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Vasectomy with transurethral resection of prostate
VASECTOMY WITH TRANSURETHRAL RESECTION
OF PROSTATE*
NORRIS W. WHITLOCK, JACK W. McANINCH, RAY E. STUTZMAN,
M.D.
M.D. M.D.
From the Urology Service, Department of Surgery, Letterman Army Medical Center, Presidio of San Francisco, California
ABSTRACT - A retrospective study was made of 200 patients undergoing transurethral prostatectomy. Half of these patients received bilateral vasectomies. The vasectomixed patients had a S-per cent incidence of epididymitis as compared with a e-per cent incidence in the nonvasectomized patients. Vasectomy failed to provide adequate protection against postoperative epididymitis and cannot be recommended as a routine procedure with a transurethral prostatectomy.
Bilateral vasectomy in conjunction with prostatectomy has long been a controversial issue in the urologic literature. The concept of this procedure as prophylaxis against postprostatectomy epididymitis is attributed to Proust in 1904 and Albarran in 1909, and is advocated in many of the standard texts and journals.‘-’ In recent years improved equipment and optics have led to more precise prostatic resections, and perhaps prophylactic vasectomy is no longer necessary to prevent epididymitis. The purpose of this report is to determine whether or not prophylactic vasectomy with transurethral prostatectomy is still a valid procedure. Material and Methods A retrospective secutive patients resections of the Medical Center. second and third staff supervision.
study was made of 200 conwho underwent transurethral prostate at Letterman Army All resections were done by year urology residents with
Presented at the Western Section of the American Urological Association, San Francisco, California, March 13, 1977. *The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
UROLOGY
/ FEBRUARY 1979
/
VOLUME XIII.
NUMBER 2
The patients were placed into two equal groups. Group I consisted of 100 patients who underwent bilateral vasectomies immediately before transurethral resection. All vasectomies were done through scrotal incisions with a segment of vas deferens removed for pathologic confirmation; the cut ends were tied with chromic catgut. Group II consisted of 100 patients who did not undergo vasectomy and who had no prior history of vasectomy or epididymitis. Hospital and outpatient charts were reviewed for information concerning the two groups. Information included the occurrence of epididymitis, use of pre- and postoperative antibiotics, history of prior urinary tract infections, history of prior catheterization, postoperative catheter time, grams of tissue resected, pre- and postoperative urine culture results, hospital days, and the patient’s age. The follow-up was from three months to six years. Epididymitis was defined as tenderness, swelling, and/or induration of the epididymis accompanied with or without fever. Results The results are summarized in Table I. There was a significant difference in the occurrence of epididymitis between the two groups, with the
135
TABLE I.
Patients in whom epididymitis developed
Preoperative Case No.
Time of Urine Onset Culture
Infection Catheterization
Group I (100 vasectomized patients) Neg. 1 2 wk Neg. 2 3 4 5
6 mo. 2 da. 2 mo. 2 yr.
Neg.
Neg.
pas.*
Pos.
Pos.
Neg. Neg.
Neg. Neg.
Neg. Neg.
Group II (100 nonvasectomized patients) 2 yr. Neg. Pos. 1 2
9 mo.
Neg. Neg.
Pos. t
Neg.
Pos. Neg.
*Less than 100,000 Escherichia coli. f Greater than 100,000 beta streptococci.
