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Surgical Therapy of Male Infertility
0022-534 7/93/1495-137 4$03.00/0 Vol. 149, 1374-1376, May 1993
THE JOURNAL OF UROLOGY Copyright© 1993 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Printed in U.S.A.
Editorial SURGICAL THERAPY OF MALE INFERTILITY The surgical treatment of male infertility consists largely of · the bilateral operations had the same degree of response as the 2 types of operations: 1) varicocele repair and 2) treatment of unilateral procedures. It is noteworthy that the authors used a obstructive azoospermia. The 4 preceding articles address con- microsurgical technique with preservation of the testicular troversial issues regarding details of technique and predictors artery for repair of recurrent varicoceles and in patients with of success. Ross and Rupprnan (page 1361) discuss the question prior inguinal surgery. Several studies now show that open of open versus laparoscopic treatment of varicocele. They used microsurgical techniques can be completed with operating times a high inguinal technique in 565 men under iocal anesthesia as short as that reported by the authors. 1• 2• 5 As with any new and reported minimal requirements for postoperative analgesia technique, experience is the key to reducing operating time. and rapid return to work. These results compare favorably with The issue of testicular artery ligation versus preservation is those reported for laparoscopic varicocelectomy. The use of directly addressed by Matsuda et al (page 1357). They report local anesthesia, standard instrumentation and the relatively the first prospective randomized study of open varicocelectomy short operating time make this approach significantly more with intentional ligation or preservation of the testicular artery. cost-effective than a laparoscopic technique. Furthermore, an They found no difference in semen analysis between the groups open approach eliminates the small but inevitable risk of seri- postoperatively. The pregnancy rates were 37.8% in the artery ous intra-abdominal morbidity associated with any laparos- preserved group and 23.8% in the artery ligated group. Although copic procedure. this difference was not statistically significant (p <0.12), this Only 13.3% of these open procedures were bilateral. Current finding indicates a strong trend and the difference is more reports indicate that bilateral varicoceles are much more com- likely to become significant if extended to a larger series. One mon than previously suspected. Using high resolution ultra- case (6%) of obvious testicular atrophy occurred in the ligated sound, color flow Doppler or a <_:areful examination of the fully group (14 ml. preoperatively to 6 ml. postoperatively). All relaxed scrotum in a warm room, the incidence of bilateral patients in this study had unilateral repairs. The authors argue lesions is reported to be 30 to 70%. Laparoscopic repair of for testicular artery ligation because its preservation is technibilateral lesions is likely to be associated with a more rapid to cally difficult and time-consuming. They also refer to reports return to strenuous activity than even minimally invasive open of higher recurrence rates when artery preservation is not techniques. Laparoscopic repair also provides optical magnifi- performed microsurgically. This result is due to failure to ligate cation, enhancing operator ability to identify and preserve the the small periarterial venae comitantes that can cause recurtesticular artery and lymphatics. rence.6 With microsurgical arterial preservation the periarterial Ross and Ruppman reported 41 hydroceles (7.3%) using a venous plexus is ligated and recurrence rates are low. 1• 2• 5 technique that does not attempt to preserve these structures. Varicocelectomy remains a controversial issue. Many anOf these hydroceles 7 grew to a size necessitating hydrocelec- drologists still question the role of varicocele and the efficacy tomy. Although the effect of hydrocele on testicular function is of varicocelectomy as a treatment for male infertility. Curunknown, it is possible that increased fluid surrounding the rently, there is little doubt that varicocele is associated with a testis may alter the temperature regulating mechanism of the substantial risk of deteriorating testicular function with testis affected by varicocele. Open microsurgical techniques time. 1- 11 It is likely that prophylactic varicocelectomy in young allow identification and preservation of enough lymphatics to men with significant varicoceles will reduce the incidence of eliminate hydrocele as a complication. 