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The Effect of Vasectomy Upon the Incidence of Epididymitis after Prostatectomy; An Analysisof 810 Operations1
THE JOURNAL OF UROLOGY
Vol. 63, No. 5, May, 1950 Printed in U.S. A.
THE EFFECT OF VASECTOMY UPON THE INCIDENCE OF EPIDIDYMITIS AFTER PROSTATECTOMY; AN ANALYSIS OF 810 OPERATIONS 1 STANWOOD S. SCHMIDT
AND
FRANK HINMAN
From the Department of Surgery-Urology, University of California Medical School, San Francisco, Calif.
After having performed routine vasectomy for many years as part of the preoperative preparation of patients in whom prostatectomy was contemplated, in 1943 we decided to re-evaluate the incidence of epididymitis following the advent of the newer antibiotics. Accordingly, the routine use of vasectomy was abandoned. After 2 years, however, it became obvious that the incidence of postoperative epididymitis had risen significantly, hence, vasectomy was resumed as a routine procedure. This paper is concerned with a statistical analysis of the two groups of patients, those in whom vasectomy was not done and those in whom vasectomy was performed preoperatively. In a consideration of the etiology of epididymitis, three important predisposing factors present themselves: urinary infection (particularly in the presence of residual urine), instrumentation and the condition of the verumontanum. Crabtree and Brodny2 have emphasized the importance of postoperative infection in the prostatic fossa in producing epididymitis. Rathbun 3 considered instrumentation an important predisposing factor. The work of Kreutzmann4 has put both of these concepts upon a firm footing by demonstrating that cultures of the vas are negative except in cases where the urine is infected and by demonstrating that instrumentation doubles the frequency of positive cultures from the vas and hence doubles the possibility of epididymitis. Lommel5 considered that inflammation of the verumontanum was necessary for the entry of bacteria into the ejaculatory ducts. Rolnick 6 supported this view and also considered congestion of the verumontanum as predisposing to the entry of bacteria. Direct trauma to the ejaculatory ducts, as frequently occurs in prostatectomy, may be added to this list. There are three possible routes by which infection may reach the epididymis: it may pass through the lumen of the vas, through the sheath of the vas and by the blood stream. The theory of lymphatic transmission has been discarded by most observers. The classical work of Rolnick 6 • 7 demonstrated that all three of these routes are possible. He considers that infection commonly passes through the lumen of the vas. The work of Richard 8 supports this, as well as the numerous clinical 1 Read at annual meeting. American Urological Association, Los Angeles, Calif. May 19, 1949. 2 Crabtree and Brodny: Tr. Am. A. Genito-Urin. Surgeons, 23: 383, 1930. 3 Rathbun: Cited by Crabtree and Brodny. 4 Kreutzmann: J. Urol., 39: 123, 1938. 5 Lommel: Cited by Rolnick. 6 6 Rolnick: Surg., Gynec. & Obst., 41: 15, 1925. 7 Rolnick: Surg., Gynec. & Obst., 47: 806, 1928. 8 Richard: Deutsche Ztschr. f. Chir., 210: 260, 1928. 872
VASECTOMY AND INCIDENCE OF EPIDIDYMITIS
873
observations that, following vasectomy, infection has passed down the vas to the site of interruption but has not affected the epididymis. The proven value of vasectomy also bears this out and demonstrates that epididymitis due to bloodborne infection is uncommon. Rolnick 6 • 9 • 39 has theorized that in the presence of inflammation or congestion of theverumontanum, bacteria will travel up the ejaculatory ducts to the seminal vesicles. These in turn become infected and force bacteria up the vas to the tail of the epididymis, from whence infection spreads by a peritubular route to the rest of the epididymis. He also contends that infection may travel from the seminal vesicles by means of the sheath of the vas and thus may produce either funiculitis, perivasitis, periorchitis or orchitis. That the seminal vesicles must first become involved in all cases is seriously questioned by the numerous case reports of patients who pass small amounts of urine through the cut end of the vas with each voiding.4 • 10 , 11 • 12 These reports, together with that of O'Conor, 13 conclusively demonstrate that infection can travel through the lumen of an intact vas to the epididymis and serve to explain the clinical observation that a patient who must strain in order to urinate is more likely to force infection into the vas than one who voids freely. In considering the procedure of vasectomy, two factors stand out as important: vasectomy should best be performed before urethral instrumentation is carried out, and it is safer to excise a segment of vas with its sheath. The concept of infection ascending the vas lies behind the rationale of interrupting the