vasectomized patients having a 5-per cent incidence as compared with a e-per cent incidence in the nonvasectomized patients. In 2 of the 5 vasectomized patients (Cases 1 and 3) epididymitis developed as an acute postoperative complication. In 2 nonvasectomized patients epididymitis developed at two years and at nine months, respectively. All cases were unilateral. Only 1 of the vasectomized patients (Case 3) had a positive history of preoperative catheterization and of a positive preoperative urine culture. In the 2 nonvasectomized patients, one (Case 1) had a positive history for catheterization, and the other (Case 2) had a positive preoperative urine culture. Table II shows a comparison of the two groups. There was a 23-per cent incidence of preoperative catheterization in group I as compared with a 15-per cent incidence in group II. The reason for this is unclear. Group I patients were routinely placed on a regimen of antibiotics, usually nitrofurantoins, in the immediate postoperative period. In group II, however, antibiotics were not used routinely but were given to those patients with positive urine cultures or clinical urinary tract infections. Lower incidence of positive postoperative cultures in group I may reflect the use of prophylactic postoperative antibiotics. The indications for the use of preoperative antibiotics were identical between group I and group II. A major difference between the two groups was the length of hospital stay, with an average of sixteen days for group I and thirteen and one-fourth days for group II. Prolonged hospital stay has been shown to increase the risk of iatrogenic wound infections;* whether or not this is a factor in postprostatectomy epididymitis cannot be stated.
136
Comment Numerous articles have been published in the urologic literature reviewing the occurrence of epididymitis with and without vasectomy (Table III). Schmidt and Hinmang in a review of 810 cases showed an epididymitis rate of 15.05 per cent without vasectomy and 3.75 per cent with vasectomy. Sixty-two per cent of these cases were transurethral resections. In this group, the epididymitis rate was 9.06 per cent without ligation and 2.66 per cent with ligation. Similar studies10-12 have reported the occurrence of epididymitis ranging from 4.08 per cent to 16 per cent with vasectomy, ligation, or vas crush, and 20 to 25 per cent without such procedures. The latter figure is believed to be statistically unreliable because of the relatively small number of patients who received no vasectomy with their resections. Another approach was taken by Graham and Grayhack13 who performed unilateral vasectomies, allowing the contralateral side to act as a control. In this study of 194 patients, 81 per cent had transurethral resections. Epididymitis developed on the nonvasectomized side 6.2 per cent of the time with bilateral epididymitis developing in 1.5 per cent of the patients. In none of the patients in their series did epididymitis develop on the ligated side only. Other studies14 have confirmed their results. Lynn and Nesbit, l5 however, found the occurrence of epididymitis to be only 4 per cent without ligation and 2.7 per cent with ligation. All were transurethral resections. These authors believe that vas section at the time of transurethral prostatectomy did not significantly rethe of postoperative duce incidence epididymitis. TABLE II.
Comparison of the two groups
Patient Data Epididymitis Preoperative antibiotics Postoperative antibiotics Prior urinary tract infection Prior catheterization Grams of tissue resected Postoperative catheter time Positive preoperative culture and sensitivity - urine Positive postoperative culture and sensitivity - urine Length of hospital stay Age of patient
Group I
Group II
5% 25% 100% 18% 23%
2% 33% 55% 14%
14.5 Gm. 3.7 da. 11%
15% 15.9 Gm. 3.6 da. 13%
5.4%
10.75%
16 da. 67.2 yr.
13.25 da. 66.5 yr.
UROLOGY / FEBRUARY1979 / VOLUMEXIII, NUMBER2
TABLE
III. Comparison of studies which reviewed occurrence
of
epididymitis with and without vasectomy Transurethral Resection of Prostate Total No. No. of of Cases Cases
Reference Schmidt and Hinmaus Melchoir et al. lo
810 2122
Warres”
234
Casteel, Thompson, and Wepfler’s
319
508 Vasectomy (188) No vasectomy (320) 2122 Bilateral vasectomy (2082) Unilateral vasectomy (28) No vasectomy (12) 234 Vasectomy (108) Vas crush (104) No vasectomy (22) 238 Ligation (105) Vas crush (128) No vasectomy (5)
The most plausible theory explaining the mechanism of epididymitis is that of reflux of infected urine into the vas deferens.16 This has served as the rationale for performing vasectomies to prevent epididymitis. Apfelbach” reported 2 cases of spontaneous vas deferens reflux demonstrated radiographically after prostatectomy. Studies18-20 which attempted to demonstrate the reflux of bacteria into the vas defe-
TABLE
IV.
