Vaso-Epididymal Anastomosis

Vol. 26, No. 8, August 1975 Printed in U.SA.

FERTILITY AND STERILITY Copyright" 1975 The American Fertility Society

V ASO-EPIDIDYMAL ANASTOMOSIS JITENDRA K. KAR, M.S.,

AND

ACHYUT M. PHADKE, M.B.B.S

Family Welfare Bureau, Bombay 4, India

The beginning of the 20th century witnessed the ingenious efforts of Dr. Martin/ of Philadelphia, to overcome an occlusion of the vas deferens by surgical means. In 1902, Dr. Edward Martin performed the frrst vaso-epididymal anastomosis in one man and incidentally in three dogs. Motile sperm were seen in the semen after 1 month, and the wife subsequently became pregnant. The operation was popularized by Dr. Francis Hagner· 3 and was extensively tried by Vincent O'Conor 5 • 6 in the United States. Hagner's series was notable for impressive successes. The optimism aroused by Hagner's work was soon eclipsed by conflicting results obtained by other surgeons. 7• 19 In the British Isles, Howard Hanley 20 used his own modified technique but declared that the operation was not equally successful in his hands. Dr. Bayle,21 from France, using a modification of Hagner's technique, reported encouraging results. In India, pioneer work in this field was done by the late Dr. G. M. Phadke. 22 • 23 The results obtained by him were equal to the best achieved by any surgeon. One of the authors (J. K. K.) learned the intricacies of the operation from Dr. G. M. Phadke, and the present series includes only the patients operated upon by him at the Family Welfare Bureau in the last 20 years.

Received July 24, 1974.

MATERIALS AND METHODS

The patients in this study were selected from among those who, since 1954, had attended the Family Welfare Bureau for infertility evaluation. For each patient a thorough history was taken, physical examination was carried out, and a semen analysis was performed two or three times, at intervals of 15 to 30 days, to assess the magnitude of variations in sperm counts occurring spontaneously. A testicular biopsy was carried out in all patients showing azoospermia. When there was no obvious disparity in the two gonads, the biopsy was performed only on one side, but when one of the testes was clinically abnormal the biopsy was performed on the better side. Each patient was explored for vasoepididymostomy if semen analyses repeatedly revealed azoospermia, testicular biopsy demonstrated normal spermatogenesis, and fructose was present in the semen. In such cases, clinically, the testes were of normal size and the epididymides were turgid, enlarged, and full. Not infrequently, a nodule was felt at the lower pole of epididymis. Patients with congenital bilateral absence of the vas deferens, ejaculatory duct obstruction, or post-vasectomy sterility were not included in this study. (Congenital bilateral absence of the vas deferens is by no means rare. During the last 20 years, 88 cases of congenital bilateral absence of the vas deferens and

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KAR AND PHADKE

23 cases of ejaculatory duct obstruction were encountered at the Bureau.) In earlier years, vaso-epididymal anastomosis (VEA) was performed on both sides, and an internal nylon bristle was used as a splint. In some of these cases, the incidence of infection was distressingly high. Subsequently, all operations were carried out without internal splints. Thus in 92 patients internal nylon splints were used and in 189 patients no internal splint of any kind was used. In recent years, VEA operations were purposely performed only on one side. The rationale for doing unilateral operations was as follows. Our experiences with re-anastomoses were far from satisfactory. It was thought that a vasoepididymostomy performed successfully on one side was all that was necessary. In addition, the patient still had another chance if the first operation ended in failure. In the present series, 185 bilateral and 96 unilateral operations were performed. The patients on whom unilateral operations were performed were classified into two categories, namely the "obligatory" and "optional" types. In the obligatory category were included 4 7 patients on whom unilateral operations were performed because of some genital abnormality on the other side. The surgeon had little choice in such cases, and a unilateral operation was the only possible solution. In the optional category were included 49 patients in whom unilateral operations were performed by choice. Twenty-five patients were re-explored 1 to 1'-h years after the first operation. In them, semen tests at the end of this period had shown persistent azoospermia. In two patients a spermatocele teeming with spermatozoa was found to be attached to the head of the epididymis, and a lateral anastomosis between the spermatocele and the vas deferens was performed. In 10 patients, the vasa deferentia

