Unilateral obstruction of the vas deferens caused by childhood inguinal herniorrhaphy in male infertility patients

Sexual dysfunction between laparoscopic and open inguinal hernia repair: a systematic review and meta-analysis

PURPOSE

Sexual dysfunction after inguinal hernia complication is considered rare. However, its consequences impact on quality of life inevitably. Laparoscopic and open inguinal hernia repair may be comparable in terms of recurrent rate, overall complications, and chronic pain. Therefore, its complication is still questionable between these approaches. In this study, we compared sexual dysfunction and related complications between laparoscopic and open inguinal hernia repair.

METHODS

Systematic review and meta-analysis of randomized controlled trials (RCTs) studies were performed to compare laparoscopic and open inguinal hernia repair. Risk ratio (RR) and 95% confidence intervals (95% CI) were used as pooled effect size measures.

RESULT

Thirty RCTs (12,022 patients) were included. Overall, 6014 (50.02%) underwent laparoscopic hernia repair, and 6008 (49.98%) underwent open hernia repair. Laparoscopic approach provided non-significance benefit on pain during sexual activity (RR 0.57; 95% CI 0.18, 1.76), Vas deferens injury (RR 0.46; 95% CI 0.13, 1.63), orchitis (RR 0.84; CI 0.61,1.17), scrotal hematoma (RR 0.99; CI 0.62,1.60), and testicular atrophy (RR 0.46; CI 0.17,1.20). Meanwhile, the open inguinal hernia approach seems to perform better for cord seroma complications and testicular pain.

CONCLUSION

There is no advantage of laparoscopic inguinal hernia repair over an open approach concerning sexual dysfunction. On the contrary, there is an increasing risk of cord seroma after laparoscopic inguinal hernia repair with statistical significance.

Does the Choice of Suture Materials Affect the Vas Deferens After Hernia Ring Closure in Inguinal Hernia Surgery: An Experimental Study in Rats

INTRODUCTION

Laparoscopic inguinal hernia repair is a commonly performed procedure in children. Currently, monofilament polypropylene and braided silk are the two most frequently used materials. Studies have suggested more tissue inflammatory reactions with the use of multifilament non-absorbable sutures. However, little is known about the effects of suture materials on adjacent vas deferens. The aim of this experiment was to compare the effect of non-absorbable monofilament and multifilament sutures on vas deferens in laparoscopic hernia repair.

METHODS

All animal operations were performed by a single surgeon under aseptic conditions and anaesthesia. Ten male Sprague Dawley rats were divided into two groups. In Group I, "hernia repair" was performed using 5.0 Silk. In Group II, polypropylene sutures (Prolene®; Ethicon, Somerville, N.J., USA) were used. All animals also received sham operations in the left groin as a control. After 14 days, the animals were euthanised and a segment of vas deferens just adjacent to the suture was excised for histological review by an experienced pathologist who was blind to the treatment groups of the respective specimens.

RESULTS

The body sizes of the rats in each group were comparable. Group I had significantly smaller vas deferens than Group II (diameter: 0.2 vs. 0.6 ± 0.2, p = 0.005). Silk sutures appeared to cause more tissue adhesion than Prolene® sutures, as graded by blind assessors (adhesion grade: 2.8 ± 1.3 vs. 1.8 ± 0.8, p = 0.1), although this did not reach statistical significance. There was no significant difference in the histological fibrosis score and inflammation score.

CONCLUSION

The only effect of non-absorbable sutures on vas deferens in this rat model was the reduced cross-sectional area of vas deferens and increased tissue adhesion when using silk sutures. However, there was no significant histological difference in inflammation or fibrosis caused by either material.

Application of Noncontact Laparoscopic High Ligation of the Hernia Sac of the Vas Deferens in Children with Indirect Inguinal Hernia

Objective: This study aims to evaluate the usefulness of vas deferens noncontact laparoscopic high ligation of the hernia sac in children with indirect inguinal hernia (IIH). Materials and Methods: The clinical data of 146 male children with IIH treated in the Anhui Children's Hospital from January 2018 to June 2019 were analyzed retrospectively. There were 82 patients in the observation group in which the inner ring opening was sutured and closed using the vas deferens noncontact suture and 64 patients in the control group in which the peritoneum at the inner ring opening was closed using the intradermal suture. The operation time, surgical complications, postoperative complications, and recurrence rate were compared between the two groups (followed up for 2 years). Results: The operation was successful in all the patients in both groups. In the observation group, there was one case of intraoperative spermatic cord vascular injury and one case of infra-abdominal wall vascular injury, and no intraoperative complications occurred in the control group. The operation time was 12.8 ± 1.4 minutes in the control group and 10.4 ± 2.6 minutes in the observation group (P < .01). The two groups of patients were followed up for 2 years, and no complications and no recurrence occurred. Conclusion: The vas deferens noncontact laparoscopic high ligation of the hernia sac to close the inner ring opening has several advantages: The operation is simple; the operation time is shorter than the traditional method, avoiding the possibility of vas deferens injury; and it is a safe, reliable, and effective surgical method. However, due to the small number of clinical cases in this study, its long-term effect requires further observation.

Risks and benefits of pediatric inguinal hernia repair: Conventional open repair vs laparoscopic percutaneous extraperitoneal closure

INTRODUCTION

Considerable debate exists regarding the benefits of laparoscopic percutaneous extraperitoneal closure (LPEC) over conventional open repair (OR). We assessed the outcomes and feasibility of LPEC compared to OR for pediatric inguinal hernia (IH).

METHODS

We retrospectively analyzed 570 children who underwent LPEC or OR. Parents decided the operative method after obtaining informed consent. Patient characteristics, operative time, complications and contralateral metachronous IH (CMIH) were compared between the groups.

RESULTS

A total of 329 children underwent LPEC and 241 underwent OR. There was no significant difference in the incidence of recurrence or testicular ascent between the LPEC and OR groups (0.3% vs 0.4%, P = 0.825, 0.3% vs 0.8%, P = 0.391, respectively). No testicular atrophy was recognized in either group. One patient with postoperative chronic inguinal pain was recognized in each group. There was no surgical site infection (SSI) in the OR group; however, the LPEC group more frequently demonstrated umbilical port site (UPS)-related complications, such as incisional hernia, minor deformity, granuloma formation, cellulitis and superficial SSI. Ten (4.1%) developed CMIH in OR; in contrast, no case of CMIH was experienced after LPEC (P < 0.001).