Orandi et al. Is
/ FEBRUARY1979
2.66 9.06 2.60 2.60 25.00 0.92 16.34 25.09 1.96 7.00 20.00
rens showed that with sterile preoperative urine and no catheterization, only 4.8 to 9.5 per cent of the vas deferens cultured were positive (Table IV). With sterile urine and a preoperative catheter, 0 to 10.6 per cent of the vas deferens cultured were positive, and those with infected urine but no catheterization had a 15-per cent positive culture rate. When patients had both infected urine and were catheterized, the rate of
No. of
Group and No. of Cases
100
Sterile urine, no catheter (21) Sterile urine, catheter (47) Infected urine, catheter (32) Sterile urine (74) Infected urine (67) Sterile urine, no catheter (21) Sterile urine, catheter (4) Infected urine, no catheter (54) Suprapubic catheter(4) Infected urine, catheter (52)
Cases
Beck and Taylor18
UROLOGY
Patients with Epididymitis (%)
Comparison of studies which attempted to demonstrate re$ux of bacteria into vas deferens
Reference
KendaIl*O
Procedure and No. of Cases
141 135
/ VOLUMEXIII. NUMBER2
Positive Vas Deferens Culture % No. 2
9.5
5
10.6
12
37.5
0
0 47.0 4.8
32 1 0
0
8
15.0
1
25.0
19
36.0
137
positive vas cultures increased 36 to 47 per cent. Certain questions have been raised regarding the evidence of reflux of bacteria into the vas lumen. How effective will a vasectomy be if at the time of vasectomy the vas and the epididymis have already been seeded with bacteria? Several authorszOlzl have suggested that a vasectomy will be effective only in those patients who have uninfected urine and who have never undergone instrumentation. Our study indicates that there may be several factors leading to our decreased incidence of postprostatectomy epididymitis. First, with improvements in equipment and optics, resections can be performed more accurately, thereby avoiding injury to the verumontanum. Second, symptoms of prostatism are being recognized sooner by both patient and referring physician, and prostatectomy is being performed before the patient has urinary retention. Third, the patients are spending less time in the hospital, thereby decreasing their chances of contact with hospital pathogens. Finally, the use of prophylactic antibiotics in all of the patients in the vasectomized group failed to prevent epididymitis, a result which is consistent with the literature. Our data support the fact that vasectomy, a procedure which itself has a substantial rate of complications including epididymitis,22 does not reduce the incidence of postprostatectomy epididymitis. It should be noted that all statistics in this article deal only with transurethral resections and one cannot extrapolate these conclusions to other forms of prostatectomy. Technical Publications Editor Letterman Army Medical Center Presidio of San Francisco California 94129
138
References 1. Barnes RW: Endoscopic Prostatic Surgery, St. Louis, C. V. Mosby Co., 1943, p. 79. 2. Weyrauch AM: Surgery of the Prostate, Philadelphia, W. B. Saunders Co., 1959, p. 133. 3. Karafin L, and Kendall AR: Urology, Hagerstown, Harper & Row, 1975, p. 21. 4. Valk WL, Mehust WK, Melchoir J, and Foret JD: The present status of resection of the prostate for benign prostatic hypertrophy, Urol. Clin. North Am. 2: 85 (1975). 5. Campbell MF, and Harrison JH: Urology, Philadelphia, W. B. Saunders Co., 1970, p. 2489. 6. Creevy CD: Transurethral prostatic resection. Prevention and treatment of complications, Med. Clin. North Am. 43: 1749 (1959). 7. Burgess AH: Murphy, and some principles of urinary surgery, Surg. Gvnecol. Obstet. 54: 257 (1932). 