Intravasal azoospermia: a surgical dilemma.

OBJECTIVES: To determine the incidence of intravasal azoospermia (IVA) and evaluate which factors before and during surgery influence outcome, by prospectively and intentionally performing bilateral vasovasostomies (VVs) only in men with intraoperative IVA. PATIENTS AND METHODS: Using a multilayer technique, 472 men underwent microsurgical reconstructive procedures. Intravasal fluid was examined for sperm by the surgeon and a pathologist. Strict enrolment criteria included total absence of sperm or sperm parts and bilateral VV as a treatment procedure. Patients were followed up by semen analysis and paternity assessed only by naturally conceived pregnancies. RESULTS: Of the 472 patients, 27 (5.7%) had bilateral IVA; 15 of these patients were available for a follow-up of 1-47 months. Eleven patients had identical gross appearance of intravasal fluid bilaterally. Of these patients, five had sperm in the ejaculate after surgery (three with clear intravasal fluid and two with no fluid). Bilaterally different vasal fluid was found in four men. Unilateral clear fluid was present in three patients, two of whom had sperm in semen analysed after VV. Overall, there was sperm in the ejaculate in seven of 15 patients with IVA; five of these seven had clear fluid in at least one vas deferens. One patient with unilaterally clear fluid achieved paternity by a naturally conceived pregnancy. The difference between the mean (SEM) obstruction interval in men who had sperm in a semen sample after VV, at 16.7 (3. 30) years, and in persistently azoospermic patients, at 15.5 (1.89) years, was not statistically significant (P = 0.741). CONCLUSION: The results of VV in patients with IVA are unsatisfactory; the patency rate is higher in men with copious clear fluid in at least one vas. The obstructive interval in patients with IVA does not appear to influence the outcome of VV.

Identification of RS as a flagellar and head sperm protein.

RS is 20-kDa microtubule-associated protein found in several human tissues. Sequence analysis showed that the polypeptide is highly related to a rat protein whose level has been previously reported to be correlated with sperm fertility. The present study examines the intracellular distribution of RS in spermatozoa from both humans and rats employing a specific antibody to the polypeptide and immunofluorescence microscopy. We demonstrate that in humans, RS is mainly a flagellum protein, but in rats, it is also abundant in the sperm head. In the sperm tail, RS was found to be co-localized with beta-tubulin, a major component of the axoneme, suggesting that RS is also associated with the flagellum axoneme. Contrary to a previous report, incubation of isolated spermatozoa from both humans and rats in the presence of ornidazole, a reported male contraceptive drug in rats, did not result in modulation in the level of RS, suggesting that the drug does not act directly on sperm RS. Mol. Reprod. Dev. 55:189-196, 2000.

Comparison of absorbable and nonabsorbable sutures for microsurgical vasovasostomy in rats.

OBJECTIVES: At least 12% of initially patent vasovasostomies (VVs) shut down. Currently, only nonabsorbable sutures are used for VV. A synthetic, slowly absorbing, monofilament polyglactin suture has been developed that retains tensile strength for up to 6 months. We performed a prospective controlled randomized study comparing absorbable and nonabsorbable sutures for rat VVs. METHODS: Bilateral microsurgical VV was performed in three groups of 36 Wistar male rats, with 10-0 nylon, 10-0 polypropylene, and 10-0 polyglactin sutures. Twelve control rats underwent sham operations. Three rats in each group were killed at 2, 6, 12, and 24 weeks. The abdominal end of the vas deferens was transected and the intraluminal fluid examined microscopically for presence of sperm. The segment of the vas deferens containing the anastomosis was excised. Fluid from the testicular end was examined for sperm to confirm spermatogenesis. Patency was confirmed by an antegrade indigo carmine vasogram of the anastomotic segment. Segments were randomly sent for histologic or tensile strength evaluation. RESULTS: The mean tensile strength of the anastomoses performed with nylon was slightly higher than in polypropylene and polyglactin sutures, although the difference was not statistically significant. Polyglactin consistently maintained tensile strength throughout 6 months without significant fluctuations. The mean patency rate in the polyglactin group was 96%, in nylon 81%, and in polypropylene 61%. Although polyglactin had a consistently higher patency rate compared with nonabsorbable sutures, the difference was not statistically significant (P = 0.11) but indicated a strong trend. The occurrence of microscopic sperm granuloma, muscle layer injuries, intimal fibrosis, and adventitial fibrosis of the vas deferens was not significantly different between suture types. CONCLUSIONS: The three suture materials appear equivalent with respect to overall tensile strength of anastomosis; with histologic evaluation, the trend was toward better patency with polyglactin. Polyglactin 10-0 microsurgical suture is a viable alternative to nonabsorbable sutures in microsurgical VVs, although further studies are indicated to assess long-term results.