CONCLUSION

In conclusion, both LPEC and OR are feasible in the management of pediatric IH, because of their high success rates and low risk of complications. LPEC could be the superior procedure with respect to the prevention of CMIH. However, to maximize the merits of LPEC over OR, it is important to reduce UPS-related complications in LPEC. A longer follow-up is needed to assess male fertility in patients who receive LPEC.

Influence of inguinal hernia repair on sperm autoimmunity: The largest single center experience

BACKGROUND

Studies on immunological infertility after inguinal hernia correction are few and not very representative. Anti-sperm antibodies have been shown to reduce male fertility. Although the extent of infertility due to anti-sperm antibodies alone is not very clear, data indicates that about 8%-10% of infertile patients have immunological infertility DESIGN: This retrospective study includes all infertile male patients (n = 2258) who underwent mixed antiglobulin reaction tests and urologic examination from 2000 to 2020. Sperm quality (assessed by the number of spermatozoa, their motility, vitality, and normal form) was also evaluated. Among these patients, 191 had previously undergone unilateral or bilateral inguinal hernia surgery repair. The aim of the study is to evaluate if there is a higher incidence of positive mixed antiglobulin reaction test among patients undergoing inguinal hernioplasty compared to the unselected infertile population.

RESULTS

Anti-sperm antibodies would seem to increase in both patients who performed general andrological surgery and groin hernia correction, respectively 3.48 (95% Confidence Interval: 1.70-7.10; p < 0.001) and 2.45 (95% Confidence Interval: 1.01-5.99; p < 0.05) times more than the unselected infertile population.

CONCLUSIONS

Mixed antiglobulin reaction test could be useful in patients undergone previous scrotal surgery or hernia correction men, to avoid false unexplained infertility diagnoses and to direct the couple to assisted reproductive technology procedures. Basal evaluation of spermatozoa does not actually consider andrological surgery as an indication to autoimmunity investigation.

Cellular Therapy via Spermatogonial Stem Cells for Treating Impaired Spermatogenesis, Non-Obstructive Azoospermia

Male infertility is a major health problem affecting about 8–12% of couples worldwide. Spermatogenesis starts in the early fetus and completes after puberty, passing through different stages. Male infertility can result from primary or congenital, acquired, or idiopathic causes. The absence of sperm in semen, or azoospermia, results from non-obstructive causes (pretesticular and testicular), and post-testicular obstructive causes. Several medications such as antihypertensive drugs, antidepressants, chemotherapy, and radiotherapy could lead to impaired spermatogenesis and lead to a non-obstructive azoospermia. Spermatogonial stem cells (SSCs) are the basis for spermatogenesis and fertility in men. SSCs are characterized by their capacity to maintain the self-renewal process and differentiation into spermatozoa throughout the male reproductive life and transmit genetic information to the next generation. SSCs originate from gonocytes in the postnatal testis, which originate from long-lived primordial germ cells during embryonic development. The treatment of infertility in males has a poor prognosis. However, SSCs are viewed as a promising alternative for the regeneration of the impaired or damaged spermatogenesis. SSC transplantation is a promising technique for male infertility treatment and restoration of spermatogenesis in the case of degenerative diseases such as cancer, radiotherapy, and chemotherapy. The process involves isolation of SSCs and cryopreservation from a testicular biopsy before starting cancer treatment, followed by intra-testicular stem cell transplantation. In general, treatment for male infertility, even with SSC transplantation, still has several obstacles. The efficiency of cryopreservation, exclusion of malignant cells contamination in cancer patients, and socio-cultural attitudes remain major challenges to the wider application of SSCs as alternatives. Furthermore, there are limitations in experience and knowledge regarding cryopreservation of SSCs. However, the level of infrastructure or availability of regulatory approval to process and preserve testicular tissue makes them tangible and accurate therapy options for male infertility caused by non-obstructive azoospermia, though in their infancy, at least to date.

Laparoscopy-assisted vasovasostomy for post-herniorrhaphy vas deferens obstruction

INTRODUCTION

Repair of obstructive azoospermia caused by childhood herniorrhaphy may be difficult. Therefore, intracytoplasmic sperm injection using testicular sperm is performed. However, vasovasostomy combined with laparoscopic surgery is challenging.

CASE PRESENTATION

A 42-year-old man underwent inguinal hernia repair at age 3. He had normal testicular size, azoospermia, normal hormone levels (follicle-stimulating hormone, luteinizing hormone, and testosterone), absence of Y chromosome micro deletion, and karyotype:46XY, t(1:21)(p34.1:q22.3). He was diagnosed with obstructive azoospermia. Repeated intracytoplasmic sperm injections using testicular sperm resulted in miscarriages. Vasovasostomy combined with laparoscopic surgery was subsequently performed. Postoperative semen analysis result was almost normal. After intracytoplasmic sperm injection of ejaculated sperm, his wife got pregnant.

CONCLUSION

Even if patients have chromosomal abnormalities, performing microsurgical re-anastomosis first is recommended. To our knowledge, this is the first case of a laparoscopy-assisted vasovasostomy for post-herniorrhaphy vas deferens obstruction in Japan.

A comparison of preoperative and postoperative testicular volume and blood flow in patients with inguinal hernia, hydrocele, and cord cyst: A prospective cohort study

OBJECTIVE

To evaluate the effect of inguinal operations performed with a modified Ferguson technique upon testicular volume and blood flow.

METHODS

This study involved 23 children receiving surgery for inguinal hernia, hydrocele, and cord cyst. This was a prospective study performed between April 2016 and June 2016 in a medical faculty pediatric surgery unit. The color Doppler ultrasound (CDUS) was used to assess testicular volume and blood flow before and after a modified Ferguson technique surgery. The pre- and post operative testicular volume and blood flow were compared with the contralateral testes. SPSS software was used to statistically analyze the data arising; the Mann-Whitney U test and Friedman test were used to compare samples, and P<0.05 was accepted as statistically significant.

RESULTS

Preoperative and postoperative testicular volumes were not statistically different when compared to contralateral testes. In patients with right sided inguinal pathology, testicular blood flow on the right side was significantly lower than that on the left side (P=0.023). The testicular blood flow was not statistically different compared with the contralateral testes during the first week evaluation and first month evaluation. The blood flow, probably reduced due to the pressure caused by inguinal pathology, was normalized through surgery.

