Sperm Granuloma and Reversibility of Vasectomy.
Sperm Granuloma and Reversibility of Vasectomy.
Ninety-two consecutive patients who had undergone bilateral vasectomy 1 month to 28 years earlier were studied at the time of vasectomy reversal for sperm output, dilatation of the vas-deferens lumen, and sperm granuloma. Thirty-nine men had unilateral or bilateral sperm granuloma. The presence of of a sperm granuloma virtually assured normal sperm in the vas fluid no matter how long ago the vasectomy was performed. In the absence of a sperm granuloma, the interval since vasectomy had an important influence on the quality of vas fluid. The presence of a sperm granuloma was associated with significantly less dilatation of vas-deferens lumen at the testicular end. The site of the vasectomy and the amount of vas deferens removed did not influence sperm quality. A sperm granuloma on only one side resulted in normal spermatozoa in the vas fluid on that side, whereas the side without the sperm granuloma had abnormal spermatozoa or no spermatozoa in the vas fluid. It is concluded that when sperm granuloma follows vasectomy it vents the high pressure otherwise created by vasectomy and prevents disruption of sperm output in the vas fluid.
Source: Silber SJ.: Lancet. 1977 Sep 17;2(8038):588-9. Links
Mens Health Week has a recipe for ageing well (Scoop.co.nz)
Helping Kiwi men have fulfilling and happy lives as they grow older is the aim of this years International Mens Health Week (11 17 June). Age Concern New Zealand and the College of Nurses (Aotearoa) NZ are leading the celebrations and are urging men to look after their health and well-being.
“VV” vs. “VE”
Vasovasostomy (VV) and vasoepididymostomy (VE) are very different operations. Since the aim of VV is to reconnect the vas where it was severed at the time of vasectomy, it is a true “reverse vasectomy”. A VV can often be performed by lifting the vas tubes out of the scrotum through a small incision, just as they were lifted out at the time of the vasectomy. The vasectomy site will be either a gap or a nodule (lump), but either way, the objective is to freshen the ends on either side of the vasectomy site and suture them back together. Left and right sides can usually be repaired in turn through the same 1/2- to 1-inch vertical incision in the center of the scrotum, all under local anesthesia in a doctor’s office. The procedure is performed under magnification using optical loupes or a microscope, 10 -18 sutures are used on each side, and it takes 3-4 hours.
A VE is different in a number of ways. (1) Since the epididymis is attached to the testes, VE requires delivery of the testes, that is, the testes must be taken out of the scrotum while the connection between the epididymis and vas is made. This requires an incision larger than that needed for VV. (2) Also, the portion of the vas between the vasectomy site and the epididymis is not used, so the gap that must be bridged is longer, requiring that the upper section of vas be “mobilized” to provide the needed length. In order to do this, the surgeon must usually make two incisions, one left and one right, which can be extended up toward each groin to allow for dissection and loosening of higher portions of the vas. (3) Finally, the epididymal tubes are much smaller than the vas tubes. A microscope must be used, the connection between epididymis and vas (VE) is often not as strong as the connection between vas and vas (VV), and the success rate of VE is not as high as the success rate of VV. A VE is more technically demanding than a VV, and some surgeons who are excellent at VV’s may not perform VE’s frequently enough to be comfortable with them.
Most doctors would agree that delivery of the testes through bilateral (both sides) incisions is beyond the scope of an office environment and that general anesthesia and a formal operating room in a hospital or ambulatory surgery center should be used. In addition, since the success rate (return of sperm to the semen) with bilateral VE is only about 65%, one should consider using a surgical facility in which sperm can be harvested, evaluated and frozen at the time of the VE so that sperm is available for in-vitro fertilization if the VE fails. Saving sperm at the time of VV is much less practical for two reasons: (1) the sperm seen at the time of VV are usually not motile (active) and therefore not acceptable for freezing and in-vitro fertilization, and (2) the success rate of VV when sperm are seen coming from the lower end is very high.
VV VE
testes not seen must be delivered
gap length usually short usually long
incisions one, short, midline two, longer, left and right
magnification loupes or microscope microscope necessary
anesthesia local works fine general advisable
procedure location office or operating room operating room
sperm storage not practical advisable
fees surgeon surgeon, anesthesia, facility
Which men need a VE?
Ah … that’s the big question. We know that the longer the interval in years between vasectomy and reversal, the greater the likelihood of a secondary obstruction in the epididymis. But some men have secondary obstruction after only two years and some do not have it after 30 years. Wouldn’t it be nice if we could determine with certainty which men need a VE before they have their surgery? Unfortunately, we cannot.
