RESUMO
Background: In vasovasostomy (VV) surgery, the micro-surgical technique has consistently been shown to provide superior outcomes to both macroscopic and loupe-assisted techniques, with large studies showing overall patency rates of ~86% and pregnancy rates of ~52%. However, the question of whether a single- or double-layer anastomosis offers the best outcomes remains contentious, and despite the popularity of the two-layer technique, a meta-analysis suggests little difference in outcomes. This study records the outcomes of a single-surgeon series of a simplified single-layer technique, along with the comparative outcomes and predictive factors. Methods: A retrospective analysis of 237 consecutive patients undergoing microsurgical vasectomy reversal between 2010 and 2022 in a single institution was performed. A microsurgical, single-layer, six-point, 8-0 nylon anastomosis was performed with macroscopic intra-operative assessment of vasal fluid. An ipsilateral vasoepididymostomy (VE) was only performed in cases of complete absence of vasal fluid or the presence of toothpaste-like discharge (bilateral VE were excluded from this series). Semen analysis was performed 3 months postoperatively to assess for the presence of motile sperm. Results: A total of 237 men underwent microsurgical vasectomy reversal over a 12-year period. The median age of men at vasectomy was 34 years. The median age at vasectomy reversal was 42 years. The median obstructive interval was 7.3 years. An overall patency rate of 85.8% was achieved (motile sperm present), with 53.8% having a sperm count greater than 15 million/mL on initial 3-month assessment. For obstructive intervals of <3, 3-8, 9-14, and ≥15 years, there were declining patency rates of 96.3%, 90.5%, 80.0%, and 74.1%, respectively (P=0.04). These are the equivalent outcomes to published high-volume two-layer studies. We found no difference between patency rates of VV performed on the straight vas vs. the convoluted vas, and no difference when only one side could be re-anastomosed (20 patients). Conclusions: Using a micro-surgical technique in high volume, similar outcomes can be achieved from a simplified single-layer VV technique with fewer sutures, as compared to the more complex two-layer techniques described. We postulate that this may be due to reduced ischaemia relating to fewer sutures and less tissue-handling. Given the associated time and cost savings, as well as the easier learning curve involved, we would advocate the use of this technique in routine VV practise.
RESUMO
BACKGROUND: When compared with conventional external beam radiotherapy, hypofractionated radiotherapy has led to less treatment sessions and improved quality of life without compromising oncological outcomes for men with prostate cancer. Evidence has shown transurethral prostatic resection prior to brachytherapy and external beam radiotherapy is associated with worsening genitourinary toxicity. However, there is no review of genitourinary toxicity when TURP occurs prior to definitive hypofractionated radiotherapy. In this review, we seek to illustrate the genitourinary outcomes for men with localized prostate cancer who underwent transurethral resection of the prostate prior to receiving definitive hypofractionated radiotherapy. Genitourinary outcomes are explored, and any predictive risk factors for increased genitourinary toxicity are described. METHODS: PubMed, Medline (Ovid), EMBASE and Cochrane Library were all searched for relevant articles published in English within the last 25 years. This scoping review identified a total of 579 articles. Following screening by authors, 11 articles were included for analysis. RESULTS: Five studies reported on acute and late toxicity. One article reported only acute toxicity while 5 documented late toxicity only. While most articles found no increased risk of acute toxicity, the risk of late toxicity, particularly hematuria was noted to be significant. Risk factors including poor baseline urinary function, prostate volume, number of prior transurethral prostatic resections, timing of radiotherapy following transurethral prostatic resection, volume of the intraprostatic resection cavity and mean dose delivered to the cavity were all found to influence genitourinary outcomes. CONCLUSION: For those who have undergone prior TURP hypofractionated radiotherapy may increase the risk of late urinary toxicity, particularly hematuria. Those with persisting bladder dysfunction following TURP are at greatest risk and careful management of these men is required. Close collaboration between urologists and radiation oncologists is recommended to discuss the management of patients with residual baseline bladder dysfunction prior to commencing hypofractionated radiotherapy.