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VASOVENOUS FISTULA AFTER VASECTOMY
0022-5347/97/1586-2243$03.00/0 THEJOURSAL OF UROLOGY Copyright 0 1997 by AMERICAN UROLGGICAL ASSOCIATION, INC
Vol. 158,2243,December 1997 Printed in U . S A .
VASOVENOUS FISTULA AFTER VASECTOMY RAW R. W A N , KIMBERLY H. CUESTA
AND
JAMES SQUADRITO, JR.
From the Departments of Urology and Pathology, Thomas Jefferson University, Philadelphia, Pennsylvania
KEY WORDS:vasectomy, fistula Approximately 500,000 vasectomies a r e performed in the United States each year. Early complications include hematoma ( 2 %) and infection (3.4%). An uncommon complication is vascular fistula formation. To our knowledge we report the first case of a vasovenous fistula. CASE REPORT
A 44-year-old man initially presented with hematospermia and gross hematuria. Three months previously, he had undergone a routine vasectomy through a 2-incision technique with no intraopwative complications. Postoperatively a large scrotnl hcniatoma and persistent left scrotal pain were present. lJrinulysis showed no red blood cells. On examination the left testicle was swollen and tender. Applying pressure to thc left scrotum and spermatic cord caused the next void to be grossly bloody. Serum laboratory tests, urine culture and excretory urography were normal. Cystoscopy revealed blood emanating from the left ejaculatory duct. Left scrotal exploration demonstrated a vein traversing into the area of the vas deferens where previously placed clips were present tfig. 1). The vein was ligated after which the vas deferens was dissected to clean tissue and ligated. Histopathological examination revealed multiple vascular structures, abnormal in number and caliber, which were adherent to the adjacent vas deferens (fig. 2). Chronic inflammation. fibrous tissue and nerve proliferation were also present. At followup the hematuria and hematospermia had resolved and persistent left hemiscrotal pain had improved significantly.
FIG. 1. Vasovenous fistula. Short arrow shows distal limb of vas deferens. Open arrow demonstrates surgical clip. Long armw shows vein.
DISCL'SSION
Complications from vasectomy range between 2 and 3%. Hematoma and infection a r e the more common complications. Long-term complications include vasitis nodosa, chronic testicular pain, sperm granuloma and epididymal obstruction.' To our knowledge no cases of vasovenous fistulas have been previously reported. Aauman described the only reported case of a n arteriovenous fistula after vasectomy.ZExploration suggested a suture to have penetrated the deferential artery and pampiniform plexus. Ligation of the arterial and venous sides was performed. The postoperative hematoma in our case was probably significant in the fistula formation. Figure 1 shows that the surgcal clip is directly related to the fistula. We propose that the hematoma occurred due to bleeding from a vein adjacent to the clip. The inflammatory response to the clip may have then involved this neighboring injured vein resulting in fistula formation, Our patient and the one Aauman described had large hematomas immediately after vasectomy.2
FIG.2. Histopathology of vasovenous fistula. Cross-sectionof vas deferens show vas deferens (black arrow) surrounded by numerous blood vessels (open arrow) that are contained in fibrovascular tissue. Reduced from X50.
tomy so as not to injure vascular structures is important to prevent these complications. Surgical treatment is warranted when vascular fistulas arise. REFERENCES
<'ON('I,tiSlONS
Vascular fistulas post-vasectomy a r e rare. Only 1 arteriovenous fistula and no vasovenous fistulas have been previOUsIV described. Careful operative technique during vasecAcrepttxd for publication May 2, 1997 Supported in part by a National Institutes of Health grant
2243
1. Goldstein. M.: Surgery of male infertility and other scrotal disorders. In: Campbell's Urology, 6th ed. Edited by P. c. Walsh, A. B. Retik. T. A. Stamey and E. D. Vaughan, Jr. Philadelphia: W. B. Saunders Co., vol. 3. chapt. 87. pp. 3124-3125, 1992. 2. Aauman. J. R.: Swrmatic cord arteriovenous fistula: an unusual complication o i vasectomy J Urol , 134: 768, 1985
Vol. 158,2243,December 1997 Printed in U . S A .