8: Meares- EM: Factors that influence surgical wound infections, Urology 6: 535 (1975). 9. Schmidt SS, and Hinman F: The effect of vasectomy upon the incidence of epididymitis after prostatectomy; an analysis of 810 operations, J. Ural. 63: 872 (1950). 10. Melchoir J, Valk WL, Foret JW, and Winston RM: Transurethral prostatectomy and epididymitis, ibid. 112: 647 (1974). 11. Warres HL: Postprostatectomy epididymitis, Am. Surg. 29: 126 (1963). 12. Casteel CK, Thompson IM, and Wipfler EJ: Vas crush for prevention of postprostatectomy epididymitis: an experimental and clinical study, J. Ural. 93: 476 (1965). 13. Graham JB, and Grayhack JT: Epididymitis following unilateral vasectomy and prostatic surgery, ibid. 87: 582 (1962). 14. Rinker JR, Hancock CV, and Henderson WD: A statistical study of unilateral prophylactic vasectomy in the prevention of epididymitis: 1029 cases, ibid. 104: 303 (1970). _ 15. iynn JM, and Nesbit RM: The in&ten&s of vasectomy upon the incidence of epididymitis following transurethral prostatectomy, ibid. 59: 72 (1948). 16. Rolnick HC: The mechanism of epididymitis, Surg. Gynecol. Obstet. 41: 15 (1925). 17. Apfelhach CL: Vas deferens reflux following prostatic surgery, J. Urol. 94: 164 (1965). 18. Beck AD, and Taylor DE: Postprostatectomy epididymitis: a bacteriological and clinical survev. ibid. 104: 143 (1970). 19. O&h A, Hilf MM, Femkdes M, and Draper’JW: Vas culture, epididymitis and postprostatectomy fever, ibid. 96: 367 (lQt% 20. Kendall AR: Rationale of prophylactic vasectomy, ibid. 89: 712 (1963). 21. Reeves JF, Scott R, and Scott FB: Prevention of epididymitis after prostatectomy by prophylactic antibiotics and partial vasectomy, ibid. 92: 528 (1964). 22. Leader AJ, Axelrad SD, Frankowski R, and Mumford SD: Complications of 2711 vasectomies, ibid. 111: 365 (1974).
UROLOGY
/
FEBRUARY
1979
/
VOLUME
XIII.
NUMBER
2
OF PROSTATE*
NORRIS W. WHITLOCK, JACK W. McANINCH, RAY E. STUTZMAN,
M.D.
M.D. M.D.
From the Urology Service, Department of Surgery, Letterman Army Medical Center, Presidio of San Francisco, California
ABSTRACT - A retrospective study was made of 200 patients undergoing transurethral prostatectomy. Half of these patients received bilateral vasectomies. The vasectomixed patients had a S-per cent incidence of epididymitis as compared with a e-per cent incidence in the nonvasectomized patients. Vasectomy failed to provide adequate protection against postoperative epididymitis and cannot be recommended as a routine procedure with a transurethral prostatectomy.
Bilateral vasectomy in conjunction with prostatectomy has long been a controversial issue in the urologic literature. The concept of this procedure as prophylaxis against postprostatectomy epididymitis is attributed to Proust in 1904 and Albarran in 1909, and is advocated in many of the standard texts and journals.‘-’ In recent years improved equipment and optics have led to more precise prostatic resections, and perhaps prophylactic vasectomy is no longer necessary to prevent epididymitis. The purpose of this report is to determine whether or not prophylactic vasectomy with transurethral prostatectomy is still a valid procedure. Material and Methods A retrospective secutive patients resections of the Medical Center. second and third staff supervision.
study was made of 200 conwho underwent transurethral prostate at Letterman Army All resections were done by year urology residents with
Presented at the Western Section of the American Urological Association, San Francisco, California, March 13, 1977. *The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
UROLOGY
/ FEBRUARY 1979
/
VOLUME XIII.
