Recanalization following vasectomy

RECANALIZATION

FOLLOWING

VASECTOMY

JULIUS O . ESHO, M .D . GERALD W . IRELAND . M .D . ALEXANDER S . CASS, M .D . From the Department of Urology, St . Paul-Ramsey Hospital, and the University of Minnesota Medical School, St . Paul, Minnesota

ABSTRACT-Most authors hate not differentiated between early and late recanalization following bilateral vasectomy for sterilization . Their reported recanalization rates probably reflect only early recanalization . Long-term follow-up semen examinations are required to document late recanalization . This regimen may be unacceptable to some patients and physicians . No symptomatic postvasectomy complication preceded the recanalization .

One controversial issue of bilateral vasectomy or sterilization for the urologist has been the hnique and its resulting rate of recanalization . The time and predisposing conditions of recanalization have not been determined and are the <:Subject of this report . Material and Method More than IA00 bilateral vasectomies for steri:ization have been performed under a local anes'tbetic and intravenous diazepam (Valium) in the outpatient clinic since June, 1970 . Eight hundred eighty-nine patients have been followed for a ' ,,Minimum period of six months The first 500 'cases have been followed for a.1,2 period ranging from twelve to thirty-six months . The case his-tones have been examined to determine the incidence, time and predisposing conditions of ''recanalization . The technique of vasectomy was either vas fir,, igation or vas fulguration . With both techniques ;:about 1 .5 cm . of vas was excised and submitted -' Jr histopathologic examination. With vas ligaaft n the cut ends of the vas were ligated with 3-0 ghromic catgut, With vas fulguration the lumen of both cut vas ends was electrofulgurated, and then the distal (bladder) cut end was buried in t'Its .fascial sheath . All vasectomy patients were requested to subt semen specimens for sperm analysis at eight

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weeks after vasectomy . If any sperm, motile or immotile, were present, further semen examinations were done at four-week intervals until aspermia was documented . Subsequent semen examinations were requested at four monthly intervals for one year and yearly thereafter . Results Initial semen examinations One hundred nineteen patients failed to submit semen for the eight-week postvasectomy examination . Specimens of 658 of the 770 patients were negative at eight weeks, 63 more were negative at twelve weeks, and an additional 17 at sixteen weeks . Specimens of 19 patients took four to six months to become negative, and specimens of 7 patients were not negative until six to twelve months after vasectomy (Table I) . Six patients continued to have some sperm, motile and/or nonmotile, in all specimens . At first the sperm count usually dropped to small numbers and then rose to larger numbers of active sperm (Table II) . Early recanalization developed in these patients, and 4 were treated by repeat vasectomy, while 2 are awaiting surgery . All 6 patients had histologic proof sections two vasavasectomy labeled "right" "left"offrom their ofprevious and had and no symptomatic postoperative complications that could be blamed for recanalization . At the time of the repeat bilateral vasectomy a section of each

211



TABLE I .

Results of initial semen examinations in 770 patients

- Negative Results -7 Number of Total Patients Per Cent

re and C finical Data 1

Eight weeks Twelve weeks Sixteen weeks Four to six months Six to twelve months Sperm always present (recanalization)

658 721 738 757 764 6 770 889`

TOTAL STUDY TOTAL

85 .5 94 96 98 .4 99 .2 0.8

'119 patients failed to attend .

vas including the previous vas site was excised and diatrizoate meglumine (Renografin) was injected into some of the specimens . A recanalization channel was demonstrated on at least one side (Fig . 1) . All vas sections had multiple sections cut for histopathologic examination which revealed evidence of recanalization on one side . Following repeat vasectomy results of examinations for semen were negative . Later semen examinations

Two hundred fifteen patients submitted semen specimens for yearly evaluations . Many patients could not be traced, while others refused to submit specimens for personal reasons, such as death of spouse or wife's subsequent hysterectomy . Three patients, who initially had negative specimens, were found to have large numbers of active spermatozoa (Table II) . These were late recanalizations and were also treated by repeat vasectomy. These patients had histologic proof of sections of two vasa labeled "right" and "left" from their previous vasectomy and had no symptomatic postoperative complications that could predispose to recanalization . IIistopathologic examination of the vas sections revealed recanalization on one side . Following the repeat bilateral vasectomy, negative results on semen examinations were obtained . Comment Recanalization appears to occur at two different times after bilateral vasectomy, early and late . With early recanalization results of the initial postvasectomy semen examinations never became negative . With late recanalization per-

