Analysis of international practice patterns regarding postvasectomy fertility options.

OBJECTIVE: To review the management of postvasectomy fertility options by urologists with vs without andrology fellowship and compare the features of practice in the USA vs UK. MATERIALS AND METHODS: We conducted an audit of all American Urological Association-affiliated urologists regarding their practice in managing men requesting vasectomy reversal (VR). Standards of practice were assessed against 10 index parameters deemed, by 1 UK study, to reflect best practice. Fisher exact test was used to test the hypothesis that management of postvasectomy fertility options and practice of VR are no different when undertaken by urologists with vs without andrology training and no different in the USA vs UK. RESULTS: Three hundred twenty-five of 645 US respondents (50.4%) practiced VR vs 178 of 213 (83.6%) in the UK; only 11.9% in the US and 10% in the UK performed >25 and >15 (P <.0001) VR/year, respectively. Compared with the UK urologists the US urologists offered more detailed information on all fertility options and/or outcomes, used microsurgical techniques more often, but less frequently counseled couples together, and referred patients to specialist centers for in vitro fertilization with intracytoplasmic sperm injection (P <.0001-.05). Only 74 of the US and 61 of the UK urologists were fellowship-trained in andrology. Most non-fellowship-trained urologists, in both the countries, performed <5 VR/year and were, statistically, significantly less likely to counsel couples about all fertility options, be conversant in in vitro fertilization with intracytoplasmic sperm injection, provide individualized outcomes data, and use microsurgical techniques (P <.0001-.05). CONCLUSION: Significant differences exist in the standards of practice between both the US and UK urologists performing VR. Concordance with the indices of "best practice" improves with andrology training and increasing number of procedures performed.

Intraoperative assessment of technical skills on live patients using economy of hand motion: establishing learning curves of surgical competence.

BACKGROUND: On surgical simulators, measures of economy of hand motion have been shown to be reliable, valid, and objective measures of technical competence. Our goal was to validate hand-motion analysis (HMA) as an objective measure of surgical skill on real patients. METHODS: HMA (hand movement frequency, hand travel distance) was evaluated serially on 2 standardized, live patient surgeries (vasectomy, vasectomy reversal) for both a novice and experienced surgeon. HMA parameters were correlated with blinded, case-matched assessments of technical skill using previously validated global rating scales and surgical checklist scores applied to unedited surgical videos. Serial hand-motion data from the novice and experienced surgeon were plotted to establish competency-based learning curves over time. RESULTS: Intraoperative HMA correlated significantly with case-matched global rating and checklist scores. Meaningful improvements in the number of hand movements and hand travel distance were shown over time for the novice surgeon, but remained stable for the experienced surgeon. CONCLUSIONS: Intraoperative assessment of economy of hand motion represents a feasible, objective, and valid measure of technical skill and can be used to establish competency-based surgical learning curves.

[Microsurgical vasovasostomy at the Erasmus MC, 1998-2002: results and predictive factors]. / Microchirurgische vasovasostomie in het Erasmus MC, 1998-2002: resultaten en voorspellende factoren.

OBJECTIVE: To determine the results ofmicrosurgical vasovasostomy procedures with special emphasis on the technical aspects and predictive factors for successful procedures. DESIGN: Descriptive. METHOD: In 1998-2002, 217 vasovasostomy procedures were performed in an outpatients' clinic setting at the Erasmus MC, Rotterdam, The Netherlands. RESULTS: Refertilisation was successful in 77% of men and 42% of couples reported a spontaneous pregnancy within one year. The most important predictive factors for a successful outcome were the interval between vasectomy and reversal and the age of the partner. Patency rates were 89% and 62% when the interval was < 5 years and > 15 years, respectively. Rates of spontaneous pregnancy were 56% and 21%, respectively. These reductions in rates of patency and pregnancy were attributed primarily to epididymal dysfunction and an increasing interval between vasectomy and reversal. Only 20% of men with a partner aged > 35 years reported spontaneous pregnancies. The risk of secondary epididymal obstruction was 25% after an interval of > 10 years. For these cases, a vasoepididymostomy is needed to achieve patency.