NUMBER 2
The patients were placed into two equal groups. Group I consisted of 100 patients who underwent bilateral vasectomies immediately before transurethral resection. All vasectomies were done through scrotal incisions with a segment of vas deferens removed for pathologic confirmation; the cut ends were tied with chromic catgut. Group II consisted of 100 patients who did not undergo vasectomy and who had no prior history of vasectomy or epididymitis. Hospital and outpatient charts were reviewed for information concerning the two groups. Information included the occurrence of epididymitis, use of pre- and postoperative antibiotics, history of prior urinary tract infections, history of prior catheterization, postoperative catheter time, grams of tissue resected, pre- and postoperative urine culture results, hospital days, and the patient’s age. The follow-up was from three months to six years. Epididymitis was defined as tenderness, swelling, and/or induration of the epididymis accompanied with or without fever. Results The results are summarized in Table I. There was a significant difference in the occurrence of epididymitis between the two groups, with the
135
TABLE I.
Patients in whom epididymitis developed
Preoperative Case No.
Time of Urine Onset Culture
Infection Catheterization
Group I (100 vasectomized patients) Neg. 1 2 wk Neg. 2 3 4 5
6 mo. 2 da. 2 mo. 2 yr.
Neg.
Neg.
pas.*
Pos.
Pos.
Neg. Neg.
Neg. Neg.
Neg. Neg.
Group II (100 nonvasectomized patients) 2 yr. Neg. Pos. 1 2
9 mo.
Neg. Neg.
Pos. t
Neg.
Pos. Neg.
*Less than 100,000 Escherichia coli. f Greater than 100,000 beta streptococci.
vasectomized patients having a 5-per cent incidence as compared with a e-per cent incidence in the nonvasectomized patients. In 2 of the 5 vasectomized patients (Cases 1 and 3) epididymitis developed as an acute postoperative complication. In 2 nonvasectomized patients epididymitis developed at two years and at nine months, respectively. All cases were unilateral. Only 1 of the vasectomized patients (Case 3) had a positive history of preoperative catheterization and of a positive preoperative urine culture. In the 2 nonvasectomized patients, one (Case 1) had a positive history for catheterization, and the other (Case 2) had a positive preoperative urine culture. Table II shows a comparison of the two groups. There was a 23-per cent incidence of preoperative catheterization in group I as compared with a 15-per cent incidence in group II. The reason for this is unclear. Group I patients were routinely placed on a regimen of antibiotics, usually nitrofurantoins, in the immediate postoperative period. In group II, however, antibiotics were not used routinely but were given to those patients with positive urine cultures or clinical urinary tract infections. Lower incidence of positive postoperative cultures in group I may reflect the use of prophylactic postoperative antibiotics. The indications for the use of preoperative antibiotics were identical between group I and group II. A major difference between the two groups was the length of hospital stay, with an average of sixteen days for group I and thirteen and one-fourth days for group II. Prolonged hospital stay has been shown to increase the risk of iatrogenic wound infections;* whether or not this is a factor in postprostatectomy epididymitis cannot be stated.
136
Comment Numerous articles have been published in the urologic literature reviewing the occurrence of epididymitis with and without vasectomy (Table III). Schmidt and Hinmang in a review of 810 cases showed an epididymitis rate of 15.05 per cent without vasectomy and 3.75 per cent with vasectomy. Sixty-two per cent of these cases were transurethral resections. In this group, the epididymitis rate was 9.06 per cent without ligation and 2.66 per cent with ligation. Similar studies10-12 have reported the occurrence of epididymitis ranging from 4.08 per cent to 16 per cent with vasectomy, ligation, or vas crush, and 20 to 25 per cent without such procedures. The latter figure is believed to be statistically unreliable because of the relatively small number of patients who received no vasectomy with their resections. Another approach was taken by Graham and Grayhack13 who performed unilateral vasectomies, allowing the contralateral side to act as a control. In this study of 194 patients, 81 per cent had transurethral resections. Epididymitis developed on the nonvasectomized side 6.2 per cent of the time with bilateral epididymitis developing in 1.5 per cent of the patients. In none of the patients in their series did epididymitis develop on the ligated side only. Other studies14 have confirmed their results. Lynn and Nesbit, l5 however, found the occurrence of epididymitis to be only 4 per cent without ligation and 2.7 per cent with ligation. All were transurethral resections. These authors believe that vas section at the time of transurethral prostatectomy did not significantly rethe of postoperative duce incidence epididymitis. TABLE II.