212

FIGURE 1 . Diatrizoate meglumine injected through vas sections which included site of previous vasectomy . (A) Right side shows recanalization ; (B) left side obstructed from previous vasectomy .

sistent rising sperm counts occur at a variable time period after results of the initial postvasectomy semen examinations were negative . Transient reappearance of sperm after vasectomy iss temporary and is followed by negative results and not by persistent rising sperm counts .1,4 The type of follow-up of postvasectomy semen examinations will determine the accurate incidence of recanalization . Most authors recommend follow-up semen examinations until two consecutive negative results are achieved . This regimen should accurately document the early :, recanalization rate but would fail to detect late recanalization (Table III) . Four or six months' postvasectomy semen examination would detectt some cases of late recanalization . However, many, studies documenting the rate of sperm disappearance after vasectomy have shown a period Of' four to six months or even longer is required be fore 100 per cent sperm disappearance is' achieved .`,' Yearly postvasectomy semen ez-, aminations would detect late recanalization :-: However, many of our patients have failed to ," follow this regimen . Smith6 aptly described th,(&j psychologic dilemma " . . . regular semen exam,-[; nations indefinitely . . . totally defeating the ob ject of the operation which is to free the patiel from worry." Sperm granuloma has been shown to be the ; most obvious predisposing condition for recanal -, zation .''7 '8 However, many sperm granulomashave been observed without evidence of recanalh , zation . None of our patients had a precedi4 sperm granuloma diagnosed, but sperm grant! loma can be asymptomatic and thus not dial;:, nosed by the physician .

UROLOGY / FEBRUARY 1974 / VOLUME III, NUMBER' *

I-+ W

Lv

z



None

33

9

'Not known.

Wound infection

41

8

Negative Negative Negative

2 3 2

None

None

24

7

94

60 30 72 31

Numerous dead sperm NK 33 NK 1 .7 100 0 .02 98 6 .3 Awaiting repeat vasectomy

2 3 4 5 14

None

39

6

Some dead sperm Some dead sperm 31 .6 Many dead sperm Negative

34 68

Numerous motile sperm 97 .5 107 NK 265 Awaiting repeat vasectomy

2 9 10

None

NK NK

25

NK NK

5

20 40 Repeat vasectomy

24

5 6 6

None 75 77 None

4

None

Numerous motile sperm 84 15 .1 Majority 19 .9 100 18 100 18 Repeat vasectomy

2 2 3 5 7 8

None

26

3

55 60 70 NK 58

100 98 98 NK 96

25 1 .7 0 .67 4 .2 17 .8 Repeat vasectomy

2 3 4 6 7 7

27

4

81 66 51 50

NK 98 NK 97

22 .4 39 .8 Repeat vasectomy 53 .2 26 .9 Repeat vasectomy 13 14 14

None None

Motility I (Per Cent)

9 9 11

NK

Late Normal Morphology (Per Cent)

0,06 7 Repeat vasectomy

Million Sperm (Per MI .)

11 12 16

Motility I I Postvasectomy (Months) (Per Ceni)

Semen Examinations

NK*

Few dead sperm 22 Repeat vasectomy

3 5 6 6

None

None

26

38

Complications

' Postvasectomy (Months)

2

Case

Age (Years)

Initial Normal Morphology Million Sperm (Per Cent) (Per MI .)



TABLE Ill . Author

Studies reporting incidence of recanalization$ Number of Cases

Stokes, 1941 74 Dickinson and Gamble, 1950 14 Mueller-Schmid et al ., 1960 10 Chaset, 1962 15 Datta and Ghosh, 1965 16 Schmidt, 1966 8 Alderman, 196817 Carlson, 19700 Jackson et al ., 1970 1& Sekhon, 19701 5 Livingstone, 1971" Schmidt, 1971 11 Marshall and Lyon, 1972' Moss, 19722 ' Kase and Goldfarb, 1973 11 Klapproth and Young, 1973' Esho, Ireland, and Cass, 1973

Number of Recanalizations

200 1,865 1,000 282 175 432 1,923 1,241 330 70 3,200 700 200 400 500 1,000 889 14,407

TOTALS

Per Cent

6 5 0 6 1 5 19 0 6 4 4 0 2 0 2 8 6*

3 0 .27 0 2 .12 0 .57 1 .16 0 .99 0 1 .82 5 .71 0 .13 0 1 0 0 .4 0 .8 0 .7

74

0 .51

*And three late reanastomoses (1 .4 per cent) in 215 patients with yearly follow-up .