1• 2 Furthermore, the future infertility and result in a far greater reduction in health microscope allows preservation of the testicular artery in a care costs than any alteration in technique. With this in mind, majority of cases. Penn et al reported a 14% incidence of minimizing morbidity becomes a central concern. As indicated testicular atrophy among 98 renal transplant patients in whom by Ross and Ruppman open varicocelectomy is a safe and the spermatic vessels were deliberately divided. 3 A more likely effective method without the potential for major complications outcome of testicular artery ligation than atrophy may be a less associated with laparoscopy, and with an equivalent postoperthan optimal response to varicocelectomy. The occasional an- ative recovery when used for unilateral operations. The same ecdotal report of an oligospermic patient becoming azoospermic authors invoked microscopic technique to preserve the testicafter varicocelectomy represents a complication of bilateral ular artery and individually ligated each vein, thus preserving procedures. 4 the perivenous and intervenous lymphatics but only when Unilateral operations that successfully eliminate a significant operating on recurrent varicoceles or men with prior inguinal varicocele will often result in improvement in the function of surgery. If they used this technique for all cases they could the contralateral testis. This will occur even when the function prevent hydrocele, the most common complication. Preventing of the ipsilateral testis is compromised by testicular artery ischemic injury is even more relevant when operating on a ligation or hydrocele. This finding explains the excellent preg- solitary testis, or in adolescents and young men in whom the nancy rates reported by Ross and Ruppman. The semen analy- operation is performed prophylactically. At the least, it is sis data reported by the authors were collected only from the inarguable that testicular artery ligation and hydrocele formatwo-thirds of patients who responded to surgery. It would be tion are unlikely to enhance testicular function. interesting to know whether the hydroceles reported in that Advances in technique have radically altered the prognosis series were more common in the nonresponders and whether for the treatment of obstructive azoospermia. Microsurgical Requests for reprints: Department of Urology, New York Hospital- repair of vasal obstruction is routinely associated with patency rates greater than 90% and pregnancy rates averaging 50%. Cornell Medical Center, 525 E. 68th St., New York, New York 10021. 1374
1375
SURGICAL THERAPY OF MALE INFERTILITY
Repair of epididymal obstruction remains problematic for several reasons. Unlike the vas deferens, the epididymis has little or no muscular support for its delicate mucosa. Vasoepididymal anastomoses are technically the most challenging of all microsurgical repairs. Furthermore, the epididymis has an important role in the acquisition of sperm motility and fertilizing capacity. Although in obstructed systems sperm can acquire motility and fertilizing capacity with little or no exposure to the epididymal environment, 12• 13 it is clear that the more epididymis sperm are exposed to the greater the fertilizing capacity of the sperm. Niederberger and Ross (page 1364) showed that the best predictor of successful microsurgical vasoepididymostomy is the presence of sperm in the epididymal fluid at surgery. This finding is consistent with the data accumulated in large series of vasovasostomies in which far better outcomes can be expected after vasovasostomy when sperm are found in the fluid sampled from the testicular end of the vas. 14 The authors used a microsurgical end-to-side technique first described by Wagenknecht et al, 15 and reported in this country by Fogdestam et al1 6 and popularized by Thomas. 17 The authors state that a testis biopsy positive for spermatogenesis is not a predicator of success. Clearly, however, spermatogenesis must be present for epididymal fluid to contain sperm. It should not be construed from these results that a testis biopsy is unnecessary to diagnose epididymal obstruction. The biopsies in this study were not evaluated quantitatively and the number of patients studied was not large (22). It is likely that men with severely impaired spermatogenesis will have poorer outcomes than those with normal or mildly impaired spermatogenesis. Of greater interest is the authors' finding that the presence of motile versus nonmotile sperm in the epididymal fluid was not a significant predictor of success. This important finding suggests that vasoepididymostomy should be performed at the lowest level in the epididymis at which sperm and good flow are found, regardless of motility. This approach will allow preservation of the greatest length of epididymis for the acquisition of motility and fertilizing capacity. The issue of end-to-end versus end-to-side anastomosis is probably not important. An end-to-end technique is useful in distal epididymal obstructions associated with a short vas, a situation frequently encountered at vasectomy reversal. 