ADVERSE EFFECTS ON VASOEPIDIDYMOSTOMY OUTCOMES FOR MEN WITH CONCOMITANT ABNORMALITIES IN THE PROSTATE AND SEMINAL VESICLE

Purpose

Following microsurgical vasoepididymostomy as many as 85% of men have sperm in the ejaculate, yet only 30 to 50% will spontaneously father children. We examined the possibility that there may be concomitant abnormalities in the prostate and seminal vesicle, which may be associated with low pregnancy rates.

Materials and Methods

Transrectal ultrasound was performed in azoospermic men with suspected epididymal obstruction, excluding those who had undergone vasectomy, to identify abnormalities of the seminal vesicles and ejaculatory ducts. Microsurgical vasoepididymostomy was attempted in all men.

Results

Transrectal ultrasound revealed ejaculatory duct dilatation in 13 of 40 men (33%), although only 3 had accompanying seminal vesicle dilatation. Two men had atrophic seminal vesicles with normal ejaculatory ducts. At surgery 8 of 40 patients (20%) were deemed to have irreparable conditions. For the 27 men followed at least 6 months postoperatively patency and pregnancy rates were 75 and 22%, respectively. Mean sperm counts plus or minus standard deviation were significantly higher in men without compared to those with seminal vesicle or ejaculatory duct abnormalities (43 ± 68 versus 5.7 ± 6.9 x 10⁶ sperm per ml., respectively), and so was the percentage of motile sperm (30 ± 16% versus 1.2 ± 2.2%, respectively). Pregnancy rates were also higher in men without (6 of 19, 32%) than with (0 of 8, 0%) seminal vesicle or ejaculatory duct abnormalities.

Conclusions

Transrectal ultrasound detected abnormalities of the seminal vesicles and ejaculatory ducts are common in men with suspected epididymal obstruction. These abnormalities are associated with a poor outcome for vasoepididymostomy. We recommended that all men with suspected epididymal obstruction undergo transrectal ultrasound before any attempted reconstruction.     

Vasoepididymostomy for Vasectomy Reversal: A Critical Assessment in the Era of Intracytoplasmic Sperm Injection

Purpose

We compared vasoepididymostomy to microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection for treatment of epididymal obstruction secondary to vasectomy.

Materials and Methods

Results in patients who underwent vasoepididymostomy for vasectomy reversal at our institution were compared to those reported previously for microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection performed for obstructive azoospermia. The pregnancy rates, delivery rates, complications, cost per procedure and cost per delivery were compared. A cost per newborn analysis was performed using pregnancy and delivery rates, and reported cost estimates for the complications of assisted reproductive techniques.

Results

A total of 55 men underwent 58 vasoepididymostomies in an attempt to restore fertility after vasectomy. Median followup was 19 months (range 0 to 115). Median obstructive interval was 12 years. There were no major complications. The patency rate after 6 months was 85%. Of the couples 20 achieved 24 pregnancies and 16 had 17 live births. The pregnancy rate at 1 year was 44%. There were 4 miscarriages and there are 3 ongoing pregnancies. The live delivery rate was 36%. Assuming a 29% delivery rate for microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection, the cost per newborn was $51,024, compared to $31,099 for vasoepididymostomy.

Conclusions

Vasoepididymostomy is more successful and more cost-effective than microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection for vasectomy reversal. It does not expose the women to complications in the treatment of a male problem and it is indicated for treatment of epididymal obstruction secondary to vasectomy. Microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection should be reserved for cases not amenable to surgical reconstruction.     

Microsurgical vasoepididymostomy with sperm cryopreservation for future assisted reproduction

BACKGROUND: Although obstructive azoospermia is treatable with microscopic seminal reconstruction, the number of patients who choose to undergo vasoepididymostomy is limited because of recent advances in assisted reproductive technology (ART). We attempted to define the outcome of surgical reconstruction in patients with suspected epididymal obstruction and no previous history of vasectomy. METHODS: We described 40 eligible end-to-side vasoepididymostomy procedures performed on 24 azoospermic patients who had either bilateral or unilateral epididymal obstruction. RESULTS: The overall patency rate following surgery was 54% (13/24) and for four patients (17%), natural intercourse resulted in pregnancy. Two pregnancies were initiated with intracytoplasmic sperm injections using frozen sperm collected during vasoepididymostomy. CONCLUSIONS: In the era of modern ART, microsurgical vasoepididymostomy with cryopreservation of sperm collected during the operation is recommended for patients with epididymal obstructions.     