The type of bilateral vasectomy performed does influence the incidence of recanalization . Excision of long segments of each vas has resulted in . no recanalization . 910 The resection of

such a long segment makes any future reanastomosis procedure difficult. Schmidt's 1 Li2 technique of vas fulguration with burying of the distal (bladder) cut vas end in its fascial sheath has resulted in no early recanalization . Long-term

follow-up semen examination will determine if there are any late recanalizations with this method . St . Paul-Ramsey Hospital and Medical Center St . Paul, Minnesota 55101 (DR . CASS) References 1 . Esao, J . 0 ., CAse, A. S ., and IRELAND, G . V. : Morbidity associated with vasectomy, J . Urol. 110 : 413 (1973) . 2 . IDEM : Comparison of ligation and fulguration methods of vasectomy, in press . 3 . MARSHALL, S ., and LYON, H . P . : Variability of sperm disappearance from the ejaculate after vasectomy, J . Urol. 107 : 815 (1972) . 4 . TEMPLE, J . C . : Semen examinations after vasectomy, Lancet 2 : 1258 (1970) . 5 . KLAPPROTH, H . J ., and YDUNG, 1 . S . : Vasectomy, vas ligation and vas occlusion, Urology 1 : 292 (1973) . 6 . SMITH, . C . C . : Semen examination after vasectomy, Lancet 1 : 38 (1971) .

214

7 . FRIEDMAN, N . B ., and GARSKE, G . L . ; Inflammatory reactions involving sperm and the seminiferous tubules; extravasation, spermatic granulomas and granulomatousi orchitis, J . Urol . 62 : 363 (1949) . 8 . SCHMIUT, S . S . : Technics and complications of elective . vasectomy, Fertil . Steril . 17 : 467 (1966) . 9 . C.ARLSON, IT . E . : Vasectomy of election, South . Med . J..63 : 766 (1970) . 10 . MUELLER-SCHMID, P ., REIMANN-HUNZIKER, G ., and RELMANN-HUNZIKER, R. : Erfahrungen mit der Operativen Storilisierung des Mannes, Praxis 49 : 352 (1960) . 11 . SciV tu'r, S . S . : Technique of vasectomy, Br . Med. J:t 2 : 524 (1971). 12. IDEM : Prevention of failure in vasectomy, J . Urol . 109 ;'E 296 (1973) . 13 . STOKES, W . R . : Delayed anastomo .sis of the vas deferens following vasectomy, Hum . Fertil . 6 : 79 (1941) . 14 . DICKINSON, R . L ., and GAMBLE, C . J . : Techniques Of; Permanent Conception Control, Monograph, Baltimore ; Waverly Press, Inc ., 1950 . 15 . CHASET, N . : Male sterilization, J . Urol . 87 : 512 (1962).= 16, DATTA, A . K., and GHOSH, S . : Failed vasectomy,. jy Indian Med . Assoc . 41 : 548 (1963) . 17 . ALDERMAN, P . M . : Vasectomy for voluntary malei sterilization, Lancet 2 : 1137 (1968) . ' 18 . JACKSON, P ., et al . : A male sterilization clinic, Br . Med ^ J . 4 : 295 (1970) . 19 . SEKI-ION, C . S . : Percutaneous vasectomy : a comparative study using a new instrument and technique, Indian J . Med . Res . 58 : 1433 (1970) . 20 . LivINGSTONE, E . S . : Vasectomy : a review of 3200 oPe tions, Can . Med . Assoc . J . 105 : 1065 (1971) . 21 . Moss, H . C . : Vanadium clips for sterilization 0 Lions . J .A.M .A.215 :639 (1971) . 22. KAsE, S ., and GOLDF .ARB, H . : Office vasectomy ; re of 500 cases, Urology 1 : 60 (1973) .

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NUMBER 2