CONCLUSIONS

The modified Ferguson technique do not change the testes volume and blood flow.

Treatment of contralateral hydrocele in neonatal testicular torsion: Is less more?

OBJECTIVE

Treatment of neonatal testicular torsion has two objectives: salvage of the involved testicle (which is rarely achieved) and preservation of the contralateral gonad. The second goal universally involves contralateral testicular scrotal fixation to prevent the future occurrence of contralateral torsion. However, there is controversy with regards to management of a synchronous contralateral hydrocele. It has been our policy not to address the contralateral hydrocele through an inguinal incision to minimize potential injury to the spermatic cord. Our objective in this study was to determine whether the decision to manage a contralateral hydrocele in cases of neonatal testicular torsion solely through a scrotal approach is safe and effective.

PATIENTS AND METHOD

We reviewed all cases of neonatal testicular torsion occurring at our institution between the years 1999 and 2006. Age at presentation, physical examination, ultrasonographic and intraoperative findings were recorded. Patients were followed after initial surgical intervention to determine the likelihood of developing a subsequent hydrocele or hernia.

RESULTS

Thirty-seven patients were identified as presenting with neonatal torsion. Age of presentation averaged 3.5 days (range 1-14 days). Left-sided pathology was seen more commonly than the right, with a 25:12 distribution. All torsed testicles were nonviable. Twenty-two patients were noted to have a contralateral hydrocele at presentation. All hydroceles were opened through a scrotal approach at the time of contralateral scrotal fixation. No patient underwent an inguinal exploration to examine for a patent process vaginalis. None of the patients who presented with a hydrocele have developed a clinical hydrocele or hernia after an average 7.5 years (range 4.3-11.2) follow-up.

CONCLUSION

We have demonstrated that approaching a contralateral hydrocele in cases of neonatal testicular torsion solely through a scrotal incision is safe and effective. Inguinal exploration was not performed in our study and our long-term results demonstrate that such an approach would have brought no additional benefit. In avoiding an inguinal approach we did not subject our patients to unnecessary risk of testicular or vasal injury. Contralateral hydrocele is commonly seen in cases of neonatal testicular torsion. In our experience this is a condition of minimal clinical significance and does not warrant formal inguinal exploration for treatment. This conservative management strategy minimizes the potential of contralateral spermatic cord injury in the neonate. The aims of the study were met.

Effects of single-port laparoscopic percutaneous extraperitoneal closure on the orientation of the vas deferens and testicular perfusion and volume: Experience from a single center

OBJECTIVE

To investigate the influence of single-port laparoscopic percutaneous extraperitoneal closure (LPEC) on the orientation of the vas deferens and testicular perfusion and volume in pediatric patients undergoing inguinal hernia repair.

METHODS

A total of 92 consecutively enrolled boys preoperatively diagnosed with a unilateral inguinal hernia underwent single-port LPEC between June 2013 and June 2014. The orientation of the vas deferens and the testicular perfusion and volume of these patients were ultrasonographically assessed preoperatively, one month after surgery and six months after surgery.

RESULTS

The surgical procedures were performed successfully without conversion or serious perioperative complications. Ultrasonography showed no angulation or distortion of the vas deferens on the surgical side during a six-month follow-up period. Similarly, there were no perioperative changes in testicular perfusion or volume.

CONCLUSION

Our experience suggests that the single-port LPEC technique can be safe and effective in pediatric patients with an inguinal hernia and that this technique does not affect the orientation of the vas deferens or testicular perfusion or volume.

Long-Term Outcome of Low Scrotal Approach Orchiopexy without Ligation of the Processus Vaginalis

PURPOSE

We performed low scrotal approach orchiopexy in patients with prescrotal cryptorchidism. The processus vaginalis was not ligated if it was not widely patent. We retrospectively evaluated the long-term outcomes of low scrotal approach orchiopexy without processus vaginalis ligation.

MATERIALS AND METHODS

A total of 137 patients (227 testes) were diagnosed with prescrotal cryptorchidism between October 2009 and April 2014. All patients underwent low scrotal approach orchiopexy. Mean age at surgery was 34.9 months. The processus vaginalis was deemed to be not widely patent when a sound could not be passed into the abdominal cavity through the internal inguinal ring, and the processus vaginalis was not ligated in such cases.

RESULTS

Intraoperative findings revealed that the processus vaginalis was widely patent in 10 testes and was not widely patent in 217. A widely patent processus vaginalis was closed via scrotal approach in 5 testes, while an inguinal approach was necessary in 5. Median followup was 44 months (range 20 to 73). Postoperative complications included reascending testis in 1 case where an inguinal approach was necessary. No patient manifested testicular atrophy or inguinal hernia.

CONCLUSIONS

Low scrotal approach orchiopexy is a useful and safe procedure for treating patients with prescrotal cryptorchidism. Ligation is unnecessary when the processus vaginalis is not widely patent.

Clinical features and therapeutic strategies of obstructive azoospermia in patients treated by bilateral inguinal hernia repair in childhood

Childhood inguinal herniorrhaphy is one common cause of seminal tract obstruction. Vasovasostomy (VV) can reconstruct seminal deferens and result in appearance of sperm and natural pregnancy in some patients. Secondary epididymal obstruction caused by a relatively long-term vasal obstruction is a common cause of lower patency compared with VV due to vasectomy in adults. From July 2007 to June 2012, a total of 62 patients, with history of childhood inguinal herniorrhaphy and diagnosed as obstructive azoospermia were treated in our center. The overall patency rate and natural pregnancy rate were 56.5% (35/62) and 25.8% (16/62), respectively. 48.4% (30/62) of the patients underwent bilateral VV in the inguinal region, with a patency rate of 76.7% (23/30) and a natural pregnancy rate of 36.7% (11/30), respectively. 30.6% (19/62) of the patients underwent bilateral VV and unilateral or bilateral vasoepididymostomies due to ipsilateral epididymal obstruction with the patency and natural pregnancy rate decreasing to 63.2% (12/19) and 26.3% (5/19). 21.0% (13/62) of the patients merely underwent vasal exploration without reconstruction due to failure to find distal vasal stump, etc. Our study indicate that microsurgical reanastomosis is an effective treatment for some patients with seminal tract obstruction caused by childhood inguinal herniorrhaphy.