August 1975

were thickened and were adherent to the hydrocele sac and neighboring structures. These patients previously had undergone bilateral hydrocele operations. It was necessary to divide the vas deferens, which was remotely placed from the proposed site of the anastomosis, and the anastomosis could be done only after approximating the vas deferens to the head of the epididymis. In one patient, the epididymis on the right side contained numerous motile spermatozoa, but, unfortunately, the vas deferens on that side was blocked. The left epididymis was fibrosed, atrophic, and devoid of fluid and spermatozoa. However, the vas deferens on left side was patent and was eventually anastomosed across the scrotal septum to the epididymis on the right side. In 12 patients, VEA operations were performed even though the epididymides on both sides had shown absence of spermatozoa at the time of operation. In 71 patients, epididymal biopsies were performed and studied to understand the underlying pathology. All of the operated patients were subsequently followed for 2 to 5 years. A regular monthly semen analysis was carried out in most of them.

Etiologic Factors The cause of the obstruction in obstructive azoospermia is not always known. The obstruction can result from infections, operations, congenital malformations, and idiopathic factors. Infections. There was history of smallpox in 114 patients. That smallpox produces obstructive azoospermia is seldom realized. Recently, Phadke et aJ.2 4 demonstrated that obstruction was present in 80% of the azoospermic patients who had had smallpox. Thirty-six patients had a history of syphilis or gonorrhea. Postgonorrheal obstructions in the genital tract are well known and require no elaboration.

•

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In 25 patients there was history of 8 pyrexial illness (enteric fever?) of 1 to 3 weeks' duration. In the absence of reports of Widal tests and blood studies, it is prudent to term it "nonspecific pyrexial illness." Five patients had a history of Koch's infection. In them, the epididymides c were irregularly enlarged and nodular, and the vasa deferentia were irregularly beaded. Three of these patients had a history of a scrotal sinus discharge. The seminal volumes of these patients were reduced and fructose tests were "weakly D positive." Living microfilaria were detected in epididymal secretions during operations on two patients. There was no history or clinical evidence suggestive of filarial infection. The scrotal skin was not thick- F ened or edematous, nor was there a hydrocele. The epididymides were turgid and enlarged and yielded copious fluid which showed numerous motile spermatozoa in addition to living microfilaria. Operations. Two patients had underFIG 1. Congenital anomalies encountered while gone bilateral hernioplasties and thirty perfonning vaso-epididymostomy. A, Right vas patients had a history of bilateral hydro- deferens absent; left testis undescended. B, Epion right shows spermatocele; left vas cele operation. We have often seen pa- didymis deferens absent. C, Epididymides absent on both tients in whom bilateral hydrocele opera- sides; left vas deferens absent. D, Failure of union tions have produced azoospermia. The of epididymis and testis; epididymis separated by vascular mesentery. E, Failure of union of body practice of excising the hydrocele sac and and tail of epididymis. F, Failure of development everting and suturing it to the posterior of body and lower pole of epididymis (three cases). aspect of the epididymis virtually stran- G, No connection between lower pole of epididymis gulates the epididymis, with resulting and vas deferens. adhesions and fibrosis. Congenital Anomalies. In the present collapse of the epididymis, which was series, congenital anomalies were very flat and flabby but not fibrosed. The lower infrequent and were noted in only nine pole of the epididymis was not nodular. patients (Fig. 1). Macroscopic epididymal This could have been a congenital lesion cysts varying in size from pinhead to pea, due to failure of canalization of the lower as described by Hanley and Hodges, 25 portion of the epididymal tubule and the beginning of the vas deferens. were observed in some instances. Idiopathic Factors. In 102 patients the cause of obstruction could not be ascer- Pathologic Physiology tained. In such cases the head of the epiIt is well known that in patients with didymis was enlarged and turgid. The body was well formed, but below the obstructive azoospermia spermatogenesis midpiece and tail there was a virtual continues normally, although, according

