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Introduction Repair of obstructive azoospermia caused by childhood herniorrhaphy may be difficult. Therefore, intracytoplasmic sperm injection using testicular sperm is performed. However, vasovasostomy combined with laparoscopic surgery is challenging. Case presentation A 42-year-old man underwent inguinal hernia repair at age 3. He had normal testicular size, azoospermia, normal hormone levels (follicle-stimulating hormone, luteinizing hormone, and testosterone), absence of Y chromosome micro deletion, and karyotype:46XY, t(1:21)(p34.1:q22.3). He was diagnosed with obstructive azoospermia. Repeated intracytoplasmic sperm injections using testicular sperm resulted in miscarriages. Vasovasostomy combined with laparoscopic surgery was subsequently performed. Postoperative semen analysis result was almost normal. After intracytoplasmic sperm injection of ejaculated sperm, his wife got pregnant. Conclusion Even if patients have chromosomal abnormalities, performing microsurgical re-anastomosis first is recommended. To our knowledge, this is the first case of a laparoscopy-assisted vasovasostomy for post-herniorrhaphy vas deferens obstruction in Japan.

OBJECTIVE Improvements in success rates of assisted reproduction led to predictions that infertility surgery in both women and men would become extinct in developed countries. We sought to identify the changes in reproductive surgery that occurred between 2001 and 2015 to determine whether these predictions have been accurate. DESIGN The Australian Institute of Health and Welfare (AIHW) national procedural dataset and the Australian Medicare Benefits Scheme (MBS) claims database were searched for procedure data for male and female reproductive surgery and assisted reproduction from January 2001 to December 2015. The denominators were based on annual point estimates of the total population aged 25-44 years (female) and 25-55 years (male) from the Australian Bureau of Statistics (ABS). This dataset provides procedures undertaken but not their indications. RESULTS Over the study period the incidence of tubal surgery fell by 66%, vasectomy reversal by 33%, and surgical varicocoelectomy by 50%. In contrast, the rate of hysteroscopic myomectomy increased by 48%, hysteroscopic septoplasty by 125%, and laparoscopy for severe endometriosis increased by 84%. In vitro fertilisation oocyte retrievals increased by 90%. The rate of abdominal myomectomy was unchanged. CONCLUSION Fertility surgery is not dead but has evolved.

Background In the era of improving assisted reproductive technology (ART), patients with obstructive azoospermia (OA) have 2 options: vasal repair or testicular sperm extraction with intracytoplasmic sperm injection. Vasal repair, including vasovasostomy (VV) and vasoepididymostomy (VE), is the only option that leads to natural conception. Methods This article reviews the surgical techniques, outcomes, and predictors of postoperative patency and pregnancy, with a focus on articles that have reported over the last 10 years, using PubMed database searches. Main findings The reported mean patency rate was 87% and the mean pregnancy rate was 49% for a patient following microscopic VV and/or VE for vasectomy reversal. Recently, robot‐assisted techniques were introduced and have achieved a high rate of success. The predictors and predictive models of postoperative patency and pregnancy also have been reported. The obstructive interval, presence of a granuloma, and intraoperative sperm findings predict postoperative patency. These factors also predict postoperative fertility. In addition, the female partner's age and the same female partner correlate with pregnancy after surgery. Conclusion In the era of ART, the physician should present and discuss with both the patient with OA and his partner the most appropriate procedure to conceive by using these predictors.

Purpose To investigate the incidence, etiology, treatment indications, and outcomes regarding infertile male patients in Japan. Methods Between April, 2014 and March, 2015, the authors contacted 47 clinical specialists in male infertility who had been certified by the Japan Society for Reproductive Medicine. The participating clinicians were sent a questionnaire regarding information on their infertile patients, according to etiology and the number and success rates of male infertility operations that had been performed in their practice. Results Thirty-nine specialists returned the questionnaire and provided information regarding 7268 patients. The etiology of infertility included testicular factors, sexual disorders, and seminal tract obstruction. During the study year, the clinicians performed varicocelectomies, testicular sperm extractions (TESEs), and re-anastomoses of the seminal tract. The rate of successful varicocelectomies was >70%. The sperm retrieval rates with conventional TESE and microdissection TESE were 98.3% and 34.0%, respectively, while the patency rates with vasovasostomy and epididymovasostomy were 81.8% and 61.0%, respectively. Conclusion Surgical outcomes for infertile male patients are favorable and can be of great clinical benefit for infertile couples. To achieve this, urologists should work in collaboration with gynecological specialists in order to optimize the treatment of both partners.

Summary The purpose of this study was to identify factors which impact a couples’ decision‐making between the options of vasectomy reversal vs. sperm retrieval/in vitro fertilization/intracytoplasmic sperm injection when counseled both by a reproductive urologist and a reproductive endocrinologist. A retrospective chart review was performed of couples who wish to achieve a pregnancy with a male partner with a history of prior vasectomy, in a couples’ private fertility center. Of patients presenting for fertility options with a history of vasectomy, 175 couples elected to be counseled by both a reproductive urologist and a reproductive endocrinologist on the options between vasectomy reversal and sperm retrieval/in vitro fertilization/intracytoplasmic sperm injection, with 78.3% of the couples opting for vasectomy reversal and 21.7% opting for sperm retrieval/in vitro fertilization/intracytoplasmic sperm injection. The overall mean age of the male partners was 40.5 years of age, and the mean age of the female partners was 33. The mean obstructed interval was 9.7 years. Twenty‐three percent of the female partners in couples selecting vasectomy reversal had diminished ovarian reserve, and 31.6% of couples selecting sperm retrieval/in vitro fertilization/intracytoplasmic sperm injection had female partners with diminished ovarian reserve, two of which elected to have donor oocyte in vitro fertilization/intracytoplasmic sperm injection. Male age, female age, and ovarian reserve status did not have significant roles in this decision‐making (p value 0.3578, 0.1185, and 0.3041, respectively); however, a longer obstructed interval since vasectomy was a significant factor associated with couples opting for sperm retrieval/in vitro fertilization/intracytoplasmic sperm injection (0.0238). In this study, the majority of couples who were counseled on vasectomy reversal vs. sperm retrieval/in vitro fertilization/intracytoplasmic sperm injection by a reproductive urologist and reproductive endocrinologist chose vasectomy reversal. Neither male partner age, female partner age, nor ovarian reserve status seemed to impact the decision; however, a longer obstructed interval was a significant factor that was associated with the decision of couples toward sperm retrieval/in vitro fertilization/intracytoplasmic sperm injection rather than vasectomy reversal.