Effect of arsenic contaminated drinking water on human chromosome: a case study

Arsenic contamination of ground water has become a serious problem all over the world. Large number of people from Uttar Pradesh, Bihar and West Bengal of India are suffering due to consumption of arsenic contaminated drinking water. Study was carried out on 30 individuals residing in Ballia District, UP where the maximum concentration of arsenic was observed around 0.37 ppm in drinking water. Blood samples were collected from them to find out the problem related with arsenic. Cytogenetic study of the blood samples indicates that out of 30, two persons developed Klinefelter syndrome.

The epidemiology and etiology of azoospermia

The misconception that infertility is typically associated with the female is commonly faced in the management of infertile men. It is uncommon for a patient to present for an infertility evaluation with an abnormal semen analysis report before an extensive female partner workup has been performed. Additionally, a man is usually considered fertile based only on seminal parameters without a physical exam. This behavior may lead to a delay in both the exact diagnosis and in possible specific infertility treatment. Moreover, male factor infertility can result from an underlying medical condition that is often treatable but could possibly be life-threatening. The responsibility of male factor in couple's infertility has been exponentially rising in recent years due to a comprehensive evaluation of reproductive male function and improved diagnostic tools. Despite this improvement in diagnosis, azoospermia is always the most challenging topic associated with infertility treatment. Several conditions that interfere with spermatogenesis and reduce sperm production and quality can lead to azoospermia. Azoospermia may also occur because of a reproductive tract obstruction. Optimal management of patients with azoospermia requires a full understanding of the disease etiology. This review will discuss in detail the epidemiology and etiology of azoospermia. A thorough literature survey was performed using the Medline, EMBASE, BIOSIS, and Cochrane databases. We restricted the survey to clinical publications that were relevant to male infertility and azoospermia. Many of the recommendations included are not based on controlled studies.

Ventrally dislocated attachment of the ovarian suspensory ligament, a risk factor for tubal occlusion as a postoperative complication of inguinal hernia repair: efficacy of laparoscopic inguinal hernia repair for preventing tubal damage

PURPOSE

Although the traditional cutdown inguinal hernia repair in children is well established, tubal occlusion has been reported as a complication in girls. The purpose was to investigate the mechanism of this complication and the efficacy of laparoscopic repair for preventing tubal occlusion.

METHODS

Between October 2006 and May 2010, we performed laparoscopic hernia repair in 100 girls (54 with a right hernia, including 2 with an inguinal ovarian hernia, 40 with a left hernia, including 3 with an inguinal ovarian hernias, and 6 with bilateral hernias). During laparoscopic repair we examined the anatomical relationship between the ovary, ovarian suspensory ligament, internal inguinal ring, and round ligament on both sides.

RESULTS

In 17 cases, 5 with an inguinal ovarian hernia and 12 without, the suspensory ligaments were ventrally dislocated and attached around the internal inguinal ring, and the ovary and fallopian tube were positioned near the internal inguinal ring and above the pelvic brim on the side of the original hernia.

CONCLUSION

This ventrally dislocated attachment may facilitate sliding of the ovaries and tubes into the hernial sac and induce tubal occlusion as a postoperative complication of inguinal hernia repair. The laparoscopic procedure makes it easy to prevent this complication.

Effects of chemical sympathectomy on contralateral testicular histology and fertility in unilateral vasectomy

Unilateral obstruction or injury to the vas deferens can result in significant injury to the contralateral testicle. Although various pathways have been proposed, the mechanism of contralateral testicular deterioration remains controversial. The present animal study was performed to evaluate the effects of unilateral vasectomy on ipsilateral and contralateral testicular histology and fertility in rats that were chemically sympathectomized neonatally. The study comprised 40 male albino rats: 20 received a placebo and the other 20 underwent chemical sympathectomy neonatally. When 60 days old, each group of 20 rats was divided into two groups that underwent either a sham operation or an operation to create unilateral left vasectomy. Eight weeks after surgery, each male rat was housed with two known fertile female rats for 25 days, and then their testes were harvested. Mean seminiferous tubular diameters (MSTD) and mean testicular biopsy scores (MTBS) were determined for each testis. Although MSTD and MTBS were not significantly different between groups, chemical sympathectomy prevented the decrease in total fertility rates of the rats with unilateral left vasectomy in our study. Prevention of this decrease by chemical sympathectomy suggests that the sympathetic nervous system may play a role in the testicular degeneration associated with vasectomy.

Microsurgical reconstruction of iatrogenic injuries to the epididymis from hydrocelectomy

PURPOSE

We determined the feasibility and outcome of microsurgical reconstruction of the excurrent ductal tract in men with obstruction secondary to iatrogenic injury to the epididymis from hydrocelectomy.

MATERIALS AND METHODS

A retrospective chart review was done to identify men with iatrogenic injury to the epididymis or scrotal vas deferens and a history of hydrocelectomy. The outcome of microsurgical reconstruction was assessed by postoperative semen analysis. Pregnancy data were noted in patients actively attempting to conceive at a followup of 6 months or greater.

RESULTS

Eight men were found to have iatrogenic injury to the epididymides (6) or scrotal vas deferens (2) due to previous hydrocelectomy. Injury was bilateral in 4 men and unilateral in 4 with contralateral testicular absence, dysfunction or obstruction resulting from different etiologies, rendering all patients azoospermic. The mean obstructive interval was 16 years (range 6 to 32). Bilateral and unilateral vasoepididymostomy was performed in 4 and 2 men each, and crossed vasovasostomy was performed in 2. Postoperative semen analysis data were available on 6 men. A patent microsurgical anastomosis was observed in 5 of 6 cases (83%). Four of the 5 men with patency had a followup of greater than 6 months, of whom 3 actively pursued conception. One pregnancy was achieved naturally and 1 was achieved by in vitro fertilization with intracytoplasmic sperm injection.

CONCLUSIONS

Hydrocelectomy may result in inadvertent injury to the excurrent ductal tract, causing obstruction and infertility. Microsurgical reconstruction results in the restoration of spermatozoa to the ejaculate in 83% of cases. The return of spermatozoa to the ejaculate may provide the couple with an opportunity to conceive naturally or through assisted reproduction.

