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PubMed1998

Trends in vasectomy. Analysis of one teaching practice.

PROBLEM BEING ADDRESSED: How can a teaching practice develop a referral service and incorporate educational opportunities for family medicine residents, clinical clerks, and community family physicians? OBJECTIVE OF PROGRAM: To develop a high-quality vasectomy service within a teaching practice to change the surgical procedure to the no-scalpel vasectomy (NSV) technique; to educate family medicine residents, clinical clerks, and community family physicians about vasectomy and the NSV technique; and to monitor outcomes and compare them with published results. MAIN COMPONENTS OF PROGRAM: The program took place in an urban family medicine residency program. Data on number of procedures, types of patients choosing vasectomy, and outcomes are presented, along with information on number of learners who viewed, assisted with, or became competent to perform NSV. CONCLUSIONS: A few family medicine residents and some interested community physicians could be trained to perform NSV competently. Involving learners in the procedure does not seem to change the rate of complications.

Adult↗
PubMed2006

Prospective randomized clinical trial comparing the effects of a masticatory bite wafer and avoidance of hard food on pain associated with initial orthodontic tooth movement.

INTRODUCTION: The purpose of this prospective, randomized clinical trial was to compare the use of masticatory bite wafers with the avoidance of mastication in reducing pain and discomfort associated with initial orthodontic tooth movement. METHODS: Eighty-four subjects (mean age, 14.1 years), randomly allocated to a bite-wafer group (BWG) or a reduced-mastication group (RMG), completed the study. In each subject, 1 arch was bonded and ligated with a round austenitic active 0.016-in nickel-titanium wire, and placebo instructions were given. The subjects in the BWG then performed immediate supervised mastication of the wafers for 10 minutes, and they were instructed thereafter to bite on the wafers to prevent pain for the next 7 days. The subjects in the RMG were instructed not to masticate for 3 hours after placement of the fixed appliance and to avoid masticating hard food for 7 days. Each patient's level of anxiety was assessed before treatment with standard psychometric questionnaires. Each patient recorded the level of pain immediately after archwire ligation on a 100-mm visual analogue scale (VAS) and used a pain diary with a verbal rating scale for the next 7 days. RESULTS: No statistically significant differences in the VAS immediately after ligation of the archwires were observed between the 2 groups. The median pain score for the BWG was higher for the first 4 days. The median peak difference was reached on the evening of the first day. At this maximum value, the median pain score of the BWG was higher and statistically significant (P = .006). CONCLUSIONS: Although the amount of pain and discomfort reported by the patients undergoing fixed orthodontic therapy varied, more pain was reported by those using bite wafers than by those who avoided masticatory activity after placement of fixed appliances.).

Adolescent↗
PubMed2004

A comparison of vas occlusion techniques: cautery more effective than ligation and excision with fascial interposition.

BACKGROUND: Vasectomy techniques have been the subject of relatively few rigorous studies. The objective of this analysis was to compare the effectiveness of two techniques for vas occlusion: intraluminal cautery versus ligation and excision with fascial interposition. More specifically, we aimed to compare early failure rates, sperm concentrations, and time to success between the two techniques. METHODS: We compared semen analysis data from men following vasectomy using two occlusion techniques. Data on intraluminal cautery came from a prospective observational study conducted at four sites. Data on ligation and excision with fascial interposition came from a multicenter randomized controlled trial that evaluated the efficacy of ligation and excision with versus without fascial interposition. The surgical techniques used in the fascial interposition study were standardized. The surgeons in the cautery study used their customary techniques, which varied among sites in terms of type of cautery, use of fascial interposition, excision of a short segment of the vas, and use of an open-ended technique. Men in both studies had semen analyses two weeks after vasectomy and then approximately every four weeks. The two outcome measures for the analyses presented here are (a) time to success, defined as severe oligozoospermia, or <100,000 sperm/mL in two consecutive semen analyses; and (b) early vasectomy failure, defined as >10 million sperm/mL at week 12 or later. RESULTS: Vasectomy with cautery was associated with a significantly more rapid progression to severe oligozoospermia and with significantly fewer early failures (1% versus 5%). CONCLUSION: The use of cautery improves vasectomy outcomes. Limitations of this comparison include (a) the variety of surgical techniques in the cautery study and differences in methods of fascial interposition between the two studies, (b) the uncertain correlation between sperm concentrations after vasectomy and the risk of pregnancy, and (c) the use of historical controls and different study sites.

