A modified vasoepididymostomy performed with the sling and blanket technique.

A modification is presented for the end-to-end type of vasoepididymostomy known as the sling and blanket. We have exploited the differences in size between the vas and epididymis to gain a mechanical advantage. When the epididymis is transected the redundant tunic is preserved. The sling is created from the tunic, which is drawn forward and sutured to the vas posteriorly about 1 cm. from its cut end. The sling provides support so that the end-to-end anastomosis between the vas lumen and specific epididymal tubule may be completed in 1 plane and without rotation. The blanket is created from the remaining epididymal tunic, which is sutured anteriorly to cover the anastomosis and stabilize the vas. The procedure was performed on 8 patients with primary epididymal obstruction. The patency rate was 50% and the pregnancy rate was 25%. Although vasoepididymostomy remains a difficult microsurgical operation, this modification seems to be beneficial in selected cases.

The use of a vacuum constrictor device to augment a partial erection following an intracavernous injection.

Intracavernous injections and vacuum constrictor devices have been used for the nonoperative management of impotence and sexual dysfunction. Although most men are able to use these methods successfully, it currently is well known that up to 30 to 35 per cent of the patients may have only a partial response to the injections. We observed 22 men with partial tumescence after an intracavernous injection of papaverine (15 to 30 mg.) and phentolamine (0.5 to 1.0 mg.). The penis was not rigid and the buckling pressures never exceeded 50 mm. Hg after 20 minutes of observation. In each case we immediately applied a vacuum constrictor device because these devices had been used successfully by other men with similar diagnoses. A total of 21 men responded within 30 to 60 seconds and achieved a rigid erection with buckling pressures of greater than 100 mm. Hg (16) and 60 mm. Hg (5). These findings indicate that a vacuum constrictor device may be used to augment a partial response to an intracavernous injection and that the availability of injections and vacuum constrictor devices provides these men with a more complete nonoperative program.

Penile plethysmography on impotent men using vacuum constrictor devices.

Vacuum constrictor devices achieve an erection-like state of the penis by means of a clear plastic cylinder, a vacuum pump, and a constrictor ring. Although these devices are noninvasive compared with penile injections and implants, they have been used less often in clinical practice. Part of the hesitancy to prescribe these devices has been related to the lack of published data concerning the effects of constriction on penile blood flow. In this report, we utilized penile plethysmography to estimate penile blood flow on 51 men before, during, and after the use of the constrictor ring. All patients demonstrated a 70-75 percent decline in the amplitude of the pulse-volume curve during constriction, but continuous blood flow was maintained in each case. Within sixty seconds after removal of the ring, the amplitude returned to baseline values for all men, including 12 patients with a penile brachial index of less than 0.7. Among 33 patients, there was evidence of a transient increase of amplitude following constriction, which was consistent with a postischemic hyperemia. These findings suggest normal penile blood flow, and indicate that the use of constrictor rings may be safe for patients with these tracings. Penile plethysmography appears to be a useful technique to help with patient selection and constrictor ring fit. Follow-up tracings probably should be scheduled at periodic intervals for men utilizing these rings and devices.

Comprehensive scrotal flow and scan technique for detection of varicoceles.

We describe a noninvasive modified radionuclide technique, the "comprehensive scrotal flow and scan," for the detection of varicoceles. The procedure utilizes in-vivo-labeled pyrophosphate red blood cells and 99mTc-pertechnetate as a blood pool scanning agent. The procedure includes an immediate flow study along with early and delayed static images, both in the upright and supine position. These studies were examined by visual inspection and by computer analysis. Data were obtained from 50 patients and 8 control subjects. The technique demonstrated a 91.1 per cent sensitivity when compared to physical examination and an 84.6 per cent sensitivity when compared to venography from patients with subclinical or poorly palpable varicoceles.

The management of varicoceles by microdissection of the spermatic cord at the external inguinal ring.

A new technique for the management of varicoceles was carried out on 71 infertile men. The procedure combined microdissection of the spermatic cord at the external inguinal ring, ligation of the dilated veins, and controlled sclerosis of small cross-collateral veins. These procedures were performed on an outpatient basis and usually with local anesthesia. The surgery was completed within 20 to 30 minutes, and the postoperative morbidity was minimal. Twenty-four cases were followed for at least 18 months postoperatively. Among this group, the mean values for sperm density and sperm motility increased after surgery. The difference between the means were significant (P less than 0.001). The pregnancy rate among this group was 29.3%.