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FIG. 2. Epididymal biopsy from a patient with obstructive azoospermia showing a section of epididymal tubule. The lumen of the tubule contains several giant mononuclear and multinuclear macrophage cells. Many of the macrophages show ingested sperm heads in the cytoplasm (hematoxylin and eosin, x 344).

to Bayle21 and Rolnick, 26 at a reduced rate. Nevertheless, Heller and Clermont27 convincingly demonstrated that the spermatogenic cycle in man is 74 ± 5 days, and their study was conducted on vasectomized patients. Steinach believed that after vasectomy there is atrophy of the seminiferous tubules, with compensatory hyperplasia of the Leydig cells. We have never seen hyperplasia of the Leydig cells in patients with obstructive azoospermia. Howard and Simmons28 reported normal excretion of urinary 17 -ketosteroids in men with absent or blocked vas deferens. Phadke et al. 29 reported that seminal fructose levels in patients with obstructive lesions were identical with fructose levels observed in normospermic men. Phadke30 · 31 studied the fate of spermatozoa in patients with obstructive azoospermia. He demonstrated that, in the majority of such patients, the sper-

matozoa were phagocytosed by the spermiophage cells in the lumina of the epididymal tubules (Figs. 2 and 3). Rarely, if ever, did the spermatozoa extravasate into the interstitial tissue of the epididymis. Spermiophage cells are derived from the reticuloendothelial system of cells, and endothelial cells are also engaged in antibody formation. Indeed, sperm agglutinins have been demonstrated32· 33 in blood serum of patients with obstructive azoospermia. Gonococcal, tubercular, filarial, and nonspecific streptococcal, staphylococcal, and Escherichia coli infections invade the epididymis by way of the vas deferens. The reaction to bacteria is peritubular and interstitial rather than intratubular, and the extension is by way of the lymphatics. Tubular stenosis is caused by the presence or contracture of scar tissue. Most of the enzyme hyalurondiase 34 in semen comes from the testes, and its presence in semen indicates patency of the

..

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FIG. 3. An oil immersion photomicrograph of a spermiophage cell from the epididymal fluid of a patient with obstructive azoospermia. The cell has a diameter of 33.6 ~-tm. The nucleus measures 8.4 ~-tm and is of the open, vesicular type. The cytoplasm is foamy and granular and contains several ingested spermatozoa. The tails of spermatozoa can be seen on the right (hematoxylin and eosin, x 1435).

vaso-epididymal ducts. It is thought that, during their sojourn in the epididymal tubule from the caput to the cauda, spermatozoa undergo physiologic maturation and acquire fertilizing ability. 35-37 This normal relationship is inverted when obstructive lesions are present. 37 It has been reported38"40 that epididymal spermatozoa are nonmotile, possibly because of an acid environment and lack of fructose. We did not find this to be true; we observed motile spermatozoa in the epididymal secretions of a majority of our patients. · Weisman41 and Rolnick38 have reported that spermatozoa _recovered from spermatocele are immature and lack fertilizing ability. Various investigators42-45 who have studied sperm granulomas believe that the primary lesion in such cases is extravasation of spermatozoa into the interstitial tissue of the epididymis, where they are phagocytosed by macrophages and are surrounded by extensive fibrosis. During vaso-epididymostomy,

the epididymal tubule or tubules are cut in several places and there is ample opportunity for spermatozoa to extravasate into the interstitial tissues, and yet the occurrence of sperm granuloma is a rarity; nevertheless, the capacity of sperm to excite a fibrous tissue reaction is noteworthy.

