Microrecanalization after vasectomy in man

The "filarial dance" is not characteristic of filariasis: observations of "dancing megasperm" on high-resolution sonography in patients from nonendemic areas mimicking the filarial dance and a proposed mechanism for this phenomenon

The objective of this series was to show that the sonographic appearance described as the "filarial dance" is not characteristic of filariasis but occurs in nonendemic areas as a manifestation of epididymal obstruction. An experienced observer documented cases after initial observation of the filarial dance in routine clinical practice using high-frequency linear array transducers. The filarial dance was described as excessive to-and-fro movement of echogenic particles within a prominent epididymis and graded 1 to 4 according to the extent and distribution of the abnormality. The country of birth, exposure to filarial infection or travel to a filarial-endemic area, previous scrotal surgery including vasectomy, any previous or current scrotal inflammatory disease, and any congenital testicular abnormalities were recorded. Over a 10-year period, sonographic appearances consistent with the filarial dance were observed in 18 patients (bilateral in 6). The mean patient age was 47.7 (range, 28-91) years. The abnormality was graded in the 24 affected testes as follows: grade 1, n = 3; grade 2, n = 8; grade 3, n = 8; and grade 4, n = 5. No patient had a history of filariasis or travel to an endemic area. Six of 18 patients (33.3%) had bilateral vasectomies; 5 (27.8%) had a history of epididymo-orchitis in the ipsilateral testis; 3 (16.7%) had previous scrotal surgery; and 4 (22.2%) had no relevant urologic history. We have described a sonographic appearance identical to the filarial dance in men with no history of filarial infection. Most had previous scrotal surgery or infection, suggesting that the filarial dance may not always be due to movement of filarial worms. The unifying condition in patients with filariasis and our patients is lymphatic obstruction, likely the underlying cause of the appearance in both groups.

Micro-recanalization in a biodegradable graft for reconstruction of the vas deferens is enhanced by sildenafil citrate

This study investigated the effect of sildenafil citrate on micro-recanalization and neovascularization, which were previously demonstrated in a rat model using biodegradable grafts (BGs) for vas deferens reconstruction. A total of 24 male rats underwent bilateral vasectomy with removal of a 0.5-cm vasal segment and were randomly assigned to four groups. Groups 1 and 2 underwent immediate vasovasostomy. Groups 3 and 4 underwent interposition of a 0.5-cm BG in the vasal gap. Groups 1 and 3 were given 5 mg kg(-1) day(-1) oral sildenafil. Other groups were given placebo. Rats were housed with females 12 weeks postoperatively. Reconstructed vasal segments were harvested 16 weeks postoperatively and analyzed histologically. Fluid from the distal vasal stump was analyzed for motile sperm. Urine samples obtained 16 weeks postoperatively were analyzed for cGMP levels. cGMP levels in rats treated with sildenafil were significantly higher than in control rats. No pregnancies were sired by grafted groups. In all, 5/6 rats in group 1 and 3/6 rats in group 2 sired litters. No motile sperm were noted in the vasal fluid of the grafted groups. Motile sperm were noted in all rats in group 1 and in 5/6 rats in group 2. In addition, 29 and 4 microcanals were detected in the sildenafil and placebo groups, respectively (P = 0.023). No microcanal exceeded 3 mm in length. An average of 12 and 28 blood vessels per graft were noted in the placebo and sildenafil groups, respectively (P < 0.0001). In conclusion, sildenafil enhances micro-recanalization and neovascularization in BG used for vas deferens reconstruction, but does not increase the microcanal length after 16 weeks.

Effectiveness of vasectomy techniques

The effectiveness of various vasectomy techniques is reviewed, with a focus on methods used for vas occlusion. Spontaneous recanalization of the vas is more common than generally recognized and is often transient. Simple ligation and excision has an unacceptably high risk for failure. Techniques that include cautery seem to have a lower risk for failure than techniques that do not include cautery. There is insufficient evidence to recommend a particular standardized cautery technique, but adding fascial interposition to cautery seems to be associated with the lowest risk for failure.