Physical Exam
There are a few clues on physical exam: (1) An epididymis that is very enlarged, firm, and tender is more likely to be obstructed than one which is small, soft, and non-tender. (2) A nodule (lump) at the vasectomy site may be “sperm granuloma”, a place where sperm leaking from the lower end of the severed vas are being recycled. If the inflammation needed to recycle sperm is taking place at the vasectomy site, it is not taking place upstream, thereby sparing the epididymis and reducing pressure within it. So a vasectomy site lump is a good thing, but not all lumps are granulomas … some are just knots of the suture or clips used during the vasectomy. (3) Some surgeons believe that high (away from the testes) vasectomy sites are a good sign … more vas on the testis side of the vasectomy site to absorb the back pressure.
Operative findings
When the vasectomy site is investigated and the lower end is freshened, the fluid that may drain from the lower end is an important clue. If the fluid contains sperm, the likelihood of an upstream obstruction is very low and the likelihood of sperm reappearance in the semen after VV is very high. If the fluid contains no sperm, especially if it is thick or creamy and packed with white blood cells (pus cells), the likelihood of an upstream obstruction is very high and the likelihood of sperm reappearance in the semen after VV is very low. No fluid at all is a relatively poor sign, and watery fluid, even though devoid of sperm, is a relatively good sign.
There are three approaches to vasectomy reversal:
(1) A surgeon may perform a bilateral VV through a single incision in the office or in a facility, regardless of the lower end fluid findings, because (a) most patients have good lower end fluid findings and do not need a VE, (b) some patients enjoy return of sperm to the semen and cause a pregnancy even when lower end findings are adverse, and (c) VV’s are technically less demanding and more likely to remain open than VE’s.
(2) A surgeon may perform all reversals under general anesthesia through two incisions in an operating room with a lab ready to accept sperm for storage. By delivering the testes, the surgeon can work with excellent exposure and go right to a VE on one or both sides he or she feels that fertility would be better with a VE.
The problem with approach number 1 is that when there is epididymal obstruction on both sides (which occurs about 17% of the time on average), the procedure fails and the patient has paid full fee for a procedure from which he has derived no benefit. In addition if the patient chooses to undergo a subsequent VE, the VV has caused some scarring and loss of upper end length in the process of trimming and suturing the upper end, making the subsequent VE more challenging and perhaps less likely to succeed.
One problem with approach number 2 is that all patients pay for the operating room and anesthesia when most would have achieved success in an office environment. When even the most liberal criteria for performing a VE rather than a VV are used (as was done in a recent study), 75% of men in an operating room had a VV on both sides and 8% of men had a VV on one side. Since the VV techniques used in the office and operating room are so similar, these 83% of patients may have enjoyed a return of sperm to the semen at a much lower cost, an important consideration for an operation not covered by most insurance carriers. Another problem with approach number 2 is that after the larger bilateral incisions patients may take longer to recover than after a single smaller incision and perhaps need more time before returning to work.
(3) A third approach is an attempt to address the problems above. Patients have their procedure in the office. The first step of the procedure is to explore one vas on the testis side of the vasectomy site through a small midline incision. This lower end is opened and the fluid evaluated. If findings are favorable, proceed with VV. If findings are very unfavorable (no fluid or thick fluid with no sperm), no connection is made and for that side the patient is charged an exploration fee much lower than a VV fee. The upper end is left unharmed, there is minimal scarring, and the patient can undergo a VE and sperm harvesting in an operating room at a later date. If the lower end fluid findings are equivocal (watery or thin fluid but no sperm), the patient and doctor can make a decision together about whether to proceed. Then the other side is managed the same way. Most patients, regardless of the interval between vasectomy and reversal, will have favorable findings on both sides, will have a VV on both sides, and will experience a return of sperm to the semen.
Approach number 3 makes the most sense for men whose intervals are short (less than 10 years) and who have no adverse physical findings. Why spend thousands of dollars for an operating room and anesthesia when the likelihood of success with an office procedure is so high? Approach number 2 may make sense when the interval is long. Approach number 1 has, for this practice, provided the results summarized in the page with Results Charts. However, since early 2005, this practice has utilized approach number 3.
Whichever approach is used, vasectomy reversal takes about 3-4 hours. Postoperatively, a dressing is held in place with an athletic supporter. A small soft drain may be left in the scrotum for one to two days to allow egress of blood and thereby prevent swelling.
AUDIO from Medialink and Pfizer: Men’s Health Week Raises Awareness of Preventable Health Problems Among Men (PR Newswire via Yahoo! Finance)
From June 11-17 this year, Men’s Health Week serves to raise awareness of preventable health problems.
June 11-17: International Men’s Health Week (PR Newswire via Yahoo! Finance)
Next week marks the 13th year of International Men’s Health Week, celebrated annually during the week preceding and including Father’s Day to honor the importance of men’s health and wellness.