18 There is probably no operation in urology with results so dependent on technical perfection. Once sperm are found in the epididymal tubule, a good outcome depends on accurate mucosal approximation and a watertight, tension-free closure around it. Even in experienced hands vasoepididymostomy frequently fails. In these cases and in men with unreconstructable acquired or congenital lesions microsurgically aspirated epididymal sperm can be used in conjunction with in vitro fertilization to salvage pregnancy. Marmar et al (page 1368) underscore the importance of a team approach in achieving improved results with this technically and logistically demanding procedure. In their first 10 couples there were no fertilizations or pregnancies. They then showed that improved stimulation protocols, cleaner techniques for microsurgical sperm aspiration and enhanced methods of sperm processing yielded a 20% pregnancy rate. Better stimulation protocols produced more oocytes of better quality. Micropuncture of the epididymal tubule (first used to study epididymal physiology in animals 19), as opposed to cutting the tubule and aspirating the effluxing fluid, resulted in less contamination with blood and tissue fluids. Pentoxifylline stimulation, mini-Percoll filtration and incubation with human follicular fluid provided better quality sperm. We have found that adding oocyte micromanipulation to this armamentarium of techniques can result in pregnancy rates greater than 30%. 20 The authors also demonstrate the feasibility of a mobile program in which sperm can be collected at a single microsurgical center, processed and transported to a local in vitro fertilization team. The authors used transrectal ultrasound to
evaluate preoperatively the seminal vesicles of patients with congenital absence of the vas deferens. This concept derives from a previous study, which revealed that many men with congenital absence of the vas deferens have seminal vesicles. 21 The authors reasoned that men with more seminal vesicle tissue on one side were likely to have a more complete epididymis on that side as well. Their findings confirmed their suspicions. There is general agreement that better sperm and consequently better results are obtained when more epididymis is present. The findings of Marmar et al indicate that transrectal ultrasound is a useful preoperative procedure to determine which testis should be exposed first. Because of the 20% incidence of an absent kidney associated with congenital absence of the vas deferens, renal ultrasound should be performed as well. 21 We performed testis biopsies on all such patients preoperatively. We have found that testis biopsies on these patients always reveal spermatogenesis. 21 It is cost-effective to eliminate biopsy except in men with an elevated serum follicle-stimulating hormone level and bilateral small soft testes. Advances in the surgical treatment of male infertility are dependent on honest evaluation and reporting of results, innovation and fine tuning of technologies, and a well coordinated multidisciplinary approach. The 4 preceding articles exemplify these attributes. Marc Goldstein Department of Urology The New York Hospital-Cornell Medical Center New York, New York REFERENCES
1. Marmar, J. L., DeBenedictis, T. J. and Praiss, D.: The management of varicoceles by microdissection of the spermatic cord at the external inguinal ring. Fertil. Steril., 43: 583, 1985. 2. Goldstein, M., Gilbert, B. R., Dicker, A. P., Dwosh, J. and Gnecco, C.: Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique. J. Urol., 148: 1808, 1992. 3. Penn, I., Mackie, G., Halgrimson, C. G. and Starzl, T. E.: Testicular complications following renal transplantation. Ann. Surg., 176: 697, 1972. 4. Silber, S. J.: Microsurgical aspects ofvaricocele. Fertil. Steril., 31: 230, 1979. 5. Kaye, K. W.: Modified high varicocelectomy; outpatient microsurgical procedure. Urology, 32: 13, 1988. 6. Beck, E. M., Schlegel, P. N. and Goldstein, M.: Intraoperative varicocele anatomy: a macroscopic and microscopic study. J. Urol., 148: 1190, 1992. 