Effect of methylene blue, indigo carmine, and Renografin on human sperm motility.

OBJECTIVES: To evaluate the effect of commonly used intraoperative vasography and tissue staining agents, indigo carmine, methylene blue, and Renografin, on sperm motility. METHODS: Semen from 20 healthy men was obtained after 2 to 4 days of abstinence. Sperm motility was initially evaluated in each specimen. Standard solutions of indigo carmine, methylene blue, and Renografin-60 were diluted 2x and 4x with lactated Ringer's solution. Equal aliquots of sperm were mixed with undiluted and diluted drugs, and sperm motility was assessed. RESULTS: Initial mean sperm motility was 70.3%+/-3.0%. Undiluted methylene blue and Renografin severely depressed sperm motility to 1.1%+/-0.5% and 2.3%+/-0.7%, respectively (P <0.05). Diluted methylene blue depressed motility to 4.9%+/-1.8% and 11.2%+/-3.0% (P < 0.05). Diluted Renografin depressed motility to 25.1%+/-4.1% and 55.3%+/-3.3% (P < 0.05). Although undiluted and 2x-diluted indigo carmine moderately decreased sperm motility (48.9%+/-3.2% and 61.7%+/-3.0%, P < 0.05), 4x-diluted indigo carmine had minimal effect on sperm motility (67.3%+/-2.8%, P > 0.05). Lactated Ringer's solution had no effect on sperm motility. CONCLUSIONS: We found a severe, immediate reduction in sperm motility after exposure to undiluted standard solutions of methylene blue and Renografin. Dilution of Renografin significantly decreased its negative impact on the sperm motility, whereas the adverse effect of methylene blue remained fairly constant even with increasing dilution. Sperm motility should be assessed prior to application of these agents. Sperm should be aspirated for immediate use and/or cryopreservation prior to the use of these agents. Indigo carmine may be safely used as a tissue stain or vasography agent with a minimal effect on sperm motility in dilutions of 4x and higher.

Controlled comparison of percutaneous and microsurgical sperm retrieval in men with obstructive azoospermia.

A controlled comparison of the efficacy and reliability of sperm retrieval by testicular fine needle aspiration (TFNA), percutaneous testicular needle biopsy (PercBiopsy) and microsurgical epididymal sperm aspiration (MESA) was performed in nine patients with obstructive azoospermia. During a planned MESA procedure, sperm retrieval was attempted on the same testis with TFNA and PercBiopsy. Spermatozoa were obtained from all patients using MESA and PercBiopsy. Spermatozoa were retrieved using TFNA from 6/9 (67%) men. The mean number of epididymal spermatozoa retrieved with MESA (15 x 106) was significantly higher (P = 0.003) than that retrieved percutaneously from the testis. The mean number of spermatozoa obtained by PercBiopsy was 0.116 x 10(6) while TFNA recovered 0.014 x 106 spermatozoa (P = 0.025). MESA is the optimal choice to retrieve the greatest number of spermatozoa with highest motility for assisted reproduction and subsequent cryopreservation. However, percutaneous testicular retrieval does not require microsurgical expertise and is less invasive. Our results suggest that the optimal percutaneous procedure for sperm retrieval from the testis involves percutaneous testicular needle biopsy with an automatic biopsy gun.

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.

Acute scrotal symptoms due to perforated appendix in children: case report and review of literature.

Acute appendicitis is rarely included in the differential diagnosis of acute scrotum. We report a case of an unusual presentation of acute appendicitis as acute left scrotal swelling. The relevant literature is reviewed.

Fungal infections of the perivesical space.

We describe 3 patients with fungal infection in the perivesical space who manifested lower abdominal pain and urinary tract symptomatology. Imaging studies demonstrated perivesical abnormalities. Urine culture was positive for fungus in only 1 patients. Management required surgical exploration, drainage, débridement of necrotic tissue and in 1 patient partial bladder resection. Systemic antifungal therapy was administered postoperatively. All patients had a successful outcome.