Cautery↗
PubMed2003

Studies on sperm storage in the vas deferens of the spinifex hopping mouse (Notomys alexis).

The cauda epididymidis, with its relatively cool temperature (32-35 degrees C), is considered to be the main site of sperm storage in male mammals. However, in the adult male spinifex hopping mouse, Notomys alexis, similar numbers of spermatozoa are found in the vas deferens to those in the cauda epididymidis. The present study shows that, unlike in the laboratory mouse in which spermatozoa of the vas deferens are found mainly in the epididymal region of the duct, spermatozoa in the hopping mouse are localized mainly to the middle and urethral regions of the vas deferens which lies in the inguinal and lower abdominal region of the body cavity. After ligation of the vas deferens close to its connection with the epididymis, many spermatozoa in the vas deferens retain the potential for motility for up to 2 weeks, indicating that the viability of spermatozoa is not compromised by being restricted to core body temperature. This urethral region of the vas deferens, in which spermatozoa reside, has a highly divergent structural organization compared with that of common laboratory rodents in which there is an expanded lumen with a network of epithelial folds. Ultrastructural observations of the cells lining the duct indicate that there are not any marked differences in morphology compared with the cells lining the duct in common laboratory murids, but the infoldings of the vas deferens of the hopping mouse are highly vascular which might facilitate supply of oxygen and nutrients to the spermatozoa residing in the lumen.

Animals↗
PubMed2005

Vasectomy surgical techniques in South and South East Asia.

BACKGROUND: Simple ligation of the vas with suture material and excision of a small vas segment is believed to be the most common vasectomy occlusion technique performed in low-resource settings. Ligation and excision (LE) is associated with a risk of occlusion and contraceptive failure which can be reduced by performing fascial interposition (FI) along with LE. Combining FI with intra luminal thermal cautery could be even more effective. The objective of this study was to determine the surgical vasectomy techniques currently used in five Asian countries and to evaluate the facilitating and limiting factors to introduction and assessment of FI and thermal cautery in these countries. METHODS: Between December 2003 and February 2004, 3 to 6 major vasectomy centers from Cambodia, Thailand, India, Nepal, and Bangladesh were visited and interviews with 5 to 11 key informants in each country were conducted. Vasectomy techniques performed in each center were observed. Vasectomy techniques using hand-held, battery-driven cautery devices and FI were demonstrated and performed under supervision by local providers. Information about interest and open-mindedness regarding the use of thermal cautery and/or FI was gathered. RESULTS: The use of vasectomy was marginal in Thailand and Cambodia. In India, Nepal, and Bangladesh, vasectomy was supported by national reproductive health programs. Most vasectomies were performed using the No-Scalpel Vasectomy (NSV) technique and simple LE. The addition of FI to LE, although largely known, was seldom performed. The main reasons reported were: 1) insufficient surgical skills, 2) time needed to perform the technique, and 3) technique not being mandatory according to country standards. Thermal cautery devices for vasectomy were not available in any selected countries. Pilot hands-on assessment showed that the technique could be safely and effectively performed by Asian providers. However, in addition to provision of supplies, introducing cautery with FI could be associated with the same barriers encountered when introducing FI in combination with LE. CONCLUSION: Further studies assessing the effectiveness, safety, and feasibility of implementation are needed before thermal cautery combined with FI is introduced in Asia on a large scale. Until thermal cautery is introduced in a country, vasectomy providers should practice LE with FI to maximize effectiveness of vasectomy procedure.

Bangladesh↗
PubMed2002

Ischemia, whether from ligation or torsion, causes ultrastructural changes on the contralateral testis.

OBJECTIVE: Unilateral testicular torsion results with a decrease in contralateral testicular blood flow caused by a reflexive sympathetic response. The aim of this study was to investigate whether twisting of the spermatic cord, or testicular ischemia without twisting, activates this reflex mechanism and causes ultrastructural changes in the contralateral side. MATERIALS AND METHODS: Thirty adult male albino Wistar rats were randomly allocated into three groups of sham, torsion, and ligation. Right testes were twisted 720 degrees counterclockwise in the torsion group. Right spermatic cords were ligated permanently with a silk suture including the vas deferens in the ligation group. After 24 h of testicular ischemia, contralateral left testes were removed for electron microscopic evaluation. RESULTS: Contralateral testes showed similar ultrastructural changes in the torsion and ligation groups. The fibrous tunica propria enveloping the seminiferous tubule was thickened due to increased collagen fibers. The basal lamina was continuous but thickened and showed several foldings. The gap between basal lamina and the germ cells was increased because of collagen fibers. Leydig cells showed mitochondrial degeneration with the loss of its cristae. Leydig cells lost their contact with its neighborhood cells in some areas, and these gaps were filled with collagen fibers. Germ cells showed dilated cisternae of smooth endoplasmic reticulum, cytoplasmic electron-dense bodies and clear regions. CONCLUSIONS: Similar electron microscopic findings observed in the torsion and ligation groups indicate that testicular ischemia rather than twisting of the spermatic cord is responsible for the ultrastructural changes in the contralateral side.