7. Lipshultz, L. I. and Corriere, J. N., Jr.: Progressive testicular atrophy in the varicocele patient. J. Urol., 117: 175, 1977. 8. Nagler, H. M., Li, X.-Z., Lizza, E. F., Deitch, A. and de Vere White, R.: Varicocele: temporal considerations. J. Urol., 134: 411, 1985. 9. Hadziselimovic, F., Herzog, B., Liebundgut, B., Jenny, P. and Buser, M.: Testicular and vascular changes in children and adults with varicocele. J. Urol., part 2, 142: 583, 1989. 10. Kass, E. J., Chandra, R. S. and Belman, A. B.: Testicular histology in the adolescent with a varicocele. Pediatrics, 79: 996, 1987. 11. Gorelick, J. and Goldstein, M.: Loss of fertility in men with varicocele. Fertil. Steril., 59: 613, 1993. 12. Silber, S. J., Ord, T., Balmaceda, J., Patrizio, P. and Asch, R. H.: Congenital absence of the vas deferens. The fertilizing capacity of human epididymal sperm. New Engl. J. Med., 323: 1788, 1990. 13. Jow, W.W., Steckel, J., Schlegel, P. N., Magid, M. S. and Goldstein, M.: Motile sperm in human testis biopsy specimens. J. Androl., in press. 14. Belker, A. M., Thomas, A. J., Jr., Fuchs, E. F., Konnak, J. W. and Sharlip, I. D.: Results of 1,469 microsurgical vasectomy reversals by the vasovasostomy study group. J. Urol., 145: 505, 1991. 15. Wagenknecht, L. V., Klosterhalfen, H. and Schirren, C.: Microsurgery in andrologic urology. I. Refertilization. J. Microsurg., 1: 370, 1980. 16. Fogdestam, I., Fall, M. and Nilsson, S.: Microsurgical epididymo-
1376
GOLDSTEIN
vasostomy in the treatment of occlusive azoospermia. Fertil. Steril., 46: 925, 1986. 17. Thomas, A. J., Jr.: Vasoepididymostomy. Urol. Clin. N. Amer., 14: 527, 1987. 18. Schlegel, P. N. and Goldstein, M.: Microsurgical vasoepididymostomy: refinements and results. J. Urol., submitted for publication. 19. Howards, S. S., Johnson, A. and Jessee, S.: Micropuncture and microanalytic studies of the testis and epididymis. Fertil. Steril., 26: 13, 1975.
20. Schlegel, P. N., Berkeley, A. S., Goldstein, M., Alikani, M., Adler, A., Gilbert, B. R., Cohen, J. and Rosenwaks, Z.: Epididymal micropuncture with IVF for treatment of surgically unreconstructable vasal obstruction. Presented at the annual meeting of the American Fertility Society, New Orleans, abstract S28, November 2-5, 1992. 21. Goldstein, M. and Schlossberg, S.: Men with congenital absence of the vas deferens often have seminal vesicles. J. Urol., 140: 85, 1988.
THE JOURNAL OF UROLOGY Copyright© 1993 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Printed in U.S.A.
Editorial SURGICAL THERAPY OF MALE INFERTILITY The surgical treatment of male infertility consists largely of · the bilateral operations had the same degree of response as the 2 types of operations: 1) varicocele repair and 2) treatment of unilateral procedures. It is noteworthy that the authors used a obstructive azoospermia. The 4 preceding articles address con- microsurgical technique with preservation of the testicular troversial issues regarding details of technique and predictors artery for repair of recurrent varicoceles and in patients with of success. Ross and Rupprnan (page 1361) discuss the question prior inguinal surgery. Several studies now show that open of open versus laparoscopic treatment of varicocele. They used microsurgical techniques can be completed with operating times a high inguinal technique in 565 men under iocal anesthesia as short as that reported by the authors. 1• 2• 5 As with any new and reported minimal requirements for postoperative analgesia technique, experience is the key to reducing operating time. and rapid return to work. These results compare favorably with The issue of testicular artery ligation versus preservation is those reported for laparoscopic varicocelectomy. The use of directly addressed by Matsuda et al (page 1357). They report local anesthesia, standard instrumentation and the relatively the first prospective randomized study of open varicocelectomy short operating time make this approach significantly more with intentional ligation or preservation of the testicular artery. cost-effective than a laparoscopic technique. Furthermore, an They found no difference in semen analysis between the groups open approach eliminates the small but inevitable risk of seri- postoperatively. The pregnancy rates were 37.8% in the artery ous intra-abdominal morbidity associated with any laparos- preserved group and 23.8% in the artery ligated group. Although copic procedure. this difference was not statistically significant (p <0.12), this Only 13.3% of these open procedures were bilateral. Current finding indicates a strong trend and the difference is more reports