Crossover transseptal vasovasostomy: alternative for very selected cases of iatrogenic injury to vas deferens

ABSTRACT Inguinal herniorraphy is a possible cause of iatrogenic seminal tract obstruction. Diagnosing and correcting these vasal injuries can be challenging. Successful re-anastomosis is technically challenging, with relatively low success rates. An uncommon alternative for selected cases is the crossover transseptal vasovasostomy. We herein report a case of a 36-year-old male patient with vas deferens injury after herniorraphy and a contralateral hypotrophic testis. He was successfully treated through microsurgical crossover transseptal vasovasostomy, with spontaneous pregnancy achieved, and the technique is presented in details.

Various surgical techniques for the repair of injured vas deferens in rat experiments.

OBJECTIVE: The aim of this study was to evaluate whether the different vasovasostomy techniques can be performed using only the operating loupe in a rat model. The secondary aims were to evaluate the patency rate and inflammation of the vas deferens (VD) after contusion and the different vasovasostomy repair techniques. METHODS: A total of 40 male rats were divided into 4 groups based on the type of surgery: 1. contusion of the VD; 2. cutting of the VD and vasovasostomy with absorbable sutures; 3. cutting and joining of the VD using absorbable sutures with an intraluminally situated lead fibre; and 4. cutting and joining of the VD using non-absorbable sutures with an intraluminally situated lead fibre. Ninety days after the surgery the VD was resected, patency and histopathological signs of inflammation in the VD were evaluated. RESULTS: All vasovasostomy techniques were successfully performed in all animals using only the operating loupe. The patency rate was 100% in the subgroup with contusion. Differences in the patency rates were found among the subgroups with vasovasostomy (P=0.007). The patency rate was higher in the subgroup that underwent group 3. Compared with vasovasostomies, contusion was associated with lower rates of inflammation (P=0.02) and severe inflammation (P=0.003). No differences were found among the subgroups of vasovasostomy techniques. CONCLUSION: Contusion of the VD was not related to impairment in terms of patency. Vasovasostomy with an intraluminally situated lead fibre resulted in the highest patency rate among the standard vasovasostomy techniques.

[Clinical application of the disposable vasographic interventional therapy kit in vasoseminal vesiculography].

OBJECTIVE: To investigate the success rate and safety of percutaneous vasoseminal vesiculography with the disposable vasographic interventional therapy kit (VITK). METHODS: This study included ninety-six 19－65 (mean 43) years old male patients with infertility, hematospermia, seminal vesicle cyst, ejaculatory duct cyst, ejaculatory dysfunction, or vas deferens injury, with disease courses varying from 1 month to 7 years. With an open, multi-centered, single-group, self-controlled design and using the disposable VITK, we treated the patients by percutaneous vasoseminal vesiculography via injection of contrast medium into the vas deferens cavity under local anesthesia. RESULTS: Percutaneous vasoseminal vesiculography was successfully performed in 92 (97.87%) of the patients, which revealed abnormal seminal ducts in 51 cases (54.3%). Among the 28 infertile patients, 3 were found with bilateral and 5 with unilateral vas deferens obstruction. Vesiculitis was detected in 36 (81.8%) of the 44 hematospermia patients and bilateral vas deferens abnormality in 5 (38.5%) of the 13 patients with ejaculatory dysfunction. Transectional damage was observed in 2 patients with vas deferens injury induced by bilateral inguinal hernia repair. Three cases of seminal vesicle cyst and 4 cases of ejaculatory cyst were definitely diagnosed by vasoseminal vesiculography. CONCLUSIONS: The disposable vasographic interventional therapy kit, with the advantages of simple operation and high safety, deserves a wide clinical application in vasoseminal vesiculography.

[Surgical treatment of azoospermia caused by iatrogenic injury to bilateral vas deferens].