Clinical experience with an artificial spermatocele.

Artificial spermatoceles were implanted into three patients with congenital absence of the vas. In each case, the testicular biopsy demonstrated normal spermatogenesis, and the dilated epididymal tubule was packed with spermatozoa. The ciliated epididymal mucosa appeared normal despite the tubular dilatation. The spermatoceles were constructed of expanded polytetrafluoroethylene, and they were microsurgically implanted over the cut end of the epididymis. The grafts were aspirated monthly for up to six months, and the aspirates containing spermatozoa were used for artificial insemination. Spermatozoa were consistently retrieved from each patient, but no pregnancies have resulted. The most obvious finding was that the spermatozoa lacked motility. In the discussion, other problems related to artificial spermatoceles are reviewed, including epididymal development and sperm maturation, aspiration techniques, and sperm storage.

The identification of functioning plasma cells in cervical tissue by an immunoperoxidase technique.

The detection of sperm agglutinating antibodies in the blood has become a basic screening test for the infertility workup. However, documentation of these antibodies in the cervical mucus has been variable because procurement and preparation of this genital secretion is often difficult. In this report the local immune response has been examined in cervical tissue instead of mucus. A small biopsy was taken from the endo- and ectocervix and treated by an immunoperoxidase technique. Functioning plasma cells were clearly identified. This technique may be adaptable for clinical practice as part of the evaluation of immune infertility.

Values for zinc in whole semen, fractions of split ejaculate, and expressed prostatic fluid.

Since the prostate gland secretes specific substances, several investigators have suggested that measurement of these products may be useful for the evaluation of prostatitis. In our laboratory we have measured seminal zinc as a marker of prostatic secretion to establish normal values and define the confidence limits for this assay. Zinc assays were performed on whole semen, fractions of the split ejaculate, and expressed prostatic fluid from among a population of 456 men. We hope that these data will be useful when compared with data from patients with prostatic disease.

Functional role of spermagglutinating antibodies in men.

The presence of spermagglutinating antibodies in blood and semen has been associated with reduced fertility in men. In this study 203 men were screened for infertility. An antibody measurement was performed on the blood and semen of each patient. Each semen specimen was also examined for spontaneous agglutination. Twelve patients with a positive reaction in the blood underwent a sperm-cervical mucus contact test. We have attempted to correlate the findings in blood with the observed functional results in semen and cervical mucus. We believe that these simple tests should be included in the infertility work-up in order to determine the presence of immune infertility.

A protocol for evaluation of prostatitis.

The traditional office diagnosis of prostatitis has been based on clinical history, rectal palpation of the gland, and a microscopic examination of the expressed prostatic fluid. In light of present day information this appraoch appears to be incomplete. We have examined 41 consecutive patients with complaints of prostatitis along with 17 controls. In each case expressed prostatic fluid was collected under sterile conditions. On each specimen, we performed a bacterial culture, microscopic examination for white blood cells, and assay for zinc. The intent of this protocol was to classify clearly those with bacterial prostatitis from those with nonbacterial prostatitis and prostatodynia. We believe this approach is simple to perform even in the setting of a busy office practice.

Modification of the Friberg microagglutination tray technique for detection of sperm antibodies.

The Friberg microagglutination tray technique for the detection of sperm-agglutinating antibodies in the serum has several advantages over other techniques. Microquantities of a single-donor sperm specimen may be used for several tests and the agglutinates may be examined directly with an inverted lense microscope. However, in its original form, there were a few technical problems. The technique has been modified to eliminate the problems. The donor sperm is filtered through a glass wool filter. The procedure was adapted for Terasaki tissue culture plates. With these modifications the technique seems more practical for clinical usage.

An estimate of the fertility potential of the fractions of the split ejaculate in terms of the motile sperm count.

