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Vasoepididymostomy: A Modified Microsurgical Technique
Accepted 229
230
THE MANAGEMENT OF UROLITHIASIS IN HORSESHOE KIDNEYS. Daniel M. Newman and William L. Sherrill*, Indianapolis, IN (Presentation to be made by Dr. Newman)
VASOEPIDIDYMOSTOMY: A MODIFIED MICROSURGICAL TECHNIQUE. Anthony J. Thomas, Jr., Cleveland, OH (Presentation to be made by Dr. Thomas) Fifty men underwent either unilateral or bilateral microsurgical vasoepididymostomy. The vas lumen was anastomosed to a carefully isolated, unroofed tubule of the epididymis proximal to the obstruction. Eighty-two anastomoses were performed in these fifty men: 16 were unilateral and 33 were bilateral procedures. Sixteen anastomoses were to the caput, 42 to the corpus and 24 to the cauda epididymis. Seven men were lost to follow up without any semen analyses performed. Of the remaining 43 men, 33(77%) have sperm in their semen. Of those with more than six months follow up
Nephrolithiasis is a common complication in horseshoe kidneys and is amenable to endourologic techniques and
Extracorporeal Shock Wave Lithotripsy (ESWL). Experience gained in 26 ESWL treatments and 10 Percutaneous Nephrostolithotomies (PCNL) in 19 patients will be reported. Although patients treated with ESWL had smaller stones than those undergoing PCNL (1.3 cm. vs. 1.63 cm.), a higher percentage of PCNL cases had a successful outcome (100% vs. 67%). The success of ESWL was highly dependent on stone burden as only 25% (2 of 8) of patients with multi-
11
11
ple stones or stones larger than 2 cm. in diameter were
(38 men), 16(42%) have thus far achieved a pregnancy with
treated successfully in this manner.
their respective spouses. None of the seven men who underwent either unilateral or bilateral caput anastomoses has achieved a pregnancy. This method of 11 end-to-side anastomosis seems to offer certain advantages over the end-to-end technique described by Silber: Only one open tubule, exuding sperm, is exposed; the field of surgery is relatively bloodless; and there is no need to resect and/or excise any of the epididymis which
This is believed to
be due to the anatomic features of these kidneys which
make their treatment with ESWL technically difficult and impedes the elimination of gravel. Conversely, the very same anatomic features favor PCNL, usually via an upper pole posterior approach. No serious complications occured in PCNL treated patients. Three
staghorn calculi treated with this approach will be presented. Technical points peculiar to PCNL in these patients will be presented. PCNL is also useful in evaluat-
11
11
11
may have the advantage of protecting the blood supply to both epididymis and testis.
ing and treating possible obstructive lesions in these patients.
231 GONADAL DYSFUNCTION IN PATIENTS FOLLOWING TESTICULAR TORSION: LH AND FSH RESPONSE TO GONADOTROPIN RELEASING HORMONE (GnRH).*Harry Fisch, Eliahu Laor, Roberto E. Reid, Bhupendra M. Talia and Selwyn Z. Freed, Bronx, N.Y. (Presentation to be made by Dr. Harry Fisch). The GnRH stimulation test was used to measure testicular function in 14 postpubertal patients treated for unilateral testicular torsion. Of the 14 patients, 11 were treated by detorsion and 3 underwent orchiectomy. Five normal male volunteers were used as controls. Patients treated by
detorsion were subdivided into three groups based on the degree of atrophy of the detorted testicle. Group I - no testicular atrophy (n=5), Group II - 25% testicular atrophy (n=2) and Group III - >90% testicular atrophy (n=4). Mean duration of torsion was found to be greatest in the
orcbiectomy group, 161 hours, compared to 6, 16 and 29 hours for Groups I, II and III respectively. The serum LH and FSH response to an intravenous bolus of 100 mcg. of synthetic GnRH was assessed in all patients. All groups of patients had mean FSH responses to GnRH which were greater
than controls (p<.05). Patients who underwent orchiectomy had the greatest FSH response to GnRH, even greater than
patients with marked testicular atrophy (Group III), (p<.05). Mean LH response to GnRH was normal in patients without atrophy (Group I) but was greater than controls in patients who had developed atrophy (Groups II and III) or underwent orchiectomy (p<.05). These results clearly demonstrate that: (1) All patients treated for torsion displayed some degree of testicular dysfunction. (2) Patients who underwent orchiectomy displayed more dysfunction than patients who developed marked atrophy following detorsion. (3) Testicular dysfunction after torsion is more likely to involve spermatogenic
before Leydig cell function. Our data suggests that removal of a viable testicle is unwarranted in cases of testicular torsion in humans.