vas in order to prevent infection from reaching the epididymis. The cases cited by O'Conor13 in which N eoSilvol passed from the bladder to the tail of the epididymis within 24 hours, together with Kreutzmann's4 work, establish the importance of performing vasectomy before instrumentation of any sort is performed. The work of Rolnick14 on dogs in regard to interruption and regeneration of the vas clearly indicates that the best method of securing permanent division of the vas is to excise a section of the vas together with its sheath. The unsatisfactory clinical experience with the so-called closed method of vasoligation bears this out and thus excision is commonly practiced.15-19 A brief mention of the disadvantages of postoperative epididymitis is in order at this point. Epididymitis is a painful condition, and in the older age group in whom prostatectomy is performed its disadvantages are more marked than in a younger group. Briefly enumerated they are: pain, mental depression and lowered morale, a lowering of the general resistance of the patient, increased susceptibility to other infections, increased danger of thrombophlebitis, atelectasis and Rolnick: J. Urol., 14: 371, 1925. Meade: Brit. J. Urol., 19: 35, 1947. 11 Keyes: Cited by Crabtree and Brodny. 12 Hanley: Brit. J. Urol., 17: 54, 1945. 13 O'Conor: J. Urol., 33: 422, 1935. 14 Rolnick: Arch. Surg., 9: 188, 1924. 16 Colston: J.A.M.A., 90: 526, 1928. 16 Cashman: New York State J. Med., 30: 1364, 1930. 17 McKay: South. M. J., 21: 799, 1928. 18 Pugh: Cited by Abeshouse. 19 Alyea: J. Urol., 19: 65, 1928. 9
10
874
STANWOOD S. SCHMIDT AND FRANK HINMAN
pneumonia (since the patient will resist ambulation more than otherwise), longer incontinence, postponement of instrumentation, subsequent delay in fistula closure, the possibility of abscess formation or orchitis, the possibility of a local or blood-borne spread of the infection, an increased financial drain on the patient and a slower hospital turnover. The disadvantages of vasoligation are limited to the possibility of infection, such as may occur in any operative wound, and of permanent sterility, which in most cases is not significant in this group. The incidence of postoperative epididymitis has been reported from many clinics (table 1).2 • 16 • 19 • 2 0-39 In open prostatectomy it has been reported as varying from 6 per cent to 50 per cent without vasectomy and from O per cent to 4 per cent in series in which vasectomy was done. In transurethral prostatectomy it has been reported as varying from 1 per cent to 8 per cent without vasectomy and 2.66 per cent following vasectomy. With vasoligation, it has been reported as 13.6 per cent following transurethral resection. Preoperative epididymitis has been reported as 7.58 per cent and 11.86 per cent. Complications of vasectomy have been reported as varying from 1 per cent to 3.5 per cent (see table 2). The present study covers operations on the prostate performed at the Franklin Hospital by the senior author and associates over the period of 9 years between 1939 and 1948. Only cases having had orchiectomy are excluded. The series includes 6 types of operations: transurethral, conservative perinea!, radical perinea!, suprapubic, retropubic and perinea! biopsy cases. Both private and clinic patients are included in this series. Follow-ups were secured on most of these patients for a period of 3 months or longer. Vasectomy was performed in most cases either upon entry to the hospital or before cystoscopy was performed. Cases in which vasectomy was performed elsewhere are included. The technique of vasectomy includes a high scrotal incision to expose the vas. A segment of vas 1 cm. or more in length is excised. Strict attention is given to aseptic technique. A total of 810 operations was analysed. The pathologic changes included benign hypertrophy, median bar, carcinoma and 1 case each of granuloma and of coincident carcinoma and sarcoma, both apparently primary (unreported cases of Dr. Clark Johnson). In 5 patients radical perinea! prostatectomy followed initial Randall: J. Urol., 16: 141, 1926. Aschner: J. Urol., 12: 251, 1924. 22 Read and Morgan: Am. J. Surg., 6: 282, 1929. 23 Young: Surg., Gynec. & Obst., 36: 589, 1923. 24 Crockett and Washburn: J. Urol., 26: 643, 1931. 25 Rathbun: Cited by Abeshouse. 26 Burgess: Cited by Abeshouse. 27 White: Cited by Alyea. 28 McDonald: Cited by Goldstein. 29 Engel: Urol. & Cutan. Rev., 36: 180, 1932. 30 Thompson: J. Urol., 40: 121, 1938. 31 Collings: Cited by Abeshouse. 32 Alcock: J. Urol., 28: 545, 1932. 33 Davis: Cited by Abeshouse. 34 Lynn and Nesbit: J. Urol., 59: 72, 1948. 36 O'Neil: Tr. Am. A. Genito-Urin. Surgeons, 22: 267, 1929. 36 Swan: New England J. Med., 205: 1043, 1931. 37 Abeshouse: Am. J. Surg., 32: 8, 1936. 38 Goldstein: J. Urol., 17: 25, 1927. 39 Rolnick: J. Urol., 12: 445, 1924.