We evaluated pre-operative and intraoperative factors associated with successful patency following bilateral microsurgical vasovasostomy (VV). We retrospectively reviewed the charts of 1331 men who underwent bilateral VV by two surgeons between 2006 and 2013. Vasal fluid was examined intraoperatively for gross quality (i.e., clear or opaque and creamy/thick) and for the presence of spermatozoa on microscopy (i.e., whole spermatozoa, sperm fragments, or azoospermia). Post-operative patency was assessed by semen analysis or patient report of conception. Perioperative factors were explored using descriptive statistics and examined in logistic regression models for associations with post-operative patency. The median age at VV was 39 years [interquartile range (IQR): 35-44] and the median obstructive interval (OI) was 7 years (IQR: 4-11). Overall, 1307 patients achieved post-operative patency (98%) while 24 remained obstructed (2%). Among those who became patent, 410 reported conception. After adjustment for potential confounders, only microscopic examination of the intravasal fluid for the presence of spermatozoa (bilateral or unilateral whole spermatozoa vs. sperm parts/azoospermia) at the time of VV was significantly associated with post-operative patency with an odds ratio (OR) of 14.2 (95% CI: 5.8-34.9; p =

Summary The technique and the results of microsurgical vasectomy reversal in a singlecentre study over 18 years are presented. Both vasovasostomy (VV) and epididymovasostomy (EV) were carried out in a three-layer technique. With strict adherence to the strategy, end-to-end VV was only performed if spermatozoa had been demonstrated at the epididymal stump of the vas. In all other cases, EV was carried out in a preocclusive region of the epididymal tubule. The outpatient procedure of refertilization was associated with a very low complication rate, which underlines its minimal-invasive character. The follow-up rate was 71%, the overall patency rate was 89% and the pregnancy rate was 59%. Secondary azoospermia was only observed in 1% of the patients. In relation to the intervals of obstruction, the patency and pregnancy rates were higher after short-term obstruction than after long-term obstruction. Correspondingly, higher success rates were found after VV than after EV. This is understandable because the probability for indication of EV increases with longer periods of obstruction. There is a significant discrepancy between patency and pregnancy rates that is likely to be caused by a relevant number of patients with postoperative asthenozoospermia. The duration of obstruction is an important factor concerning epididymal damage, but it only disproportionately affects the results of refertilization if the technology of EV is implemented consistently in case of an epididymal granuloma. Good clinical results are achieved with this strategy, as evidenced by pregnancy rates and semen analyses.

Anatomically, the human epididymis is unusual when compared with the excurrent duct of other eutherian mammals. Furthermore, clinical observations suggest that it may not be as important for sperm maturation as is the case for laboratory animals. In contrast, hierarchical clustering of microarray data of epididymides from normal men revealed 2274 modulated qualifiers between the epididymal segments, 1184, 713, and 269 of them being highly expressed in the caput, corpus, and cauda, respectively. The organization of qualifiers according to their similarities by gene ontology indicated that caput transcripts are dedicated to cell-cell adhesion, whereas the corpus is characterized by genes involved in response to other organisms (ie, defense mechanisms) and the cauda transcriptome is specialized in muscle contraction and establishment of localization. A region-specific gene expression pattern thus characterizes the human epididymis as in animal models. In humans, vasectomies have consequences on the epididymal transcriptome. Cluster analysis revealed that 1363 genes are expressed in both normal and vasectomized epididymides, whereas 911 and 660 of them are specifically expressed in normal and vasectomized epididymides, respectively. Three of the affected genes are particularly interesting because of their involvement in sperm biochemical remodeling during epididymal transit: dicarbonyl/l-xylulose reductase, Niemann-Pick disease, type C2, and cysteine-rich secretory protein 1. In some vasovasostomized men, these modifications in gene expression induced by vasectomy are irreversible, thus affecting the biochemical parameters, and potentially, the function of their ejaculated sperm. This may explain the discrepancies between a surgically successful vasovasostomy and fertility recovery.

Contraceptive techniques which target vas deferens have been paid great attention for their good efficacy, safety and reversibility. We have made a filtering-type intra-vas device (IVD) using nano-copper complex/polymer composites. Twenty male adult Beagle dogs and 40 male rabbits were randomly assigned to four groups (sham-operation, IVD, reversal and vasectomy groups). Dogs' semen parameters, concentration of α-glucosidase, copper and zinc ions were tested pre-operation and 1, 3, 6 and 12 months post-operation. The pregnancy rates of the rabbits were evaluated by mating trials after the IVDs were implanted. The histology of testis, epididymides and vas deferens of the animals was examined using an electron microscope. Apoptosis of the cells in the testes, epididymides and vas deferens was detected by TUNEL method. There was no sperm in the semen of dogs, which had been inserted IVD and vasectomized at 1, 3, 6 and 12 months post-operation. The concentration of α-glucosidase in the IVD group, reversal group and sham-operation group was not significantly different between pre- and post-operation. The pregnancy rates of the female rabbits in the vasectomy, IVD and reversal groups were all zero, but the pregnancy rate in the reversal group, after taking out IVD, and that of the sham-operation group was 60% and 80%, respectively. The ultrastructures of the testes, epididymides and vas deferens of the male animals in the IVD group and sham-operation group were in normal ranges compared with the vasectomy group. The apoptosis of the cells in the testes, epididymides and vas deferens in the vasectomy group of both dogs and rabbits was obvious compared with the other groups. No significant changes in the quantities of copper and zinc ions were found in semen of the male dogs both pre- and post-operation. Our studies demonstrated that the filtering-type nano-copper complex/polymer composites intra-vas device may be an efficacious, safe and reversible male contraceptive device.

Vasectomy is a very common operation and has been accepted as a method of family planning by ≈ 42 million couples worldwide. While it is usually a well-tolerated and highly effective form of birth control, it has a risk of significant morbidity in ≈ 1% of patients [1]. One particularly troubling complication after vasectomy is chronic testicular pain, which has been defined as intermittent or constant, unilateral or bilateral testicular pain for ≥ 3 months. The pain is intense enough to interfere with the patient’s daily activities and prompts him to seek medical attention [2]. The definition of chronic testicular pain after vasectomy has developed with time, as have the names of this syndrome. Various terms have been applied to this condition, including postvasectomy orchalgia, congestive epididymitis, and chronic testicular pain. Currently the syndrome is generally termed postvasectomy pain syndrome (PVPS) [3]. In this article we review the salient diagnostic and therapeutic features of this vexing medical problem.