Animals↗
PubMed2006

Acute effect of vasectomy on the function of the rat epididymal epithelium and vas deferens.

Persistent infertility after apparently successful vasectomy reversal is common. One possible etiology is epididymal epithelial dysfunction resulting in improper sperm maturation after vasectomy reversal. The epididymal epithelium secretes a number of proteins that are thought to be required for the maturation of sperm. Ligation of the vas deferens during vasectomy may affect the synthesis of some of these proteins. In the present study, the function of the epididymal epithelium was assessed at early times after vasectomy (1, 4, and 7 days) by measuring the level of mRNA of 4 secreted proteins: Crisp-1, clusterin, osteopontin, and transferrin. In addition, the site of synthesis of these proteins was determined by immunocytochemistry. The results demonstrated that the expression of Crisp-1 and clusterin, representative epididymal secretory proteins, was largely unaffected by vasectomy. However, osteopontin mRNA increased in the vas deferens in response to vasectomy. Immunocytochemical localization of osteopontin suggested that both infiltrating immune cells and deferential luminal epithelium were responsible for this up-regulation. Transferrin expression was viewed as a marker for immune cells at the site of injury. However, both the caput epididymis and deferential epithelia were found to express transferrin, in addition to immune cells. In conclusion, there appear to be only minor changes in expression of genes encoding epididymal secretory proteins acutely after vasectomy, but, not surprisingly, there was evidence of an inflammatory response after vasectomy.

Animals↗
PubMed1995

Testicular development and the formation of spermatic granulomas of the epididymis after obstruction of the vas deferens in immature rats.

PURPOSE: Aims were to determine the effects of obstruction of the vas deferens prior to sexual maturation on testicular growth and the formation of spermatic granulomas. MATERIALS AND METHODS: The vas deferens was ligated and divided bilaterally in 10-day-old Lewis rats. RESULTS: Testis weight and volume did not differ significantly between obstructed rats and sham controls at the majority of the intervals studied, including the end of the experiment at 128 days, although some temporary changes were observed. Testes of obstructed animals showed normal histological differentiation. Nearly all obstructed animals developed spermatic granulomas of the epididymis once they matured. CONCLUSIONS: When obstructed prior to sexual maturation, the testes are affected only transiently, but significant epididymal alterations occur. Spermatic granulomas are located predominantly in the epididymis rather than the vas deferens.

Animals↗
PubMed1985

Lectin staining of rat testis and epididymis after ligation of excurrent ducts at different levels.

Seven rhodamine-conjugated lectins (PNA, RCA I, SBA, Con A, WGA, UEA I, and DBA; see Table 1) were utilized in studying the staining pattern of glycoproteins in rat testis and epididymis after ligation of ductuli efferentes (DE), corpus epididymidis (CE), and vas deferens (VD) for various time periods. Ductuli efferentes ligation caused a widening of seminferous tubules and detachment of spermatids with formation of multinuclear cells. These cells acquired a strong affinity for all lectins. Corpus epididymidis ligation also caused degeneration of spermatids with increased lectin staining in some tubules, but after 7 days another cell population close to the periphery of seminiferous tubules showed an increased nuclear affinity for some lectins followed by a clear degeneration and strong cytoplasmic staining with all lectins. Vas deferens ligation caused no degenerative changes in testicular spermatids. However, the peripheral cell population showed degenerative changes similar to those found after CE ligation. In both cases this was coincident with the formation of spermatic granulomas at the site of ligation. Ductuli efferentes ligation caused a gradual decrease of intratubular content in caput epididymidis, while the contrary was true after CE ligation. The latter was associated with intratubular accumulation of lectin-positive swollen cells and sperm aggregates as well as an increased lectin staining of narrow cells in initial segment and light cells in distal caput. After VD ligation an increased staining of light cells was initially found in distal cauda and distal caput, but, concomitant with distension of the tubules this reaction decreased.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1997

Laparoscopy in the management of pediatric varicoceles.