20
21
875
VASECTOMY AND INCIDENCE OF EPIDIDYMITIS TABLE AUTHOR
1
TYPE OF OPERATION
CASES
PER CENT EPIDIDYMITIS
No vasectomy-open operation Randall Aschner Read and Morgan Young Crockett and Washburn Crabtree and Brodny Cashman Rathbun Burgess White Alyea McDonald
Perinea! Suprapubic One-stage suprapubic Two-stage suprapubic
34 66
Perineal
11.8 21.2 10.0 15.0 50.0
100
20.0 16.0
1624
21.6
208
50 100 118
25.0 6.0 22.0 33.0 39.0 incl. preop. 26.27 postop. (11.9 preop.)
No vasectomy-TUR Engel Thompson
Collings Alcock Davis Lynn and Nesbit
TUR TUR-1932 TUR-1937 TUR TUR TUR TUR
64 100 (16 vasectomies) 30 93 616 300
6.25 8.00 1.00 6.67 6.45 3.09 4.00
Vasectomy Read and Morgan O'Neil Crabtree and Brodny Swan Cashman Burgess Abeshouse Goldstein Pugh (vasoligation) Nesbit .....
Open Open Open Open Open Open Open Open TUR
TUR
84 consec.
0
84
2.39 2.83 1.5 0 2.83 0
141 514 Three years 106
177 208 25 125 300
0
4.0 13.6 2.66
transurethral resection. Two-stage transurethral resection cases are listed as one operation, while cases in which repeat transurethral resection was necessary after a period of months to years are listed as separate cases. Antibiotics were used
876
STANWOOD S. SCHMIDT AND FRANK HINMAN
only where specific indication existed and not routinely. In tabulating the days of hospitalization, two-stage operations and operative deaths were excluded. With the exception of a two-year period, vasectomy was performed in the majority of patients. Exceptions were made in men of the younger age groups in whom sterilization was not entirely desirable and in patients who objected to the procedure. Epididymitis had been present in 38 cases in the period up to 2 months prior to hospitalization. Eight of these cases had followed prostatic surgery elsewhere. It occurred in 13 cases within 2 months of surgery, of which 5 cases preceded entry, 2 cases were present upon entry and 6 cases developed during preoperative hospitalization. There were no cases of preoperative epididymitis which followed vasectomy. The data on the number of each type of operation and the respective number of vasectomies are presented in table 3, together with the incidence of epididymitis. A total of 320 vasectomies was done preoperatively, of which roughly 10 per cent had been done prior to the hospitalization recorded. A total of 85 patients developed epididymitis postoperatively, of which only 12 cases followed vasoligaTABLE
2.-Complications of vasectomy
Read and Morgan, one orchitis, one abscess .. O'Neil ..................................... . Crabtree and Brodny ....................... . Swan ...................................... . Abeshouse ................................. . Nesbit ..................................... .
2 cases in 84 (2.39%) 2 cases in 84 3.5% in 309 cases 3 scrotal abscesses in 3 years 2.4% abscess in 208 cases (7.21% vasitis) 1% in 300 cases 2 scrotal abscess 1 hematoma
tion. This represented 3.75 per cent of the cases in which vasectomy had been performed. Seventy-three patients, or 15.05 per cent of the group in whom vasectomy was not done, developed epididymitis postoperatively. Inasmuch as there are few figures in the literature giving the incidence of epididymitis following transurethral resection a separate analysis has been made of this operation. 18 • 2 s-34 Out of a total of 508 cases of transurethral resection, 188 had preoperative vasectomy. A total of 34 cases of epididymitis occurred postoperatively. Only 5 of these, or 2.66 per cent of the number in whom vasectomy was done, developed postoperative epididymitis. Twenty-nine patients, or 9.06 per cent of those not having vasectomy, developed it. An analysis of the number of postoperative days in patients who underwent perineal and transurethral prostatectomy shows that the average patient with epididymitis spent from 2 to 6½ days longer in the hospital. This supports the previously made statement that epididymitis prolongs hospitalization. No significant difference was noted in comparing the incidence of epididymitis in the first 5 years with that of the last 4 years. This is of interest in view of the advent of penicillin and the more widespread use of the sulfonamides during the latter period.
