Applications of microsurgery in urology

Surgical treatment for male infertility

Given the nature of the multiple causes of male infertility, some of them are «reversible» and can be managed with a surgical procedure to recover, in some cases, the fertilizing capacity of the male reproductive tract. With appropriate use of diagnostic tools and clinical judgement, the physician can identify the ideal candidates for these procedures. Together with the expertise and experience of the surgeon, these treatments can manage to resolve the barrier, and men may become fertile again. In this chapter, we will review some of the most commonly used surgical procedures for the treatment of male infertility and make a brief description of their technical details.

Management of ejaculatory duct obstruction: etiology, diagnosis, and treatment

Abnormalities of the distal ejaculatory ducts related to infertility have been well-documented. Although there are no specific findings associated with ejaculatory duct obstruction, several clinical findings are highly suggestive. A diagnosis of ejaculatory duct obstruction is suggested in an infertile male with oligospermia or azoospermia with low ejaculate volume, normal secondary sex characteristics, testes, and hormonal profile, and dilated seminal vesicles, midline cyst, or calcifications on TRUS. Other causes of infertility may be concomitantly present and need to be evaluated and treated. Trans urethral resection of ejaculatory ducts (TURED) has resulted in marked improvement in semen parameters, and pregnancies have been achieved. Proper patient selection and surgical experience are necessary to obtain optimal results. In case of testicular dysfunction, chances of success are minimal. Extended follow-up periods are needed after TURED to examine the long-term effects of this procedure. Better understanding of the anatomy and pathology of the ejaculatory ducts will continue to refine diagnostic and therapeutic procedures for this disorder.

Ejaculatory duct obstruction

PURPOSE OF REVIEW

We surveyed the growing literature on ejaculatory duct obstruction and provide suggestions regarding its diagnosis and management.

RECENT FINDINGS

Ejaculatory duct obstruction is a rare cause of male infertility. With the advent of the high resolution transurethral ultrasound (TRUS) technology, there has been an increase in diagnosis of this disorder. As for the treatment, it appears that central cystic lesions and partial obstructions respond best to transurethral resection of the ejaculatory ducts (TURED).

SUMMARY

Ejaculatory duct obstruction is a rare but surgically correctable cause of male infertility. Although there are no pathognomonic findings associated with ejaculatory duct obstruction, the diagnosis should be suspected in an infertile male with oligospermia or azoospermia with low ejaculate volume, normal secondary sex characteristics, testes, and hormonal profile, and dilated seminal vesicles, midline cyst, or calcifications on TRUS. In select cases, TURED has resulted in marked improvement in semen parameters, and pregnancies have been achieved. More studies are needed in the areas of diagnosis and long-term surgical outcome.

Transurethral resection of the ejaculatory duct

Complete bilateral ejaculatory duct obstruction has long been recognized as an uncommon, treatable form of male infertility. Partial ejaculatory duct obstruction reflects a disturbance of ejaculation where sperm quality is impaired during transit through the distal vas deferens and ejaculatory ducts. With the advent and increased use of high-resolution transrectal ultrasonography, abnormalities of the distal ejaculatory ducts related to infertility have been well documented. Although there are no pathognomonic findings associated with ejaculatory duct obstruction, several clinical findings are highly suggestive. In an infertile man with oligospermia or azoospermia with low ejaculate volume, normal secondary sexual characteristics, testes and hormonal profile and dilated seminal vesicles, midline cyst, or calcification on transrectal ultrasonography, ejaculatory duct obstruction is suggested. Of course, other causes of infertility may be concomitantly present and need to be searched for and treated as well. In selected cases, transurethral resection has resulted in marked improvement in semen parameters and pregnancies have been achieved. As is the case with all surgical procedures, proper patient selection and surgical experience are necessary to obtain optimal results. However, it appears that the treatments currently available for relief of ejaculatory obstruction are not optimally effective. Only approximately one half of treated patients will have an improvement in semen parameters and only about one quarter of treated patients will contribute to a pregnancy. What remains to be determined is how to manage the additional nearly 50% of patients who do not benefit from transurethral resection of ejaculatory obstruction. Based on my experience, I suggest that transrectal ultrasonography should be the first diagnostic procedure used when infertile men are suspected of having ejaculatory duct obstruction; however, vasography should still be considered for a more comprehensive diagnosis of ejaculatory duct obstruction. In patients showing atrophic seminal vesicles on transrectal ultrasonography and having a history of pulmonary tuberculosis, further study is not necessary and microscopic epididymal sperm aspiration is recommended for in vitro fertilization. Qualitative measurement of semen fructose may be helpful in the diagnosis of partial ejaculatory duct obstruction. Patients having midline cyst and being treated by transurethral resection are expected to have the best outcome.