OBJECTIVES To investigate the use of a newly designed stent in the reconstruction of the vas deferens. MATERIALS AND METHODS In 26 New Zealand White rabbits, 13 conventional one-layer microscopic reconstructions were compared with 13 stented reconstructions of the vas deferens. The newly designed nonabsorbable polymeric stent was shaped to facilitate the rejoining of the two loose ends of the vas deferens, using a central ridge to prevent migration. Semen was collected before and after surgery, using an artificial vaginal system (26 samples before and 115 after surgery). The individual and average total sperm count, motility and progressive motile sperm density (PMSD), were compared after surgery for both groups. After the final semen analysis, rabbits were killed and patency was assessed histologically at the site of the anastomosis. RESULTS After an initial decline the mean total sperm count increased in both groups. The increase was significantly larger (P = 0.05) in the stented rabbits. The mean motility and PMSD showed no significant differences between both groups (P = 0.11 and 0.71, respectively). Histological examination of the anastomosed area showed partial obstruction (>50% narrowing of the original lumen) in five of the 13 conventionally treated rabbits, with no strictures in the stented group. Despite the narrowing in the conventional group the patency rates were not affected. The mean (range) operating time for the conventional and stented groups was 132 (99–168) and 98 (62–113) min, respectively (P

OBJECTIVE To investigate the current incidence of vasectomy reversal procedures, the techniques used and which practitioners use them. PATIENTS AND METHODS Using a questionnaire, 130 general surgeons and urologists practising in Merseyside and North Wales were surveyed. RESULTS The response rate was 74%, with 24 urological surgeons and 14 general surgeons undertaking vasectomy reversal. Annually, urological surgeons carried out significantly more procedures than did general surgeons, at 8.5 and 5.3 (P = 0.029), respectively. They were also more likely to use double-layer closure and microsurgical techniques, whilst significantly less likely to use stents. Urologists reported significantly greater patency rates, at 76% and 52% (P = 0.017), respectively, with no significant differences in subsequent pregnancy rates (30% vs 25%). Only one practitioner checked tubal patency in the female partner before vasectomy reversal. CONCLUSIONS The use of vasectomy reversal is a cost-effective treatment for men wanting paternity after vasectomy. The technique used by the clinician and proper audit of the results require close attention; it would also appear to be obvious that all the partners of men seeking a vasectomy reversal should have their fertility status established before reversal, something that is clearly not done at present.

Objectives To examine trends in vasectomy and vasovasostomy, and the surgical complications and factors associated with reversal after vasectomy, and paternity after vasovasostomy. Patients and methods Procedure rates were estimated from 1980 to 1996 in the population of Western Australia. Linked hospital morbidity records were used in the follow-up of men after vasectomy to estimate the risks of complications and reversals. Records of vasovasostomies were linked to the paternity field on birth registrations. Independent effects of the study factors were examined using Cox regression. Results There was little net change in vasectomy rates, whereas vasovasostomy rates increased in men aged 30–49 years. Risks of surgical complications were low and decreased for vasovasostomy. At 12–15 years after vasectomy, the risk of reversal levelled at 2.4% in the total cohort and at 11.1% in men aged 20–24 years. The risk of vasovasostomy was 69% greater after vasectomy performed in 1994–96 than in 1980–84 (P = 0.011). The factors strongly associated with reversal were age

Objective To determine, in failed vasectomy reversal, the usefulness of a revised anastomosis using microsurgery in achieving sperm in the ejaculate and fertility, and to relate the outcome to the site of the anastomosis, length of time from vasectomy, and presence or absence of sperm in the vas at surgery. Patients and methods In a series of 28 patients with confirmed anastomotic obstruction undergoing vasectomy reversal (over a 10-year period), a microsurgical technique using an oblique end-to-end two-layer interrupted anastomosis with 10/0 Nylon was used to establish vasal continuity. Subsequent seminal analysis at 3–6 months and ensuing paternity were related to several variables. The results were compared with those obtained after 137 cases of primary microsurgical vasovasostomy. Results Sperm was restored to the ejaculate in 16 (57%) of the patients and successful fertilization was reported in nine (32%). The interval between vasectomy and reversal surgery was relevant to the outcome, with four out of four men having sperm in the ejaculate within 5 years and three achieving paternity. However, the fertility rate was still moderate after an interval of 6–10 years (two of six) and at > 10 years (four of 18). The presence of sperm in the ejaculate was related to whether or not sperm were found in the testicular end of the vas at operation, but absence did not preclude a successful outcome. The overall results were not significantly different from those after primary microsurgical reversal surgery. Conclusion Microscopic vasovasostomy after previous obstructive failure provides the patient with a further reasonable chance of becoming fertile; although diminishing with time from vasectomy, even after a prolonged period there can be success. The absence of sperm at the time of vasovasostomy does not necessarily indicate failure, but in these cases the presence of thick creamy fluid in the vas predicts a poor outcome, and alternative methods of management should be considered. A microsurgical technique extending, if necessary, well into the convoluted part of the vas, is recommended. Microsurgical skills, relevant equipment and adequate time are required.

Objectives To determine the incidence of intravasal azoospermia (IVA) and evaluate which factors before and during surgery influence outcome, by prospectively and intentionally performing bilateral vasovasostomies (VVs) only in men with intraoperative IVA. Patients and methods Using a multilayer technique, 472 men underwent microsurgical reconstructive procedures. Intravasal fluid was examined for sperm by the surgeon and a pathologist. Strict enrolment criteria included total absence of sperm or sperm parts and bilateral VV as a treatment procedure. Patients were followed up by semen analysis and paternity assessed only by naturally conceived pregnancies. Results Of the 472 patients, 27 (5.7%) had bilateral IVA; 15 of these patients were available for a follow-up of 1–47 months. Eleven patients had identical gross appearance of intravasal fluid bilaterally. Of these patients, five had sperm in the ejaculate after surgery (three with clear intravasal fluid and two with no fluid). Bilaterally different vasal fluid was found in four men. Unilateral clear fluid was present in three patients, two of whom had sperm in semen analysed after VV. Overall, there was sperm in the ejaculate in seven of 15 patients with IVA; five of these seven had clear fluid in at least one vas deferens. One patient with unilaterally clear fluid achieved paternity by a naturally conceived pregnancy. The difference between the mean (sem) obstruction interval in men who had sperm in a semen sample after VV, at 16.7 (3.30) years, and in persistently azoospermic patients, at 15.5 (1.89) years, was not statistically significant (P = 0.741). Conclusion The results of VV in patients with IVA are unsatisfactory; the patency rate is higher in men with copious clear fluid in at least one vas. The obstructive interval in patients with IVA does not appear to influence the outcome of VV.