232 FERI'ILITY
IN
THE
LEWIS
RAT
FOLLCWING
MICROSURGICAL
VASECI'CMY REVERSAL. *E. Scott Yarbro,* Peter O. Carey, Stuart S. Howards, and *Terry T. Turner. Charlottesville, VA (Presentation to be made by Dr. Yarbro) The diminished pregnancy rate after vasovasostany (W) despite a 90%+ patency rate is a subject of concern. Twenty-four adult male Lewis rats underwent bilateral vasectany (V) followed by bilateral W at 3 rronths (Group I) • There were 10 sham operated controls (Group II) . All rats underwent fertility testing prior to V and prior to sacrifice at 1 or 3 rronths after W or sham W. Patency of each vasa was detennined at sacrifice by rreasuring vasal flow rates at low and high pressures. One hundred percent of Groups I rats had at least one patent vas and overall 88% of the vasa were patent. The vasal flow rates at low pressure at 1 and 3 rronths after W were not significantly different fran the flow rates in Group II. However, at high pressure, there was a 30% reduction in the rrean flow rate of Group I compared to Group II at 1 rronth (p=O. 02) . Similarly, there was a 25% reduction in the mean flow rate of Group I animals at 3 rronths post-W when canpared to age matched Group II controls (p=0.07). There was only one pregnancy in Group I (4%), whereas all of Group II rats (100%) were fertile. All rats had been proven to be fertile prior to V. An additional 20 male Lewis rats (10 W and 10 sham controls) were tested for the presence of sperm post-operatively by examination of vaginal smaars. Ninety percent of the W group and 100% of controls had sperm in the ejaculate. We conclude that although there is a reduction in the rrean flow rates at high pressures post-W, 90% will have sperm in the ejaculate. This is probably due to flow through a fixed, non-distensible segirent of the vas at the anasta:m:::>tic site and this becares evident as the system is stressed with high flows. Also, with time there appears to be a gradual irnproverrent in flow rates after W. The infertility in the Lewis rat is probably not due to either partial or total obstruction at the anastarosis.
161A
230
THE MANAGEMENT OF UROLITHIASIS IN HORSESHOE KIDNEYS. Daniel M. Newman and William L. Sherrill*, Indianapolis, IN (Presentation to be made by Dr. Newman)
VASOEPIDIDYMOSTOMY: A MODIFIED MICROSURGICAL TECHNIQUE. Anthony J. Thomas, Jr., Cleveland, OH (Presentation to be made by Dr. Thomas) Fifty men underwent either unilateral or bilateral microsurgical vasoepididymostomy. The vas lumen was anastomosed to a carefully isolated, unroofed tubule of the epididymis proximal to the obstruction. Eighty-two anastomoses were performed in these fifty men: 16 were unilateral and 33 were bilateral procedures. Sixteen anastomoses were to the caput, 42 to the corpus and 24 to the cauda epididymis. Seven men were lost to follow up without any semen analyses performed. Of the remaining 43 men, 33(77%) have sperm in their semen. Of those with more than six months follow up
Nephrolithiasis is a common complication in horseshoe kidneys and is amenable to endourologic techniques and
Extracorporeal Shock Wave Lithotripsy (ESWL). Experience gained in 26 ESWL treatments and 10 Percutaneous Nephrostolithotomies (PCNL) in 19 patients will be reported. Although patients treated with ESWL had smaller stones than those undergoing PCNL (1.3 cm. vs. 1.63 cm.), a higher percentage of PCNL cases had a successful outcome (100% vs. 67%). The success of ESWL was highly dependent on stone burden as only 25% (2 of 8) of patients with multi-
11
11
ple stones or stones larger than 2 cm. in diameter were
(38 men), 16(42%) have thus far achieved a pregnancy with
treated successfully in this manner.
their respective spouses. None of the seven men who underwent either unilateral or bilateral caput anastomoses has achieved a pregnancy. This method of 11 end-to-side anastomosis seems to offer certain advantages over the end-to-end technique described by Silber: Only one open tubule, exuding sperm, is exposed; the field of surgery is relatively bloodless; and there is no need to resect and/or excise any of the epididymis which
This is believed to
be due to the anatomic features of these kidneys which
make their treatment with ESWL technically difficult and impedes the elimination of gravel. Conversely, the very same anatomic features favor PCNL, usually via an upper pole posterior approach. No serious complications occured in PCNL treated patients. Three
staghorn calculi treated with this approach will be presented. Technical points peculiar to PCNL in these patients will be presented. PCNL is also useful in evaluat-
11
11
11
may have the advantage of protecting the blood supply to both epididymis and testis.
ing and treating possible obstructive lesions in these patients.