The effects of orchidopexy and orchidectomy on testes of rats subjected to ipsilateral abdominal testis with vas deferens obstruction

An experimental study was planned to evaluate and compare the effects of orchidopexy and orchidectomy on the testes of rats subjected to unilateral abdominal testis with vas deferens obstruction. Four groups were established. Rats in the control group underwent a sham procedure. While the testis was maintained in the abdomen with the vas deferens ligated for 8 weeks in group 2, rats in groups 3 and 4 underwent orchidopexy or orchidectomy after 4 weeks. Remaining testes were harvested at the end of the 8-week period. Testis and body weights were obtained during harvest. Samples were evaluated through DNA flow cytometry, and percentages of haploid cells were determined. Groups were compared through unpaired t-test, and p-values less than 0.05 were considered significant. All three treatments had decreased testis weight over body weight values of ipsilateral testes. Ipsilateral orchidectomy increased the value among contralateral testes. However, none of the groups had a contralateral testicular value less than the sham-operated group. All three treatments decreased the percentage of haploid cells among ipsilateral testes, but only an abdominal testis was associated with a decrease in the percentage of haploid cells among contralateral testes. Maintaining a testis with an obstructed vas deferens in the abdomen for 8 weeks damages both ipsilateral and contralateral testes. Orchidopexy, while showing amelioration of the ipsilateral testis, spares the contralateral testis as well as orchidectomy. Orchidopexy for an undescended testis with vas deferens obstruction is a rational approach.

Serial follow-up study of serum testosterone and antisperm antibodies in patients with non-obstructive azoospermia after conventional or microdissection testicular sperm extraction

Testicular sperm extraction (TESE) combined with intracytoplasmic sperm injection is becoming a first-line treatment even for non-obstructive azoospermia. The current focus of TESE is the identification of seminiferous tubules that contain spermatozoa and minimization of testicular damage. Although microdissection TESE has been introduced as a preferred procedure for sperm retrieval, no serial follow-up studies of testicular damage have been reported. In the present study, we assayed serum testosterone concentrations and for the presence of antisperm antibodies (ASA) for 1 year after conventional multiple TESE or microdissection TESE and compared postoperative testicular damage between procedures. Thirteen patients who underwent conventional multiple TESE and 12 patients who underwent microdissection TESE were included in this study. Serum total and free testosterone concentrations were evaluated before operation and 1, 6 and 12 months after TESE. Serum ASA was also evaluated before and 12 months after TESE. Serum total and free testosterone concentrations in all patients in both groups showed no significant postoperative decrease. A comparison between the two groups of serum total and free testosterone concentrations showed no significant difference (total testosterone, p = 0.2477; free testosterone, p = 0.3098). No incidence of new ASA formation was identified in the present study. In conclusion, TESE procedures cause neither a decrease of serum testosterone nor formation of ASA. Serum testosterone concentration are similar between patients in the conventional multiple TESE and microdissection groups. Therefore, microdissection TESE is safe with respect to testicular damage, particularly for patients with hypogonadism.

Results of microsurgical anastomosis in men with seminal tract obstruction due to inguinal herniorrhaphy

The incidence of vasal injury during inguinal herniorrhaphy is estimated at 0.5%. We sought to assess the patency rates and long-term fertility outcome after microsurgical repair of vasal obstruction related to prior inguinal herniorrhaphy.

METHODS

Twenty procedures were performed on 13 men diagnosed with infertility and vasal injury secondary to previous inguinal herniorrhaphy. Eight of these men had undergone bilateral and 5 unilateral inguinal herniorrhaphy. Twelve procedures were vasovasostomies, 3 were crossover vasovasostomies, 2 were vasoepididymostomies, and 3 were crossover vasoepididymostomies. Eight patients were azoospermic, 2 were severely oligospermic (<1 M/mL), 1 was oligospermic, and 2 were asthenospermic. Patency data was obtained on all 13 patients, and pregnancy data was available for 10 couples (77%), with a mean follow-up of 69.5 months.

RESULTS

The overall patency rate was 65%. In the vasovasostomy group, the patency rate was 60% (9/15), and in the vasoepididymostomy group it was 80% (4/5). Among the azoospermic patients, 13 procedures were performed. The patency rate was 42.9% for the vasovasostomy (3/7), and 100% for the vasoepididymostomy procedure (4/4). The overall pregnancy rate was 40%. Of the men who underwent vasoepididymostomy, 80% (4/5) established a pregnancy.

CONCLUSIONS

Microsurgical vasovasostomy after inguinal vas injury results in a reasonable patency rate but a lower pregnancy rate than that after vasectomy reversal. When microsurgical vasoepididymostomy was possible, it resulted in high patency and pregnancy rate. Crossover vasoepididymostomy, when appropriate, can be a useful alternative to inguinal vasovasostomy.

Temporary stretch of the testicular pedicle may damage the vas deferens and the testis

BACKGROUND/PURPOSE

The authors aimed to investigate the effects of temporary stretching of the spermatic cord, a commonly performed manipulation during inguinal surgery, on the vas deferens and the testis.

METHODS

Forty adult male Wistar-Albino rats were divided equally into 4 groups. The right spermatic cord and testis were exposed via a transverse suprascrotal incision. In the study groups, a continuous horizontal stretch force was applied to the vas deferens and vessels in a distal direction for 60 seconds. In group 1 (G1) a 1.25-Newton (N), and in group 2 (G2) a 0.75-N stretch force was applied. Group 3 (G3) and group 4 (G4) served as sham and control groups, respectively. The animals were killed 28 days later. Sections of the vas deferens were examined histologically and their dimensions measured. Both testes were excised, weighed, and examined microscopically. Kruskal-Wallis test and Mann-Whitney U test were used to compare means in the different groups.

RESULTS

The mean wall thickness of the vas deferens was 378 +/- 133 mum in G1 and was significantly diminished compared to G2, G3, and G4, in which the mean wall thickness was 497 +/- 142 mum, 500 +/- 10 mum and 521 +/- 95 mum, respectively (P <.05). The mean right testicular weights were 1.18 +/- 0.10 g and 1.23 +/- 0.17 g in G1 and G2, respectively, and each was significantly lower than in G3 (1.23 +/- 0.09 g) and G4 (1.25 +/- 0.08 g; P <.05). The mean right testicular weights showed no difference between G1 and G2 (P >.05). Necrosis was seen in the right testes in 50.0% and 42.9% of the animals in G1 and G2, respectively. No histopathologic alterations were observed in the vas deferens in all groups. Microscopic examination of the left testes was normal.