Operative Technique We followed the technique described by Dr. G. M. Phadke. 22 · 23 Essentially, it is a modification of the HumphreysHotchkiss10 method, and only the salient features are described below. Under spinal anesthesia the spermatic cord was exposed and picked up through a scrotal incision. The vas deferens and its blood vessels were isolated from other structures of the cord along the entire scrotal length of the cord, from the external abdominal ring to the globus minor of the epididymis. By exerting digital pressure on the scrotum, the testis was

KAR AND PHADKE

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A A

B

FIG. 4. A, lateral view of the epididymal incision. Note the protruding epididymal tubules, and the trimmed edges of the incision. B, Proposed sites for incisions in the epididymis and vas deferens for VEA.

pushed upward and was delivered through the scrotal incision and isolated. The tunica vaginalis was incised transversely to expose the head of the epididymis. The turgid, dilated and tortuous epididymal tubules were visible through the glistening tunica. At a suitable site, as far down as possible, a longitudinal incision, 1 em in length, was made in the epididymis (Fig. 4). The milky fluid which oozed out was examined microscopically. Normally, millions of actively motile spermatozoa, together with numerous spermiophage cells and red blood cells, were seen. If the epididymal fluid did not contain spermatozoa or if the spermatozoa were feebly active or nonmotile, the incision was deepened and extended toward the head of the epididymis. The edges of the incision were trimmed with fine curved scissors. The patency of the vas deferens was subsequently tested. A suitable portion of vas which could be easily approximated to the epididymal incision was cut transversely just deep enough to incise its anterior half (Fig. 5). A 20-gauge needle

FIG. 5. A, The vas deferens is cut transversely, deep enough to incise the anterior half. B, Cross-section of the vas deferens. (Modified after Amelar, 18 p 126.)

was introduced into the exposed lumen of the vas deferens, and 5 to 10 ml of sterile isotonic saline solution containing 500,000 units of crystalline penicillin were injected through the attached hypodermic syringe. If the vas was patent, the saline solution could be injected freely, but when an obstruction was present, a resistance was felt. If more force was used, the vas distended and the fluid regurgitated. Splitting of the Vas Deferens. The needle was then pierced through the anterior wall of the vas deferens after traversing the desired length. The tip of a no. 11 Bard-Parker knife was engaged in the bevel of the needle, with the cutting edge pointing upward. The vas was immobilized by an assistant, and the needle with engaged knife point in situ was swiftly withdrawn by the operator. This maneuver resulted in longitudinal splitting of the vas deferens (Fig. 6).

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VASO-EPIDIDYMAL ANASTOMOSIS

A

SUTURE

YLON BRISTLE

B

B FIG. 6. A, Technique of splitting the vas deferens (see text for details). B, The incision of the vas deferens opened out.

Anastomosis. To reduce tension, two or three anchoring linen stitches were made between the tail of the epididymis and the vas deferens below the proposed site of the anastomosis (Fig. 7). The cut ends of the epididymis and the vas deferens were joined with interrupted sutures of 5-0 Anacap silk in two layers. Three stitches in each layer were usually sufficient. Suture knots were kept outside the opening of the anastomosis. A portion of the epididymal tubules was incorporated into each stitch. Internal Splint. After the posterior stitches had been made, the nylon bristle was inserted into the lumen of the vas deferens and was gradually and gently pushed in toward the inguinal region for a length of 20 to 25 em. The other end of the bristle was drawn through the lower end of epididymis, below the site of the anastomosis, and through the scrotal skin to the exterior, where it was secured. The nylon splint was removed when the skin sutures were removed, 7 days after the operation. In cases where a nylon splint was not used, a 20-gauge, blunt, atraumatic needle was introduced into the lumen of the vas deferens after the posterior stitches had been made; the anterior

FIG. 7. A, Technique of vasa-epididymal anastomosis with internal nylon splint (description in text). B, Anteroposterior view of the completed anastomosis.

interrupted sutures were then made. The presence of the needle prevented inadvertent occlusion of the anastomosis stoma. Before the needle was withdrawn, 5 to 10 ml of penicillin-containing saline solution were injected to flush the site of operation and to remove tiny blood clots. Throughout the operation, the exposed parts were periodically sprayed with saline solution to prevent drying. Meticulous hemostasis was secured with cautery, and the parts were replaced in the scrotum. The wound was closed in two layers and a firm scrotal support was given. Postoperative Treatment. Each patient was hospitalized for 1 week. A firm scrotal support was given. Broad-spectrum antibiotics and oxyphenbutazone (Tanderil) were administered for 1 week. The sutures were removed on the 6th day and the patient was allowed to go home. A semen analysis was performed at the end of 3 weeks. The presence of living