indicate that bilateral varicoceles are much more com- likely to become significant if extended to a larger series. One mon than previously suspected. Using high resolution ultra- case (6%) of obvious testicular atrophy occurred in the ligated sound, color flow Doppler or a <_:areful examination of the fully group (14 ml. preoperatively to 6 ml. postoperatively). All relaxed scrotum in a warm room, the incidence of bilateral patients in this study had unilateral repairs. The authors argue lesions is reported to be 30 to 70%. Laparoscopic repair of for testicular artery ligation because its preservation is technibilateral lesions is likely to be associated with a more rapid to cally difficult and time-consuming. They also refer to reports return to strenuous activity than even minimally invasive open of higher recurrence rates when artery preservation is not techniques. Laparoscopic repair also provides optical magnifi- performed microsurgically. This result is due to failure to ligate cation, enhancing operator ability to identify and preserve the the small periarterial venae comitantes that can cause recurtesticular artery and lymphatics. rence.6 With microsurgical arterial preservation the periarterial Ross and Ruppman reported 41 hydroceles (7.3%) using a venous plexus is ligated and recurrence rates are low. 1• 2• 5 technique that does not attempt to preserve these structures. Varicocelectomy remains a controversial issue. Many anOf these hydroceles 7 grew to a size necessitating hydrocelec- drologists still question the role of varicocele and the efficacy tomy. Although the effect of hydrocele on testicular function is of varicocelectomy as a treatment for male infertility. Curunknown, it is possible that increased fluid surrounding the rently, there is little doubt that varicocele is associated with a testis may alter the temperature regulating mechanism of the substantial risk of deteriorating testicular function with testis affected by varicocele. Open microsurgical techniques time. 1- 11 It is likely that prophylactic varicocelectomy in young allow identification and preservation of enough lymphatics to men with significant varicoceles will reduce the incidence of eliminate hydrocele as a complication. 1• 2 Furthermore, the future infertility and result in a far greater reduction in health microscope allows preservation of the testicular artery in a care costs than any alteration in technique. With this in mind, majority of cases. Penn et al reported a 14% incidence of minimizing morbidity becomes a central concern. As indicated testicular atrophy among 98 renal transplant patients in whom by Ross and Ruppman open varicocelectomy is a safe and the spermatic vessels were deliberately divided. 3 A more likely effective method without the potential for major complications outcome of testicular artery ligation than atrophy may be a less associated with laparoscopy, and with an equivalent postoperthan optimal response to varicocelectomy. The occasional an- ative recovery when used for unilateral operations. The same ecdotal report of an oligospermic patient becoming azoospermic authors invoked microscopic technique to preserve the testicafter varicocelectomy represents a complication of bilateral ular artery and individually ligated each vein, thus preserving procedures. 4 the perivenous and intervenous lymphatics but only when Unilateral operations that successfully eliminate a significant operating on recurrent varicoceles or men with prior inguinal varicocele will often result in improvement in the function of surgery. If they used this technique for all cases they could the contralateral testis. This will occur even when the function prevent hydrocele, the most common complication. Preventing of the ipsilateral testis is compromised by testicular artery ischemic injury is even more relevant when operating on a ligation or hydrocele. This finding explains the excellent preg- solitary testis, or in adolescents and young men in whom the nancy rates reported by Ross and Ruppman. The semen analy- operation is performed prophylactically. At the least, it is sis data reported by the authors were collected only from the inarguable that testicular artery ligation and hydrocele formatwo-thirds of patients who responded to surgery. It would be tion are unlikely to enhance testicular function. interesting to know whether the hydroceles reported in that Advances in technique have radically altered the prognosis series were more common in the nonresponders and whether for the treatment of obstructive azoospermia. Microsurgical Requests for reprints: Department of Urology, New York Hospital- repair of vasal obstruction is routinely associated with patency rates greater than 90% and pregnancy rates averaging 50%. Cornell Medical Center, 525 E. 68th St., New York, New York 10021. 1374