Prospective analysis of outcomes after microsurgical intussusception vasoepididymostomy

OBJECTIVE: To prospectively analyse the outcomes of microsurgical vasoepididymostomy using the intussusception technique, as vasoepididymostomy is considered the most challenging reconstructive microsurgery in urology. PATIENTS AND METHODS: From 1998 to 2003, of 324 men with obstructive azoospermia who had undergone microsurgical reconstruction of the reproductive tracts, 68 (21%) had intussusception vasoepididymostomy bilaterally or unilaterally in a functionally solitary testis. The outcomes of these patients were analysed prospectively. RESULTS: The mean age was 39.8 years for the men and 31.8 years for their partners. The causes of obstruction were after vasectomy in 31%, infection in 22%, iatrogenic in 19%, trauma in 1.5%, and idiopathic in 27%. The median duration of obstruction was 18.8 years; 37% of patients had had previous failed attempts at reconstruction. The mean (range) follow-up was 15.2 (1-36) months. The overall patency (>10 000 sperm/mL) rate was 84% (53/63). Patency was achieved in 60% (38/63) of men at 1 month after surgery. The mean best sperm count was 12.8 (0.01-80) x 10(6)/mL, with a 21 (0-30)% motility. Among patients with a follow-up of > 1 year, the natural paternity rate was 40%. The median time to achieve a natural pregnancy was 14.3 (3-30) months. Pregnancy was achieved with in vitro fertilization or intracytoplasmic sperm injection in 31% of cases, all using fresh ejaculated sperm. CONCLUSIONS: A favourable patency and pregnancy rate can be achieved using microsurgical intussusception vasoepididymostomy. Even when assisted-reproductive technology is needed, fresh ejaculated sperm can be used without requiring a subsequent sperm retrieval procedure. Thus, microsurgical reconstruction of the reproductive tract should be primary therapeutic method in cases of azoospermia from epididymal obstruction.     

FERTILITY OUTCOME AFTER REPEAT VASOEPIDIDYMOSTOMY

PURPOSE: Historically, epididymal obstruction has been treated with surgical reconstruction. We determine whether it is worthwhile for patients to undergo repeat surgical reconstruction after failed vasoepididymostomy or whether they should be advised only to undergo sperm acquisition for assisted reproductive technique. MATERIALS AND METHODS: A total of 18 patients underwent repeat vasoepididymostomy performed by a single urologist (A. J. T.). Cases were divided based on the etiology of obstruction into groups 1--prior vasectomy (4), 2--congenital (7) and 3--inflammatory (7). Data were available regarding time of obstruction between initial and repeat vasoepididymostomy, quality of epididymal fluid, levels of anastomoses, semen analyses at least 12 months after surgery for all 18 men and pregnancy rates based on more than 18 months of followup in 12. RESULTS: Mean patient age at repeat vasoepididymostomy was 40.6 years (50.5, 36 and 39.4 years for groups 1, 2 and 3, respectively). Mean interval between vasectomy and initial vasoepididymostomy was 12.3 years (range 10 to 18). Mean interval between initial and repeat vasoepididymostomy was 19 months (range 12 to 41). Of the patients 10 underwent unilateral and 8 bilateral anastomoses, for a total of 26 repeat anastomoses. Overall patency rate was 66.7% (12 of 18) with sperm in the ejaculate in 75, 85 and 43% of patients in groups 1, 2 and 3, respectively. The patency rates according to the levels of the anastomosis were 66.7, 62.5 and 100% in the caput, corpus and cauda, respectively. Natural conception occurred in 3 of 12 couples (25%, 2 caput and 1 caudal anastomosis) during a mean followup of 23 months (range 13 to 34). All 3 cases had congenital obstruction. Pregnancy was achieved in 2 group 1 cases with cryopreserved sperm extracted at repeat vasoepididymostomy, and in 1 case each in groups 1 and 2 with microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection. CONCLUSIONS: After repeat vasoepididymostomy two-thirds of men have sperm in the semen. Natural conception occurred in 25% of patients (3 of 12) followed for more than 18 months. Inability to establish pregnancy in the remaining 7 of 9 patients with sperm in the semen with a followup longer than 18 months may be due to epididymal dysfunction or partial obstruction and subsequent poor sperm quality. Aspiration of motile sperm and cryopreservation were possible in 11 of 18 cases at repeat vasoepididymostomy and should be recommended in case azoospermia remains or occurs after surgery. It appears worthwhile to offer patients repeat vasoepididymostomy after a failed initial procedure.     