CONCLUSIONS

In an experimental animal model, temporary stretching of the spermatic cord resulted in significant thinning of the smooth muscle layer of the vas deferens and testicular atrophy.

Subtotal obstruction of the male reproductive tract

Bilateral obstruction of the male reproductive tract is suspected in men with azoospermia, normal testicular volume and normal FSH. A testicular biopsy is required to differentiate between an obstruction and a testicular insufficiency. Unilateral or subtotal bilateral obstructions and epididymal dysfunction may cause severe oligozoospermia in men with a normal spermatogenesis. However, information on spermatogenesis in oligozoospermic men is lacking, since testicular biopsy is not routinely performed. Men with a sperm concentration of <1 x 10(6) spermatozoa/ml were investigated for possible partial obstruction by performing a testicular biopsy under local anaesthesia. Spermatogenesis was determined by the Johnsen scoring method. A testicular biopsy was performed in 78 men with severe oligozoospermia. The medical history showed male accessory gland infection in 12.8%, previous hernia repair in 14.1% and a history of cryptorchidism in 12.8%. A normal or slightly disturbed spermatogenesis (Johnsen score >8) was present in 39/78 (50%) of the men. Hernia repair occurred more often in men with normal spermatogenesis. A varicocele was predominantly seen in men with a disturbed spermatogenesis. FSH was significantly lower ( P<0.0001) in men with normal spermatogenesis. Subtotal obstruction of the male reproductive tract is a frequent cause of severe oligozoospermia in men with a normal testicular volume and a normal FSH. In other cases, an epididymal dysfunction might explain the oligozoospermia in men with a normal testicular biopsy score.

Male antisperm antibodies: association with a modified sperm stress test and lipid peroxidation

We previously reported a modified sperm stress test (MOST), low scores (< 0.39) in which were associated with sperm-related abnormal in vitro fertilization. Preliminary observations suggested that the presence of male sperm antibodies (ASA) could give low MOST scores. It was therefore decided to undertake a study to verify this possible association and also to ascertain if such a relationship was causal in nature. Six hundred and fifty semen samples from patients consulting for infertility were assessed for basic seminal characteristics, motion parameters (CASA), ASA and MOST. Thirty-nine samples (6%) were ASA-positive. Samples with and without ASA showed similar characteristics, except for percentage of normal forms and MOST scores (0.35 +/- 0.03 vs. 0.67 +/- 0.01, P < 0.001, for ASA-positive and -negative, respectively). There was a strong statistical association between presence of ASA and low MOST scores (P < 0.0001). One-hundred per cent of ASA-positive samples displayed low MOST scores. To verify the nature of this relationship, we incubated ASA-free spermatozoa with ASA-positive and -negative (control) sera. Despite an increase in the percentage of ASA-bearing spermatozoa in those aliquots incubated with ASA-positive serum, their original (pre-incubation) MOST scores remained unchanged. Furthermore, the rate of lipid peroxidation, indirectly reflected in MOST scores, was not different in the aliquots incubated with ASA. In conclusion, there seems to be a strong association between presence of ASA and low MOST values in semen samples of infertile patients; however, the relationship does not appear to be causal.

Outcome of surgical treatment for obstructive azoospermia

The efficacy of reanastomosis was evaluated in 30 patients with obstructive azoospermia, including 19 postvasectomy cases; 7 cases complicating inguinal herniorrhaphy; 2 cases with a characterized isolated congenital anomaly; 1 case of Young's syndrome; and 1 case with an unknown, possibly congenital cause. In the postvasectomy group. successful vasovasostomy was achieved in 15 of 18 cases (83.3%; 1 postvasectomy patient dropped out of the study prior to analysis). Duration of obstruction in the 3 cases where anastomosis failed was 6, 9, and 20 years. In the group where obstruction followed inguinal herniorrhaphy, unilateral vasovasostomy was performed in 6 cases, and transepididymovasostomy was performed in 1 case. Success was achieved in 3 of 6 cases (50%; 1 case was not included because failure of spermatogenesis was detected postoperatively). In all 4 remaining cases, microsurgical epididymovasostomy or transepididymovasostomy was performed, but success was achieved only in the case of Young's syndrome. Although mailed questionnaires and telephone interviews indicated occurrence of natural pregnancy in only 4 affected couples, postoperative sperm counts were relatively satisfactory as in previous reports.

Serial ultrasonography, hormonal profile and antisperm antibody response after testicular sperm aspiration

BACKGROUND

In many fertility centres, intracytoplasmic sperm injection (ICSI) with epididymal or testicular spermatozoa is a routine treatment for men with azoospermia. In this prospective study, the physiological consequences after testicular sperm aspiration (TESA), using suction and a 19 gauge needle, were evaluated.

METHODS AND RESULTS

Thirty-five consecutive men with azoospermia underwent TESA. Testicular ultrasonography with Doppler flow imaging was performed and testicular volumes were evaluated pre-operatively and 3 months after aspiration. If focal testicular lesions were found, further examinations were performed 6 and 9 months after TESA. Serum FSH, testosterone and antisperm antibodies (ASA) were analysed. Focal testicular lesions were seen in four out of 61 testes (6.6%) at the 3 month investigation point. Three lesions were resolved after 6 months and all after 9 months. Testicular echogenicity remained unchanged in 50 cases (82%) 3 months after TESA. Four men (11.4%) reported severe subjective discomfort post-operatively, but only one had a medical consultation where an intratesticular haematoma was diagnosed. There were no significant changes in FSH and testosterone after surgery and testicular volumes were similar after 3 months. There were three borderline cases of ASA in serum, but none was classified as ASA-positive.

CONCLUSIONS

The puncture method of testicular sperm aspiration seems to be a safe method for sperm retrieval, with minimal physiological consequences.

Does contraction of mesh following tension free hernioplasty effect testicular or femoral vessel blood flow?