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or dead spermatozoa, spermatids, or macrophages with ingested spermatozoa indicated the patency of the anastomosis. If the semen specimen showed the prescence of pus cells, the patient was vigorously treated with antibiotics and prostatic massages. In the absence of infection, testosterone propionate was administered parenterally, 50 mg three times per week for 4 weeks, and 100 mg of vitamin E were given orally, daily, for the same period, since testosterone enhances secretions of the epididymis and vitamin E in large doses helps in minimizing fibrosis. The patient was encouraged to resume normal sex life as early as possible. The tight scrotal suspender was dispensed with after 1 month. RESULTS

operative sperm counts were consistently under 10 million/mi. Twenty patients (7.117%) again became azoospermic after a variable length of time. Pregnancies occurred in 40 instances (14.23% ). Unilateral versus Bilateral Operations (Table 1). In this series, bilateral YEA operations were performed in 185 patients. They were successful in 102 instances (55.13%), and pregnancies occurred in 32 cases (17 .3% ). Unilateral operations by choice were successful in 23 of 49 operated cases (48.83%) and in 5 instances (10.2%) the wives became pregnant. In 4 7 patients operations were performed on one side because of some genital abnormality on the other side: atrophic testis on one side, 9 patients; vas deferens blocked on one side, 20 patients; absence of vas deferens on one side, 2 patients; epididymis on one side showed absence of sperm, 15 patients; undescended testis on one side, 1 patient. In this group of "obligatory" unilateral operations, success was achieved in 12 cases (25.5%), and in 3 instances (6.36%) the wives became pregnant. Splinted versus Nonsplinted Operations (Table 2). In 92 patients YEA operations were performed with an internal nylon splint. In 40 instances (43.47%) the operations were successful; 16 pregnancies (17.39%) occurred.

Negative Explorations. In 37 patients the YEA operation could not be performed for the following reasons: epididymides showing absence of spermatozoa, 16 patients; vasa deferentia blocked on both sides, 17 patients; epididymides showing absence of sperm and vasa deferentia blocked on both sides, 3 patients; congenital bilateral absence of epididymis, 1 patient. Results of Anastomosis (Table 1). The YEA operation was performed in the remaining 281 patients. It was successful in 137 patients (48.75%). However, in only 56 instances (19.93%) were the postoperative sperm counts above 20 million/ During 189 operations no internal ml. In 46 patients (16.37% ), the post- splint was used. Of these, 97 operations TABLE 1. Results ofVaso-Epididymal Anastomosis Operations Type and no. of operations

Category

Unilateral Bilateral

Total no. of operated patients Successful operations Postoperative sperm counts (million/mi) 0-10 11-20 21 and above Patients again became azoospermic Pregnancies

185 102 (55.13%) 32(17.3%) 11 (5.94%) 44 (23.79%) 15 (8.108%) 32 (17.3%)

Obligatory

Optional

47 12 (25.5%)

49 23 (46.93%)

2 (4.25%) 1 (2.12%) 7 (14.89%) 2 (4.25%) 3 (6.36%)

12 (24.48%) 3 (6.12%) 5 (10.2%) 3 (6.12%) 5 (10.2%)

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TABLE 2. Comparison ofVaso-Epididymal Anastomosis Operations Performed with and without Splints Types and no. of operations

Category

With nylon splint

Total no. of operated patients Successful operations Postoperative sperm counts (million/ml) 0-10 11-20 21 and above Patients again became azoospermic Pregnancies

Without splint

Bilateral

Unilateral

Bilateral

Unilateral

58 27 (46.56%)

34 13 (38.23%)

127 75 (59.06%)

62 22 (35.48%)

7 (12.07%) 2 (3.448%) 15 (25.86%) 3 (5.172%) 11 (18.97%)