877
VASECTOMY AND INCIDENCE OF EPIDIDYMITIS
Nine cases, or 10.6 per cent of the 85 cases with postoperative epididymitis, developed complications. Seven patients developed scrotal abscesses requiring drainage. One patient developed bilateral suppurative orchitis and in 1 case an acute hydrocele was drained. Fourteen patients, or 4.38 per cent of the 320 having had preoperative vasectomy, developed complications of this procedure. Wound infection or disruption occurred in 10, hematoma in 2, inguinal abscess in 1 and a severe dermatitis due to the skin antiseptic in L Drainage was necessary in 2 of the cases of wound infection, 1 hematoma and the inguinal abscess. TABLE TUR
3
P.P,
S-P
RAD P.P.
--- ---
Number of cases ............... 508
217
Vasectomy ..................... 188 103 % Cases having vasectomy ..... 37.0% 47.5% Epididymitis ................... 34 36 % All cases developing epididymitis .................... 6.69% 16.6% Epididymitis after vasectomy .. % Epididymitis after vasectomy
5 2.66%
4 3.88%
Epididymitis-no vasectomy .... 29 32 % Epididymitis-no vasectomy. 9.06% 28.1%
56
17
19
4 23.5%
33.9% 6
10.7% l
7
R-P
P. BIOPSY
3
3
1
1
41.2%
85
12 3.75%
2 5 38.5%
320 39.5%
10.5%
5.26% 5 13.5%
ALL
-- -- --5 7 810
l
1
73 15.05%
Age range per operation ........
19-90
49-88
53-84
53-78
19-90
Age range-vasectomy ..........
37-90
55-85
57-84
61-76
37-90
Average age-vasectomy ........
66.4
67.8
69.4
Average age-Operation ........
61.9
68.4
65.4
64.1
Average age-epididymitis ......
60.4
67.3
65.5
66.0
TUR, transurethral resection; P.P., perinea! prostatectomy; Rad. P.P., radical perineal prostatectomy; S-P, suprapubic prostatectomy; R-P, retropubic prostatectomy; P. Biopsy, perineal biopsy.
Vasitis or funiculitis developed in 15, or 4.68 per cent, of the 320 cases in which vasectomy had been performed. Drainage was necessary in 2 of these. In view of the demonstration that infection descends the lumen or the sheath of the vas to the site of interruption, these cases should be considered separately and not as complications of vasectomy. It is probable that, without previous vasectomy, epididymitis would have developed in these cases. The incidence of epididymitis in this series is in agreement with the reports of Crabtree and Brodny and others who report a significantly lower incidence of epididymitis in open prostatectomy following vasectomy. Lynn and Nesbit report
878
STANWOOD S. SCHMIDT AND FRANK HINMAN
finding no significant difference between two series of 300 cases each of transurethral resection, but have a rather limited number of cases of epididymitis. Nesbit has resumed vasectomy as a part of his preoperative preparation. Statistical analysis has been made of the figures in this series and a "highly significant difference" is reported between the series having had vasectomy and those not, both in regard to the total number of cases in this series (in which X 2 = 24) and in regard to the cases undergoing transurethral resection (in which x 2 = 6.78). A comparison of the incidence of epididymitis between various reports is difficult. There is wide discrepancy between the number of cases reported and in the pre- and postoperative treatment, as well as in the type of surgery and technique. Certain factors which are considered important in affecting the incidence of epididymitis are: the amount and type of instrumentation preceding vasectomy, careful cleansing of the urethra as a preliminary to instrumentation, urinary infection, the presence of residual urine both pre- and postoperatively, aseptic vasectomy and surgical trauma to the verumontanum and to the ejaculatory ducts (which are occasionally cut in transurethral resection). This group does not believe that the routine use of sulfonamides is advisable in an attempt to prevent epididymitis where other indications for their use are lacking, but considers that vasectomy performed before initial instrumentation and adequate drainage of infected urine, both pre- and postoperatively are of greater importance. The complications which develop in a small percentage of patients receiving the sulfonamides have been reported many times and it may be of interest to mention a death from agranulocytosis which occurred on the teaching service at another hospital following the administration of only 0.5 gm. of sulfadiazine daily. We have not considered that either the sulfonamides or penicillin have any great effect upon the course of epididymitis but rely upon elevation, icebags and local block of the spermatic cord. SUMMARY
A total of 810 prostatectomies has been analysed, of which 320 cases had vasectomy preoperatively. Epididymitis occurred postoperatively in 15.05 per cent of the cases in which vasectomy was not done and in 3.75 per cent of the cases having preoperative vasectomy. Epididymitis followed transurethral resection in 9.06 per cent of patients on whom vasectomy was not done and in 2.66 per cent of patients who had preoperative vasectomy. It is concluded from this series that preoperative vasectomy is of significant value in preventing epididymitis following both open prostatectomy and transurethral resection. Vasectomy should be a part of the preoperative preparation of patients in whom prostatic surgery is contemplated. An exception may be made in the younger age group or in patients objecting to the procedure, but the increased risk of epididymitis must be acknowledged.