BACKGROUND/PURPOSE: The authors present their early experience with laparoscopic ligation of varicoceles in children. METHODS: Over a period of 30 months, 17 children underwent laparoscopic treatment of unilateral varicoceles (age range, 7 to 16 years). Nine underwent ligation of veins alone and eight (including four children who had recurrent varicoceles) underwent ligation of testicular veins and artery. In three patients, vas-associated veins were ligated in addition to the main testicular vessels. RESULTS: The average operation time was 30 minuts (range, 14 to 75) and hospital stay, 11 hours (range, 4 to 22). There were no technical failures. Minor scrotal emphysema developed in one child, and a painful, tender swelling above the epididymis developed in another. At an average follow-up of 24 months (range, 6 to 30), all patients were asymptomatic and had marked reduction in the size of the varicoceles. CONCLUSION: Further experience and long-term follow-up are clearly required before the efficacy of this procedure is established.

Adolescent↗
PubMedDate not supplied

Tunica vaginalis sperm reservoir in a monkey model of vas deferens obstruction.

Repeat microscopic epididymal sperm aspiration (MESA) is used to treat congenital absence of the vas deferens (CAVD). Use of alloplastic implants as reservoirs results in poor sperm motility and pregnancy rates. An autoplastic tunica vaginalis reservoir for epididymal sperm has been used in four patients, with one resultant pregnancy. We studied this technique in a monkey model. Eight reservoirs were created in four monkeys (Cercopithecus aethiops). The vas deferens was ligated close to the epididymis. A transverse incision was made in the caput epididymis, and sperm were aspirated for analysis. Cut margins of the epididymal duct were sutured open to the visceral layer of the tunica vaginalis. The defect in the parietal layer of the tunica vaginalis was repaired, and sterile Tyrode's solution was instilled in the potential space between the parietal and visceral layers. Initial epididymal sperm obtained at the creation of the sperm reservoir demonstrated adequate mean motility (60.5%, grade 1.5), morphology (82.8% normal), and viability by Eosin-Y exclusion (69.9%). At 4 weeks, no reservoirs were palpable. Percutaneous aspiration (25-gauge angiocatheter) yielded no fluid. Surgical exposure of the reservoirs demonstrated significant adhesions and scar formation between the parietal and visceral layers of the tunica vaginalis, obliterating the potential space. No sperm were detected in irrigant fluids at this time. In conclusion, adhesion and scar formation may prevent use of the tunica vaginalis reservoir as an alternative to repeat MESA in treatment of CAVD.

Animals↗
PubMedDate not supplied

Identification of androgen binding-protein (ABP) from testis and epididymis of the seasonal rodent, Octodon degus (Molina, 1872).

ABP, a Sertoli cell secretory product, was identified in the seasonal rodent Octodon degus (Molina, 1872). It was shown to be present in cytosols from the testis and epididymis. It migrated with an Rf of 0.37 on nondenaturing polyacrylamide gels. Ligation of the vas efferens caused the disappearance of ABP from the epididymis and its accumulation in the testis, indicating its testicular origin. Binding to [3H]5 alpha-DHT was specific and completely reversible, with an apparent Kd of 3.5 +/- 0.4 X 10(-9) M. Half-times of association and dissociation were at 15 and 120 minutes, respectively. Binding equilibrium was achieved at 120 minutes. Steroid affinity relative to the best competitor, 5 alpha-DHT, was 0.27 for testosterone, 0.06 for 17 beta-estradiol, and 0.01 for cyproterone acetate. The presence and similar characteristics of ABP in a wide variety of mammals, including those with special reproductive strategies such as seasonal breeding, suggests that this protein may play a general role in the mechanisms regulating spermatogenesis, probably affecting the transport and concentration of androgens in the testis and epididymis.

3-Oxo-5-alpha-Steroid 4-Dehydrogenase↗
PubMed2006

Is the laparoscopic Palomo procedure for pediatric varicocele safe and effective? Nine years of unicentric experience.