Should all urologists performing vasectomy reversals be able to perform vasoepididymostomies if required?

PURPOSE: While vasectomy reversal is a highly successful procedure 10% to 30% of reversals may fail. Despite the general consensus that an epididymal obstruction may occur following a vasectomy and that some men should undergo vasoepididymostomy (VE) rather than vasovasostomy (VV), the practice of many urologists in our region has been to offer only VV for vasectomy reversal. We examined the potential causes for vasectomy reversal failure in patients who had undergone VV without an attempt at VE. MATERIALS AND METHODS: We conducted a retrospective review of patients who had undergone redo vasectomy reversal from January 1999 to September 2001. A total of 22 patients underwent redo reversal with a minimum followup of 2 years. The medical records of all patients were then reviewed. Patients and partners seen postoperatively in the clinic were questioned regarding any pregnancy or deliveries. RESULTS: We examined 22 patients who had undergone redo vasectomy reversal. Of 22 patients 9 (40.9%) underwent repeat VV, 8 (36.3%) underwent bilateral VE for a presumed unrecognized epididymal obstruction and 5 (22.7%) had a combination of VE and VV. Of the 44 reproductive units studied 23 (52.3%) had a failed vasal anastomosis while 21 (47.7%) had an unrecognized epididymal obstruction. Based on semen analysis patency was observed in 75% of patients who had undergone vasovasostomy as a redo procedure. A patency rate of 60% was found in patients who underwent vasoepididymostomy and vasovasostomy unilaterally, and patency rates for bilateral VE were 63%. CONCLUSIONS: Our study indicates that a large proportion of men (48%) have an epididymal obstruction as the etiology for vasectomy reversal failure. We recommend that all surgeons offering vasectomy reversals be able to offer VE if required based on intraoperative findings to serve the patient adequately as well as his partner and their future fertility.     

SEMINAL TRACT OBSTRUCTION CAUSED BY CHILDHOOD INGUINAL HERNIORRHAPHY: RESULTS OF MICROSURGICAL REANASTOMOSIS

Purpose

Childhood inguinal herniorrhaphy is a frequent causes of seminal tract obstruction. We investigate the characteristics of this obstruction, surgical techniques for reanastomosis and outcomes in patients with bilateral or unilateral obstruction caused by inguinal herniorrhaphy in childhood.

Materials and Methods

We treated 22 men an average of 30.5 years old in whom average duration of obstruction was 27.1 years. Obstruction was bilateral in 9 patients and unilateral in 13, and 14 had azoospermia preoperatively. Microsurgical 2 layer vasovasostomy and/or specific tubule epididymovasostomy was performed.

Results

Inguinal and crossed vasovasostomy was done in 18 and 4 patients, respectively. The distal end of the vas was found at the internal inguinal ring or in the pelvic cavity in 57.1% of the vasa and more than 3 cm. of the vas had been resected in 37%. Sperm was noted in vasal fluid in 45.2% of the vasa during the operation and the patency rate of inguinal vasovasostomy was 88.9%. Ipsilateral epididymovasostomy performed after patent inguinal vasovasostomy in 5 patients with secondary epididymal obstruction resulted in normal sperm density and 3 pregnancies. In 7 men more than 2 procedures were done. There was sperm in the ejaculate in 12 of the 14 patients who had had azoospermia preoperatively and apparently increased sperm density postoperatively in 4 of the 8 who had not had azoospermia preoperatively. Pregnancy was achieved by 7 of the 21 married men (33.3%).