Comparison of the two groups
Patient Data Epididymitis Preoperative antibiotics Postoperative antibiotics Prior urinary tract infection Prior catheterization Grams of tissue resected Postoperative catheter time Positive preoperative culture and sensitivity - urine Positive postoperative culture and sensitivity - urine Length of hospital stay Age of patient
Group I
Group II
5% 25% 100% 18% 23%
2% 33% 55% 14%
14.5 Gm. 3.7 da. 11%
15% 15.9 Gm. 3.6 da. 13%
5.4%
10.75%
16 da. 67.2 yr.
13.25 da. 66.5 yr.
UROLOGY / FEBRUARY1979 / VOLUMEXIII, NUMBER2
TABLE
III. Comparison of studies which reviewed occurrence
of
epididymitis with and without vasectomy Transurethral Resection of Prostate Total No. No. of of Cases Cases
Reference Schmidt and Hinmaus Melchoir et al. lo
810 2122
Warres”
234
Casteel, Thompson, and Wepfler’s
319
508 Vasectomy (188) No vasectomy (320) 2122 Bilateral vasectomy (2082) Unilateral vasectomy (28) No vasectomy (12) 234 Vasectomy (108) Vas crush (104) No vasectomy (22) 238 Ligation (105) Vas crush (128) No vasectomy (5)
The most plausible theory explaining the mechanism of epididymitis is that of reflux of infected urine into the vas deferens.16 This has served as the rationale for performing vasectomies to prevent epididymitis. Apfelbach” reported 2 cases of spontaneous vas deferens reflux demonstrated radiographically after prostatectomy. Studies18-20 which attempted to demonstrate the reflux of bacteria into the vas defe-
TABLE
IV.
Orandi et al. Is
/ FEBRUARY1979
2.66 9.06 2.60 2.60 25.00 0.92 16.34 25.09 1.96 7.00 20.00
rens showed that with sterile preoperative urine and no catheterization, only 4.8 to 9.5 per cent of the vas deferens cultured were positive (Table IV). With sterile urine and a preoperative catheter, 0 to 10.6 per cent of the vas deferens cultured were positive, and those with infected urine but no catheterization had a 15-per cent positive culture rate. When patients had both infected urine and were catheterized, the rate of
No. of
Group and No. of Cases
100
Sterile urine, no catheter (21) Sterile urine, catheter (47) Infected urine, catheter (32) Sterile urine (74) Infected urine (67) Sterile urine, no catheter (21) Sterile urine, catheter (4) Infected urine, no catheter (54) Suprapubic catheter(4) Infected urine, catheter (52)
Cases
Beck and Taylor18
UROLOGY
Patients with Epididymitis (%)
Comparison of studies which attempted to demonstrate re$ux of bacteria into vas deferens
Reference
KendaIl*O
Procedure and No. of Cases
141 135
/ VOLUMEXIII. NUMBER2
Positive Vas Deferens Culture % No. 2
9.5
5
10.6
12
37.5
0
0 47.0 4.8
32 1 0
0
8
15.0
1
25.0
19
36.0
137
positive vas cultures increased 36 to 47 per cent. Certain questions have been raised regarding the evidence of reflux of bacteria into the vas lumen. How effective will a vasectomy be if at the time of vasectomy the vas and the epididymis have already been seeded with bacteria? Several authorszOlzl have suggested that a vasectomy will be effective only in those patients who have uninfected urine and who have never undergone instrumentation. Our study indicates that there may be several factors leading to our decreased incidence of postprostatectomy epididymitis. First, with improvements in equipment and optics, resections can be performed more accurately, thereby avoiding injury to the verumontanum. Second, symptoms of prostatism are being recognized sooner by both patient and referring physician, and prostatectomy is