Yefim Sheynkin

MICROSURGICAL REPAIR OF IATROGENIC INJURY TO THE VAS DEFERENS

PURPOSE We determined the incidence of iatrogenic injuries to the vas deferens at a tertiary care university infertility center and the results of surgical repair. MATERIALS AND METHODS Records of 472 patients surgically explored for obstructive azoospermia between 1984 to 1996 were reviewed. Enrollment criteria included history of inguinal, pelvic and scrotal (other than vasectomy) surgery. Conventional ipsilateral and crossover vasovasostomies and vasoepididymostomies were performed. Patency rate was defined as presence of complete sperm with tails in a postoperative semen analysis. Followup included a minimum of 2 semen analyses. Only naturally conceived pregnancies were included. RESULTS Of 472 patients 34 (7.2%) had an iatrogenic injury to the vas deferens with a mean obstruction interval of 20.5 +/- 1.9 years. Mean patient age was 36.7 +/- 1.8 years. Iatrogenic injury to the vas deferens was secondary to bilateral inguinal hernia repair in 19 patients, unilateral hernia repair in 11, renal transplantation in 2, appendectomy in 1 and spermatocelectomy in 1. Pediatric inguinal hernia repair was the most common etiology of the vasal injury (20 patients), followed by adult inguinal hernia repair (10). A total of 36 microsurgical reconstructive procedures were performed, including 20 ipsilateral and 16 crossed vasovasostomies and vasoepididymostomies. There were 26 patients (29 procedures) available for followup (mean 21.0 +/- 3.7 months). Total patency rate per procedure was 65% and pregnancy rate was 39%. Patency and pregnancy rates per conventional ipsilateral procedures were 62.5 and 35.7% and per crossover procedures 64.2 and 42.8%, respectively. CONCLUSIONS Pediatric inguinal hernia repair is the most common cause of iatrogenic injury to the vas deferens. Results of treatment of iatrogenic injury to the vas deferens are somewhat lower than for patients with obstructive azoospermia due to vasectomy. Iatrogenic injuries are associated with longer vasal defects, impaired blood supply and longer obstructive intervals frequently resulting in secondary epididymal obstruction. Crossover reconstruction is particularly useful when contralateral testicular atrophy is present. Intraoperatively aspirated sperm should be cryopreserved for later use in case the reconstruction fails.

Protection from scrotal hyperthermia in laptop computer users

OBJECTIVE To evaluate methods of prevention of scrotal hyperthermia in laptop computer (LC) users. DESIGN Experimental study. SETTING University hospital. PATIENT(S) Twenty-nine healthy male volunteers. INTERVENTION(S) Right and left scrotal temperature and LC and lap pad temperatures were recorded during three separate 60-minute sessions using a working LC in a laptop position: session 1, sitting with closely approximated legs; session 2, sitting with closely approximated legs with a lap pad below the working LC; and session 3, sitting with legs apart at a 70°angle with a lap pad below the working LC. MAIN OUTCOME MEASURE(S) Scrotal temperature elevation. RESULT(S) Scrotal temperature increased significantly regardless of leg position or use of a lap pad. However, it was significantly lower in session 3 (1.41 °C ± 0.66 °C on the left and 1.47 °C ± 0.62 °C on the right) than in session 2 (2.18 °C ± 0.69 °C and 2.06 °C ± 0.72 °C) or session 1 (2.31 °C ± 0.96 °C and 2.56 °C ± 0.91 °C). A scrotal temperature elevation of 1 °C was reached at 11 minutes in session 1, 14 minutes in session 2, and 28 minutes in session 3. CONCLUSION(S) Sitting position with closely approximated legs is the major cause of scrotal hyperthermia. Scrotal shielding with a lap pad does not protect from scrotal temperature elevation. Prevention of scrotal hyperthermia in LC users presently is not feasible. However, scrotal hyperthermia may be reduced by a modified sitting position (legs apart) and significantly shorter use of LC.