Conclusions

Microsurgical reanastomosis of the seminal tract resulted in high patency and pregnancy rates in cases of seminal tract obstruction caused by childhood inguinal herniorrhaphy. Patients should elect seminal tract reanastomosis or assisted reproductive technology using epididymal or testicular sperm after receiving sufficient information on each treatment modality.     

TRIANGULATION END-TO-SIDE VASOEPIDIDYMOSTOMY

Purpose

A technique and the preliminary results of triangulation vasoepididymostomy are described.

Materials and Methods

Triangulation vasoepididymostomy is performed by placing 3 double-armed 10-zero nylon sutures into the epididymis so that each suture forms 1 side of a triangle. An opening in the tubule is made between the sutures and they are brought inside-out, invaginating the epididymal tubule into the vas deferens.

Results

Triangulation end-to-side vasoepididymostomy was performed bilaterally in 12 men, and sperm was found in the postoperative ejaculate of 11 (92%). Operative time was 156 +/− 14 minutes.

Conclusions

Triangulation vasoepididymostomy is reasonably successful in restoring sperm to the ejaculate and should be considered as an alternative method of vasoepididymostomy.     

SPERM PELLET ANALYSIS: A TECHNIQUE TO DETECT THE PRESENCE OF SPERM IN MEN CONSIDERED TO HAVE AZOOSPERMIA BY ROUTINE SEMEN ANALYSIS

Purpose

In men considered to have azoospermia by routine semen analyses sperm may be identified after centrifuging the semen. Because these sperm may be used for intracytoplasmic sperm injection, we describe our technique and findings of sperm pelleting.

Materials and Methods

Semen centrifugation for sperm pellet analysis was performed in 140 consecutive men in whom no sperm was identified on routine semen analysis and who were categorized as having obstructive or nonobstructive azoospermia. Obstructive azoospermia was defined as failed vasectomy reversal, failed reconstruction for congenital vasal or epididymal occlusion, or an acquired obstruction unrelated to ejaculatory duct obstruction. Patients with congenital absence of the vas deferens or who had undergone vasectomy were not included in the study. Nonobstructive azoospermia was defined as moderate to severe testicular atrophy with markedly elevated serum follicle-stimulating hormone (greater than 3 times normal), or a testicular biopsy that revealed maturational arrest, severe hypospermatogenesis or the Sertoli-cell-only pattern. Obstructive and nonobstructive azoospermia were present in 70 men who provided 109 samples and 70 who provided 103, respectively.

Results

Motile and nonmotile sperm was identified in 13 of the 70 patients (18.6%) with obstructive and in 16 of the 70 (22.8%) with nonobstructive azoospermia. Pellet variability, that is the absence of sperm in 1 specimen and its presence in another from the same patient, was noted in 7 of the 17 men (41.2%) with obstructive and 2 of the 17 (11.8%) with nonobstructive azoospermia (not statistically significant). Motile sperm was present in the pellets of 6 of the 70 men (8.6%) with obstructive and 15 of the 70 (21.4%) with nonobstructive azoospermia. The median number of motile sperm was lower in the obstructive than in the nonobstructive group (0 sperm in 17 samples versus 5 sperm in 41 samples, p <0.001). The median value of 0 in the obstructive azoospermia group reflects the finding that 9 of the 17 samples did not contain motile sperm. Similarly the median number of nonmotile sperm was lower in the obstructive than in the nonobstructive group (5 versus 8 sperm).

Conclusions

We demonstrated the presence of motile and nonmotile sperm in a significant number of men considered to have azoospermia by routine semen analysis. Semen centrifugation (sperm pelleting) should be performed in all men considered to have this condition by routine semen analysis, especially those with testicular failure and those in whom intracytoplasmic sperm injection is possible.     