OBJECTIVE: To investigate the treatment of azoospermia induced by iatrogenic injury to the bilateral vas deferens. METHODS: We retrospectively analyzed 11 cases of azoospermia caused by iatrogenic injury to bilateral vas deferens. The patients were aged 20－33 years, all diagnosed with azoospermia preoperatively and none with a history of pelvic operation. Seven of them had received bilateral inguinal hernia repair and the other 4 undergone bilateral orchidopexy in the childhood. RESULTS: Intraoperative exploration of the bilateral inguinal region was performed in all the patients. Bilateral vas deference atresia was found in the inguinal canal in 6 cases, which was treated by microscopic vasovasostomy following removal of the atresic segment. Vas deferens residual was observed in or near the deep inguinal ring in the other 5 cases, with the distal vas deferens inaccessible, which was treated by bilateral vasovasostomy in 3 cases and unilateral vasovasostomy in 2 (for longer defect segment than could be anastomosed) following combined laparoscopic exploration of the abdominal cavity. The patients were followed up for 3－12 months postoperatively, during which sperm were detected in 7 cases, with sperm concentration ranging from 0.4×106/ml to 35×106/ml and grade a+b sperm from 15% to 46%. CONCLUSIONS: For the diagnosis of azoospermia, especially in patients with no history of pelvic operation, special attention should be paid to iatrogenic injury to the vas deferens. For the treatment of the disease, non-tension vasovasostomy is essential and, when necessary, the vas deferens can be reconstructed by changing its anatomical path and shortening its length.

Mechanism, assessment, and incidence of male infertility after inguinal hernia surgery: a review of the preclinical and clinical literature.

BACKGROUND: The treatment of inguinal hernia has changed considerably over the past 15 years. We reviewed the preclinical and clinical literature to find out the effect of inguinal hernia surgery on male fertility because it has been suggested that hernia surgery may impair testicular function and male fertility. DATA SOURCES: A search on Embase, MEDLINE, and the Cochrane Library was performed to find related articles. CONCLUSIONS: Animal models show substantial effects of hernia repair on the structures in the spermatic cord, which is more pronounced in mesh repairs. Although the number of studies and the included numbers of patients were limited, clinical studies indicate that these potential adverse effects do not seem to have a clinical impact on male fertility in humans with inguinal hernias. Future clinical studies, preferably with bilateral patients, are necessary to investigate the clinical relevance of the effects of inguinal hernia and hernia surgery on male fertility.

Prematurity, not age at operation or incarceration, impacts complication rates of inguinal hernia repair.

PURPOSE: Inguinal hernia repair (IHR) remains the most common procedure in pediatric surgery. Although postoperative sequelae are well described, we examined if prematurity and age were important determinants of postoperative complications. METHODS: A retrospective review of children younger than 2 years undergoing IHR from 2004 to 2007 was performed, with a minimum of 1-year follow-up. Patients were segregated into groups based on age at diagnosis (A, 0-3; B: 4-26; C: 27-52; D: 53-104 weeks), with or without prematurity. Incarceration rates were investigated. Complications were categorized as major (vas injury, recurrence, testicular atrophy) or minor (wound infection, "high" testicle, hydrocele) and compared. RESULTS: Two hundred sixty-eight patients were analyzed (98 premature), with 14 major complications (5.2%) and 26 (9.7%) minor complications overall. Groups A and B accounted for more major (12/14) and minor complications (22/26) when compared with groups C and D (P < .005). In patients less than 26 weeks (groups A and B), premature infants had more complications than term infants (27.7% vs 12.1%, P = .01). Of 22 patients with incarcerated hernias, 2 (9.1%) had major complications (P < .5 vs nonincarcerated patients). CONCLUSIONS: Our study suggests that prematurity, rather than age at operation or incarceration, affects complication rates after IHR. This information should be used to frame the discussion of informed consent for this commonly performed procedure.

Influence of a new self-gripping hernia mesh on male fertility in a rat model.