Effect of Methylene Blue, Indigo Carmine, and Renografin on Human Sperm Motility

OBJECTIVES To evaluate the effect of commonly used intraoperative vasography and tissue staining agents, indigo carmine, methylene blue, and Renografin, on sperm motility. METHODS Semen from 20 healthy men was obtained after 2 to 4 days of abstinence. Sperm motility was initially evaluated in each specimen. Standard solutions of indigo carmine, methylene blue, and Renografin-60 were diluted 2x and 4x with lactated Ringers solution. Equal aliquots of sperm were mixed with undiluted and diluted drugs, and sperm motility was assessed. RESULTS Initial mean sperm motility was 70.3%+/-3.0%. Undiluted methylene blue and Renografin severely depressed sperm motility to 1.1%+/-0.5% and 2.3%+/-0.7%, respectively (P <0.05). Diluted methylene blue depressed motility to 4.9%+/-1.8% and 11.2%+/-3.0% (P < 0.05). Diluted Renografin depressed motility to 25.1%+/-4.1% and 55.3%+/-3.3% (P < 0.05). Although undiluted and 2x-diluted indigo carmine moderately decreased sperm motility (48.9%+/-3.2% and 61.7%+/-3.0%, P < 0.05), 4x-diluted indigo carmine had minimal effect on sperm motility (67.3%+/-2.8%, P > 0.05). Lactated Ringers solution had no effect on sperm motility. CONCLUSIONS We found a severe, immediate reduction in sperm motility after exposure to undiluted standard solutions of methylene blue and Renografin. Dilution of Renografin significantly decreased its negative impact on the sperm motility, whereas the adverse effect of methylene blue remained fairly constant even with increasing dilution. Sperm motility should be assessed prior to application of these agents. Sperm should be aspirated for immediate use and/or cryopreservation prior to the use of these agents. Indigo carmine may be safely used as a tissue stain or vasography agent with a minimal effect on sperm motility in dilutions of 4x and higher.

Intraoperative Sonographically Guided Needle Localization of Nonpalpable Testicular Tumors

2Department of Urology, Stony Brook University School of Medicine, Stony Brook, NY 11790. esticular carcinoma is the most common malignancy in men 15–34 years old. Orchiectomy is considered standard management for testicular masses. In patients with bilateral tumors and those with a solitary testicle, this approach results in infertility, lifelong dependency on androgen substitution, and the psychological distress of castration. For these reasons, testis-sparing surgery has been advocated in a select group of patients with palpable and nonpalpable tumors. For nonpalpable tumors, this approach is based on precise intraoperative localization and accurate frozen tissue analysis of the testicular mass [1, 2]. We report two cases of nonpalpable intratesticular tumors successfully treated by intraoperative sonographically guided needle localization and subsequent microsurgical excision that spared the remainder of the affected testicle.

Comparison of absorbable and nonabsorbable sutures for microsurgical vasovasostomy in rats

OBJECTIVES At least 12% of initially patent vasovasostomies (VVs) shut down. Currently, only nonabsorbable sutures are used for VV. A synthetic, slowly absorbing, monofilament polyglactin suture has been developed that retains tensile strength for up to 6 months. We performed a prospective controlled randomized study comparing absorbable and nonabsorbable sutures for rat VVs. METHODS Bilateral microsurgical VV was performed in three groups of 36 Wistar male rats, with 10-0 nylon, 10-0 polypropylene, and 10-0 polyglactin sutures. Twelve control rats underwent sham operations. Three rats in each group were killed at 2, 6, 12, and 24 weeks. The abdominal end of the vas deferens was transected and the intraluminal fluid examined microscopically for presence of sperm. The segment of the vas deferens containing the anastomosis was excised. Fluid from the testicular end was examined for sperm to confirm spermatogenesis. Patency was confirmed by an antegrade indigo carmine vasogram of the anastomotic segment. Segments were randomly sent for histologic or tensile strength evaluation. RESULTS The mean tensile strength of the anastomoses performed with nylon was slightly higher than in polypropylene and polyglactin sutures, although the difference was not statistically significant. Polyglactin consistently maintained tensile strength throughout 6 months without significant fluctuations. The mean patency rate in the polyglactin group was 96%, in nylon 81%, and in polypropylene 61%. Although polyglactin had a consistently higher patency rate compared with nonabsorbable sutures, the difference was not statistically significant (P = 0.11) but indicated a strong trend. The occurrence of microscopic sperm granuloma, muscle layer injuries, intimal fibrosis, and adventitial fibrosis of the vas deferens was not significantly different between suture types. CONCLUSIONS The three suture materials appear equivalent with respect to overall tensile strength of anastomosis; with histologic evaluation, the trend was toward better patency with polyglactin. Polyglactin 10-0 microsurgical suture is a viable alternative to nonabsorbable sutures in microsurgical VVs, although further studies are indicated to assess long-term results.