Vol. 63, No. 5, May, 1950 Printed in U.S. A.
THE EFFECT OF VASECTOMY UPON THE INCIDENCE OF EPIDIDYMITIS AFTER PROSTATECTOMY; AN ANALYSIS OF 810 OPERATIONS 1 STANWOOD S. SCHMIDT
AND
FRANK HINMAN
From the Department of Surgery-Urology, University of California Medical School, San Francisco, Calif.
After having performed routine vasectomy for many years as part of the preoperative preparation of patients in whom prostatectomy was contemplated, in 1943 we decided to re-evaluate the incidence of epididymitis following the advent of the newer antibiotics. Accordingly, the routine use of vasectomy was abandoned. After 2 years, however, it became obvious that the incidence of postoperative epididymitis had risen significantly, hence, vasectomy was resumed as a routine procedure. This paper is concerned with a statistical analysis of the two groups of patients, those in whom vasectomy was not done and those in whom vasectomy was performed preoperatively. In a consideration of the etiology of epididymitis, three important predisposing factors present themselves: urinary infection (particularly in the presence of residual urine), instrumentation and the condition of the verumontanum. Crabtree and Brodny2 have emphasized the importance of postoperative infection in the prostatic fossa in producing epididymitis. Rathbun 3 considered instrumentation an important predisposing factor. The work of Kreutzmann4 has put both of these concepts upon a firm footing by demonstrating that cultures of the vas are negative except in cases where the urine is infected and by demonstrating that instrumentation doubles the frequency of positive cultures from the vas and hence doubles the possibility of epididymitis. Lommel5 considered that inflammation of the verumontanum was necessary for the entry of bacteria into the ejaculatory ducts. Rolnick 6 supported this view and also considered congestion of the verumontanum as predisposing to the entry of bacteria. Direct trauma to the ejaculatory ducts, as frequently occurs in prostatectomy, may be added to this list. There are three possible routes by which infection may reach the epididymis: it may pass through the lumen of the vas, through the sheath of the vas and by the blood stream. The theory of lymphatic transmission has been discarded by most observers. The classical work of Rolnick 6 • 7 demonstrated that all three of these routes are possible. He considers that infection commonly passes through the lumen of the vas. The work of Richard 8 supports this, as well as the numerous clinical 1 Read at annual meeting. American Urological Association, Los Angeles, Calif. May 19, 1949. 2 Crabtree and Brodny: Tr. Am. A. Genito-Urin. Surgeons, 23: 383, 1930. 3 Rathbun: Cited by Crabtree and Brodny. 4 Kreutzmann: J. Urol., 39: 123, 1938. 5 Lommel: Cited by Rolnick. 6 6 Rolnick: Surg., Gynec. & Obst., 41: 15, 1925. 7 Rolnick: Surg., Gynec. & Obst., 47: 806, 1928. 8 Richard: Deutsche Ztschr. f. Chir., 210: 260, 1928. 872
VASECTOMY AND INCIDENCE OF EPIDIDYMITIS
873
observations that, following vasectomy, infection has passed down the vas to the site of interruption but has not affected the epididymis. The proven value of vasectomy also bears this out and demonstrates that epididymitis due to bloodborne infection is uncommon. Rolnick 6 • 9 • 39 has theorized that in the presence of inflammation or congestion of theverumontanum, bacteria will travel up the ejaculatory ducts to the seminal vesicles. These in turn become infected and force bacteria up the vas to the tail of the epididymis, from whence infection spreads by a peritubular route to the rest of the epididymis. He also contends that infection may travel from the seminal vesicles by means of the sheath of the vas and thus may produce either funiculitis, perivasitis, periorchitis or orchitis. That the seminal vesicles must first become involved in all cases is seriously questioned by the numerous case reports of patients who pass small amounts of urine through the cut end of the vas with each voiding.4 • 10 , 11 • 12 These reports, together with that of O'Conor, 13 conclusively demonstrate that infection can travel through the lumen of an intact vas to the epididymis and serve to explain the clinical observation that a patient who must strain in order to urinate is more likely to force infection into the vas than one who voids freely. In considering the procedure of vasectomy, two factors stand out as important: vasectomy should best be performed before urethral instrumentation is carried out, and it is safer to excise a segment of vas with its sheath. The concept of infection ascending the vas lies behind the rationale of interrupting the vas in order to prevent infection from reaching the epididymis. The cases cited by O'Conor13 