diagnosis and therapy hernioraphy post obstruksi

8/12/2019 diagnosis and therapy hernioraphy post obstruksi

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International Journal of Urology(2000) 7, S35S38

Postgraduate Course: Operative Andrology

Diagnosis and treatment of post-herniorrhaphy vas

deferens obstruction

TADASHI MATSUDA

Department of Urology, Kansai Medical University, Osaka, Japan

Abstract Childhood inguinal herniorrhaphy (IH) is one of the most frequent causes of seminal tract obstruc-tion. The incidence of vasal obstruction was found to be as high as 26.7% in subfertile patientswith a history of childhood IH. The distal end of the vas deferens was found at the internalinguinal ring or in the pelvic cavity in 56.7% of cases, more than 3cm of the vas deferens hadbeen resected in 37.9% of cases, and sperm was found in vasal fluid in 45.5% of cases during cor-rective surgery. Microsurgical two-layer vasovasostomy resulted in the postoperative appearance ofsperm in 39% of patients. In patients with postoperative azoospermia, a secondary epididymalobstruction caused by a long-term vasal obstruction is a highly probable cause. Ipsilateral epididy-

movasostomy following successful inguinal vasovasostomy results in the postoperative appearanceof sperm in the ejaculate in 100% of the patients and a subsequent natural pregnancy rate of 50%.The overall pregnancy rate among couples, following surgery in 18 patients, was 43%, excludingpregnancies achieved by in vitro fertilization or intracytoplasmic sperm injection. Microsurgicalreanastomosis of the seminal tract resulted in high impregnation rates among partners of patientswith seminal tract obstruction caused by childhood IH. After receiving sufficient information oneach treatment modality, patients can choose their preferred treatment, either reanastomosis of theseminal tract or assisted reproductive technology using epididymal or testicular sperm.

Introduction

Vas deferens obstruction caused by childhood inguinalherniorrhaphy (IH) is one of the most common causesof seminal tract obstruction. The success rate forreanastomosis in post-herniorrhaphy patients is poorerthan that in vasectomy reversal patients. This may bedue to the technical difficulty associated with micro-surgical anastomosis in the inguinal region, andbecause long-term obstruction has the potential tocause secondary epididymal obstruction1 or spermato-genic failure.2 This paper describes the diagnosticmethods, clinical findings, surgical techniques and out-

comes of seminal tract reanastomosis, in patients withvasal obstruction caused by childhood IH.

Methods

Diagnosis

Diagnosis of obstructive azoospermia is based on fullspermatogenesis in the majority of the seminiferous

tubules, the resulting presence of many sperm in the

testis, normal testes volume and normal levels ofserum FSH. If an azoospermic patient has a history ofbilateral herniorrhaphy and normal-sized testes, bilat-eral vasal obstruction in the inguinal region is highlyprobable, and a surgical approach to the inguinalregion under general anesthesia is recommended. Inour previous study, the incidence of vasal obstructionwas as high as 26.7% in subfertile patients with a his-tory of childhood IH when unilateral obstruction wascarefully diagnosed (Table 1).3 In patients with normalseminal volume and normal findings in the transrectalultrasonography, obstruction of the ejaculatory ducts

and congenital bilateral vas deferens atresia can beruled out. We believe that routine vasography with ascrotal incision should play a limited role in diagnosisand may even be potentially harmful. In cases ofobstruction in the inguinal region, it is difficult to pin-point the obstruction site by vasography with a lowinjection pressure. Secondary epididymal obstructionmay occur when the contrast medium is injected undera high injection pressure in order to visualize theinguinal vas deferens. We recommend that vasography,


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S36 Postgraduate Course: Operative Andrology

when necessary, should be performed during vasova-sostomy with a low injection pressure.