Early microrecanalization of vas deferens following biodegradable graft implantation in bilaterally vasectomized rats

We evaluated a biodegradable graft for reconstruction of rat vasa deferentia with long obstructed or missing segments. A total of 47 Sprague-Dawley rats underwent bilateral vasectomy and were divided into groups according to length of the vas deferens affected (0.5, 1, 1.5 cm). After 8 weeks, poly-(D,L-lactide) (PDLA) grafts were used to reconnect the vas deferens. Grafts and adjoining vasa deferentia were excised 8 and 12 weeks later and evaluated microscopically. At 8 weeks, microscopic changes included a robust inflammatory response around the grafts. All grafts were still intact but in the early stages of degradation. No microtubules, indicative of vas deferens recanalization, were identified. One specimen showed evidence of healing and neovascularization at the interface zone between the vas deferens and the graft. At 12 weeks, grafts were further degraded but still present. Microscopic evaluation showed decreased inflammation. Seven specimens showed neovascularization at the interface zone; two of these showed distinct epithelialized vas deferens microcanals at the graft edges. One specimen showed a microcanal spanning the entire 0.5-cm graft. A time period of 8 weeks is not ample enough for vas deferens regeneration in the setting of a biodegradable PDLA graft; however, early evidence of re-growth was seen at 12 weeks. A longer healing time should permit further biodegradation of the graft, as well as re-growth and possible eventual reconnection of the vas deferens, allowing passage of sperm. These findings suggest a potential role for biodegradable grafts in the reconstruction of vas deferens with long obstructed segments.

Fulguration of the lumen does not improve vasectomy sterilization rates

OBJECTIVES

To assess the effect of adding lumen diathermy fulguration to our standard technique of vas ligation with polyglactin 910 (Vicryl(TM), Ethicon, Sommerville, NJ, USA) excision and fascial interposition, in an attempt to improve our sterilization rates. We previously reported the effect of changing suture material on vasectomy success rates; 3005 post-vasectomy semen analyses (PVSA) revealed a decrease in sterilization rates after surgery on changing from chromic catgut to polyglactin 910.

PATIENTS AND METHODS

We retrospectively reviewed PVSA undertaken for vasectomies performed by urological surgeons at the Mid-Yorkshire NHS Trust for 18 months from September 2005 to February 2007.

RESULTS

There were 592 vasectomies in all; the age distribution of patients between the groups treated with the standard and new method was similar. Overall, 166 patients (28%) failed to provide two semen samples as instructed, and so were excluded from further analyses. Sterility was achieved in 367 patients (86%); a further 28 (7%) have indeterminate analyses to date, with one of the last two PVSAs showing sperm, with the PVSA of 32 (7%) patients showing persisting sperm. For the eight surgeons reviewed the sterility rates were broadly similar.

CONCLUSIONS

The introduction of diathermy fulguration of the lumen has not improved vasectomy sterilization rates, with up to 14% having sperm on PVSA.

Frequency and patterns of early recanalization after vasectomy

Background

Our understanding of early post-vasectomy recanalization is limited to histopathological studies. The objective of this study was to estimate the frequency and to describe semen analysis patterns of early recanalization after vasectomy.

Methods

Charts displaying serial post-vasectomy semen analyses were created using the semen analysis results from 826 and 389 men participating in a randomized trial of fascial interposition (FI) and an observational study of cautery, respectively. In the FI trial, participants were randomly allocated to vas occlusion by ligation and excision with or without FI. In the cautery study, sites used their usual cautery occlusion technique, two with and two without FI. Presumed early recanalization was based on the assessment of individual semen analysis charts by three independent reviewers. Discrepancies were resolved by consensus.

Results

Presumed early recanalization was characterized by a very low sperm concentration within two weeks after vasectomy followed by return to large numbers of sperm over the next few weeks. The overall proportion of men with presumed early recanalization was 13% (95% CI 12%–15%). The risk was highest with ligation and excision without FI (25%) and lowest for thermal cautery with FI (0%). The highest proportion of presumed early recanalization was observed among men classified as vasectomy failures.