附睾输精管吻合术治疗梗阻性无精子症

目的探讨附睾输精管吻合术在梗阻性无精子症治疗中的作用。方法选择23例确诊为梗阻性无精子症并初步怀疑为附睾水平梗阻的患者进行阴囊探查，观察睾丸、附睾及输精管情况，对其中19例确定为附睾水平梗阻并在附睾液中找到活精子的患者用8-0尼龙线施行双侧或单侧附睾输精管端侧吻合术，术后随访其疗效。结果19例获随访8～34个月，9例(47％)于术后3～9个月从精液中检出活精子，其中5例配偶受孕成功。结论阴囊探查简单、易行，有助于梗阻性无精子症的诊断和治疗，附睾输精管吻合术治疗梗阻性无精子症取得初步效果，值得进一步探讨。     

PARTIAL OBSTRUCTION, NOT ANTISPERM ANTIBODIES, CAUSING INFERTILITY AFTER VASOVASOSTOMY

Purpose

We determined whether men who may have partial obstruction and antisperm antibodies after vasovasostomy can be distinguished from other infertile men with antisperm antibodies only, and whether repeat microsurgical reversal is beneficial in such patients.

Materials and Methods

A total of 412 patients underwent indirect immunobead testing for antisperm antibodies at our laboratory from December 1991 through July 1996. Of 95 patients with an assay greater than 20% binding 49 had normal partners and were grouped by history of vasovasostomy (20), varicocele (9), cryptorchidism (8) and epididymo-orchitis (12). Semen analysis characteristics and antisperm antibody binding variables were compared across histories. Pregnancy rates were compared between patients treated surgically for partial obstruction and those treated for antisperm antibodies. Mean followup was 33.8 months.

Results

Compared to the other 3 groups, men with a history of vasectomy and reversal had significantly lower sperm concentration (p = 0.002), poorer motility (p <0.001), lower overall binding on the indirect immunobead assay (p <0.001) and lower IgA binding (p = 0.008). The clinical diagnosis of partial obstruction was based on a sense of epididymal fullness by palpation, as well as the aforementioned semen parameters. Of the 20 patients with a history of vasectomy and reversal 14 were diagnosed with partial obstruction and underwent repeat microsurgical reversal and 6 with a history of vasovasostomy but no evidence of obstruction received no further therapy and never established pregnancies. The remaining 29 patients underwent sperm washing and assisted reproduction. Of 14 patients 7 (50%) established pregnancies after repeat reversal compared to only 5 of 29 patients (17.2%) treated with assisted reproduction (P = 0.025).

Conclusions

Antisperm antibodies are not a significant factor in persistently infertile post-reversal cases with the aforementioned criteria. Repeat reversal appears to be the most successful treatment option in this setting.     

The Feasibility of Cryopreservation of Sperm Harvested Intraoperatively During Vasectomy Reversals

Purpose

Intracytoplasmic sperm injection during in vitro fertilization involves the microinjection of a single sperm into each egg from the partner. Pregnancies have resulted from this powerful new technology when fewer than 100 motile sperm were present in the semen, or when sperm were obtained from the epididymis or testicle by open operations or needle aspirations. Some surgeons have cryopreserved sperm obtained from the vas or epididymis during vasectomy reversals. However, cryopreservation of nonmotile sperm serves no useful purpose.

Materials and Methods

We performed a retrospective analysis of 603 vasectomy reversals in which the intraoperative vasal and/or epididymal fluid was examined microscopically. The motility of the sperm obtained intraoperatively was used as a gauge for the potential use of such sperm for in vitro fertilization and intracytoplasmic sperm injection after cryopreservation and thawing, should the vasectomy reversal fail.

Results

Motile sperm were present in the intraoperative vasal or epididymal fluid in 35% of all vasectomy reversals (34% of first and 39% of repeat procedures). The percentage of reversals in which motile sperm were present in the intraoperative fluid was not related to the time from vasectomy until reversal.

Conclusions

The absence of motile sperm in the intraoperative vasal or epididymal fluid precludes consideration of sperm cryopreservation during vasectomy reversals. Although to our knowledge the minimum percentage of sperm motility needed for in vitro fertilization and intracytoplasmic sperm injection after cryopreservation and thawing has not been established, our results provide surgeons with information to judge the merit of sperm harvesting and cryopreservation during vasectomy reversals.     

Microscopic evaluation of the vasal fluid for sperm at the time of vasectomy reversal: Do we really need to check?