1375
SURGICAL THERAPY OF MALE INFERTILITY
Repair of epididymal obstruction remains problematic for several reasons. Unlike the vas deferens, the epididymis has little or no muscular support for its delicate mucosa. Vasoepididymal anastomoses are technically the most challenging of all microsurgical repairs. Furthermore, the epididymis has an important role in the acquisition of sperm motility and fertilizing capacity. Although in obstructed systems sperm can acquire motility and fertilizing capacity with little or no exposure to the epididymal environment, 12• 13 it is clear that the more epididymis sperm are exposed to the greater the fertilizing capacity of the sperm. Niederberger and Ross (page 1364) showed that the best predictor of successful microsurgical vasoepididymostomy is the presence of sperm in the epididymal fluid at surgery. This finding is consistent with the data accumulated in large series of vasovasostomies in which far better outcomes can be expected after vasovasostomy when sperm are found in the fluid sampled from the testicular end of the vas. 14 The authors used a microsurgical end-to-side technique first described by Wagenknecht et al, 15 and reported in this country by Fogdestam et al1 6 and popularized by Thomas. 17 The authors state that a testis biopsy positive for spermatogenesis is not a predicator of success. Clearly, however, spermatogenesis must be present for epididymal fluid to contain sperm. It should not be construed from these results that a testis biopsy is unnecessary to diagnose epididymal obstruction. The biopsies in this study were not evaluated quantitatively and the number of patients studied was not large (22). It is likely that men with severely impaired spermatogenesis will have poorer outcomes than those with normal or mildly impaired spermatogenesis. Of greater interest is the authors' finding that the presence of motile versus nonmotile sperm in the epididymal fluid was not a significant predictor of success. This important finding suggests that vasoepididymostomy should be performed at the lowest level in the epididymis at which sperm and good flow are found, regardless of motility. This approach will allow preservation of the greatest length of epididymis for the acquisition of motility and fertilizing capacity. The issue of end-to-end versus end-to-side anastomosis is probably not important. An end-to-end technique is useful in distal epididymal obstructions associated with a short vas, a situation frequently encountered at vasectomy reversal. 18 There is probably no operation in urology with results so dependent on technical perfection. Once sperm are found in the epididymal tubule, a good outcome depends on accurate mucosal approximation and a watertight, tension-free closure around it. Even in experienced hands vasoepididymostomy frequently fails. In these cases and in men with unreconstructable acquired or congenital lesions microsurgically aspirated epididymal sperm can be used in conjunction with in vitro fertilization to salvage pregnancy. Marmar et al (page 1368) underscore the importance of a team approach in achieving improved results with this technically and logistically demanding procedure. In their first 10 couples there were no fertilizations or pregnancies. They then showed that improved stimulation protocols, cleaner techniques for microsurgical sperm aspiration and enhanced methods of sperm processing yielded a 20% pregnancy rate. Better stimulation protocols produced more oocytes of better quality. Micropuncture of the epididymal tubule (first used to study epididymal physiology in animals 19), as opposed to cutting the tubule and aspirating the effluxing fluid, resulted in less contamination with blood and tissue fluids. Pentoxifylline stimulation, mini-Percoll filtration and incubation with human follicular fluid provided better quality sperm. We have found that adding oocyte micromanipulation to this armamentarium of techniques can result in pregnancy rates greater than 30%. 20 The authors also demonstrate the feasibility of a mobile program in which sperm can be collected at a single microsurgical center, processed and transported to a local in vitro fertilization team. The authors used transrectal ultrasound to
