The high rate of noncompliance for post-vasectomy semen examination: medical and legal considerations.

The records of 1,029 consecutive patients undergoing bilateral vasectomy were reviewed. Of the 1,029 patients 375 (36%) never returned postoperatively and the partners of 2 of these 375 later became pregnant. A total of 560 patients (54%) was followed until the recommended demonstration of azoospermia occurred on 2 consecutive occasions. There were 84 patients (8%) who did not return after the first demonstration of azoospermia, while 7 (1%) still had sperm in the semen at the last examination. Three other patients had persistent nonmotile sperm postoperatively; 2 of them underwent repeat vasectomy followed by azoospermia and 1 was placed in a special clearance category of sterility as described. We discuss practical and legal considerations regarding the management of noncompliant patients.

PIP: Urologists reviewed the medical charts of 1029 consecutive patients who had experienced a bilateral vasectomy (cauterization of the mucosa at each end and of the divided vas deferens) at the University of Louisville's School of Medicine in Kentucky between February and December 1986 to examine the medical and legal ramifications of vasectomized men not returning to have physicians examine their semen. Only 54.4% of the men returned for the recommended 2 semen examinations. 8.2% returned only once. 7 men (1% of the 654 who returned for semen examination) had sperm in their last semen sample. 36.4% (375) did not return at all after the vasectomy. Partners of 2 of these men conceived. 1 pregnancy occurred 29 months postoperatively. The men did not want to have his semen examined, however, for fear of learning he was sterile. The other pregnancy occurred 67 months after the vasectomy and the man's sperm had many motile sperm. Late recanalization of the vas deferens most likely occurred in this case. Other than recommending to patients before and during the vasectomy to submit 2 semen samples after the vasectomy, the urologists had no mechanisms in place to assure compliance. The high noncompliance rate in this study made the researchers consider their new legal responsibilities. Court cases for somewhat related medical situations have resulted in the jury finding the physician negligent because he/she did not fully inform the patient of the risk of noncompliance. Thus physicians, even though they may believe they are not responsible for noncompliance, should prudently inform patients of their risk of not complying by perhaps sending a punctually written notice. These warnings may protect them from potential litigation. Nevertheless the courts may appropriate more responsibility of patient actions to the physicians than is either morally justified or reasonable.

Cutaneous transureteroureterostomy as a form of diversion in children with a compromised urinary tract.

Our experience with children who require supravesical diversion in the face of a compromised urinary tract indicates that in selected cases transureteroureterostomy with cutaneous ureterostomy will lead to a stabilized urinary tract that will be free from infection and postoperative complications.