Objective To compare the outcome of a modified one-layer and two-layer vasovasotomy (VV) in two groups of similar men undergoing vasectomy reversal. Patients and methods The charts and surgical records of all surgical procedures performed on men undergoing a modified one- or two-layer VV between June 1992 and July 1994 were retrospectively reviewed. A successful outcome (patency) was defined as sperm present at follow-up (mean follow-up 8 weeks). A modified one-layer VV was used in 17 men (group 1) and a two-layer VV in 23 (group 2). Results Sperm were present in both groups if surgery was undertaken after vasal obstruction lasting 96 months. The mean operative duration was 96 min for a modified one-layer VV and 167 min for the two-layer VV. Conclusions The simpler and faster modified one-layer VV provides sufficient accuracy for successful vasectomy reversal in most cases. For most patients, both procedures have equivalent patency.

Recent technical advances in microscopy have greatly improved the reconstruction of the seminal tract in cases of obstructive azoospermia. The authors evaluated the clinical outcome of 28 patients with obstructive azoospermia who underwent microsurgical reconstruction (i.e. vasovasostomy or unilateral epididymovasostomy). Diagnoses included post-vasectomy cases (n = 9) childhood inguinal herniorrhaphy (n = 10) and cases of unknown cause (n = 9). 6 of the unknown cases proved to be inoperable. The authors analyzed the outcome of the surgical reconstructions of operable cases according to the causes of obstruction duration of obstruction quality of the fluid obtained from the distal seminal tract (concentration morphology and motility of sperm) and the histologic findings of the testis. The surgical outcome was analyzed with regard to the incidence of patency and pregnancy. The incidence of patency achieved in nine vasectomy cases was 89% while the incidence of pregnancy was 44%. In contrast the incidence of patency in the 9 operable cases with herniorrhaphy was 44% while the pregnancy rate was 0%. Of 4 cases of unknown cause who underwent epididymovasostomy the incidence of patency was 100% and the incidence of pregnancy was 75%. The outcomes were worse in post-vasectomy cases with long-term obstruction of more than 10 years; however this was not statistically significant. The outcome was significantly worse in cases with low sperm concentrations. There was no significant relationship between histologic findings and surgical outcome. The surgical outcome of vasovasostomy of post-herniorrhaphy cases was significantly worse than that of post-vasectomy cases. With regard to epididymovasostomy a unilateral repair was clinically evaluated. (authors)

This study evaluates the use of sutureless laser welding for vasovasostomy. In 14 rodents, the left vas deferens underwent vasovasostomy using an albumin-based solder applied to the adventitia of the vas deferens. The solder contained the dye, indocyanine green, to allow selective absorption and denaturation by a fiber-coupled 800-nm diode laser. The right vas deferens served as a control, receiving conventional layered microsurgical repair. We used a removable 4/0 nylon stent and microclamps to appose the vas deferens during repair, with no need for stay sutures. The mean time to perform laser solder repair (23.5 min) and conventional repair (23.3 min) were not significantly different (P = 0.91). However, examination after 8 weeks showed that granuloma formation (G) and patency (P) rates for the conventional suture technique (G, 14%; P, 93%) were significantly better than observed for the laser solder technique (G, 57%; P, 50%). © 1998 Wiley-Liss, Inc. MICROSURGERY 18:414–418, 1998

Objective To evaluate changes in histology and semen variables after using an elastomeric-hydrogel matrix plug as a reversible vasectomy device in dogs, and to determine the potential applications for improving fertility after vasectomy reversal. Materials and methods Semen samples from six adult male dogs were obtained after left vasal ligation, placement of the plug in the right vas deferens, and subsequent removal of the plug. The vasa, epididymides and testes were evaluated histologically in four of the dogs after removal of the implant. Results No sperm were present in the ejaculate after the plug was removed. Histological sections showed intraluminal spermatids in areas where the plug had been placed. The lumen was occluded, secondary to foreign-body giant-cell reaction, at the vasotomy suture site, but other areas of the vas previously containing the implant remained patent after it was removed. Conclusions There were no sperm in the ejaculate after the plug was removed because the vasal lumen was occluded as a result of an inflammatory reaction to the suture material. In contrast, areas that had contained the implant but without a vasotomy suture were not inflamed. We suggest that further trials comparing various suture materials are carried out to determine if patency rates can be improved during vasotomy closure or vasovasostomy.

OBJECTIVES To compare the outcome of loupe-assisted, modified one-layer vasovasostomy (MOLV) and conventional microsurgical MOLV for vasectomy reversal. PATIENTS AND METHODS We retrospectively analysed data for 74 patients who had a MOLV between 1993 and 2003; 42 had the standard microsurgical (x10-16) MOLV (group 1, mean age 40.5 years, SD 6.3, range 30-58) and 32 a loupe-assisted (x 3) MOLV (group 2, mean age 41.3 years, SD 6, range 28-64). With general anaesthesia, each operation was performed as an outpatient procedure or with hospitalization for one night after surgery. The patients' characteristics, patency rate, paternity rate, and operative duration were compared. RESULTS The mean (SD, range) duration of obstruction was 8.1 (5.0, 0.33-25) years in group 1 and 9.2 (4.8, 0.33-27) years in group 2. The postoperative patency and pregnancy rates were 91% and 43% for group 1 and 89% and 39% for group 2. There were no complications during or after surgery in either group, but the surgery was significantly faster for group 2. CONCLUSIONS There was no significant difference in the patency and paternity rates between loupe-assisted and microsurgical MOLV. The surgery was significantly faster with the loupe-assisted method. Because of the shorter operation duration and less expensive instruments required that should reduce the cost, the loupe-assisted MOLV should be considered as the best choice for simple vasectomy reversal.