in which N eoSilvol passed from the bladder to the tail of the epididymis within 24 hours, together with Kreutzmann's4 work, establish the importance of performing vasectomy before instrumentation of any sort is performed. The work of Rolnick14 on dogs in regard to interruption and regeneration of the vas clearly indicates that the best method of securing permanent division of the vas is to excise a section of the vas together with its sheath. The unsatisfactory clinical experience with the so-called closed method of vasoligation bears this out and thus excision is commonly practiced.15-19 A brief mention of the disadvantages of postoperative epididymitis is in order at this point. Epididymitis is a painful condition, and in the older age group in whom prostatectomy is performed its disadvantages are more marked than in a younger group. Briefly enumerated they are: pain, mental depression and lowered morale, a lowering of the general resistance of the patient, increased susceptibility to other infections, increased danger of thrombophlebitis, atelectasis and Rolnick: J. Urol., 14: 371, 1925. Meade: Brit. J. Urol., 19: 35, 1947. 11 Keyes: Cited by Crabtree and Brodny. 12 Hanley: Brit. J. Urol., 17: 54, 1945. 13 O'Conor: J. Urol., 33: 422, 1935. 14 Rolnick: Arch. Surg., 9: 188, 1924. 16 Colston: J.A.M.A., 90: 526, 1928. 16 Cashman: New York State J. Med., 30: 1364, 1930. 17 McKay: South. M. J., 21: 799, 1928. 18 Pugh: Cited by Abeshouse. 19 Alyea: J. Urol., 19: 65, 1928. 9
10
874
STANWOOD S. SCHMIDT AND FRANK HINMAN
pneumonia (since the patient will resist ambulation more than otherwise), longer incontinence, postponement of instrumentation, subsequent delay in fistula closure, the possibility of abscess formation or orchitis, the possibility of a local or blood-borne spread of the infection, an increased financial drain on the patient and a slower hospital turnover. The disadvantages of vasoligation are limited to the possibility of infection, such as may occur in any operative wound, and of permanent sterility, which in most cases is not significant in this group. The incidence of postoperative epididymitis has been reported from many clinics (table 1).2 • 16 • 19 • 2 0-39 In open prostatectomy it has been reported as varying from 6 per cent to 50 per cent without vasectomy and from O per cent to 4 per cent in series in which vasectomy was done. In transurethral prostatectomy it has been reported as varying from 1 per cent to 8 per cent without vasectomy and 2.66 per cent following vasectomy. With vasoligation, it has been reported as 13.6 per cent following transurethral resection. Preoperative epididymitis has been reported as 7.58 per cent and 11.86 per cent. Complications of vasectomy have been reported as varying from 1 per cent to 3.5 per cent (see table 2). The present study covers operations on the prostate performed at the Franklin Hospital by the senior author and associates over the period of 9 years between 1939 and 1948. Only cases having had orchiectomy are excluded. The series includes 6 types of operations: transurethral, conservative perinea!, radical perinea!, suprapubic, retropubic and perinea! biopsy cases. Both private and clinic patients are included in this series. Follow-ups were secured on most of these patients for a period of 3 months or longer. Vasectomy was performed in most cases either upon entry to the hospital or before cystoscopy was performed. Cases in which vasectomy was performed elsewhere are included. The technique of vasectomy includes a high scrotal incision to expose the vas. A segment of vas 1 cm. or more in length is excised. Strict attention is given to aseptic technique. A total of 810 operations was analysed. The pathologic changes included benign hypertrophy, median bar, carcinoma and 1 case each of granuloma and of coincident carcinoma and sarcoma, both apparently primary (unreported cases of Dr. Clark Johnson). In 5 patients radical perinea! prostatectomy followed initial Randall: J. Urol., 16: 141, 1926. Aschner: J. Urol., 12: 251, 1924. 22 Read and Morgan: Am. J. Surg., 6: 282, 1929. 23 Young: Surg., Gynec. & Obst., 36: 589, 1923. 24 Crockett and Washburn: J. Urol., 26: 643, 1931. 25 Rathbun: Cited by Abeshouse. 26 Burgess: Cited by Abeshouse. 27 White: Cited by Alyea. 28 McDonald: Cited by Goldstein. 29 Engel: Urol. & Cutan. Rev., 36: 180, 1932. 30 Thompson: J. Urol., 40: 121, 1938. 31 Collings: Cited by Abeshouse. 32 Alcock: J. Urol., 28: 545, 1932. 33 Davis: Cited by Abeshouse. 34 Lynn and Nesbit: J. Urol., 59: 72, 1948. 36 O'Neil: Tr. Am. A. Genito-Urin. Surgeons, 22: 267, 1929. 36 Swan: New England J. Med., 205: 1043, 1931. 37 Abeshouse: Am. J. Surg., 32: 8, 1936. 38 Goldstein: J. Urol., 17: 25, 1927. 39 Rolnick: J. Urol., 12: 445, 1924.