4 (11.76%) 2 (5.88%) 6 (17.64%) 1 (2.93%) 5 (14.70%)

25 (19.68%) 9 (7.086%) 29 (22.83%) 12 (9.45%) 21 (16.53%)

10 (16.12%) 2 (3.22%) 6 (9.67%) 4 (6.45%) 3 (4.83%)

were successful (51.32%), and pregnancies occurred in 24 cases (12.7%). Motility of Spermatozoa. Table 3 illustrates the motility of spermatozoa in successfully operated patients. The average sperm motility of a number of seminal studies is recorded for each patient. Motility studies were usually carried out lh · to 1 hour after collection of the semen specimen. In 48 cases (35.04%) semen analyses repeatedly showed necrospermia. In only 26 patients (18.98%) was the sperm motility satisfactory, i.e., above 40%. Time Interval between the Operation and the Appearance of Spermatozoa in Semen (Table 4). In one of two successfully operated patients spermatozoa appeared in the semen within the first 3 months after the operation. However, in one of eight successful cases, the appearance of spermatozoa in the semen was delayed for 1 year or more; in one patient spermatozoa appeared 5 years after the operation. Re-explorations (Table 5). In 25 patients, re-explorations were carried out 1 year after the initial vaso-epididymostomy. The o:Peration was successful in four instances, but none of the operated patients could father a child.

A lateral anastomosis between spermatocele and vas deferens was successful in one of two operated cases. The solitary cross-septal anastomosis between right epididymis and left vas deferens ended in failure. A termino-lateral anastomosis, which was carried out in 10 patients after the vas deferens had been transplanted, was successful in 3 patients. In 12 patients, vaso-epididymostomy was performed even though the epididymides had shown absence of spermatozoa at the time of operation. In five such cases, semen analyses postoperatively showed presence of spermatozoa. In 10 patients, vasa deferentia were blocked and were filled with cheesy material. The cheesy material was expressed by literally milking the vas deferens, and an attempt was made to flush and irrigate the vas forcibly. No patient benefited by this maneuver. DISCUSSION

Of all of the methods 7 • 9 • 20 of vasoepididymal anastomosis, only Martin 1Hagner's2· 3 method has withstood the test of time. The operative technique has changed little in the past 70 years, except

TABLE 3. Motility of Spermatozoa after Successful Vasa-Epididymal Anastomosis No. of cases according to percentage of motility Successful VEA operations

0 -occasional

1-10%

11-20%

21-40%

41% and above

137

48 (35.04%)

4 (2.92%)

23 (16.79%)

36 (26.27%)

26 (18.98%)

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TABLE 4. Interval between Anastomosis and Appearance of Sperm in Semen Interval

No. of patients

mo

71 (51.83%) 28 (20.44%) 17 (12.41%) 4 (2.92%) 17 (12.41%)

0-3 4-6 7-9 10-12 >12 Total

137

for the type of suture material used. Catgut, 20 fine silk, 10 · 11 silver wire, 2· 3 stainless steel, 12· 13 nickel alloy, 11 tantalum/1 3-0 plain catgut,20 fine ophthalmic nylon, 20 and 5-0 arterial silk 10· 11 have been recommended and used. We believe that 5-0 arterial silk is highly satisfactory and that catgut undoubtedly induces marked fibrosis. Of equal or greater importance is the capacity of spermatozoa to excite the fibrous tissue reaction, to which reference has already been made. Our findings of extensively fibrosed epididymides at the time of re-exploration bear testimony to this hypothesis. According to Hagner2 • 3 and Michelson, 12· 13 in successful operations a sinus is formed between one or more of the epididymal tubules and the vas deferens. In this series, 7% of the successfully operated patients again became azoospermic after a variable length of time. This certainly was due to the progressive TABLE 5. Findings at the Time of Re-explorations Lesion

No. of patients

Old anastomosis completely detached; epididymides showed many sperm, and vasa deferentia were patent Old anastomosis completely fibrosed; stoma blocked; epididymides showed many sperm, and vasa deferentia were patent Epididymides fibrosed and yielded no fluid; vasa deferentia were patent Old anastomosis fibrosed; epididymides showed many sperm, but vasa deferentia were blocked with cheesy material Total