Objectives To compare fibrin-glued vasovasostomy to a conventional microsurgical technique in a protocol of delayed vasovasostomy. Materials and methods Forty male Sprague-Dawley rats underwent bilateral vasectomy through a midline abdominal incision. Two weeks later all animals underwent a bilateral vasectomy reversal through a bilateral inguino-scrotal incision, following two different protocols. Invariably, the proximal segment had a larger lumen. The control group (20 rats) had a conventional modified one-layer sutured vasal anastomosis with 10/0 nylon. The experimental group (20 rats) underwent vasal anastomosis using fibrin glue and consisting of three transmural sutures with 10/0 nylon followed by the application of fibrin glue circumferentially to seal the anastomosis. The fibrin-tissue adhesive was obtained from pooled donor plasma and was virally inactivated by a solvent-detergent treatment. Seven weeks after surgery all animals were killed and the vasal specimens were evaluated for gross patency and the incidence of sperm granuloma. Results The control group had a patency rate of 85% and half had sperm granuloma. The experimental group had a patency rate of 92% and 40% had sperm granuloma; neither difference was significant. The mean operative time was significantly shorter for the fibrin glue-assisted vasovasostomy (P

The electrical pattern of the vas deferens, or electrovasogram (EVG), was studied in 22 healthy volunteers, 20 vasectomy subjects and 18 individuals after vasectomy reversal. Their mean ages were 38.8 +/- 7.3, 44.3 +/- 7.9 and 58.6 +/- 6.6 years, respectively. Two electrodes were applied to the posterior aspect of the upper part of the scrotum. During the operation of vasectomy reversal, an electrode was applied directly to each of the two vasal segments before and immediately after vasovasostomy. The electrical activity and intravasal pressure were measured. In normal subjects, slow waves or pacesetter potentials (PP) were recorded. They had identical frequency and a regular rhythm from the two electrodes and were consistent in the individual subject on all test days. PP were followed randomly by bursts of action potentials (AP). In vasectomized subjects, PP from the proximal vasal segment exhibited an irregular rhythm (vasoarrhythmia). During operation for vasectomy reversal, the proximal vasal segment recorded vasoarrhythmia whereas the distal segment revealed a silent EVG. Intravasal pressure was normal (p0.05) in the distal segment but high (p0.05) in the proximal segment. EVG performed 1-6 years after vasectomy reversal showed a normal pattern in four subjects and diminished frequency and amplitude in three. These seven subjects had impregnated their wives and had an obstructive interval of3 years. The 11 subjects who did not produce a pregnancy had a vasoarrhythmic EVG and an obstructive interval of3 years. In conclusion, an EVG could be identified for normal subjects. Vasectomy resulted in a vasoarrhythmic EVG pattern which proved to be correctable by vasectomy reversal if the obstructive interval was short.In Egypt, the electrovasographic (EVG) pattern in men 32-66 years old was studied before and after vasectomy reversal. The study group consisted of 22 healthy volunteers, 20 vasectomized men, and 18 men after vasectomy reversal. In the normal subjects, the frequency, amplitude and velocity of conduction, and time between cycles were consistent on every test day. The slow waves or pacesetter potentials (PP) recorded transcutaneously from the proximal vasal stump of the vasectomized subjects had a lower frequency and amplitude when compared with normal subjects. Specifically, they exhibited vasoarrhythmia. The proximal vasal stump of vasectomy reversal patients exhibited the same vasoarrhythmic pattern as the vasectomized patients. On the other hand, no PP or action potentials (AP) were recorded on the distal vasal stump of the vasectomy reversal patients. At the distal vasal stump during the operation, the intravasal pressure was similar to that of normal values. At the proximal vasal stump, however, the intravasal pressure was significantly higher than normal values (p 0.05). Right after the vasectomy reversal, the intravasal pressure in the proximal vasal stump was much lower than before vasal reversal (p 0.05) but that in the distal stump did not change. 1-7 years after vasectomy reversal, the wives of 7 men had conceived, for a success rate of 38.8%. 4 of these men exhibited a normal EVG pattern, while the other 3 men exhibited a diminished frequency and amplitude and a normal PP pattern. The 7 men had an obstructive interval of 2.5-4 years compared to 4-6 years for the 11 men whose wives did not conceive. These men had a vasoarrhythmic EVG (i.e, irregular frequency, amplitude, and rhythm of PP). These findings show a vasoarrhythmic pattern in vasectomized men and that its normalization depends on the duration of the obstructive interval.

This paper details the operative techniques, results and reasons for reversals of vasectomy in military personnel. Fifty-two reversals were performed by two surgeons (AC & DW) over a 7 year period. Data collection was by (i) retrospective analysis of service documents, surgical registers and laboratory records and (ii) response to a questionnaire. The interval between original vasectomy and reversal varied from 5 months to 16 years. Change of sexual partner was the most common reason for requesting the procedure. There were two recorded postoperative infections and no postoperative mortality. Post-reversal semen analysis proved anastomotic success in 49 out of 51 cases (96%). Semen analysis was not returned for the remaining case. Of the couples who had been trying for at least 18 months, 28 out of 42 (67%) had conceived, including one miscarriage. A further seven cases had been trying for less than 18 months, or had no opportunity due to physical separation. Two of these seven patients ended their relationship soon after operation. Pregnancy outcome was unknown in three cases.

The aim of our study was to investigate the healing process after vasectomy reversal, comparing two suturing techniques. Eighty Wistar rats received a two-layer vaso-vasostomy on the right side, and 40 of them also received a single-layer vaso-vasostomy on the left side. Twenty rats each time were sacrificed at 30, 45, 60, and 90 days. Results were evaluated in order to compare the two techniques used and to describe the progression of healing, with special reference to anastomotic patency rate, histologic aspect of the epididymus and testicle, and the presence and size of spermatic granuloma. We observed 45% patency with the double-layer technique compared to 20% with the single-layer technique. The testicle appeared atrophic in 20% of double-layer cases compared to 40% of single-layer cases. Comparison over time showed a progressive increase in patency of the anastomosis, reduction of spermatic granuloma, and regression of testicular damage. Our results show the superiority of the double-layer technique, and contribute to an understanding of the role of two different suturing techniques in the outcome of vasectomy reversal.

