624 CHAPTER 16 Urological surgery and equipment

Vasectomy and vasovasostomy

Vasectomy

This is the removal of a section of the vas deferens from each side with the aim of achieving infertility.

Indications: a method of birth control

Anesthesia: local or general

Postoperative care and common postoperative complications and their management

Postoperative hematoma can occur. If large, evacuation may be required. Infection can occur, but is usually superficial.

Two semen samples are required, usually at 10 and 12 weeks postvasectomy, before unprotected intercourse can take place. Viable sperm can remain distal to the site of vasectomy (in the distal vas deferens or seminal vesicles) for some weeks after vasectomy, and even longer.

Occasionally, a persistently positive semen analysis is an indication that the vas was not correctly identified at the time of surgery and has not been ligated (or, very rarely, that there were two vas deferens on one side). The potential for fertility remains in those with positive semen analysis, and re-exploration is indicated. Warn the patient that the vas deferens can later recanalize, thereby restoring fertility.

Sperm granuloma is a hard, pea-sized lump in the region of the cut ends of the vas, forming as a result of an inflammatory response to sperm leaking out of the proximal cut end of the vas. It can be a cause of persistent pain, in which case it may have to be excised or evacuated and the vas cauterized or re-ligated.

Vasovasostomy

This is vasectomy reversal.

Anesthesia

This tends to be done under general or spinal anesthesia, as it takes far longer than a vasectomy.

Postoperative care and common postoperative complications and their management

They are much the same as for vasectomy. The patient should avoid sexual intercourse for 2 weeks or so.

Vasectomy: procedure-specific consent form— recommended discussion of adverse events

Serious or frequently occurring complications

Common

•Irreversible

•Small amount of scrotal bruising

•Two semen samples are required before unprotected intercourse, both of which must show no spermatozoa.

VASECTOMY AND VASOVASOSTOMY 625

Occasional

• Bleeding requiring further surgery or bruising

Rare

•Inflammation or infection of testis or epididymis, requiring antibiotics

•Rejoining of vas ends resulting in fertility and pregnancy (1 in 2000)

•Chronic testicular pain (5%) or sperm granuloma

Alternative treatment is other forms of contraception (male or female).

Vasovasostomy: procedure-specific consent form— recommended discussion of adverse events

Serious or frequently occurring complications

Common

•Small amount of scrotal bruising

•No guarantee that sperm will return to semen

•Sperm may return but pregnancy is not always achieved

•If storing sperm, check that appropriate forms have been filled out

Occasional

• Bleeding requiring further surgery

Rare

•Inflammation or infection of testes or epididymis, requiring antibiotics

•Chronic testicular pain (5%) or sperm granuloma

Alternative therapy includes IVF, sperm aspiration, and ICSI.

626 CHAPTER 16 Urological surgery and equipment

Orchiectomy

Indications

There are two types—radical orchiectomy and simple orchiectomy.

Radical (inguinal) orchiectomy

This is done for excision of testicular cancer. This approach is used for three reasons:

•To allow ligation of the testicular lymphatics as high as possible as they pass in the spermatic cord and through the internal inguinal ring, thereby removing any cancer cells that might have started to metastasize along the cord.

•To allow cross-clamping of the cord prior to manipulation of the testis which, theoretically at least, could promote dissemination of cancer cells along the lymphatics (In reality, this probably doesn’t occur.)

•To prevent the potential for dissemination of tumor cells into the lymphatics that drain the scrotal skin that could occur if a scrotal approach is used. These lymphatics drain to inguinal nodes. Thus, direct spread of tumor to scrotal skin and violation of another lymphatic field (the groin nodes) is avoided. Historically, this was important because the only adjuvant therapy for metastatic disease was radiotherapy. The morbidity of groin and scrotal irradiation was not inconsiderable (severe skin reactions to radiotherapy, irradiation of femoral artery and nerve).

Obtain serum markers before surgery (A-fetoprotein, B-hCG, and lactic acid dehydrogenase [LDH]) and get a CXR. A full staging CT scan can wait until after surgery. If the contralateral testis has been removed or is small, offer sperm storage—there is usually time to do this.

Warn the patient that, very occasionally, what appears clinically and on ultrasound to be a malignant testis tumor turns out to be a benign tumor on subsequent histological examination.

Simple orchiectomy

This is done for hormonal control of advanced prostate cancer, via a scrotal incision, with ligation and division of the cord and complete removal of the testis and epididymis.

Alternatively, a subcapsular orchiectomy may be done, where the tunica of the testis is incised and the seminiferous tubules contained within are excised. There is the potential with this approach to leave a small number of Leydig cells that can continue to produce testosterone.

Anesthesia

Local, regional, and general anesthesia can be used. Few men will require or opt for local anesthetic.

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Postoperative care and common postoperative complications and their management

For both simple and radical orchiectomy

Scrotal hematoma can occur. Drain it if it is large or enlarging or if there are signs of infection (fever, discharge of pus from the wound).

For radical orchiectomy

Damage to the ileoinguinal nerve can lead to an area of loss of sensation overlying the scrotum.

Orchiectomy ± testicular implant: procedure-specific consent form—recommended discussion of adverse events

Serious or frequently occurring complications

Occasional

•Cancer, if found, may not be cured by orchiectomy alone.

•There may be a need for additional surgery, radiotherapy, or chemotherapy.

•Loss of future fertility

•Biopsy of contralateral testis may be required if an abnormality is found (small testis or history of maldescent).

Rare

•On pathological examination cancer may not be found, or the pathological diagnosis may be uncertain.

•Infection of incision may occur, requiring further treatment and possibly removal of the implant if this has been inserted.

•Pain requiring removal of implant

•Cosmetic expectation not always met

•Implant may lie higher in the scrotum than the normal testis did

•A palpable stitch may be felt at one end of the implant.

•Long-term risks of silicone implants are not known.