2 16

3 4

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stenosis of the anastomosis stoma or of the connecting sinusoidal tract of fibrous tissue. The incidence of negative explorations can be reduced by the proper selection of cases. The epididymides should be turgid, enlarged, and full. If they are soft, flat, and flabby the obstruction is more likely to be found in the rete testis. By the same token, surgery should be withheld when the vas deferens is irregularly beaded and thickened. A testicular biopsy is an invaluable "must" for the proper selection of cases. Fear of testicular atrophy after a biopsy is unfounded and exaggerated. We did not encounter this complication in more than 3000 testicular biopsies carried out at the Bureau. Hanley's dictum 20 that "if the testis feels normal, histologically it will be normal" is too dogmatic and erratic. On a number of occasions, testes which felt "normal" demonstrated germinal cell aplasia or spermatogenic arrest histologically. Such patients need not be explored at all. In patients with spermatogenic arrest, exploratory incisions of the epididymides will ruin what little chance of cure they have. We agree with Bayle, 21 who is averse to the idea of testing the patency of the vas deferens by injecting methylene blue and hydrogen peroxide mixture 4 • 1L 18 into the vas deferens and subsequently recovering it from the bladder through an indwelling catheter. Injection of a sterile isotonic saline solution is highly satisfactory. The addition of penicillin to the saline solution minimizes the chance of infection. The internal splint, whether of nylon, horsehair, stainless steel, catgut, or tantalum, acts like a foreign body, and Bayle21 and Hagner 2· 3 disapprove of its use. Additionally, the incidence of infection and fibrosis is higher with the use of a splint. Nevertheless, in our series better results were obtained in VEA operations carried out with internal nylon splints.

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TABLE 6. Results of Bilateral and Unilateral VEA No. of Vaso-epididymostomy

Bilateral Unilateral

Operations performed

Successful operations

Patients with normal postoperative sperm counts

Pregnancies

185 96

102 (55.13%) 35 (36.46%)

44 (23.79%) 12 (12.5%)

32 (17 .3o/o) 8 (8.33%)

This study decisively answers a crucial question as to whether a unilateral operation is advisable. The pertinent findings are summarized in Table 6. Our belief that a satisfactorily performed unilateral operation was more than adequate proved to be erroneous. Should one perform anastomosis even if the epididymal tap reveals absence of spermatozoa? Michelson 12 • 13 answered in the affirmative. We operated upon 12 patients with such findings; indeed, spermatozoa were found in the semen of 5 of them after operation, but the sperm count never became normal. In 10 patients, the vasa deferentia were blocked with cheesy material. We had thought that this material was due to Koch's infection; however, we encountered four more cases during re-exploration and ascertained that the chalky white or creamy color of the contents resulted from degenerated sperm, bacteria, droplets of fat, and leukocytes. In 12% of the successful operations, spermatozoa first appeared in the semen 1 year after the operation. The reason for this delay is unknown. Sometimes the maximal delay was 11h to 3 years; in one record case it was 5 years. We

believe that in these cases the stoma had been blocked by cellular debris, blood clots, inflammatory swelling, or adhesions and that recanalization eventually occurred. The presence or absence of hyaluronidase in semen can be of diagnostic value in such cases. The cause of persistent low sperm counts after a successful anastomosis is not known. Bayle21 ascribed this to the testicular biopsy. According to him "there is slight but constant bleeding from the biopsy site which can cause testicular damage. There may be deposition of fibrin and the vascular network of Hailers may be damaged." This suggestion is unbelievable. Indeed, the scar of biopsy is indiscernible at the time of anastomosis. We offer two possible explanations. First, in the body and tail of the epididymis there is in reality a single epididymal tubule whose multiple convolutions may be incised repeatedly. The chance of success depends on the continued patency of this single tubule. If the anastomosis is higher, as many as 8 to 10 efferent tubules perforce will be incised. If few of them or even one of them remains patent after operation, the sperm count will be consistently low. In the present series,

TABLE 7. Vaso-Epididymostomy: Results of Various Investigators No. of Investigators

Hagner·• Bayle21 Hanley20 JoeP 6 Phadke 22 • 23 O'Connor" Vazet• Kar and Phadke (this paper) "Not reported.