IntroductionDuring vasectomy reversal, intraoperative microscopic evaluation of the vasal fluid for sperm presence/quality can inform of the possibility of epididymal obstruction and need for a vasoepididymostomy (VE). In an effort to validate the utility of microscopic vasal fluid evaluation, the current initiative correlates gross vasal fluid characteristics with sperm presence and quality in a large series of VRs.MethodsA total of 1267 vasectomy reversals yielded a total of 2522 vasal-units (right/left sides) for analysis. During vasectomy reversal, vasal fluid was sampled from the testicular-end vas and the fluid was characterized (thick-paste/opaque/translucent/clear). Each aspirate underwent microscopic evaluation for sperm quality and was categorized as: motile sperm/intact-non-motile sperm/sperm parts/no sperm. The predictive utility of the gross vasal fluid characteristics with respect to microscopic sperm presence and quality was analyzed.ResultsAmong the 2522 vasal units analyzed, the side-to-side (left-right) concordance of vasal fluid quality and microscopic vasal sperm quality was 72% and 52%, respectively. When thick-pasty fluid was observed, no sperm were seen in the samples in 53% of cases, and if present, only non-motile sperm were observed. Even in the setting of more favorable vasal fluid characteristics (clear, translucent, and opaque fluid), no sperm were seen in 6–11% of cases, suggesting the possibility of epididymal obstruction and the need for VE.ConclusionsIntraoperative microscopic evaluation of the vasal fluid for sperm is a necessary practice during vasectomy reversal to optimize surgical outcomes. Reliance on gross vasal fluid characteristics in isolation may lead to unrecognized epididymal obstruction, and the need for a VE, in approximately 11% of cases.     

VASECTOMY REVERSAL ASSOCIATED WITH INCREASED REACTIVE OXYGEN SPECIES PRODUCTION BY SEMINAL FLUID LEUKOCYTES AND SPERM

Purpose

Reactive oxygen species, which are primarily produced by leukocytes, are generally detrimental to sperm. High reactive oxygen species levels are found in men with abnormal sperm function. Since men often have poor sperm characteristics and infertility after vasectomy reversal, fertile men to determine if reactive oxygen species were elevated in the former group.

Materials and Methods

We studied semen samples of men with proved fertility (39) and those with previously proved fertility who had undergone vasectomy reversal (45). The presence of leukocytes was determined by Bryan-Leishman staining. Reactive oxygen species endogenous activity was monitored by luminol dependent chemiluminescence in washed cells, including all cells in the semen, and Percoll density gradient purified sperm.

Results

After vasovasostomy men had significantly lower sperm concentration, motility and computerized motility measurements than fertile men. Mean reactive oxygen species in washed seminal cells after vasovasostomy was 684 relative light units per second compared to 49 for fertile controls (p <0.0001). Density gradient purified sperm had 53 and 0.64 relative light units per second, respectively (p <0.0001). When men with leukocytospermia were excluded from analysis, differences between the groups remained, although 9 times more reactive oxygen species were detected in men after vasectomy reversal with than those without leukocytes in semen.

Conclusions

Higher levels of reactive oxygen species are found in washed seminal cells and purified sperm after vasectomy reversal than in those of fertile men. Although leukocytes are probably a significant source of reactive oxygen species in these groups, they may not account for all of the increased reactive oxygen species after vasovasostomy. Low motility after vasectomy reversal may be related to the detrimental effects of reactive oxygen species produced by leukocytes or sperm, even in men without clinical leukocytospermia.     

梗阻性无精子症的外科治疗(附56例报告)