Prosthetic mesh can contract by 20-75% of its original size within ten months after implantation. We set out to determine whether this contraction has any effect on testicular or femoral vessel blood flow following open or laparoscopic hernia repair. Twenty patients who underwent mesh repair of a primary unilateral inguinal hernia repair by Open (10) or Laparoscopic (10) methods a median of 3 years previously were investigated by ultrasound to determine the haemodynamic characteristics of the testis and femoral vessels. There was no significant difference in testicular blood flow, volume or echogenicity between the different types of repair or the contralateral side. The vertical and transverse dimensions of the femoral artery and vein were similar in all groups as was blood flow. Mesh contraction following inguinal hernioplasty does not adversely affect the testis or femoral vessels and can be used safely for both anterior and preperitoneal approaches.

Diagnosis and treatment of post-herniorrhaphy vas deferens obstruction

Childhood inguinal herniorrhaphy (IH) is one of the most frequent causes of seminal tract obstruction. The incidence of vasal obstruction was found to be as high as 26.7% in subfertile patients with a history of childhood IH. The distal end of the vas deferens was found at the internal inguinal ring or in the pelvic cavity in 56.7% of cases, more than 3 cm of the vas deferens had been resected in 37.9% of cases, and sperm was found in vasal fluid in 45.5% of cases during corrective surgery. Microsurgical two-layer vasovasostomy resulted in the postoperative appearance of sperm in 39% of patients. In patients with postoperative azoospermia, a secondary epididymal obstruction caused by a long-term vasal obstruction is a highly probable cause. Ipsilateral epididymovasostomy following successful inguinal vasovasostomy results in the postoperative appearance of sperm in the ejaculate in 100% of the patients and a subsequent natural pregnancy rate of 50%. The overall pregnancy rate among couples, following surgery in 18 patients, was 43%, excluding pregnancies achieved by in vitro fertilization or intracytoplasmic sperm injection. Microsurgical reanastomosis of the seminal tract resulted in high impregnation rates among partners of patients with seminal tract obstruction caused by childhood IH. After receiving sufficient information on each treatment modality, patients can choose their preferred treatment, either reanastomosis of the seminal tract or assisted reproductive technology using epididymal or testicular sperm.

Effect of vasovasostomy on contralateral testicular damage associated with unilateral vasectomy in mature and immature Lewis rats

OBJECTIVE

We sought to determine if laser-assisted vasovasostomy could reverse the contralateral histologic testicular changes associated with unilateral vasectomy.

DESIGN

A prospective, randomized, blinded, controlled study.

SETTING

Animal microsurgical laboratory, St. John's Mercy Medical Center, St. Louis, Missouri.

PATIENT(S)

Twenty mature and 20 immature male Lewis rats.

INTERVENTION(S)

Ten mature and 10 immature male Lewis rats underwent unilateral vasectomy. At 5 months, testicular biopsy and laser-assisted vasovasostomies were performed followed 2 months later by evaluation of vas patency and repeat testicular biopsy. Control animals consisted of 10 rats in each group, 5 that underwent sham operations and 5 that had halothane anesthesia alone.

RESULT(S)

In the immature and mature groups unilateral vasectomy resulted in marked contralateral testicular damage in 30% (3 of 10) and 50% (5 of 10), respectively. Vas patency determined 2 months after vasovasostomy was 80% (8 of 10) in the mature group and 89% (8 of 9) in the immature group. No animal that had contralateral testicular changes after vasectomy and a patent vas after vasovasostomy showed improvement in testicular histology.

CONCLUSION(S)

It appears that contralateral testicular damage associated with unilateral vasectomy is not improved 2 months after successful vasovasostomy in mature or immature Lewis rats.

Antisperm autoantibody response is reduced by early repair of a severed vas deferens in the juvenile rat

OBJECTIVE

To determine whether antisperm autoantibody production after prepubertal vas injury is influenced by immediate repair of the vas compared to delay of the reanastomosis until sexual maturity.

DESIGN

Animal study comparing early repair, late repair, and sham-operated groups.

SETTING

Research laboratory in a medical school.

PATIENT(S)

Lewis rats.

INTERVENTION(S)

After division of the vas deferens in juvenile rats, animals in an early repair group had the vasa repaired immediately by using an absorbable intraluminal stent. Animals in a late repair group had vasa obstructed by ligation until after puberty, when they underwent microsurgical vasovasostomy (age 60 days).

MAIN OUTCOME MEASURE(S)

Antisperm antibodies were assayed by ELISA. The weights of reproductive organs were determined, and samples of testis were studied by light microscopy.

RESULT(S)

The antisperm antibody response was less when the vas was repaired immediately than if the repair was delayed until after puberty. There was a low incidence of testicular alteration in the repair groups and none in sham-operated animals.

CONCLUSION(S)

If the vas deferens is injured or obstructed prepubertally, there may be a benefit to considering immediate repair to reduce the likelihood of developing antisperm autoantibodies, which have been associated with reduced fertility.

Laparoscopic diagnosis of contralateral patent processus vaginalis in children under 1 year of age with unilateral inguinal hernia: comparison with herniography

PURPOSE

The effectiveness of laparoscopic diagnosis of contralateral patent processus vaginalis (CPPV) in children with unilateral inguinal hernia was evaluated.

METHODS

Ninety-three consecutive children under the age of 1 year were operated on for a unilateral inguinal hernia. A contralateral CPPV was diagnosed by laparoscopy via the inguinal hernia sac before ligation. The laparoscopy results of this technique were correlated with those of herniography or inguinal exploration.

RESULTS

Laparoscopy was performed on 88 patients; sensitivity was 71% and specificity 89%. The only complication arising from the procedure was wound infection in two patients.

CONCLUSION

This method is a simple, safe, and accurate procedure for selecting children for contralateral surgical exploration.

Antisperm antibodies: etiology, pathogenesis, diagnosis, and treatment

OBJECTIVE

To critically review the English-language literature and describe the current diagnosis, prevalence, etiology, and treatment of antisperm antibodies (ASA).

DESIGN

A comprehensive literature search of the English-language literature published between 1966 and December 1997 was performed on MEDLINE. Articles were also located via bibliographies of published works.

RESULT(S)

Data were excerpted from articles identified by MEDLINE search. The diagnosis, prevalence, etiology, and treatment of ASA are described.

CONCLUSION(S)

There is sufficient evidence that ASA impair fertility in couples with unexplained infertility. A number of different methodologies are available, which may be used in their detection. However, in many cases, test interpretation is subjective. Although there is not enough evidence to support systemic treatment for ASA, application of a variety of assisted reproductive technologies improves outcome.