being performed before the patient has urinary retention. Third, the patients are spending less time in the hospital, thereby decreasing their chances of contact with hospital pathogens. Finally, the use of prophylactic antibiotics in all of the patients in the vasectomized group failed to prevent epididymitis, a result which is consistent with the literature. Our data support the fact that vasectomy, a procedure which itself has a substantial rate of complications including epididymitis,22 does not reduce the incidence of postprostatectomy epididymitis. It should be noted that all statistics in this article deal only with transurethral resections and one cannot extrapolate these conclusions to other forms of prostatectomy. Technical Publications Editor Letterman Army Medical Center Presidio of San Francisco California 94129
138
References 1. Barnes RW: Endoscopic Prostatic Surgery, St. Louis, C. V. Mosby Co., 1943, p. 79. 2. Weyrauch AM: Surgery of the Prostate, Philadelphia, W. B. Saunders Co., 1959, p. 133. 3. Karafin L, and Kendall AR: Urology, Hagerstown, Harper & Row, 1975, p. 21. 4. Valk WL, Mehust WK, Melchoir J, and Foret JD: The present status of resection of the prostate for benign prostatic hypertrophy, Urol. Clin. North Am. 2: 85 (1975). 5. Campbell MF, and Harrison JH: Urology, Philadelphia, W. B. Saunders Co., 1970, p. 2489. 6. Creevy CD: Transurethral prostatic resection. Prevention and treatment of complications, Med. Clin. North Am. 43: 1749 (1959). 7. Burgess AH: Murphy, and some principles of urinary surgery, Surg. Gvnecol. Obstet. 54: 257 (1932). 8: Meares- EM: Factors that influence surgical wound infections, Urology 6: 535 (1975). 9. Schmidt SS, and Hinman F: The effect of vasectomy upon the incidence of epididymitis after prostatectomy; an analysis of 810 operations, J. Ural. 63: 872 (1950). 10. Melchoir J, Valk WL, Foret JW, and Winston RM: Transurethral prostatectomy and epididymitis, ibid. 112: 647 (1974). 11. Warres HL: Postprostatectomy epididymitis, Am. Surg. 29: 126 (1963). 12. Casteel CK, Thompson IM, and Wipfler EJ: Vas crush for prevention of postprostatectomy epididymitis: an experimental and clinical study, J. Ural. 93: 476 (1965). 13. Graham JB, and Grayhack JT: Epididymitis following unilateral vasectomy and prostatic surgery, ibid. 87: 582 (1962). 14. Rinker JR, Hancock CV, and Henderson WD: A statistical study of unilateral prophylactic vasectomy in the prevention of epididymitis: 1029 cases, ibid. 104: 303 (1970). _ 15. iynn JM, and Nesbit RM: The in&ten&s of vasectomy upon the incidence of epididymitis following transurethral prostatectomy, ibid. 59: 72 (1948). 16. Rolnick HC: The mechanism of epididymitis, Surg. Gynecol. Obstet. 41: 15 (1925). 17. Apfelhach CL: Vas deferens reflux following prostatic surgery, J. Urol. 94: 164 (1965). 18. Beck AD, and Taylor DE: Postprostatectomy epididymitis: a bacteriological and clinical survev. ibid. 104: 143 (1970). 19. O&h A, Hilf MM, Femkdes M, and Draper’JW: Vas culture, epididymitis and postprostatectomy fever, ibid. 96: 367 (lQt% 20. Kendall AR: Rationale of prophylactic vasectomy, ibid. 89: 712 (1963). 21. Reeves JF, Scott R, and Scott FB: Prevention of epididymitis after prostatectomy by prophylactic antibiotics and partial vasectomy, ibid. 92: 528 (1964). 22. Leader AJ, Axelrad SD, Frankowski R, and Mumford SD: Complications of 2711 vasectomies, ibid. 111: 365 (1974).
UROLOGY
/
FEBRUARY
1979
/
VOLUME
XIII.
NUMBER
2