Vasectomy remains the safest method of birth control and there is much to commend it in the setting of a stable family relationship. However, some aspects of this operation have been wrongly presented in an attempt to widen its popularity and increase public acceptance. A simple procedure it may be but it is not totally free of complications; sometimes the operation has to be repeated and rarely it may reverse spontaneously even after the most stringent precautions. The family planning officer who counsels a prospective candidate and the surgeon who undertakes the procedure must ensure that these facts are understood by the patient with crystal clarity and that this fact is duly recorded on a signed and witnessed permission slip. Any organization which includes vasectomy in its programme of family planning should include advice and referral for vasectomy reversal in exactly the same way that the pill may be stopped or a coil can be removed. Fertility can be successfully restored by vasovasostomy in 50% of men who wish to have their vasectomies reversed, which often is due to a change in circumstances beyond their direct control.Vasectomy is the most reliable method of birth control. More than 33 million couples now rely on it in the United States, the United Kingdom, India, China, Thailand, South Korea, Canada, the Netherlands, and New Zealand. Many of the problems associated with vasectomy can be prevented by discussion about the procedure beforehand with the couple concerned, with clear warning that complications can sometimes occur. Recently, a no-scalpel technique has been introduced by Dr Li Shunqiang in China with good results. During 10 and 12 weeks follow-up, semen should be examined. The detailed study of 1000 vasectomies performed under local anesthetic at the Margaret Pyke Centre in London defined the expected complication rate. Two patients suffered vasovagal attacks during the operation and required resuscitation. Minor hematomas occurred in 3.5%. 12 developed minor sepsis but only one abscess occurred. Three cases of epididymo-orchitis were seen. Altogether, 5.6% of patients complained of minor local symptoms including bruising. In the large Oxford Series, 7.7% sought medical advice for local pain and 3.6% for bleeding. Scrotal hematoma developed in 0.9%. 80% returned to work in 3 days and 96% within 1 week. Spermatozoa have been found in a para-aortic lymph node one year after vasectomy in a man undergoing laparotomy, and circulating antisperm antibodies can be detected by sperm-agglutination tests in the serum of 60-80% of men following vasectomy. Technical difficulties with vas anastomosis and secondary changes in the epididymis make the chances of successful restoration of fertility only a little better than 50%. There are four causes of failure of vasectomy reversal: 1) in about half of patients there is stenosis or blockage of the previous vaso-vasostomy, 2) the second most common cause is epididymal blockage, 3) development of a very high antisperm antibody response to the vasectomy, and 4) cessation of spermatogenesis.

The objective was to determine whether microsurgery achieves a better result in vasectomy reversal than other macroscopic techniques. A series of 103 consecutive patients with a median age of 36 years (range 26-58) who underwent microsurgical vasovasostomy was studied. The method was a modification of a two-layer anastomotic technique. In the first 49 patients 8/0 Vicryl was used to create a two-layer anastomosis; in the subsequent 54 patients 10/0 Ethilon was used. The results can be divided into 2 groups: 42 of the patients for whom 8/0 Vicryl was used for the anastomosis and 47 of the patients for whom 10/0 Ethilon was used. When bilateral vasovasostomy had been performed with 8/0 Vicryl 85% of the patients had sperm in the ejaculate for 6 months and longer. The rate increased to 94% in those for whom 10/0 Ethilon had been used as the suture material but the difference was not statistically significant. A significantly reduced proportion (58%: p < 0.02) of patients who underwent unilateral vasovasostomy had sperm in the ejaculate. In half of the patients sperm concentration quality and motility improved over the 12 months following reversal. In 50% of patients there was a significant improvement in sperm concentration of between 25 and 200%. Follow-up ranged from 8 months to 5 years. The fertility rate was 64% if the vasectomy had been performed within 10 years and fell to 39% if 10 years or more had elapsed. In the 10 patients who had undergone a failed reversal attempt elsewhere 4 had sperm in the ejaculate and 2 of these patients became fertile. The total number of pregnancies reported in the partners of the patients who reported back for seminal analysis 3 months or longer post operation was 31 (48%). Of these the median interval between vasectomy and vasectomy reversal was 7 years. The microsurgical approach to vasovasostomy obtained patency and fertility rates superior to those of other techniques.

Experimental rodent models simulating the condition of neurogenic infertility have drawn attention to the role of potential epididymal dysfunction as an underlying cause. This functional obstruction of the genital tract is comparable to the outcome of genital tract obstruction after vasectomy, and may explain the common finding of asthenospermia in both groups following either stimulated semen recovery or vasovasostomy, respectively. Since spermatogenic dysfunction has been reported in spinal cord injury, the relative roles of defective sperm production and sperm transport remain to be determined in men with neurogenic infertility. The objective of this study was to compare the levels of spermatogenesis in groups of vasectomized men and those with spinal cord injury, using objective measurement criteria for spermatogenesis. Groups of 10 spinal cord-injured and six vasectomized men matched for age and duration of disease, underwent incisional testicular biopsy. The specimens were divided equally for parallel quantitation of spermatogenesis by both quantitative cytometry and DNA flow cytometric analysis. Quantitative parameters showed similar values for both groups with reference to mean tubular wall thickness, mean tubular concentration of spermatids and Sertoli cells, as well as the mean spermatid: Sertoli cell ratio per tubule. Additionally, similar percentages of 1N, 2N and 4N cells, were found in both groups. Based on these preliminary findings this study provides a clinical correlation supporting the experimental observation that both anatomical and functional obstruction of the male genital tract exert a similar although minor spermatogenic insult, and that in both the putative cause for neurogenic infertility is more likely to be at the post-testicular level.

SUMMARY 1. The effects of ATP and some of its more stable analogues have been examined upon preparations of epididymal and prostatic halves of vasa deferentia and of cauda epididymides from rats that had undergone vasectomy by medial transection of the vas deferens. 2. After unilateral vasectomy, the potencies of ATP, β, γ-methylene ATP and 5’-adenylylimidodiphosphate (AppNHp) in tissues ipsilateral to the vasectomy were decreased compared to tissues from the contralateral unoperated side of the animal. 3. Tissues from bilaterally vasectomized rats were less responsive to ATP when compared to tissues taken from sham-operated rats. 4. Tissues taken from rats which had undergone vasovasostomies following unilateral vasectomy remained less responsive to these purines. 5. Responses of cauda epididymides and epididymal halves of vasa deferentia taken from unilaterally and bilaterally vasectomized rats to α, β-methylene ATP usually did not differ from those of respective controls. 6. It is proposed that the subsensitivity which develops to ATP and some of its analogues on the epididymis and vas deferens following vasectomy may reflect increased breakdown, perhaps associated with changes in structural integrity of the tissues, rather than with the sympathetic denervation which is associated with vasectomy.