BACKGROUND: The number of mesh-based therapies of inguinal hernias is increasing compared with the classical suture techniques such as Shouldice and Bassini. Many different types of meshes with regard to material, pore size and surface coating are available. A recently offered mesh (Parietene Progrip) combines the properties of a standard lightweight polypropylene mesh with a whole surface fixation by incorporation of micro hooks. Therefore, additional fixation elements such as screws, tacks or clips become redundant when using this material. However, in treated male patients the micro hooks will also come into contact with the ductus deferens. As the sensitivity of this structure is known, the question arises of whether this new self-gripping mesh might damage susceptible tissue layers and impair male fertility. METHODS: Two different meshes, a standard lightweight polypropylene mesh (Parietene-Light) and a new self-gripping polypropylene mesh (Parietene Progrip) with absorbable micro hooks were wrapped surgically around the prepared ductus deferens of each of ten Sprague-Dawley rats. In five control rats ducts were only separated bluntly from adherent tissue. After 2 months rats were sacrificed and implants were recovered together with the ductus deferens for histology and electron microscopy. RESULTS: Samples from all animals showed an unrestricted lumen of the ductus deferens. Only minor inflammatory reactions with some infiltrating cells could be observed. Giant cells were present around the mesh fibres. Scanning electron microscopy revealed no degradation of the material surface after 2 months of implantation. CONCLUSION: The new self-gripping mesh showed no harmful influence on the ductus deferens in the rat model. Considering the larger dimensions of the ductus deferens in humans any detrimental effect on the exposed tissue can be excluded. The surface of the fibres was not subjected to material degradation.

Laparoscopic completely extraperitoneal repair of inguinal hernia in children: a single-institute experience with 1,257 repairs compared with cut-down herniorrhaphy.

BACKGROUND: Conventional open herniorrhaphy in children has been reported to have 0.3-3.8% recurrence and 5.6-30% postoperative contralateral hernia rates. We developed a unique technique to achieve completely extraperitoneal ligation of PPV without any skip areas under laparoscopic control. This report introduces our technique and results compared with the cut-down herniorrhaphy. METHODS: A consecutive series of 1,585 children with inguinal hernia/hydrocele (1996-2006) was analyzed. In laparoscopic patent processus vaginalis (PPV) closure (LPC), an orifice of PPV was encircled with a 2-0 suture extraperitoneally by a specially devised Endoneedle and tied up from outside of the body achieving completely extraperitoneal ligation of the ring. The round ligament was included in the ligation, whereas the spermatic cord and testicular vessels were excluded by advancing the needle across them behind the peritoneum. Cut-down herniorrhaphy (CD), with or without diagnostic laparoscopy, or LPC was selected according to parental preference under informed consent. RESULTS: Parents gave more preference to LPC (LPC in 1,257 children, CD in 308, and miscellaneous in 20). Age ranges were equal for both groups. Sex distribution showed female preponderance in the LPC group (44.8% vs. 26.6%, p < 0.001) and umbilical hernia/cysts were predominantly included in the LPC group (11.9% vs. 2.9%, p < 0.001). Mean operation times were equal for both groups for unilateral repair (28.2 +/- 9.2 for LPC vs. 27.8 +/- 13.5 for CD) and were shorter for bilateral repair in the LPC group (35.8 +/- 11.6 vs. 46.7 +/- 17.7). The incidence of postoperative hernia recurrence and contralateral hernia in the LPC group was 0.2% and 0.8%. Two children in the CD group had injuries to their reproductive system during the operation (0.6%). CONCLUSIONS: The advantages of our technique include following: technically simple, short operation time, inspection of bilateral IIRs with simultaneous closure of cPPV, reproductive systems remain intact, routine addition of umbilicoplasty if desired, and essentially indiscernible wounds.

A novel technique for vas deferens transection repairs.

