Vasectomy: common medicolegal pitfalls

[E-Cadherine and GATA-3 are useful in the confirmation of the vas deferens in vasectomy specimens]

INTRODUCTION AND OBJECTIVES

Urologists often submit the resected tissue from vasectomies for histopathological examination in order to confirm the presence of the vas deferens. Microscopy is simple and based on haematoxylin-eosin staining; however, sample artefacts can sometimes cause confusion and immunohistochemistry can be used to identify the vas deferens.

MATERIALS AND METHODS

We investigated the utility of immunohistochemical analysis using E-cadherin and GATA-3 to confirm the presence of vas deferens epithelium in 110 vasectomy sections with different artefacts, using monoclonal antibodies and a multimer conjugated with peroxidase based technique; 5 renal arteries and 5 renal veins were stained as negative controls.

RESULTS

Membrane staining was observed for E-cadherin, which was moderate (2.7%) or strong (97.3%) in the vas deferens epithelium in all cases: 35 without artefacts, 7 with denuded epithelium, 56 with compressed/distorted epithelium, 8 with detached epithelium and 4 with displaced epithelium. GATA-3 showed moderate (31%) or strong (69%) nuclear staining in all cases, including the 76 with artefacts. In the control group, arteries and veins were negative for both markers in the endothelium, but GATA-3 occasionally stained lymphocytes in the blood vessel wall.

CONCLUSIONS

E-cadherin membrane positivity and GATA-3 nuclear expression are useful for the identification of the vas deferens in vasectomy samples containing artefacts. Vascular endothelium is negative for both markers and any possible GATA-3 staining of the lymphocytes in the blood vessel wall should not be misinterpreted.

Rethinking the value of sending vasectomy specimens for histologic examination: an analysis of arterial vasculature and failure to transect the vas deferens

OBJECTIVES

The testicular, deferential, and cremasteric arteries and their branches surround the vas deferens (VD), leaving them susceptible to injury during vasectomy. Literature describing the caliber of arteries seen in vasectomy specimens is lacking, making it difficult to categorize the significance of an observed artery. We aimed to establish reference values for arterial size typically encountered in vasectomy specimens and assess our institutional experience with failure to transect the VD.

METHODS

The luminal diameter of the largest artery in 231 consecutive VD specimens from 116 patients was measured microscopically. For comparison, the diameter of the largest artery within 10 spermatic cord cross-sections from inguinal orchiectomies was obtained. The immediate vasectomy failure rate based on histologic assessment was calculated using specimens from 2008 to 2012.

RESULTS

The luminal diameter of the largest artery encountered in a vasectomy specimen was 1.00 mm or less in 96.5% of cases. Artery sizes greater than or equal to 2.50 mm were only seen in spermatic cord resections. From 2008 to 2012, three (0.36%) of 837 patients undergoing vasectomy had specimens that showed failure to transect both VD.

CONCLUSIONS

Although the American Urologic Association and European Association of Urology state that histologic evaluation of vasectomy specimens is not required, we encourage the surgeon to send VD specimens for histologic examination. Doing so allows early identification of the failure to transect the VD and the resection of surrounding vasculature, providing quality control feedback to the surgeon.

Use of immunohistochemical markers to confirm the presence of vas deferens in vasectomy specimens

CD10 has recently been described as a marker that can distinguish wolffian duct derivatives from müllerian remnants but has yet to be tested in vasectomy specimens. We sought to determine if CD10 and pankeratin could corroborate the presence of vas deferens (VD). For the study, 103 consecutive vasectomy specimens were immunohistochemically analyzed for CD10, pankeratin, and CD31 expression in luminal and basal layer cells. In all cases with optimal epithelial histologic features (92/103), CD10 demonstrated intense apical membranous expression in all VD and weak basal cytoplasmic staining in about 98% of cases. Pankeratin demonstrated cytoplasmic and membranous expression in apical and basal layers in 99% of VD. In cases with suboptimal epithelial histologic features (11/103), the detection of epithelia was 100% for CD10 and pankeratin. Our data show that CD10 and pankeratin can be used to confirm the presence of VD in vasectomy specimens in which the epithelial histologic features are suboptimal.

[Vasectomy today: a review of 1,275 vasectomies in 10 years]

We report on a large series of 1,275 patients who underwent outpatient vasectomy performed by a single urological surgeon within a 10-year period. In addition, the results of a prospective questionnaire-based study on 217 patients regarding their opinions and motivation, and the financial aspects of the vasectomy are discussed. The mean age was 37.0+/-5.9 years. A total of 98.4% of the patients had an uneventful postoperative course. The average duration of sick leave was 2.2+/-0.21 days. During the study period, the length of sick leave dropped significantly from 2.63 (1990/91) to 1.1 days (1998/99; P=0.001). Efficacy was documented with azoospermia rates of 96.6% and 98.5% in patients who presented for two and three sperm examinations, respectively. A vast majority of patients (94.6%) felt that the procedure should be covered by their health insurance, although 88.1% stated they would also pay by themselves. A minority of patients (0.7%: 9/1,275) subsequently considered vasectomy reversal. The wish to reverse the vasectomy was significantly associated with a younger patient age. In conclusion, outpatient vasectomy provides a safe and reliable form of contraception at low cost. Overall satisfaction in appropriately counselled patients is very high. Based on these findings, further attempts to propagate vasectomy as a timely form of contraception are medically and socioeconomically recommended.

British Andrology Society guidelines for the assessment of post vasectomy semen samples (2002)

The British Andrology Society guidelines for the assessment of post vasectomy semen samples recommend that initial assessment is undertaken 16 weeks post vasectomy and after the patient has produced at least 24 ejaculates. The laboratory should examine a freshly produced seminal fluid specimen by direct microscopy and if no sperm are seen the centrifugate should be examined for the presence of motile and non-motile spermatozoa. It is recommended that the clinician should give clearance after the production of two consecutive sperm free ejaculates. In cases of persistent identification of non-motile spermatozoa the referring clinician should advise the patient regarding the cessation of other contraceptive precautions. Surgeons are responsible both preoperatively and postoperatively for the counselling of couples regarding complications and the possibility of late recanalisation after clearance.