It is expected that the majority of obstructions

caused by IH are unilateral because 90% of childhoodIH is performed unilaterally. Some of the patientswith unilateral obstruction show oligozoospermia anddecreased function of the contralateral testis due to avariety of reasons. The diagnosis of unilateral obstruc-tion is difficult, mainly because it does not causeazoospermia. Unilateral obstruction is suspected incases where there is a discrepancy between seminalfindings and testicular volume or serum FSH levels.Another diagnostic clue to obstruction is careful palpa-tion of the scrotal contents. Palpation of the vas defer-ens, when it is obstructed in the inguinal region, willreveal that it is thicker than the contralateral non-obstructed vas deferens.3

Clinical findings in cases of vas deferens

obstruction by IH

The distal vasal end

The site of obstruction in post-herniorrhaphy patientsvaried from the pelvic cavity to the scrotum. Anevaluation of 20 patients revealed the distal (seminalvesicle) end of the obstructed vasa was located at theinternal inguinal ring, or more distally in the pelvic

cavity, in 56.7% of the vasa examined (Table 2).4

Inthese cases, the vas deferens was probably ligated orcut when the hernia sac was closed at the internalinguinal ring during herniorrhaphy. Finding the distalend was sometimes difficult. We opened the peritonealcavity and found the vasal end in the pelvic cavity bypalpation of the peritoneum in some cases. In onecase, however, no distal end of the vas deferens wasidentified despite an extensive search extra- andintraperitoneally. It is unclear whether this patient had

atresia of the unilateral vas deferens, or whether therehad been extensive resection of the distal vas deferensat the time of herniorrhaphy. In 36.7% of the vasa,more than 3 cm of the vas deferens had been resectedduring previous inguinal herniorrhaphy, causing diffi-culties for the reconnection of the distal and proximalends of the vas deferens.

The proximal vasal end

Sperm was identified in fluid obtained from 45.5%of the obstructed vasa among the 20 patientsinvestigated.4 Absence of sperm in the vasal fluid isapparently more common among post-herniorrhaphypatients than among vasectomy reversal patients.5 Sec-ondary epididymal obstruction due to long-term vasalobstruction is a cause of azoospermia after patentvasovasostomy. In vasectomy reversal, the incidence ofepididymal obstruction was reported to increase whenthe obstruction interval was longer than 10years and

there was no sperm granuloma.1 In post-herniorrhaphyvasal obstruction patients, secondary epididymal ob-struction is likely because the obstruction interval islengthy and there is no sperm granuloma. Vasovasos-tomy is required, even though there are no sperm in thevasal fluid in post-herniorrhaphy vasal obstructionpatients. Secondary epididymal obstruction can beovercome with ipsilateral epididymovasostomy. In sixpatients with post-vasovasostomy azoospermia andpatent vasovasostomy, we performed ipsilateral epi-didymovasostomy, resulting in a normal sperm densityin all patients and three natural pregnancies.

The surgical technique

Under general intubated anesthesia, the inguinal canalis re-opened and the spermatic cord is exposed. Theproximal (testicular) vas deferens is identified atthe external inguinal ring and followed upward to theinternal inguinal ring until the obstruction site is iden-tified. If the distal vasal end is not found in the canal,the posterior floor of the canal is incised and the pelvic

Table1 Incidence of vas deferens obstruction causedby childhood inguinal herniorrhaphy (IH) in subfertilepatients

Total subfertile patients evaluated 723*Patients with childhood IH 54 (100%)

Bilateral operation 10

Unilateral operation 45Vas deferens obstruction 15 (27.8%)Bilateral obstruction 3Unilateral obstruction 12

* Excluding one patient who was referred because ofknown bilateral obstruction.

Table2 Locations of the distal end of the obstructed vasa

Location of distal end No. vasa

Pelvic cavity, internal ring 16Inguinal canal 9External ring, scrotum 2

No distal vas deferentia 1Total 28


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cavity is opened. Opening the peritoneum is some-times helpful to find the distal vas deferens.