Ejaculatory duct obstruction in infertile men

OBJECTIVE

To analyse our experience of ejaculatory duct obstruction (EDO) in infertile men, evaluating the diagnostic steps and the outcome of management according to the aetiology.

PATIENTS AND METHODS

Over a 7-year period, 50 infertile men were diagnosed with EDO as a contributory factor to male infertility. Diagnostic criteria included a history, physical examination, semen analyses, semen fructose measurement, hormonal study, testicular biopsy, transrectal ultrasonography (TRUS) and/or vasography. Thirty-one patients with EDO were treated by transurethral resection (26) or forced lavage via a vasotomy (five).

RESULTS

In 45 of the 50 men, semen analyses showed the typical characteristics of complete EDO. Seminal values were variable in five cases of partial EDO; the semen fructose levels were < 1.4 g/L in all five. The main cause of EDO was a midline cyst in 16, Wolffian malformation in four, tuberculosis in 17, previous genitourinary infection in five and idiopathic in eight men. In 17 patients the seminal vesicles appeared to be atrophied on TRUS; 15 of these patients had a history of pulmonary tuberculosis and subsequent vasography in five showed multiple bilateral vasal obstruction. TRUS findings correlated well with vasography except in one case. The overall rate of improved semen values and paternity was 61% and 26%, respectively. Of 16 patients with midline cysts, 14 had improved semen variables and achieved paternity, seven after transurethral resection.

CONCLUSIONS

TRUS should be the first diagnostic procedure used when infertile men are suspected of having EDO, but vasography should still be considered for a more comprehensive diagnosis. In patients with atrophic seminal vesicles on TRUS and with a history of pulmonary tuberculosis, further study is unnecessary and microscopic epididymal sperm aspiration is recommended for in vitro fertilization. The measurement of semen fructose may be helpful in diagnosing partial EDO. Patients with midline cysts who are treated by transurethral resection are expected to have the best outcome.

Laparoscopically assisted testicular autotransplantation for management of the intraabdominal undescended testis

PURPOSE

The intra-abdominal testis continues to present a considerable urological challenge and the approach to its management continues to evolve. We report our initial experience with laparoscopically assisted testicular autotransplantation.

MATERIALS AND METHODS

An intra-abdominal testicle was identified laparoscopically in 5 patients who subsequently underwent testicular autotransplantation.

RESULTS

The success rate was 100% and median operative time was 5 hours. All patients were discharged home the day after surgery with no complications and a good result.

CONCLUSIONS

Because of success with this technique, this procedure offers significant advantages (decreased hospital stay and lower morbidity) than an open or 2-stage Fowler-Stephens approach.

Testicular autotransplantation for the intra-abdominal testis

Oftentimes patients with intra-abdominal testes require more than the standard procedure to accomplish orchiopexy. Division of the spermatic vessels has been one mainstay of operative approaches for the intra-abdominal testis since Fowler and Stephens (Congenital Malformations of Rectum, Anus, and Genitouriary Tracts, chapter 19, pp 306-320, 1963) provided an anatomically rational basis for this procedure. Silber and Kelly (J Urol, 115:452-454, 1976) first described using a microvascular anastomosis to bring extra blood supply to the testicle after mobilization of a high intra-abdominal testicle into the scrotum; however, this approach has not been adopted by many for a number of reasons. The microvascular skill and instrumentation required for a successful anastomosis are not universally available and there is a misconception that the procedure is a lengthy one (Bianchi, Br J Urol 56:521-524, 1984; Bogaert et al., Urology 42:182-188, 1993). We present our series for testicular autotransplantation used over a 17 year period with a greater than 95% success.