[A survey of the contralateral inguinal hernial sac in infants less than 1 year of age using laparoscopy with anatomic verification using peritoneal radiography or surgery]

STUDY AIM

The aim of this prospective study was to evaluate the laparoscopic diagnosis of contralateral patent processus vaginalis in children with unilateral inguinal hernia.

PATIENTS AND METHOD

Between November 1995 and February 1998, 91 consecutive children (78 boys, 13 girls) under the age of 1 year were operated on for a unilateral inguinal hernia. A contralateral hernia was diagnosed by a laparoscopy through the inguinal hernia sac before ligation. Results of this technique were correlated with those of herniography (79 cases) or with inguinal exploration (12 emergency).

RESULTS

Laparoscopy was performed in 88 patients. Laparoscopy was impossible in three cases: one inguinal sac too thin, two cases of ectopic testis in the inguinal canal. Sensitivity was 73% and specificity 92%. The only complication arising from the procedure was wound infection in two patients.

CONCLUSION

This method is a simple, safe and accurate procedure in order to select children for contralateral surgical exploration.

Microsurgical repair of iatrogenic injury to the vas deferens

PURPOSE

We determined the incidence of iatrogenic injuries to the vas deferens at a tertiary care university infertility center and the results of surgical repair.

MATERIALS AND METHODS

Records of 472 patients surgically explored for obstructive azoospermia between 1984 to 1996 were reviewed. Enrollment criteria included history of inguinal, pelvic and scrotal (other than vasectomy) surgery. Conventional ipsilateral and crossover vasovasostomies and vasoepididymostomies were performed. Patency rate was defined as presence of complete sperm with tails in a postoperative semen analysis. Followup included a minimum of 2 semen analyses. Only naturally conceived pregnancies were included.

RESULTS

Of 472 patients 34 (7.2%) had an iatrogenic injury to the vas deferens with a mean obstruction interval of 20.5 +/- 1.9 years. Mean patient age was 36.7 +/- 1.8 years. Iatrogenic injury to the vas deferens was secondary to bilateral inguinal hernia repair in 19 patients, unilateral hernia repair in 11, renal transplantation in 2, appendectomy in 1 and spermatocelectomy in 1. Pediatric inguinal hernia repair was the most common etiology of the vasal injury (20 patients), followed by adult inguinal hernia repair (10). A total of 36 microsurgical reconstructive procedures were performed, including 20 ipsilateral and 16 crossed vasovasostomies and vasoepididymostomies. There were 26 patients (29 procedures) available for followup (mean 21.0 +/- 3.7 months). Total patency rate per procedure was 65% and pregnancy rate was 39%. Patency and pregnancy rates per conventional ipsilateral procedures were 62.5 and 35.7% and per crossover procedures 64.2 and 42.8%, respectively.

CONCLUSIONS

Pediatric inguinal hernia repair is the most common cause of iatrogenic injury to the vas deferens. Results of treatment of iatrogenic injury to the vas deferens are somewhat lower than for patients with obstructive azoospermia due to vasectomy. Iatrogenic injuries are associated with longer vasal defects, impaired blood supply and longer obstructive intervals frequently resulting in secondary epididymal obstruction. Crossover reconstruction is particularly useful when contralateral testicular atrophy is present. Intraoperatively aspirated sperm should be cryopreserved for later use in case the reconstruction fails.

The effect of iatrogenic vas deferens injury on fertility in an experimental rat model

The long-term result of accidental crushing of the vas deferens during inguinal surgery is unpredictable. It is stated that even a slight disturbance in the muscular layer or mucosa may endanger fertility. This study was designed to investigate the early and late histopathologic changes of iatrogenic injury on the vas and its effect on fertility in a rat model. Both vasa deferentia of 54 male rats, divided into three groups (n = 18 each), were subjected to an operative manipulation. These manipulations consisted of digital compression for 45 seconds in group A, grasping with a mosquito clamp for 2 seconds in group B, and grasping with a mosquito clamp for 2 minutes in group C. In five rats from each group, the vasa were removed on the third and 21st postoperative day for histological evaluation. The remaining 13 rats in each group were allowed to mate for a period of 4 months. Bilateral vasa were analyzed for patency and histology. A spermatic granuloma was observed in 79% of the fertile and 80% of the infertile rats. Statistical analysis showed no significant fertility difference among the three groups. There was no statistical difference between groups B and C (P > .05) in terms of high and low flow patency rates in vitro, whereas a statistical significance was present between these two groups and group A (P< .001). It can be said that type rather than time of injury is important in this experimental model, because the results of the patency test alone are sufficient to prove the possibility of functional damage in vas deferens. The authors conclude that inguinal contents should be handled carefully and contralateral exploration in asymptomatic cases older than 1 year with inguinal pathology should be avoided.

Appearance of 'natural' antisperm autoantibodies after sexual maturation of normal Lewis rats

Serum antisperm antibodies were assessed quantitatively with an ELISA in normal male Lewis rats at intervals between ages 10 and 128 days, spanning the onset of puberty. Antisperm antibodies rose between 56 and 91 days, and were significantly higher in 91- and 128-day old rats than at earlier intervals. The animals underwent normal pubertal development as indicated by increases in weights of the seminal vesicles and ventral prostate. The rise in antisperm antibodies correlated temporally with events in the postnatal development of the male reproductive system, with the increase in antisperm antibodies most closely following the time when spermatozoa reach the epididymis and proximal vas deferens at approximately 56 days. The observation that serum antisperm antibodies increased only after sexual maturation suggests that some differentiation antigens of sperm are processed and presented to the immune system under normal circumstances in this strain. Western blot analysis showed that the sera from normal postpubertal Lewis rats bound several proteins, including bands of > 100, 82-75, 78, 68, 65, 63, 54-55, 42, 37, 35, 26, and 20-22 kDa. The majority of these autoantibodies were sperm-specific as shown by the absence of comigrating bands in western blots of somatic tissue extracts, although antibodies in postpubertal sera recognized certain other proteins in somatic tissues. Several protein autoantigens, defined by sera from postpubertal animals, matched dominant autoantigens recognized by antibodies produced in response to vasectomy, prepubertal vas obstruction, or immunization with spermatozoa. This finding indicates that the antisperm antibody responses following sperm immunization, vasectomy or prepubertal vasal obstruction represent accentuation of an autoantibody response to sperm that develops normally following puberty.