Sociodemographic predictors of postvasectomy noncompliance.

Background: Postvasectomy semen analysis (PVSA) is critical to establish the success of the vasectomy but the rate of compliance with PVSA is notoriously low. We determined various sociodemographic predictors of high noncompliance rate. Study design: Retrospective chart review of 214 patients who have undergone vasectomy by one surgeon was performed. All men had similar preoperative consultation with written instruction to provide two PVSA 2 and 4 months after vasectomy. Noncompliance was defined as a failure to provide PVSA. Sociodemographic data including age, marital status, number of children, level of education and smoking history were analyzed. Results: Of 214 patients, 99 (46.2%) provided no PVSA. Rate of noncompliance was independently higher in men with four or more children, smokers and those with lower educational level. Marital status and age had no impact on postoperative compliance Conclusion: Objective sociodemographic variables were associated with a higher risk of PVSA noncompliance. A more thorough approach to vasectomy counseling and timely reminder of upcoming PVSA in a preoperatively defined group of patients will help to improve compliance and prevent possible medical and legal repercussions.

Impact of a second semen analysis on a treatment decision making in the infertile man with varicocele

OBJECTIVE To evaluate the impact of second semen analysis (SA) on a treatment decision in infertile men with varicocele and abnormal first SA. DESIGN Retrospective chart review. SETTING University hospital. INTERVENTION None. MAIN OUTCOME MEASURE(S) Standard clinical semen analysis. PATIENT(S) A total of 160 infertile men with varicocele and abnormal first SA were evaluated. Two SA were performed in the same andrology lab 3 to 8 weeks apart. Exclusion criteria were azoospermia, low semen volume, leukocytospermia, febrile illness within 3 months, and habitual heat exposure. RESULT(S) Despite fluctuation in absolute values of sperm concentration, motility, and morphology, the second SA remained abnormal in 111 out of 112 men (99.1%) with abnormal first SA. CONCLUSION(S) Initial abnormal SA is a sufficient indication for varicocele treatment because in most patients the second SA remains abnormal and does not change treatment decision. This approach will expedite treatment of infertile men with varicocele and increase its cost effectiveness.

Soft X-ray microscopy at the NSLS

Scanning Transmission X-ray Microscopes are used to image 0.1-10 micron thick specimens at 20-50 nm resolution using zone plate focusing. Many of the applications of these instruments make use of the elemental and chemical sensitivity of XANES spectroscopy combined with microscopy. Recent instrumentation developments are described, including cryoSTXM for frozen hydrated specimens, tomography, configured detector for multiple contrast recording, etc. Diffraction-based imaging is being developed for high resolution 3D microscopy.

FRI-02 AGAINST ALL ODDS: THE BEGINNING OF EXPERIMENTAL RENAL PHYSIOLOGY

anterior fascia, which leads to excision of the suprapubic fat pad. Using this same exposure, the IPP is placed via an infrapubic approach following our standard protocol for prosthetic insertion. The wound is reapproximated and two drains are placed, one subcutaneous in the area of the fat pad excision and the other in the scrotum around the pump. RESULTS: A total of eight patients have undergone suprapubic fat pad excision with simultaneous placement of IPP at our institution. Average BMI of our patient cohort is 36.6. One patient required explant secondary to prosthetic infection after inadvertent removal of his JP drains immediately post-op. At last follow up, all other patients have excellent cosmetic and functional outcomes. CONCLUSIONS: Suprapubic fat pad excision is a safe and reproducible technique that can be performed simultaneously with placement of IPP in appropriately selected patients. Functional outcomes of our initial series have been excellent. This procedure can lead to enhanced patient satisfaction in those with concurrent erectile dysfunction and significant suprapubic fat pad.

The Rock of Ages: Stones Have Stood the Test of Time!

The first emperor of the Roman Empire Caesar Augustus, James I of England, King Louis XIV of France, Russian Czar, Peter the Great and George IV had them. Martin Luther, Michelangelo, Oliver Cromwell, Sir Isaac Newton endured them. Benjamin Franklin, President James K. Polk, Lyndon B. Johnson experienced them. Actor William Schatner sold them. Even the fictional character from Seinfeld, Cosmo Kramer, suffered with them. What if Napoleon Bonaparte had not had his stone during the Russian campaign in 1812? All of world history might have changed!