Conclusion

Early recanalization, occurring within the first weeks after vasectomy, is more common than generally recognized. Its frequency depends on the occlusion technique performed.

The diagnosis of azoospermia depends on the force of centrifugation

OBJECTIVE

To determine the centrifugal force required to pellet sperm.

DESIGN

Prospective, in vitro study.

SETTING

Tertiary referral center.

PATIENT(S)

Men undergoing semen processing or postvasectomy semen analyses.

INTERVENTION(S)

In Phase I, postvasectomy semen samples were centrifuged at 600 x g, and the pellets were examined. Supernatants from samples with no visible sperm underwent repeat centrifugation at 1,000 x g; the supernatants were removed and centrifuged at 3,000 x g. Pellets from both centrifugations were examined. Phase II examined nonazoospermic semen that was divided into 3 aliquots and centrifuged at 500, 1,000, and 3,000 x g. The supernatants were examined for the presence of sperm.

MAIN OUTCOME MEASURE(S)

Sperm presence in centrifuged pellets or seminal supernatant.

RESULT(S)

Phase I: After centrifugation at 1,000 x g and 3,000 x g, sperm were noted in 12% and 0% of samples, respectively. Phase II: Sperm were noted in the supernatant in 100% of samples subjected to 500 x g and 1,000 x g, and in 92% of samples subjected to 3,000 x g centrifugation.

CONCLUSION(S)

If sperm are in the seminal plasma, they will also be present in the pellet following centrifugation at a force of 1,000 x g or greater. Semen samples that appear azoospermic upon initial wet mount microscopy should be centrifuged at a minimum of 1,000 x g for 15 minutes.

Delayed vasectomy success in men with a first postvasectomy semen analysis showing motile sperm

OBJECTIVE

To determine the frequency of and factors associated with delayed vasectomy success in men with first postvasectomy semen analysis showing motile sperm.

DESIGN

Descriptive study.

SETTING

One hospital-based family planning clinic and two private clinics from the Quebec City area, Canada.

PATIENT(S)

Three hundred nine men vasectomized between 1990 and 2001 and who had a first semen analysis showing motile sperm.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Vasectomy success, based on the last available semen analysis-either in the medical record or as requested for the study-and on sterility as established by a telephone-based questionnaire in 2003.

RESULT(S)

Among the 309 men, 174 (56.3%, 95% confidence interval 50.7%-61.7%) had delayed vasectomy success. Significant independent factors associated with delayed vasectomy success were lower sperm count in the first postvasectomy semen analysis and shorter interval between vasectomy and first postvasectomy semen analysis.

CONCLUSION(S)

Delayed vasectomy success occurs in more than half of men with a first postvasectomy semen analysis showing motile sperm. The decision to repeat vasectomy should not rely on a single semen analysis showing motile sperm.

Microcanalization in the epididymis to overcome ductal obstruction caused by chronic exposure to chromium – a study in the mature bonnet monkey (Macaca radiata Geoffroy)

In order to apprehend the toxic effects of chromium, an occupational/environmental pollutant, on the epididymis, adult bonnet monkeys were exposed to chromium (VI) in their drinking water at concentrations of 100, 200 and 400 p.p.m. for a chronic period of 180 days. At the end of the experimental period, testicles and segments of epididymis from control and treated monkeys were subjected to light microscopic (resin-embedded semi-thin sections) and transmission electron microscopic analyses. Among the various changes undergone by the epididymal epithelium, the present paper describes the origin of two different kinds of microcanals, probably caused by ductal obstruction. The first type of microcanal, which appears to provide passage for spermatozoa to bypass the obstructed main duct, is comparable with the one already reported in carbendazim-treated efferent ductules of the rat. The second type of microcanal, which is novel, consisted of a lumen in the epithelium enclosed by four to five cells, which are either modified basal cells, principal cells or a hitherto unknown cell type. This novel type of microcanal is suggested to be a device to entrap the spermatozoa which reach the core of the epithelium and may be a mechanism to prevent extravasation of sperm so as to avoid an autoimmune response of spermatic granuloma formation. Thus, the present study has shown that chronic exposure to chromium (VI) through drinking water can produce pathological manifestations in the epididymal epithelium but the epididymis, being a versatile organ, is capable of overcoming such adverse situations through novel devices.