BACKGROUND: Varicocele is a rare disorder in children that can lead to testicular atrophy and infertility; therefore, radical treatment is frequently required. Whatever treatment is chosen, postoperative complications are fairly common (hydrocele, recurrence, persistence, and testicular atrophy). Laparoscopic varicocelectomy (the laparoscopic Palomo procedure) is one of the surgical options that has recently gained popularity. The aim of this study is to assess the safety and effectiveness of laparoscopic Palomo varicocelectomy by describing a series of patients operated on during a 9 year period at the Royal Hospital for Sick Children in Edinburgh. METHODS: This is a retrospective unicentric study including patients operated on between June 1995 and June 2004. All patients preoperatively underwent ultrasound scan of the testicles (color Doppler) and the abdomen. Indications for surgery included symptoms, high-grade varicocele (grade II and III), and testicular atrophy. Pneumoperitoneum was created using carbon dioxide insufflation with intraabdominal pressure up to 12 mmHg. Three 5 mm ports were inserted. The first port was inserted just below the umbilicus (telescope) under direct vision, and the others were inserted at the left flank and in the suprapubic region. All the enlarged spermatic and vas vessels were ligated or clipped. Outcomes and possible intraoperative, postoperative, or long-term complications are described. RESULTS: Forty-one patients were included in the study. Ninety percent of symptomatic patients improved significantly postoperatively, and 62% of patients with preoperative testicular atrophy showed postoperative catch-up growth of the involved testis. Nevertheless, hydrocele represents the most frequent postoperative complication in this series of patients. Approximately 15% of the patients required some sort of further surgical intervention (12% because of postoperative hydrocele occurrence). CONCLUSIONS: The laparoscopic Palomo procedure is a safe and effective surgical option for the treatment of pediatric varicocele, although it carries a fairly high risk of postoperative hydrocele. Postoperative hydrocele seems to be related to some sort of lymphatic obstruction, therefore lymphatic sparing procedures that can be accomplished laparoscopically should be reconsidered. Nevertheless, their feasibility and effectiveness need to be more carefully assessed.

Adolescent↗
PubMed1990

The humoral autoimmune response to vasectomy described by immunoblotting from two-dimensional gels and demonstration of a human spermatozoal antigen immunochemically crossreactive with the D2 adhesion molecule.

The specificity of human serum antispermatozoal antibodies was analysed by immunoblotting after two-dimensional electrophoretic separation (IEF/PAGE) of human spermatozoal proteins. Spermatozoal proteins with Mr 20-200 kDa and pI between 4.5 and 7.8 were analysed for antigenicity. Fifteen sera (four female and 11 male) were analysed for antisperm IgG antibodies. Individual IgG binding patterns were observed. The antisperm antibody response to ligation of the vas deferens was described by immunoblotting analysis of sera taken pre- and post-operatively at regular intervals from three men undergoing vasectomy. The high resolution of spermatozoal antigens allowed a specific description of the humoral response to vasectomy. Both appearance and disappearance of spots were observed in the postoperative period, indicating induction of new antibody producing clones and binding of former free antibodies in circulating immunocomplexes. In one patient five glycosylated proteins induced an IgM response 2 weeks after vasectomy. Four of these autoantigens with Mr of 122 kDa, 119 kDa, 104 kDa and 77 kDa and pI of 5.9, 6.1, 7.7 and 6.0, respectively, have previously been shown to be intrinsic membrane proteins (Naaby-Hansen, (1990) J., Reprod. Immunol. 17). An observed immunochemical crossreactivity between the interneuronal adhesion molecule, D2-protein and an antigen extracted from human sperm and teratomas is discussed.

Adolescent↗
PubMed1975

Spermiophage cells in man.

The morphologic characteristics, occurrence, origin, and significance of spermiophage cells were reported. In the majority of patients with obstructive azoospermia and after ligation of the vas deferens, spermatogenesis continued normally and the spermatozoa so formed were eliminated by epididymal macrophages. The spermiophage cells are most probably derived from the monocytes of blood and tissue histiocytes. In order of frequency they were found in the epididymides of patients with obstructive azoospermia, rarely in the damaged seminiferous tubules of the testes, and in semen and prostatic secretions before and after vaso-epididymostomy or vaso-vasostomy. The occurrence of spermiophage cells in the prostatic secretions was documented for the first time. The ingested sperm heads, or the products of sperm disintegration along with some antigenic components, may be carried by macrophages to the basal capillaries; such a situation may favor the formation of autoantibodies against spermatozoa. This hypothesis is substantiated by the findings of various investigators.

Epididymis↗