VASOVENOUS FISTULA AFTER VASECTOMY RAW R. W A N , KIMBERLY H. CUESTA
AND
JAMES SQUADRITO, JR.
From the Departments of Urology and Pathology, Thomas Jefferson University, Philadelphia, Pennsylvania
KEY WORDS:vasectomy, fistula Approximately 500,000 vasectomies a r e performed in the United States each year. Early complications include hematoma ( 2 %) and infection (3.4%). An uncommon complication is vascular fistula formation. To our knowledge we report the first case of a vasovenous fistula. CASE REPORT
A 44-year-old man initially presented with hematospermia and gross hematuria. Three months previously, he had undergone a routine vasectomy through a 2-incision technique with no intraopwative complications. Postoperatively a large scrotnl hcniatoma and persistent left scrotal pain were present. lJrinulysis showed no red blood cells. On examination the left testicle was swollen and tender. Applying pressure to thc left scrotum and spermatic cord caused the next void to be grossly bloody. Serum laboratory tests, urine culture and excretory urography were normal. Cystoscopy revealed blood emanating from the left ejaculatory duct. Left scrotal exploration demonstrated a vein traversing into the area of the vas deferens where previously placed clips were present tfig. 1). The vein was ligated after which the vas deferens was dissected to clean tissue and ligated. Histopathological examination revealed multiple vascular structures, abnormal in number and caliber, which were adherent to the adjacent vas deferens (fig. 2). Chronic inflammation. fibrous tissue and nerve proliferation were also present. At followup the hematuria and hematospermia had resolved and persistent left hemiscrotal pain had improved significantly.
FIG. 1. Vasovenous fistula. Short arrow shows distal limb of vas deferens. Open arrow demonstrates surgical clip. Long armw shows vein.
DISCL'SSION
Complications from vasectomy range between 2 and 3%. Hematoma and infection a r e the more common complications. Long-term complications include vasitis nodosa, chronic testicular pain, sperm granuloma and epididymal obstruction.' To our knowledge no cases of vasovenous fistulas have been previously reported. Aauman described the only reported case of a n arteriovenous fistula after vasectomy.ZExploration suggested a suture to have penetrated the deferential artery and pampiniform plexus. Ligation of the arterial and venous sides was performed. The postoperative hematoma in our case was probably significant in the fistula formation. Figure 1 shows that the surgcal clip is directly related to the fistula. We propose that the hematoma occurred due to bleeding from a vein adjacent to the clip. The inflammatory response to the clip may have then involved this neighboring injured vein resulting in fistula formation, Our patient and the one Aauman described had large hematomas immediately after vasectomy.2
FIG.2. Histopathology of vasovenous fistula. Cross-sectionof vas deferens show vas deferens (black arrow) surrounded by numerous blood vessels (open arrow) that are contained in fibrovascular tissue. Reduced from X50.
tomy so as not to injure vascular structures is important to prevent these complications. Surgical treatment is warranted when vascular fistulas arise. REFERENCES
<'ON('I,tiSlONS
Vascular fistulas post-vasectomy a r e rare. Only 1 arteriovenous fistula and no vasovenous fistulas have been previOUsIV described. Careful operative technique during vasecAcrepttxd for publication May 2, 1997 Supported in part by a National Institutes of Health grant
2243
1. Goldstein. M.: Surgery of male infertility and other scrotal disorders. In: Campbell's Urology, 6th ed. Edited by P. c. Walsh, A. B. Retik. T. A. Stamey and E. D. Vaughan, Jr. Philadelphia: W. B. Saunders Co., vol. 3. chapt. 87. pp. 3124-3125, 1992. 2. Aauman. J. R.: Swrmatic cord arteriovenous fistula: an unusual complication o i vasectomy J Urol , 134: 768, 1985