Summary The significance of white blood cells in the ejaculate remains a matter of controversy. Several authors have suggested that such cells are important in the modulation of an antisperm antibody response, i.e. a predominance of suppressor/cytotoxic to helper/inducer T cells may prevent the development of antisperm antibodies. In order to examine this relationship further we have documented the white blood cell types, with emphasis on the T-lymphocyte populations, in the ejaculates of men from infertile couples with and without antisperm antibodies; the latter group was divided further into two groups—vasovasostomized men and idiopathic men. All seven of the men without antisperm antibodies had a predominance of suppressor/cytotoxic T cells to helper/inducer T cells in the ejaculate. However, only in some of the men with antibodies was there a predominance of T-helper/inducer cells. It is clear that the relationship between antisperm antibodies and seminal leucocytes is therefore not as straightforward as has been proposed.

This is the first arm of a two prong study conducted to learn two different aspects of vasovasostomy in dog vas deferens using the milliwatt carbon dioxide laser. The first study involved the evaluation of patency without collection of sperm. Six dogs were evaluated and all underwent vasectomy and subsequently had vasovasostomies performed between 4 and 12 weeks utilizing two approximating sutures and welding with the milliwatt carbon dioxide laser. Metal clips were used for both X-ray analysis and localization of the vasovasostomy site. In this investigation a vasogram was performed. Dogs were sacrificed at 4, 6, and 8 weeks postvasovasostomy. The vasovasostomy specimens were studied with electron microscopy and histological evaluation. The vasovasostomy was completed in under 120 minutes using this laser-assisted technique and was found to be a viable and promising technique for vasovasostomy.

SUMMARY 1. Anastomosis (vasovasostomy) of epididymal and prostatic halves of vasa deferentia was carried out in rats in which unilateral or bilateral medial transection (vasectomy) had been performed 4 weeks previously. 2. Noradrenaline levels in epididymal halves of vasa deferentia, 8 weeks after anastomosis with prostatic halves, were approximately 40% of those in epididymal halves of contralateral, unoperated vasa deferentia. Catecholamine fluorescence was partially restored after anastomosis. 3. Responses of epididymal halves of transected vasa deferentia to electrical field stimulation (1 ms, 60 V, 10 pulses at 0.01–50 Hz) were partially restored 8 and 15 weeks after anastomosis. 4. Noradrenaline was equipotent in causing contraction of epididymal halves of unoperated and anastomosed vasa deferentia at 8 and 15 weeks after vasovasostomy. The ability of nisoxetine (0.1 μmol/l) to potentiate the effects of noradrenaline was partially restored by vas deferens repair. 5. Noradrenaline levels and neurotransmission in prostatic halves of vasa deferentia were relatively unaffected by vasectomy and subsequent vasovasostomy. 6. Fertility was restored 4–8 weeks after bilateral anastomosis performed in a group of eight rats 4 weeks after bilateral vasectomy. 7. These observations show that in the rat the noradrenergic denervation of the epididymal segment of the vas deferens after medial transection is partially reversible by anastomosis 4 weeks later, and that full noradrenergic reinnervation of the organ is not essential for the return of fertility after vasectomy and vasovasostomy in this species.

In recent years considerable success has been achieved in the reanastomosis of the divided vas using microsurgical techniques. This report demonstrates that equally good results can be realized using a meticulous but simple technique under low power magnification. Such a technique is within the capability of any competent surgeon. 50 patients, aged between 26-56 years and in whom a bilateral vasectomy for contraceptive purposes had been performed from 14 months-7 years previously, have undergone vasovasostomy. The technique of end-to-end anastomosis of the divided vasa over a nylon splint, using fine interrupted silk sutures, was used in the majority of patients. In the end-to-end technique, each vas is approached through a small vertical scrotal incision, usually at the site of the previous vasectomy. The point of section of the vas is readily identified. It may be represented by a short slender segment of fibrosis or, on occasion, the vas is rejoined and the junction consists of vas of normal caliber with an obliterated lumen. On occasion 1 or other of the divided ends is expanded like drumsticks and they may be joined together or, less often, widely separated. In all cases the divided ends should be identified and cut back until a normal lumen can be identified by passing a blunt-ended number 22 hypodermic needle down both the proximal and distal ends. Each end should be mobilized to allow apposition without tension. A blunt-ended number 22 hypodermic needle is passed down the proximal vas and brought out through the wall of the vas about 2-3 cm from its end. Alternatively, a blunt, atraumatic needle with nylon thread may be passed down the vas and brought out through its wall in the same way. A 30 cm length of 3/0 nylon is threaded through the cannula and the cannula withdrawn over the nylon suture, thus leaving the nylon emerging from the lumen at the proximal end. This end of nylon is threaded up the distal vas for some 20-25 cm. The free end of the nylon emerging from the proximal vas is led out through the adjacent scrotal skin and anchored with an Emesay button. The nylon splints are removed 6-8 days postoperatively. In 42 of the 50 patients operated on motile sperms have reappeared in the ejaculate within 1-3 months following the procedure. In 26 patients (52%) their wives had a normal pregnancy with the birth of a health child. 1 wife aborted spontaneously. This clinical experience suggests that comparable results can be obtained using a conventional technique with low powered magnification, meticulous placement of four 7/0 silk sutures in the muscle layer only over a fine nylon splint removed within 6-8 days.

Vasovasostomy was performed in 20 rats. Vasography then was used to determine the patency of the vas. The scrotum was entered through a longitudinal incision and the scrotal contents were extruded extravaginally. The vas was divided near the epididymis and a 0.4/0.7-mm cannula was inserted into the abdominal end of the vas and contrast medium was injected under fluoroscopic control. The results were documented by radiography. It is concluded that vasography is a reliable method for assessing the success of vasovasostomy in rats.

The occurrence of alterations in testicular weight and morphology after vasectomy and vasectomy reversal by vasovasostomy was studied in Lewis rats. Animals were studied 3, 4, and 7 months after bilateral vasectomy or a vasectomy followed 3 months later by vasovasostomy. Other rats served as shamoperated controls. The weights of the testes in vasectomy and vasovasostomy animals fell into two groups—small testes weighing less than 0.88 g and normal-sized testes of 1.2 g or more. When the extent of testicular alterations was estimated in sections for light microscopy by use of a semiquantitative testicular biopsy score count (TBSC), the morphology of the testes corresponded closely to the testis weight (r = .94), small testes having correspondingly low TBSC scores. In severely altered small testes, the seminiferous tubules were narrower than in sham-operated rats, and numbers of germ cells were greatly depleted. Many tubules contained only Sertoli cells and spermatogonia, although spermatocytes were present in a minority of tubules. A few seminiferous tubules contained multinucleate spermatids. Electron microscopy of severely altered tubules revealed closely apposed processes of Sertoli cells, which contained filaments, microtubules, and endoplasmic reticulum. In contrast, testes with normal weight in vasectomy and vasovasostomy groups resembled those of the sham-operated animals. Comparison of distributions of testicular biopsy score counts demonstrated differences between vasectomy and vasovasostomy groups as time after operation increased. At the 3–4-month intervals, approximately one-third of the testes were severely altered in both vasectomy and vasovasostomy groups. However, by 7 months the proportion of altered testes progressed to 60% in animals with a vasectomy, while it remained similar to the earlier intervals in rats that had received a vasovasostomy. These results suggest that vasovasostomy may prevent the progression of testicular alterations that occur after vasectomy, but vasovasostomy does not appear effective in reversing testicular changes.