During surgical procedures involving the inguinalcanal, it is most important to preserve blood supply toboth ends of the vas deferens. To reconnect both ends,more of the vas deferens must be separated from the

spermatic cord in post-herniorrhaphy patients than inpatients undergoing vasectomy reversal. Furthermore,the deferential artery is usually obstructed at the vasalobstruction site. We believe that devascularlization ofthe vas deferens is a frequent cause of vasovasostomyfailure. Great care must be taken not to injure the dif-ferential vessels supplying blood in a retrograde wayfrom the testis. In cases of epididymovasostomy fol-lowing ipsilateral inguinal vasovasostomy, the straightpart of the vas deferens was cut as proximally as pos-sible without cutting the vasal artery in order to main-tain the blood supply to the proximal vas deferens

from the epididymis or testis.In cases where a lengthy part of the vas deferenswas resected at IH, the distal vas deferens deep in thepelvic cavity must be separated to perform vasovasos-tomy. In order to spare the missing part of the vas def-erens, the vas deferens is passed through a hole justcephalad to the pubic bone without passing theinguinal canal. It was reported that 712.2 cm of thevas deferens could be gained from retroperitonealmobilization of the vas deferens and delivery throughthe external ring.6,7 Crossed vasovasostomy of thebilateral vasa is the treatment of choice in selectedpatients.8 Crossed vasovasostomy, both scrotal and

suprapubic, is technically easier than inguinal vasova-sostomy, although much attention must be paid to pre-serve vasal vascularity.

Microsurgical two-layer vasovasostomy, accordingto Silber, is mandatory for post-herniorrhaphy vasalobstruction.9 Six to ten mucosal sutures with 10-0nylon were followed by eight to ten muscular sutureswith 9-0 nylon. There is a large discrepancy in thediameter of the vas deferens between the proximal and

distal ends. In vasectomy reversal, the proximal vasdeferens does not distend much when a sperm granul-oma is present at the proximal end. The granuloma iscaused by sperm leakage at the end, which results in adecrease in the intravasal pressure.10 In patients withobstruction caused by childhood IH, on the other hand,

no granuloma is formed at the proximal end of the vasdeferens because the obstruction occurred many yearsbefore the start of sperm production from the testis. Alonger period of obstruction also enhances distensionof the proximal vasal end. In order to anastomose thetwo ends in a water-tight fashion, the two layer tech-nique under operative microscopy is required. A multi-institutional study on seminal tract reanastomosis inJapan confirmed that the two-layer method showed abetter patency rate than the one-layer method among133 post-herniorrhaphy patients (unpublished data).

Following vasal anastomosis, the posterior and ante-

rior walls of the inguinal canal are closed and the scro-tal contents are fixed with wide tapes. The patient mustsubsequently wear tight underwear for at least onemonth and sexual intercourse is prohibited for 3 weeks.

Results

Since 1985, the author has treated 28 post-herniorrha-phy patients with vasal obstruction, 18 were azoosper-mic and 10 were not. In 44% of the 18 azoospermicpatients, sperm was found in the postoperative ejacu-late after the initial vasovasostomy, and impregnation

was achieved in three of the patients partners, two bynatural intercourse and one by intracytoplasmic injec-tion of sperm (ICSI) (Table 3). In seven patients whoshowed no sperm in the vasal fluid and persistentazoospermia, postoperative vasography showed patentanastomosis, and ipsilateral epididymovasostomy wassubsequently performed in six patients. All six patientsshowed normal sperm density after the second opera-tion and five achieved impregnation of their partners

Table3 Surgical outcomes of microsurgical reanastomosis of seminal tracts in patients with vasal obstruction caused by

childhood inguinal herniorrhaphy (IH)

Sperm density after Pregnancy (natural)Preoperative No. Sperm density after initial operation subsequent operation Initialsperm density patients 0 < 20 million/mL > 20 million/mL 0 < 20 million/mL > 20million/mL operation Overall

0 18 10 1 7 4 1 13 3 (2) 8 (5)*< 5 million/mL 8 5 3 4 (3) 4 (3)**> 5 million/mL 2 0 2 1 (1) 1 (1)

*Artificial insemination of the mans sperm: one case; intracytoplasmic sperm injection using ejaculated sperm: two cases; ** intra-cytoplasmic sperm injection using ejaculated sperm: one case.


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S38 Postgraduate Course: Operative Andrology

(Table 4): one by artificial insemination, one afterseven ICSI procedures using ejaculated sperm andthree by natural intercourse. The overall impregnationrate was 57% among married patients with sufficientfollow-up periods, with a natural impregnation rate of

36%. The surgical outcome of ten non-azoospermicpatients is shown in Table 3. Among eight patientswith severe oligozoospermia (sperm count


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diagnosis and therapy hernioraphy post obstruksi

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