Simultaneous ipsilateral vasal and epididymal reconstruction.

Injuries to the spermatic cords, sustained during childhood inguinal hernioplasty, caused unilateral testicular atrophy, multiple bilateral excurrent duct obstruction and aspermia. Simultaneous unilateral vasal reconstruction and vaso-epididymostomy resulted in satisfactory semen parameters. It is expected that vasal integrity will be maintained after multiple reconstructive procedures at different locations if further injury to the vascular supply of the excurrent duct is avoided.

Hypogonadism following long-term treatment with diethylstilbestrol.

The authors describe the abnormalities of gonadal function developing in a patient with prostate cancer who had received estrogen therapy continuously for 6 years. The pretreatment prostate biopsy showed well developed acini consistent with normal androgenization and adenocarcinoma. Twelve years later, 6 years after discontinuation of estrogen treatment, the patient presented with severe hypogonadism, gynecomastia, and primary hypothyroidism. Testicular biopsies showed ghosts of seminiferous tubules with absence of Leydig cells, and prostatic biopsies showed atrophic acini without evidence of malignancy. Despite undetectable serum testosterone levels, serum gonadotropins were inappropriately normal and responded minimally to gonadotropin-releasing hormone (GnRH) administration. Replacement therapy with levothyroxine did not correct gonadal dysfunction. Thus, prolonged estrogen therapy may result in irreversible testicular destruction and loss of the feed-back response of the hypothalamic pituitary gonadal axis.

Transvasovasostomy--an alternative operation for obstructive azoospermia.

Five patients with obstructive azoospermia are presented. They were evaluated by a complete history, physical examination and semen analysis, including fructose studies, and serum testosterone and follicle-stimulating hormone determinations. A history or suspected history of epididymitis or prostatitis was identified in 4 patients and a history of iatrogenic obstruction was found in 3. All patients underwent testicular biopsy which showed normal spermatogenesis. A vasogram was crucial in determining the site of obstruction. All patients underwent transvasovasostomy through the scrotal septum. Patients had encouraging postoperative sperm counts and fertility has been demonstrated by induction of pregnancy in 2 cases.

Testicular function after orchiopexy.

Twelve adult mongrel dogs underwent unilateral division of the spermatic vessels and contralateral testicular revascularization to compare the effect of these techniques on histology of the testes. Testicular weight reduced to average 6.5 Gm (normal 20 +/- 5 Gm) where division of the vessels was performed. The contralateral side maintained its weight and configuration (average weight 22.5 Gm). Histologic changes occurred in nonrevascularized testes indicating atrophy and hence inadequate blood perfusion for testicular survival. Sperm density was reduced, but only vas deferens draining the revascularized testis contained spermatozoa.

Localization and treatment of nonpalpable testes.

Five young males with bilateral nonpalpable testes are presented. In all instances, the testes were localized by laparoscopy. Only one patient had unilateral anorchia at laparotomy which was demonstrated by this technique. Laparoscopy may be more accurate than other nonoperative techniques for localizing nonpalpable testes. Additionally, it facilitates surgical planning and may obviate the need for surgical exploration in some patients.

Recto-ejaculatory duct fistula: an unusual complication of Crohn's disease.

A case is reported of fluid leakage per rectum after ejaculation. The patient was infertile and did not have antegrade or retrograde ejaculation. The cause of this problem is presented.

Morphologic changes of the vas deferens after vasectomy and vasovasostomy in dogs.

The fine structure of the vas deferens was studied by SEM and TEM after vasectomy and delayed vasovasostomy in 18 dogs. Mucosal changes were observed in the testicular end of the vas deferens after vasectomy. Identical changes have been observed in the vas deferens in humans after vasectomy. Microsurgical vasovasostomy resulted in reappearance of normal epithelial cells lining the lumen of the vas deferens by means of squamous metaplasia. In six dogs, prevasectomy and postvasovasostomy sperm counts were compared. These counts returned to normal levels, but they never reached or exceeded the prevasectomy values.

Epithelial changes of the vas deferens after vasectomy and vasovasostomy in dogs.

Mucosal morphology of the vas deferens was examined by scanning electron microscopy (SEM) and transmission electron microscopy (TEM) after vasectomy and vasectomy reversal in dogs. Morphological changes occurred in the proximal (testicular) end of the vas deferens after vasectomy. Luminal dilatation, with an increase in 70% mean diameter, occurred due to build up of pressure. This resulted in flattening of the columnar cells, loss of stereocilia and presence of interspersed microvilli. The urethral portion of the vas deferens remained unchanged. Following vasovasostomy, reappearance of normal epithelial cells occurred through squamous metaplasia. Identical changes have also been observed after vasectomy in human vas deferens. It is fair to assume that similar recovery of the vasal mucosa may occur in humans after successful vasovasostomy.

Incomplete differentiation of Wolffian structures: a form of Kallmann's syndrome?

We have reported a sibship in which all three males had azoospermia and a normal 46,XY karyotype. The mechanisms for the production of azoospermia were Kallmann's syndrome and bilateral agenesis of the globus major (head of the epididymis) in the proband and bilateral agenesis of the vasa deferentia and seminal vesicles in the two brothers. It is suggested that this syndrome of agenesis of the testicular excretory system may be a variant of Kallmann's syndrome.

The effect of vasovasostomy upon the structure of the vas deferens in rats.

The reasons for the discrepancy between reappearance of sperm in the ejaculate following vasovasostomy and pregnancy rates remain obscure. To determine the possible adverse effects of reanastomosis upon the structure of the vas deferens, immediate microsurgical vasovasostomy was performed on 60 adult Sprague-Dawley rats. The fine structure of the mucosa, as seen by scanning electron microscopy, showed only subtle, transient changes with return to normal architecture within 3 months. Luminal dilatation, rather than stenosis, was a constant late finding. It is concluded that microsurgical reanastomosis has little, if any, permanent deleterious effect upon the structure of the vas deferens.

Modified technique for microsurgical vasovasostomy.

A modified technique of two-layer microsurgical vasovasostomy is described which permits continuous inspection of the lumen. A stricture-free anastomosis was documented in experimental animals by mating and scanning electron microscopic studies. The success of this procedure is attributed to precise placement of fine mucosal sutures, minimal fibrosis, and a fluid-tight anastomosis.

PIP: 25 Sprague-Daveley rats had bilateral division of the vas deferens with immediate microsurgical anastomosis. The 2-layer microsurgical vasovasostomy as described in detail tin this report permits continuous imspection of the lumen. To determine the efficacy of this procedure, all the animals were mated and the anastomotic sites studied by scanning electron microscopy (EM) 2 to 4 months after surgery. Overall pregnancy rate was 50%. Early failure in the series was attributed to technical ineptitude and failure to appreciate the importance of a blood-free field. The last 10 animals had a pregnancy rate of 80%. Scanning EM showed near total, bilateral occlusion in the sterile rats, as contrasted to the widely patent lumen of animals with documented fertility. By 2 months, the luminal sutures were covered by regenerating mucosa. Fibrosis was observed in areas immediately surrounding mucosal and muscular sutures. Precisely placed mucosal sutures which evert the mucosa and decrease stenosis are critical to a stricture-free anastomosis. Expert handing of fine sutures, small needles and delicate microsurgical instruments accounted for lack of fibrosis after vasovasostomy was performed.