目的:探讨梗阻性无精子症的诊断和外科治疗方法。方法:分析2004年10月至2008年11月间收治的56例梗阻性无精子症患者的临床资料,其中43例为射精管梗阻性无精子症,13例疑为附睾水平梗阻性无精子症。常规精液分析、精浆果糖和中性α葡糖苷酶测定以及经直肠超声检查(TRUS)对其进行诊断,必要时行输精管造影检查。43例为射精管梗阻性无精子症使用经尿道射精管切开术(TURED)治疗,13例疑为附睾水平梗阻性无精子症行阴囊探查术,对其中11例确定为附睾水平梗阻行双侧或单侧附睾输精管端侧吻合术,术后随访其疗效。结果:所有患者均完成手术,术后随访3～51个月。43例射精管梗阻性无精子症TURED术后,36例(83.7%)精液检查有不同程度的改善,11例(25.6%)妻子妊娠。11例附睾水平梗阻性无精子症行输精管附睾吻合术后,6例(54.5%)精液检查检出活精子,3例(27.3%)妻子妊娠。结论:精液分析、精浆果糖和中性α葡糖苷酶测定,TRUS和输精管造影是诊断梗阻性无精子症的主要方式。TURED和输精管附睾吻合术分别是治疗射精管梗阻性无精子症和附睾水平梗阻性无精子症的有效方法。     

Repeat vasectomy reversal after initial failure: overall results and predictors for success

PURPOSE: We review the treatment outcomes for microsurgical reconstruction following failed vasectomy reversal and identify predictors for success. MATERIALS AND METHODS: We performed a retrospective review of our experience with microsurgical reconstruction in 41 men who underwent 1 or more prior unsuccessful vasectomy reversal procedures. Of these patients 20 underwent bilateral (16) or unilateral (4) vasoepididymostomy, 11 underwent bilateral (7) or unilateral (4) vasovasostomy and 10 underwent unilateral vasoepididymostomy with contralateral vasovasostomy. Postoperative followup consisted of serial semen analyses and telephone interviews. RESULTS: Patency and pregnancy followup data were available in 33 and 31 patients, respectively. Five couples had ongoing uncorrected female factor infertility problems and were not included in pregnancy rate calculations. Mean obstructive interval was 10.6 years. Overall patency and pregnancy rates were 79 and 31%, respectively. Mean total motile sperm count for patients demonstrating patency at followup was 38.0 million. History of conception with the current partner was predictive of future conception with 4 of 5 nonremarried couples (80%) initiating a pregnancy versus 3 of 18 remarried couples (17%) (p = 0.006). Other factors, including smoking history and obstructive interval, did not correlate with postoperative success. Reconstruction with vasovasostomy on at least 1 side trended toward improved patency (p = 0.17) and pregnancy rates (p = 0.15), although they did not assume statistical significance. CONCLUSIONS: Microsurgical reconstruction following failed vasectomy reversal is associated with high patency and moderate pregnancy rates at short-term followup. In our series previous conception with the current partner was predictive of future conception after reconstruction. Urologists performing repeat vasectomy reversal must be familiar with microsurgical techniques, since almost three-quarters of patients will require at least unilateral vasoepididymostomy.     

Is physical examination useful in predicting epididymal obstruction?

Objectives. To evaluate the independent predictive value of subjective epididymal fullness in predicting obstruction in azoospermic men (group 1) and determining preoperatively the need for vasoepididymostomy (VE) in men presenting for vasectomy reversal (group 2).Methods. All men were evaluated with a medical history and physical examination. During the physical examination, the epididymis was classified as full, if any portion was palpably distended, or normal. Obstruction was confirmed at surgical exploration for group 1 after a biopsy that revealed sufficient spermatogenesis. In group 2, the indications for VE were either no fluid seen from the testicular end of the vas or thick, pasty fluid devoid of sperm. In cases in which VE was required, these units were classified as obstructed.Results. The predictive value of epididymal fullness was evaluated in 51 units (12 in group 1 and 39 in group 2). The sensitivity, specificity, and positive and negative predictive values were 67%, 100%, 100%, and 83%, respectively, in group 1 and 33%, 89%, 20%, and 94%, respectively, in group 2.Conclusions. Epididymal fullness in azoospermic men is predictive of obstruction, although a normal epididymal examination cannot rule out obstruction. In men presenting for vasectomy reversal, the absence of epididymal fullness is predictive of vasal fluid that allows for vasovasostomy. Epididymal fullness may suggest, but cannot predict, unfavorable vasal fluid that requires VE.     

SUCCESSFUL SPERM RETRIEVAL BY PERCUTANEOUS EPIDIDYMAL AND TESTICULAR SPERM ASPIRATION

Purpose

We evaluated the safety and efficacy of percutaneous sperm aspiration from the epididymis or testicle as a diagnostic technique to confirm sperm production and as a therapeutic technique to harvest sperm for use in intracytoplasmic sperm injection.