Year

1931, 1936 1950 1955 1956 1956, 1958 1961 1967 1974

Cases explored

Negative explorations

Operations done

65 95 152 22 105 66 150 318

22 25 12 8 20 0 38 37

33 70 140 14 85 66 112 281

Successful operations

21 (63.6%) 33 (47.1%) 10(7.1%) 8 (55.7%) 54 (63.5%) 19 (28.7%) 64 (57.1%) 137 (48. 75%)

Pregnancies

16 (48.2%) 21 (30.0o/o) 7 (5.0%) 6 (42.8%) 24 (28.2%) 8 (12.1%) a

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whenever we were forced to do the anastomosis higher, toward the head of epididymis, the presence of severe persistent oligospermia after operation was a common, annoying, sequela. Second, the sinus tract which is formed between the epididymis and the vas deferens may be of an extremely narrow caliber or may be convoluted and beset with internal adhesions or septa. The anastomosis stoma, as well, may become partially obstructed as a result of fibrosis and adhesions. In 35% of the successful cases, there was total necrospermia after anastomosis. We tried all types of therapeutic remedies in vain. In many of such cases, spermatozoa were actively motile in the epididymal fluid at the time of operation, but after operation they became nonmotile in the semen. Spermatozoa which are habituated to an acidic epididymal environment may gradually be acquiring resistance to the vesicular alkaline fluid; however, examination of split ejaculates showed no change in sperm motility in such cases. In some of these cases, when sperm agglutinins were present in the blood, treatment with coticosteroids yielded satisfactory results. This problem merits further investigation. The results of vaso-epididymostomy in the hands of different workers are summarized in Table 7. The presence of spermatozoa in semen after the operation is at best a criterion of anatomical success, but the index of physiologic success may well be different. Ideally, the postoperative seminal characteristics should fulfill the minimal requirements of fertility, and the fertilizing ability of spermatozoa should be manifested ultimately by pregnancy. SUMMARY

Our experiences with 343 vaso-epididymal anastomosis operations carried out for the relief of obstructive azoospermia in the past 20 years were reported.

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The etiologic factors in obstructive azoospermia were discussed. Smallpox was the single most common factor responsible for the obstructive lesion in our series. Obstructive azoospermia due to congenital anomalies was very infrequent. The pathologic physiology of obstructive azoospermia was reviewed. In 37 patients vaso-epididymostomy could not be carried out because of some genital pathology or congenital abnormality. V aso-epididymal anastomosis was performed in the remaining 281 patients. The operation was successful in 137 patients (48.75%), and pregnancies occurred in 40 instances (14.23% ). However, even after successful operations, the postoperative sperm counts were above 20 million/ml in only 56 patients (19.93%). Persistent necrospermia resistant to treatment was noted in 48 patients (35.04%). In 71 patients (51.83%), spermatozoa appeared in the semen within the first 3 months after operation, but, in 17 patients (12.41%), the appearance of spermatozoa in the semen was delayed for 1 year or more. Twenty patients (7.11%) again became azoospermic after a variable length of time. In this series, bilateral operations were performed on 185 patients and unilateral operations were performed on 96 patients. Our results indicated beyond doubt that bilateral operation is the method of choice. In addition, an analysis of our data showed that operations performed with an internal nylon splint yield more satisfactory results.

Acknowledgments. We are grateful to the Director, National Library of Medicine, Department of Health, Education and Welfare, Bethesda, Maryland, for providing photostatic copies of articles which were not available in India. The authors thank Dr. L. D. Sanghavi, Dean, Indian Cancer Research Centre, for making arrangements for the photomicrographs of the epididymides in this paper.

VASO-EPIDIDYMAL ANASTOMOSIS

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