Vasectomy failure and open-ended vasectomy.
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Biomedical subjects
Publications and source records attributed to S S Schmidt.
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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.
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Spermatic granulomas are specialized abscesses which frequently occur at the site of vasectomy. Although some are often silent, others can be agonizingly painful. A series of 154 granulomas is presented. Of these, 83 were symptomatic and 63 required surgery for relief of pain.
As vasectomy continues in popularity, requests for restoration of fertility increase in number. Anastomosis of the vas deferens is a demanding, technically difficult operation. The principles governing it are different from those of other anastomoses in the body. The suitably equipped surgeon can expect, with practice, to achieve a pregnancy rate of 50% or better for his patient's wife. The operation can easily be performed under local anesthesia in either an office or hospital operating room. Hospitalization is unnecessary, and merely adds unnecessary expense. Disability is minimal, and discomfort minor. The technique of Belker is recommended for practice, since it permits one to inspect the anastomosis from within afterwards.
A battery-powered, bipolar electrocoagulator has been specifically developed for sealing the cut ends of the divided vas at vasectomy. With a minimum of electric power, the electrocoagulator destroys only the mucosa and one or two muscle cell layers of the vas, which leads to optimal fibrosis of the cut ends. This instrument has been used in more than 1000 vasectomies without a known failure and with a minimum of complications. An analysis of these cases is reported with emphasis upon the method's success in sealing the vas.
Blood samples were collected from 77 men at the time of vasovasostomy and tested for the presence of antisperm antibodies. More men with granulomas had sperm-immobilizing antibodies than did those without granulomas.
Whether antisperm antibodies develop after vasectomy probably depends on several variables, 1 of which may be the surgical technique. The levels of serum antisperm antibodies were compared in men vasectomized by 1 techniques: vasoligation and fulguration. No difference in the incidence of spermagglutinating antibody was found in the 2 groups. However, immobilizing antibodies were observed in 43 per cent of the men undergoing vasoligation but in only 29 per cent of the men vasectomized by fulguration.
After vasectomy, the lumen of the testicular side of the vas deferens dilates, apparently because of internal pressure from accumulation of spermatic fluid. This dilatation occurs within the 1st postoperative year. It causes a thinning of the wall of the vas without significant increase in the external diameter. The extent of dilatation is similar in the same man, but differs markedly between individuals, the mean increase in diameter being approximately 70%. The implications of this difference in size are discussed with regard to vas anastomosis and to the possible use of devices to rejoin the vas or to bridge a defect created by a prior vasectomy.
Vas anastomosis is successful in restoring sperm to the ejaculate in 80 to 90% of cases. A simple, end-to-end, mucosa-to-mucosa anastomosis performed with non-absorbable, monofilament sutures is, in the author's opinion, the best procedure. Pregnancies follow in about one-third of the cases.
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