Materials and Methods

We present our experience with 69 sperm aspiration procedures in men considered to have nonreconstructible obstructive azoospermia. This short outpatient procedure was performed using a butterfly needle with the patient under intravenous sedation and local anesthesia.

Results

Of the 32 diagnostic aspirations 20 demonstrated mature and motile sperm, 9 maturation arrest and 3 germ cell aplasia. In 35 of 37 therapeutic sperm aspirations (95%) adequate samples of sperm after processing (mean of 5.4 million) were obtained. Of 24 epididymal aspirations 13 (54%) had sufficient residual sperm for cryopreservation of 1 to 5 vials (mean 2.5) containing an average of 170,000 sperm per vial. In the 32 intracytoplasmic sperm injection cycles 221 of 392 eggs (56.3%) fertilized (2PN) and 6 resulted in ongoing pregnancies (21.4% per transfer). There have been no acute or chronic complications in this patient population. Ten men underwent a second successful aspiration procedure for intracytoplasmic sperm injection and 3 underwent a third aspiration without added difficulty.

Conclusions

Percutaneous epididymal or testis sperm aspiration is a minimally invasive sperm retrieval technique and appears to be an effective alternative to microsurgical epididymal sperm aspiration, which is more invasive, costly and technically difficult.     

Need for sperm retrieval and cryopreservation at vasectomy reversal

PURPOSE: Controversy exists on whether to obtain sperm for cryopreservation routinely at vasectomy reversal. With recent improvements in in vitro fertilization with intracytoplasmic sperm injection, it is now possible to obtain a small amount of testicular tissue for cryopreservation in the event of reversal failure. However, to our knowledge no studies exist of who is most likely to benefit from this procedure. MATERIALS AND METHODS: We reviewed 84 consecutive vasectomy reversals performed by 1 surgeon (J. I. S.) between July 1996 and March 2000 with followup available for 77. We grouped cases by procedure as vasovasostomy, vasoepididymostomy and vasovasostomy with vasoepididymostomy as well as bilateral or unilateral. Sperm was retrieved at reversal in 15 of 46 vasovasostomy (none used), 11 of 18 vasoepididymostomy (3 used) and 13 of 20 vasovasostomy with vasoepididymostomy (none used) cases. RESULTS: The overall anastomotic patency rate after unilateral or bilateral vasovasostomy, unilateral vasovasostomy with contralateral vasoepididymostomy and unilateral or bilateral vasoepididymostomy was 96%, 83% and 57%, respectively. The natural pregnancy rate without in vitro fertilization was 57%, 50% and 14%, respectively. The most recent vasoepididymal anastomoses were performed by the Berger triangulation technique with a 78% patency and 25% pregnancy rate. Only 8% of men with banked sperm eventually used it for assisted reproductive techniques, in whom unilateral or bilateral vasoepididymostomy failed in all. CONCLUSIONS: We currently do not recommend routine sperm retrieval for cryopreservation in men who undergoing vasovasostomy. We encourage men who require bilateral vasoepididymostomy to bank sperm at reversal. In men who undergo vasovasostomy with vasoepididymostomy we base the decision on preoperative counseling and intraoperative findings.     

Clinical Value of Renovascular Resistive Index Measurement in the Diagnosis of Acute Obstructive Uropathy

Purpose

We evaluated the clinical use of the renal resistive index in identifying patients with acute urinary tract obstruction.

Materials and Methods

Of 54 patients with suspected acute urinary tract obstruction who underwent measurements of renal resistive index 19 had unilateral obstruction documented with excretory urography and comprise our study sample. The contralateral nonobstructed kidneys served as controls. Criteria for obstruction were a resistive index of 0.70 or greater or a side to side difference of 0.10 or greater. We calculated sensitivity, specificity, and positive and negative predictive values.

Results

Sensitivity for obstruction was 42% with 11 false-positive cases, specificity was 79%, and positive and negative predictive values were 67 and 57%, respectively.

Conclusions

Renal resistive index measurements are not valuable in detecting acute urinary tract obstruction.