The immunoglobulin classes of the sperm-agglutinating antibodies in the seminal fluid and serum from four vasovasostomized men, as well as in operatively obtained testis-epididymis fluid from two of them, were investigated by specific solid-phase absorption of IgG, IgM, and IgA. In two patients the major part of the seminal agglutinins was IgA, and in one IgG, indicating that both local production and diffusion of sperm agglutinins from serum to the testis-epididymis compartment may take place. The total levels of immunoglobulins in seminal fluid generally increased after the operation, and IgM was present in two postvasovasostomy samples. This suggests a pathotopic potentiation effect of the vasectomy on the epithelial lining of the testis-epididymis compartment. Comparison of the results of solid-phase absorption with anti-IgA and anti-secretory component (SC) pointed to the presence of "free" SC in postvasovasostomy seminal fluid.

During the past decade, microsurgery has become a urologic subspecialty. Historically, vascular and vasal anastomosis have formed the foundation of genitourinary microsurgery. With the advent of improved instrumentation and the interest of devoted urologic microsurgeons, a multitude of new applications of microsurgery in urology have developed. In this paper, we discuss some of the new directions in male reproductive microsurgery.

A comparison is made of laser anastomoses of the murine vas deferens at different energies with the neodymium (Nd):YAG laser at 1.06 micron and 1.318 micron and with the CO2 laser. A total of 28 welds were performed with a free-hand technique employing a 600-micron silicon fiber with the Nd:YAG and a hand piece with a 500-micron spot size for the CO2. After 6 weeks, all animals were sacrificed and the vasa evaluated for patency. Fifteen out of 28 controls repaired with microsurgical techniques were found to be patent; 4/10 vasa were patent with use of the Nd:YAG at 1.318 micron at laser energies of 300 mW and 500 mW. At 1.06 micron, only 1/4 anastomoses was patent at a power setting of 1 W. None of the anastomoses performed with the CO2 laser was patent. Histologic study revealed intense fibrosis in all the lasered vasa, with sperm granuloma formation associated with most anastomoses. Although this is a preliminary study, it appears that the Nd:YAG laser at 1.318 micron and a power setting of 300-500 mW provides patency rates superior to the Nd:YAG at 1.06 micron and to the CO2 lasers and is equivalent to standard micro-surgical techniques in the murine vas deferens.

The results of 300 conventional vasovasostomies were evaluated clinically. The operations were carried out bilaterally under spinal or general anesthesia. Depending on the size of the nodule and the level of vasectomy, an end-to-end or side-to-side anastomosis technique was used. A higher rate of success was associated with 1) a shorter period of obstruction, 2) bilateral straight vas-to-straight vas anastomosis, 3) bilateral leakage of fluid with spermatozoa, and/or 4) seven or more days of hospitalization. Patency was established in 84% of the patients, and fertility was restored in 35%. The anatomical success rate in patients in which a two-fold magnifying loupe, four sutures of 6-0 nylon, and a stent were used in anastomosis (this procedure was used before 1970) was below 80%. Thereafter, four- to six-fold magnification and eight sutures of 9-0 nylon without stents were employed and were associated with a success rate of over 85%. The functional success rate increased from 20% before 1970 to 40% thereafter. Although several factors contribute to anatomical or functional failures, the most important is scar formation with sperm and suture granulomas at the anastomosis site. Perhaps these problems will be overcome by the new microsurgical technique for anastomosis.

Experimental studies in rats and bulls demonstrated the feasibility of using a silicone-Dacron prosthesis as a sperm reservoir in cases of excretory azoospermia. In the study of bulls, 50% of the cows inseminated with spermatozoa aspirated from the alloplastic spermatocele conceived and delivered healthy calves. The clinical results of a series of 14 humans suffering from excretory azoospermia not treatable by other means (e.g., epididymovasostomy or vasovasostomy) also are presented. THe aspirations from these spermatoceles produced motile spermatozoa; however, none of the patients'p spouses conceived after insemination.

Three instances of invasion of nerves of the spermatic cord by benign proliferative ductules of the vas deferens following vasectomy are reported. This phenomenon occurred in association with the histopathological features of vasitis nodosa and was noted in tissue removed during vasovasostomy in two cases and from a painful lower inguinal nodule at the site of vasectomy in a third example. Such neural invasion deserves attention because, especially in association with a proliferative ductular pattern, it may be mistaken for adenocarcinoma. The lesion is also of intrinsic interest in the light of benign neural invasion at other sites.3 cases of vasitis nodosa with benign neural invasion diagnosed in 1975-80 are presented. Vasitis nodosa is characterized by the development of nodular, often painful, lesions at the site of a previous vasectomy procedure. Topographic changes in these 3 men included a haphazard ramifying proliferation of doctules, associated in some areas with cicatricial connective tissue and a mild nonspecific inflammatory infiltrate. Spermatozoa were identifiable within the lumina of some of the newly formed doctules. In all 3 cases, distinct perineural and intraneural benign ductular invasion was present, with no appreciable histologic or cytologic difference between the invasive epithelial structures and their extraneural counterparts. Vasitis nodosa is considered to result from vasal obstruction with retroobstructive ductal extravasation of spermatozoa, the formation of histiocytic spermatic granulomas, and secondary regenerative ductular proliferation. There is concern that the florid ductal proliferation in this condition, especially when accompanied by epithelial invasion of nerves, could be mistaken for adenocarcinoma. The bland histocytologic appearance of the ductules and their lining epithelial cells, and the presence of spermatozoa with some of the ductular lumina, should enable differentiation of vasitis nodosa from a malignancy. The mechanism by which benign epithelial tissue assumes the capacity to invade nerves and perineural spaces is unknown.