231 GONADAL DYSFUNCTION IN PATIENTS FOLLOWING TESTICULAR TORSION: LH AND FSH RESPONSE TO GONADOTROPIN RELEASING HORMONE (GnRH).*Harry Fisch, Eliahu Laor, Roberto E. Reid, Bhupendra M. Talia and Selwyn Z. Freed, Bronx, N.Y. (Presentation to be made by Dr. Harry Fisch). The GnRH stimulation test was used to measure testicular function in 14 postpubertal patients treated for unilateral testicular torsion. Of the 14 patients, 11 were treated by detorsion and 3 underwent orchiectomy. Five normal male volunteers were used as controls. Patients treated by
detorsion were subdivided into three groups based on the degree of atrophy of the detorted testicle. Group I - no testicular atrophy (n=5), Group II - 25% testicular atrophy (n=2) and Group III - >90% testicular atrophy (n=4). Mean duration of torsion was found to be greatest in the
orcbiectomy group, 161 hours, compared to 6, 16 and 29 hours for Groups I, II and III respectively. The serum LH and FSH response to an intravenous bolus of 100 mcg. of synthetic GnRH was assessed in all patients. All groups of patients had mean FSH responses to GnRH which were greater
than controls (p<.05). Patients who underwent orchiectomy had the greatest FSH response to GnRH, even greater than
patients with marked testicular atrophy (Group III), (p<.05). Mean LH response to GnRH was normal in patients without atrophy (Group I) but was greater than controls in patients who had developed atrophy (Groups II and III) or underwent orchiectomy (p<.05). These results clearly demonstrate that: (1) All patients treated for torsion displayed some degree of testicular dysfunction. (2) Patients who underwent orchiectomy displayed more dysfunction than patients who developed marked atrophy following detorsion. (3) Testicular dysfunction after torsion is more likely to involve spermatogenic
before Leydig cell function. Our data suggests that removal of a viable testicle is unwarranted in cases of testicular torsion in humans.
232 FERI'ILITY
IN
THE
LEWIS
RAT
FOLLCWING
MICROSURGICAL
VASECI'CMY REVERSAL. *E. Scott Yarbro,* Peter O. Carey, Stuart S. Howards, and *Terry T. Turner. Charlottesville, VA (Presentation to be made by Dr. Yarbro) The diminished pregnancy rate after vasovasostany (W) despite a 90%+ patency rate is a subject of concern. Twenty-four adult male Lewis rats underwent bilateral vasectany (V) followed by bilateral W at 3 rronths (Group I) • There were 10 sham operated controls (Group II) . All rats underwent fertility testing prior to V and prior to sacrifice at 1 or 3 rronths after W or sham W. Patency of each vasa was detennined at sacrifice by rreasuring vasal flow rates at low and high pressures. One hundred percent of Groups I rats had at least one patent vas and overall 88% of the vasa were patent. The vasal flow rates at low pressure at 1 and 3 rronths after W were not significantly different fran the flow rates in Group II. However, at high pressure, there was a 30% reduction in the rrean flow rate of Group I compared to Group II at 1 rronth (p=O. 02) . Similarly, there was a 25% reduction in the mean flow rate of Group I animals at 3 rronths post-W when canpared to age matched Group II controls (p=0.07). There was only one pregnancy in Group I (4%), whereas all of Group II rats (100%) were fertile. All rats had been proven to be fertile prior to V. An additional 20 male Lewis rats (10 W and 10 sham controls) were tested for the presence of sperm post-operatively by examination of vaginal smaars. Ninety percent of the W group and 100% of controls had sperm in the ejaculate. We conclude that although there is a reduction in the rrean flow rates at high pressures post-W, 90% will have sperm in the ejaculate. This is probably due to flow through a fixed, non-distensible segirent of the vas at the anasta:m:::>tic site and this becares evident as the system is stressed with high flows. Also, with time there appears to be a gradual irnproverrent in flow rates after W. The infertility in the Lewis rat is probably not due to either partial or total obstruction at the anastarosis.
161A