and semen has been associated with reduced fertility in men. In this study 203 men were screened for infertility. An antibody measurement was performed on the blood and semen of each patient. Each semen specimen was also examined for spontaneous agglutination. Twelve patients with a positive reaction in the blood underwent a sperm-cervical mucus contact test. We have attempted to correlate the findings in blood with the observed functional results in semen and cervical mucus. We believe that these simple tests should be included in the infertility work-up in order to determine the presence of immune infertility.

Statistical Comparison of the Parameters of Semen Analysis of Whole Semen Versus The Fractions of The Split Ejaculate

The split ejaculate has proven to be a reliable method for concentrating sperm in a small volume. However, there is some controversy whether the spermatozoa in the most sperm-rich fraction of the split ejaculate has better motility than the spermatozoa in whole semen. In this study, at least two specimens of whole semen and two split ejaculates were obtained from 45 infertile males. The mean values for the parameters of the semen analysis were compared statistically. Our data indicate that increased sperm density is a consistent finding with the split ejaculate, even for severely oligospermic men. However, improved sperm motility with the split ejaculate is more variable. On the other hand, patients with mild oligospermia (10 to 40 million sperm/ml of whole semen) and high semen volumes (greater than 5.0 ml) demonstrated improvement in all parameters in the split ejaculate.

Use of papaverine during vasovasostomy

The fibrotic portion of the vas deferens is excised during the performance of a vasovasostomy until a satisfactory lumen appears on each side of the old scar. The lumen on the testicular side usually is dilated because of chronic high pressure at the site of the occlusion. On the other side the lumen of the abdominal vas usually is much smaller by comparison. A successful vasovasostomy depends on a precise mucosal-to-mucosal alignment despite the discrepancy in lumenal diameters. 2-layer anastomoses have been popularized to achieve this precise alignment. In an attempt to equalize the lumenal sizes during the anastomosis the smooth muscle relaxant papaverine (30 mg/ml) was applied to the abdominal side of the vas. Approximately 1-3 ml were dripped onto the cut end of the vas and after 1 minute the lumen was gently dilated by the lateral spring action of an angled jewelers forceps. This maneuver provided a wider lumen with excellent mucosal relaxation for the 2-layer anastomosis. Figure 1 shows the freshly cut end of the abdominal vas. The lumen measured less than 1.0 mm. When an angled jewelers forceps was introduced into the lumen the jaws barely separated by lateral spring action. Following the application of 1-3 ml of papaverine (30 mg/ml) the jaws separated to a distance of almost 1.5 mm. At this point the lumen appeared to be considerably dilated and the mucosa was relaxed for a precise 2-layer anastomosis. If the abdominal vas and its mucosa failed to relax in response to papaverine then this usually implied persistent fibrotic tissue. In these cases additional vas was removed on the abdominal side until the tissue demonstrated adequate relaxation following another application of papaverine and dilatation with the angled jewelers forceps. This maneuver seemed to be helpful for determining the adequacy of the dissection. The application of papaverine has been utilized during 61 vasovasostomies which have been followed up at least 6 months. Followup semen analyses have demonstrated 49 patients with greater than 20 million sperm/ml and greater than 40% motility. 3 patients remained azoospermic. In 4 patients late azoospermia developed. Thus far 31 pregnancies (50.8%) have been reported for all categories. Additional pregnancies are anticipated with time. It is believed that the application of 1-3 ml of papaverine (30 mg/ml) to the abdominal vas is a simple and helpful maneuver during a vasovasostomy.