[Ambulatory vasectomy. Risks and complications]

Vasectomy is the simplest and most effective method of permanent sterilization in men. In most cases, the surgical technique includes conventional vasoresection with incision of the scrotal skin or no-scalpel vasectomy as a minimally invasive method. The most important complications following surgery are haemorrhage and haematoma (1.2%), infection (3.5%), epididymitis/epididymo-orchitis (2.1%), sperm granuloma (2-70%), and chronic pain (3-8%). No long-term negative organic effects have been proven in clinical studies. The surgeon's experience and the technique applied are essential for the postoperative course, whereas performing vasectomy either on an in-patient or out-patient basis does not seem to have an influence. To evaluate the success of the vasectomy, follow-up spermiograms are obligatory. If immotile spermatozoa are present further follow-ups are necessary. Vasectomy needs to be reperformed if motile spermatozoa are detected. The chance of an unsuccessful vasectomy is below 1%. Unprotected intercourse must not be performed before two consecutive spermiograms show azoospermia.

Vasectomy

Vasectomy is regarded as the safest method now available for male fertility control. Almost 100 million men worldwide have relied on vasectomy for family planning. This review discusses all currently relevant operative techniques, including no-scalpel vasectomy, complications, possible long-term effects on the testis and epididymis, and diseases for which associations with vasectomy have been suggested, such as arteriosclerosis, autoimmune diseases and cancer of the prostate and testis. Other topics of discussion include the timing of post-operative semen analysis, patient noncompliance concerning post-operative controls, persistent cryptozoospermia and transient reappearance of spermatozoa after vasectomy, vasectomy failure and legal aspects.

Presence of sperm in the pre-vasectomy reversal semen analysis: incidence and implications

PURPOSE

We determined the incidence of sperm in the ejaculate before vasectomy reversal, and correlated this result with intraoperative and postoperative findings.

MATERIALS AND METHODS

Before vasectomy reversal semen was analyzed and granulomas were palpated in 186 men. The results were correlated with intraoperative vasal fluid and postoperative semen analyses.

RESULTS

Of 18 men (9.7%) with sperm present in the pre-reversal analysis 94% had sperm in at least 1 vas intraoperatively. The presence of palpable granulomas at the vasectomy site did not correlate with either pre-reversal or post-reversal semen analyses, or the presence of sperm in the vasal fluid intraoperatively.

CONCLUSIONS

Sperm are present in 9.7% of pre-reversal ejaculates and predict sperm in at least 1 vas intraoperatively. These findings also suggest the possibility of late vasectomy failures.

Epithelial reorganization and irregular growth following carbendazim-induced injury of the efferent ductules of the rat testis

Occlusions of the rat efferent ductules were induced by an oral gavage of carbendazim and the capacity for regeneration or recanalization of the ductules was histologically evaluated between 2 and 70 days post-treatment. At 2 days post-treatment, the efferent ductules were occluded by sloughed materials and showed various degrees of inflammation. Severely damaged epithelium showed few regenerative features at later intervals. On the other hand, epithelia with medium inflammation often exhibited irregular epithelial growth along the luminal contents or the formation of multiple abnormal ductules. These abnormal ductules were formed by migrated and original epithelia at the periphery of the occluded lumen at 16 days post-treatment, indicating attempted recanalization. At later time periods, 32 and 70 days post-treatment, the occluded original lumen was filled in by fibrotic connective tissue and surrounded by a series of abnormal ductules. These abnormal ductules were characterized by cuboidal epithelia, a small luminal diameter, fewer cilitated cells than normal, less developed organelles in the epithelial cells, and basal laminae of irregular thickness. However, there was no evidence that occluded ductules formed patent re-connections via abnormal ductules. The results suggest that occluded efferent ductules have the ability to initiate epithelial regrowth and to form new ductules, but the newly formed ductules are abnormal and are not adequate to recover from azoospermia at least at 70 days post-treatment.