evaluate preoperatively the seminal vesicles of patients with congenital absence of the vas deferens. This concept derives from a previous study, which revealed that many men with congenital absence of the vas deferens have seminal vesicles. 21 The authors reasoned that men with more seminal vesicle tissue on one side were likely to have a more complete epididymis on that side as well. Their findings confirmed their suspicions. There is general agreement that better sperm and consequently better results are obtained when more epididymis is present. The findings of Marmar et al indicate that transrectal ultrasound is a useful preoperative procedure to determine which testis should be exposed first. Because of the 20% incidence of an absent kidney associated with congenital absence of the vas deferens, renal ultrasound should be performed as well. 21 We performed testis biopsies on all such patients preoperatively. We have found that testis biopsies on these patients always reveal spermatogenesis. 21 It is cost-effective to eliminate biopsy except in men with an elevated serum follicle-stimulating hormone level and bilateral small soft testes. Advances in the surgical treatment of male infertility are dependent on honest evaluation and reporting of results, innovation and fine tuning of technologies, and a well coordinated multidisciplinary approach. The 4 preceding articles exemplify these attributes. Marc Goldstein Department of Urology The New York Hospital-Cornell Medical Center New York, New York REFERENCES
1. Marmar, J. L., DeBenedictis, T. J. and Praiss, D.: The management of varicoceles by microdissection of the spermatic cord at the external inguinal ring. Fertil. Steril., 43: 583, 1985. 2. Goldstein, M., Gilbert, B. R., Dicker, A. P., Dwosh, J. and Gnecco, C.: Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique. J. Urol., 148: 1808, 1992. 3. Penn, I., Mackie, G., Halgrimson, C. G. and Starzl, T. E.: Testicular complications following renal transplantation. Ann. Surg., 176: 697, 1972. 4. Silber, S. J.: Microsurgical aspects ofvaricocele. Fertil. Steril., 31: 230, 1979. 5. Kaye, K. W.: Modified high varicocelectomy; outpatient microsurgical procedure. Urology, 32: 13, 1988. 6. Beck, E. M., Schlegel, P. N. and Goldstein, M.: Intraoperative varicocele anatomy: a macroscopic and microscopic study. J. Urol., 148: 1190, 1992. 7. Lipshultz, L. I. and Corriere, J. N., Jr.: Progressive testicular atrophy in the varicocele patient. J. Urol., 117: 175, 1977. 8. Nagler, H. M., Li, X.-Z., Lizza, E. F., Deitch, A. and de Vere White, R.: Varicocele: temporal considerations. J. Urol., 134: 411, 1985. 9. Hadziselimovic, F., Herzog, B., Liebundgut, B., Jenny, P. and Buser, M.: Testicular and vascular changes in children and adults with varicocele. J. Urol., part 2, 142: 583, 1989. 10. Kass, E. J., Chandra, R. S. and Belman, A. B.: Testicular histology in the adolescent with a varicocele. Pediatrics, 79: 996, 1987. 11. Gorelick, J. and Goldstein, M.: Loss of fertility in men with varicocele. Fertil. Steril., 59: 613, 1993. 12. Silber, S. J., Ord, T., Balmaceda, J., Patrizio, P. and Asch, R. H.: Congenital absence of the vas deferens. The fertilizing capacity of human epididymal sperm. New Engl. J. Med., 323: 1788, 1990. 13. Jow, W.W., Steckel, J., Schlegel, P. N., Magid, M. S. and Goldstein, M.: Motile sperm in human testis biopsy specimens. J. Androl., in press. 14. Belker, A. M., Thomas, A. J., Jr., Fuchs, E. F., Konnak, J. W. and Sharlip, I. D.: Results of 1,469 microsurgical vasectomy reversals by the vasovasostomy study group. J. Urol., 145: 505, 1991. 15. Wagenknecht, L. V., Klosterhalfen, H. and Schirren, C.: Microsurgery in andrologic urology. I. Refertilization. J. Microsurg., 1: 370, 1980. 16. Fogdestam, I., Fall, M. and Nilsson, S.: Microsurgical epididymo-
1376
GOLDSTEIN
vasostomy in the treatment of occlusive azoospermia. Fertil. Steril., 46: 925, 1986. 17. Thomas, A. J., Jr.: Vasoepididymostomy. Urol. Clin. N. Amer., 14: 527, 1987. 18. Schlegel, P. N. and Goldstein, M.: Microsurgical vasoepididymostomy: refinements and results. J. Urol., submitted for publication. 19. Howards, S. S., Johnson, A. and Jessee, S.: Micropuncture and microanalytic studies of the testis and epididymis. Fertil. Steril., 26: 13, 1975.
20. Schlegel, P. N., Berkeley, A. S., Goldstein, M., Alikani, M., Adler, A., Gilbert, B. R., Cohen, J. and Rosenwaks, Z.: Epididymal micropuncture with IVF for treatment of surgically unreconstructable vasal obstruction. Presented at the annual meeting of the American Fertility Society, New Orleans, abstract S28, November 2-5, 1992. 21. Goldstein, M. and Schlossberg, S.: Men with congenital absence of the vas deferens often have seminal vesicles. J. Urol., 140: 85, 1988.