20
21
875
VASECTOMY AND INCIDENCE OF EPIDIDYMITIS TABLE AUTHOR
1
TYPE OF OPERATION
CASES
PER CENT EPIDIDYMITIS
No vasectomy-open operation Randall Aschner Read and Morgan Young Crockett and Washburn Crabtree and Brodny Cashman Rathbun Burgess White Alyea McDonald
Perinea! Suprapubic One-stage suprapubic Two-stage suprapubic
34 66
Perineal
11.8 21.2 10.0 15.0 50.0
100
20.0 16.0
1624
21.6
208
50 100 118
25.0 6.0 22.0 33.0 39.0 incl. preop. 26.27 postop. (11.9 preop.)
No vasectomy-TUR Engel Thompson
Collings Alcock Davis Lynn and Nesbit
TUR TUR-1932 TUR-1937 TUR TUR TUR TUR
64 100 (16 vasectomies) 30 93 616 300
6.25 8.00 1.00 6.67 6.45 3.09 4.00
Vasectomy Read and Morgan O'Neil Crabtree and Brodny Swan Cashman Burgess Abeshouse Goldstein Pugh (vasoligation) Nesbit .....
Open Open Open Open Open Open Open Open TUR
TUR
84 consec.
0
84
2.39 2.83 1.5 0 2.83 0
141 514 Three years 106
177 208 25 125 300
0
4.0 13.6 2.66
transurethral resection. Two-stage transurethral resection cases are listed as one operation, while cases in which repeat transurethral resection was necessary after a period of months to years are listed as separate cases. Antibiotics were used
876
STANWOOD S. SCHMIDT AND FRANK HINMAN
only where specific indication existed and not routinely. In tabulating the days of hospitalization, two-stage operations and operative deaths were excluded. With the exception of a two-year period, vasectomy was performed in the majority of patients. Exceptions were made in men of the younger age groups in whom sterilization was not entirely desirable and in patients who objected to the procedure. Epididymitis had been present in 38 cases in the period up to 2 months prior to hospitalization. Eight of these cases had followed prostatic surgery elsewhere. It occurred in 13 cases within 2 months of surgery, of which 5 cases preceded entry, 2 cases were present upon entry and 6 cases developed during preoperative hospitalization. There were no cases of preoperative epididymitis which followed vasectomy. The data on the number of each type of operation and the respective number of vasectomies are presented in table 3, together with the incidence of epididymitis. A total of 320 vasectomies was done preoperatively, of which roughly 10 per cent had been done prior to the hospitalization recorded. A total of 85 patients developed epididymitis postoperatively, of which only 12 cases followed vasoligaTABLE
2.-Complications of vasectomy
Read and Morgan, one orchitis, one abscess .. O'Neil ..................................... . Crabtree and Brodny ....................... . Swan ...................................... . Abeshouse ................................. . Nesbit ..................................... .
2 cases in 84 (2.39%) 2 cases in 84 3.5% in 309 cases 3 scrotal abscesses in 3 years 2.4% abscess in 208 cases (7.21% vasitis) 1% in 300 cases 2 scrotal abscess 1 hematoma
tion. This represented 3.75 per cent of the cases in which vasectomy had been performed. Seventy-three patients, or 15.05 per cent of the group in whom vasectomy was not done, developed epididymitis postoperatively. Inasmuch as there are few figures in the literature giving the incidence of epididymitis following transurethral resection a separate analysis has been made of this operation. 18 • 2 s-34 Out of a total of 508 cases of transurethral resection, 188 had preoperative vasectomy. A total of 34 cases of epididymitis occurred postoperatively. Only 5 of these, or 2.66 per cent of the number in whom vasectomy was done, developed postoperative epididymitis. Twenty-nine patients, or 9.06 per cent of those not having vasectomy, developed it. An analysis of the number of postoperative days in patients who underwent perineal and transurethral prostatectomy shows that the average patient with epididymitis spent from 2 to 6½ days longer in the hospital. This supports the previously made statement that epididymitis prolongs hospitalization. No significant difference was noted in comparing the incidence of epididymitis in the first 5 years with that of the last 4 years. This is of interest in view of the advent of penicillin and the more widespread use of the sulfonamides during the latter period.
877
VASECTOMY AND INCIDENCE OF EPIDIDYMITIS
Nine cases, or 10.6 per cent of the 85 cases with postoperative epididymitis, developed complications. Seven patients developed scrotal abscesses requiring drainage. One patient developed bilateral suppurative orchitis and in 1 case an acute hydrocele was drained. Fourteen patients, or 4.38 per cent of the 320 having had preoperative vasectomy, developed complications of this procedure. Wound infection or disruption occurred in 10, hematoma in 2, inguinal abscess in 1 and a severe dermatitis due to the skin antiseptic in L Drainage was necessary in 2 of the cases of wound infection, 1 hematoma and the inguinal abscess. TABLE TUR
3
P.P,
S-P
RAD P.P.