The motile sperm count is a simple index which is equivalent to the product of sperm density (millions of sperm per milliliter) and percentage of motility (motile sperm per 100 sperm x 0.01). Since other studies have demonstrated a positive correlation between this index and the pregnancy rate, it has been hypothesized that the motile sperm count could be useful for expressing the potential fertility of individual semen specimens. Collection of semen by the split ejaculate technique and subsequent artificial insemination homologous (AIH) with the best split fraction has been used for the treatment of oligospermia. We calculated the motile sperm count for whole semen and the first fraction of split ejaculates from 45 men who were studied for infertility. Subsequently, 15 couples agreed to AIH with the first fraction of the split ejaculate. The data indicate that the motile sperm count may be a reasonable index for comparing the potential fertility of the semen specimens and thereby estimating the chances of successful AIH.

Statisical comparison of the parameters of semen analysis of whole semen versus the fractions of the split ejaculate.

The split ejaculate has proven to be a reliable method for concentrating sperm in a small volume. However, there is some controversy whether the spermatozoa in the most sperm-rich fraction of the split ejaculate has better motility than the spermatozoa in whole semen. In this study, at least two specimens of whole semen and two split ejaculates were obtained from 45 infertile males. The mean values for the parameters of the semen analysis were compared statistically. Our data indicate that increased sperm density is a consistent finding with the split ejaculate, even for severely oligospermic men. However, improved sperm motility with the split ejaculate is more variable. On the other hand, patients with mild oligospermia (10 to 40 million sperm/ml of whole semen) and high semen volumes (greater than 5.0 ml) demonstrated improvement in all parameters in the split ejaculate.

Urethrographic manifestations of venereal warts (condyloma acuminata).

Intraurethral spread of venereal warts is a serious complication. Urethral involvement may be extensive and is associated with severe irritative symptoms. Spread to the bladder is possible. Recurrence are frequent and eradication difficult. We describe the urethrographic appearance of intraurethral verrucae and believe it to be strongly suggestive of the diagnosis. Voiding cystourethrography is recommended, and satisfactory visualization may be obtained with either voiding or retrograde urethrography. Voiding urethrography following intravenously administered contrast (excretory voiding cystourethrography) is particularly advantageous since it avoids the need for urethral instrumentation and, therefore, cannot contribute to retrograde spread of these contagious growths.

Intraurethral condylomas acuminata: management and review of the literature.

We report 4 cases of intraurethral conylomas, the last one representing the first reported successful management of total urethral and intravesical condylomas in a male patient. The literature is reviewed and recommendations for management based on the modalities available are given.

Postcoital-voiding insemination: technique for patients with retrograde ejaculation and infertility.

Three patients with infertility secondary to retrograde ejaculation demonstrated motile sperm in their urine after coitus. These patients were instructed to alkalinize their urine and void directly into the vagina after intercourse. The technique was called "postcoital-voiding insemination." Three pregnancies have resulted. The technique appears to be a good alternative to bladder catheterization and artificial insemination.

Semen zinc levels in infertile and postvasectomy patients and patients with prostatitis.

The semen zinc levels were determined in 18 volunteers, 132 patients postvasectomy, and in 19 patients with prostatitis. The mean values for semen zinc were the same in the volunteers and postvasectomy patients. However, the mean zinc concentration in the volunteers and postvasectomy patients was significantly different from that of the patients with prostatitis. When a group of 12 patients with prostatitis was given supplementary zinc sulfate, the levels of semen zinc rose dramatically and were significantly different from those before treatment. As part of an infertility evaluation, 153 specimens from 72 men who had not fathered a child were examined. A complete semen analysis of each specimen was made, including the semen zinc concentration. The specimens were separated into four arbitrary groups with differing fertility potential. The groups were organized by sperm counts (less than 20 million sperm/ml, 20 to 60 million sperm/ml, 60 to 100 million sperm/ml, and greater than 100 million sperm/ml). There was a trend toward increasing zinc concentrations in the groups with increasing fertility potential. Eleven patients with oligospermia and low semen zinc levels were given supplementary zinc sulfate, 80 mg three times/day for 6 months to 1 year. The parameters of the semen analysis improved in all categories. There were three pregnancies during the period of treatment.

Sutureless bivalve nephrotomy with compression hemostasis.

Experimental hemostasis in sutureless bivalve nephrotomy was used on 25 consecutive dogs. The result of this study and the review of the literature are described.