The purpose of this study is to describe a technique, that is as successful as microsurgery in terms of patency rates and histopathologic assessments, and can be performed even by untrained hands in microsurgery, for repairing vas deferens injuries that can be perceived during inguinal herniorrhaphy. Thirty male Wistar-Albino rats were randomly allocated to five groups. In control group, the vas deferens was harvested without any surgical intervention (Group 1) and in sham group the vas was harvested after a limited dissection (Group 2). Three suture approximation technique was carried out in Group 3, and a novel vasovasostomy technique was carried out by using a hypodermal needle in Groups 4 and 5, with polypropylene and polyglactin 910 (rapid vicryl), respectively. Results were evaluated in terms of operative time, patency and flow rates, inflammation and sperm granuloma. The mean operative times for hypodermal needle assisted approximation of Groups 4 and 5 were found significantly less than Group 3. The compared results of the groups in terms of patency, flow rate, inflammation and spermatic granuloma indicated Group 4 to be superior to the other groups. We have found the hypodermal needle assisted approximation technique to be easier, less time consuming and cost effective. With these promising results, this modus operandi can be described as an appropriate technique for vas deferens transection repairs.

Temporary stretch of the testicular pedicle may damage the vas deferens and the testis.

BACKGROUND/PURPOSE: The authors aimed to investigate the effects of temporary stretching of the spermatic cord, a commonly performed manipulation during inguinal surgery, on the vas deferens and the testis. METHODS: Forty adult male Wistar-Albino rats were divided equally into 4 groups. The right spermatic cord and testis were exposed via a transverse suprascrotal incision. In the study groups, a continuous horizontal stretch force was applied to the vas deferens and vessels in a distal direction for 60 seconds. In group 1 (G1) a 1.25-Newton (N), and in group 2 (G2) a 0.75-N stretch force was applied. Group 3 (G3) and group 4 (G4) served as sham and control groups, respectively. The animals were killed 28 days later. Sections of the vas deferens were examined histologically and their dimensions measured. Both testes were excised, weighed, and examined microscopically. Kruskal-Wallis test and Mann-Whitney U test were used to compare means in the different groups. RESULTS: The mean wall thickness of the vas deferens was 378 +/- 133 mum in G1 and was significantly diminished compared to G2, G3, and G4, in which the mean wall thickness was 497 +/- 142 mum, 500 +/- 10 mum and 521 +/- 95 mum, respectively (P <.05). The mean right testicular weights were 1.18 +/- 0.10 g and 1.23 +/- 0.17 g in G1 and G2, respectively, and each was significantly lower than in G3 (1.23 +/- 0.09 g) and G4 (1.25 +/- 0.08 g; P <.05). The mean right testicular weights showed no difference between G1 and G2 (P >.05). Necrosis was seen in the right testes in 50.0% and 42.9% of the animals in G1 and G2, respectively. No histopathologic alterations were observed in the vas deferens in all groups. Microscopic examination of the left testes was normal. CONCLUSIONS: In an experimental animal model, temporary stretching of the spermatic cord resulted in significant thinning of the smooth muscle layer of the vas deferens and testicular atrophy.

The incidence of spermatic cord structures in inguinal hernia sacs from male children.

Inguinal herniorrhaphy is a common surgical procedure in children. Controversy exists regarding the usefulness of microscopic examination of hernia sacs, and changes in reimbursement schemes have heightened this controversy. We summarize our experience with histologic examination of these specimens to establish benchmarks for the number of spermatic cord structures in inguinal hernia sacs from male children. A 14 1/2 consecutive calendar year review of pathology reports and histologic sections of hernia sacs was conducted at a tertiary care children's hospital. Of 7,314 males (range newborn to 19 years old), 65% had bilateral and 29% had unilateral herniorrhaphy (6% unknown). Seventeen cases contained vas deferens (0.23%); 22 had epididymis (0.30%); and 30 had embryonal rests (0.41%). Either vas deferens or epididymis was found in 0.53% of patients. No cases contained bilateral vas deferens, bilateral epididymis, or vas deferens in one side with epididymis in the contralateral side. Three hernia sacs contained co-existing vas deferens and epididymis. Our study helps to provide surgeons with information for preoperative counseling regarding potential injury to the vas deferens or epididymis. This study provides baseline comparison data for quality improvement programs. We believe that each institution should weigh the costs, risks, and benefits of performing microscopic examinations on hernia sacs, depending on their own experience and data.