--- ---
Number of cases ............... 508
217
Vasectomy ..................... 188 103 % Cases having vasectomy ..... 37.0% 47.5% Epididymitis ................... 34 36 % All cases developing epididymitis .................... 6.69% 16.6% Epididymitis after vasectomy .. % Epididymitis after vasectomy
5 2.66%
4 3.88%
Epididymitis-no vasectomy .... 29 32 % Epididymitis-no vasectomy. 9.06% 28.1%
56
17
19
4 23.5%
33.9% 6
10.7% l
7
R-P
P. BIOPSY
3
3
1
1
41.2%
85
12 3.75%
2 5 38.5%
320 39.5%
10.5%
5.26% 5 13.5%
ALL
-- -- --5 7 810
l
1
73 15.05%
Age range per operation ........
19-90
49-88
53-84
53-78
19-90
Age range-vasectomy ..........
37-90
55-85
57-84
61-76
37-90
Average age-vasectomy ........
66.4
67.8
69.4
Average age-Operation ........
61.9
68.4
65.4
64.1
Average age-epididymitis ......
60.4
67.3
65.5
66.0
TUR, transurethral resection; P.P., perinea! prostatectomy; Rad. P.P., radical perineal prostatectomy; S-P, suprapubic prostatectomy; R-P, retropubic prostatectomy; P. Biopsy, perineal biopsy.
Vasitis or funiculitis developed in 15, or 4.68 per cent, of the 320 cases in which vasectomy had been performed. Drainage was necessary in 2 of these. In view of the demonstration that infection descends the lumen or the sheath of the vas to the site of interruption, these cases should be considered separately and not as complications of vasectomy. It is probable that, without previous vasectomy, epididymitis would have developed in these cases. The incidence of epididymitis in this series is in agreement with the reports of Crabtree and Brodny and others who report a significantly lower incidence of epididymitis in open prostatectomy following vasectomy. Lynn and Nesbit report
878
STANWOOD S. SCHMIDT AND FRANK HINMAN
finding no significant difference between two series of 300 cases each of transurethral resection, but have a rather limited number of cases of epididymitis. Nesbit has resumed vasectomy as a part of his preoperative preparation. Statistical analysis has been made of the figures in this series and a "highly significant difference" is reported between the series having had vasectomy and those not, both in regard to the total number of cases in this series (in which X 2 = 24) and in regard to the cases undergoing transurethral resection (in which x 2 = 6.78). A comparison of the incidence of epididymitis between various reports is difficult. There is wide discrepancy between the number of cases reported and in the pre- and postoperative treatment, as well as in the type of surgery and technique. Certain factors which are considered important in affecting the incidence of epididymitis are: the amount and type of instrumentation preceding vasectomy, careful cleansing of the urethra as a preliminary to instrumentation, urinary infection, the presence of residual urine both pre- and postoperatively, aseptic vasectomy and surgical trauma to the verumontanum and to the ejaculatory ducts (which are occasionally cut in transurethral resection). This group does not believe that the routine use of sulfonamides is advisable in an attempt to prevent epididymitis where other indications for their use are lacking, but considers that vasectomy performed before initial instrumentation and adequate drainage of infected urine, both pre- and postoperatively are of greater importance. The complications which develop in a small percentage of patients receiving the sulfonamides have been reported many times and it may be of interest to mention a death from agranulocytosis which occurred on the teaching service at another hospital following the administration of only 0.5 gm. of sulfadiazine daily. We have not considered that either the sulfonamides or penicillin have any great effect upon the course of epididymitis but rely upon elevation, icebags and local block of the spermatic cord. SUMMARY
A total of 810 prostatectomies has been analysed, of which 320 cases had vasectomy preoperatively. Epididymitis occurred postoperatively in 15.05 per cent of the cases in which vasectomy was not done and in 3.75 per cent of the cases having preoperative vasectomy. Epididymitis followed transurethral resection in 9.06 per cent of patients on whom vasectomy was not done and in 2.66 per cent of patients who had preoperative vasectomy. It is concluded from this series that preoperative vasectomy is of significant value in preventing epididymitis following both open prostatectomy and transurethral resection. Vasectomy should be a part of the preoperative preparation of patients in whom prostatic surgery is contemplated. An exception may be made in the younger age group or in patients objecting to the procedure, but the increased risk of epididymitis must be acknowledged.