Is routine pathological evaluation of pediatric hernia sacs justified?

BACKGROUND/PURPOSE: Herniorrhaphy is the most common general surgical procedure performed on children, and hernia sac material is one of the most common tissue specimens microscopically examined in the authors' surgical pathology laboratory. The risk of accidental vas deferens ligation has prompted the recommendation that all hernia sacs be examined pathologically. The authors hypothesized that the incidence of unrecognized vas deferens or epididymis ligation is actually very low and may not warrant routine pathological examination of all pediatric hernia sacs. METHODS: Over a 3-year period (1994 to 1996), pathology reports from all hernia repairs at the authors' institution were reviewed. A total of 1,494 inguinal hernia sacs were pathologically evaluated from 1,077 pediatric patients (417 were bilateral). Pathological diagnoses not affecting clinical management (ie, chronic inflammation, irritated hernia sacs, embryonal remnants, adrenal cortical rests) were classified as incidental findings. Identification of true vas deferens was classified as a positive finding. RESULTS: The study population had a mean age of 3.9 +/- 0.1 years and 963 (89%) were boys. The incidence of vas deferens injury from herniorrhaphy was found to be 0.13% (2 of 1,494), and these were recognized by the pediatric surgeon in the operating room. CONCLUSIONS: When vas deferens injury is suspected, the sample should always be sent to the pathology department for confirmation. However, no occult carcinoma or other pathology was identified, and the remainder of the histological findings did not change the clinical treatment of any child. Given a fixed cost of pathological analysis, elimination of routine hernia sac examination may result in substantial annual savings. Therefore, in the current era of cost containment, recommendations for routine pathological examination of excised pediatric hernia sacs should be reevaluated.

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.

The effect of iatrogenic vas deferens injury on fertility in an experimental rat model.

The long-term result of accidental crushing of the vas deferens during inguinal surgery is unpredictable. It is stated that even a slight disturbance in the muscular layer or mucosa may endanger fertility. This study was designed to investigate the early and late histopathologic changes of iatrogenic injury on the vas and its effect on fertility in a rat model. Both vasa deferentia of 54 male rats, divided into three groups (n = 18 each), were subjected to an operative manipulation. These manipulations consisted of digital compression for 45 seconds in group A, grasping with a mosquito clamp for 2 seconds in group B, and grasping with a mosquito clamp for 2 minutes in group C. In five rats from each group, the vasa were removed on the third and 21st postoperative day for histological evaluation. The remaining 13 rats in each group were allowed to mate for a period of 4 months. Bilateral vasa were analyzed for patency and histology. A spermatic granuloma was observed in 79% of the fertile and 80% of the infertile rats. Statistical analysis showed no significant fertility difference among the three groups. There was no statistical difference between groups B and C (P > .05) in terms of high and low flow patency rates in vitro, whereas a statistical significance was present between these two groups and group A (P< .001). It can be said that type rather than time of injury is important in this experimental model, because the results of the patency test alone are sufficient to prove the possibility of functional damage in vas deferens. The authors conclude that inguinal contents should be handled carefully and contralateral exploration in asymptomatic cases older than 1 year with inguinal pathology should be avoided.

Spermatic granuloma. An uncommon complication of the tension-free hernia repair.

A patient with a sperm granuloma following a tension-free hernia repair utilizing Marlex mesh 4 years prior to presentation is described. The mechanism of granuloma formation is believed to be secondary to vas deferens injury due to erosion by the cut edges of the mesh at the medial end of the slit used to recreate the internal inguinal ring. Spermatic granuloma has been rarely described in hernia surgery and requires a previous vas deferens injury. While the more common and clinically significant events of hernia recurrence and wound infection should be considered first, the occurrence of spermatic granuloma as a cause of postoperative pain or a mass should be included in the differential diagnosis.