Technics and Complications of Elective Vasectomy

Transcription

1 Technics and Complications of Elective Vasectomy The Role of Spermatic Granuloma in Spontaneous Recanalization STANWOOD S. SCHMIDT, M.D. DESPITE the great frequency with which elective vasectomy is performed for birth control, 4 the failures and complications that accompany the various technics of vasectomy have received little careful study. Many technics exist, and articles continue to appear suggesting additional ones/i. 27 ranging from ligation of the vas deferens without incising the skin to resection of the entire scrotal vas. The cut ends of the vas may be ligated with silk, cotton, or linen; some authors advocate leaving the proximal end open although this is how spermatic granulomas are experimentally produced Many authors ignore the sheath of the vas, while others use it as a barrier between the cut ends. Writers in the "popular press" are unanimous in stating that one should tie each vas and remove a section The variety of technics suggests that the fundamentals of vasectomy are not widely understood and that physicians are still attempting to develop a technic that will be uniformly successful. That regeneration of the vas will frequently occur after simple ligation, single and multiple division, and resection of a segment of the vas was reported by Rolnick in The exact mechanism of regeneration was not shown. That restoration of fertility may later be requested is often overlooked by the physician. In an attempt to ensure the success of his sterilizing operation, he will often either remove large lengths of the vas, or interrupt the vas near or in its convoluted portion. He does not consider that ad- From thp Division of Urolo/l:y, University of California Medical Center, San Francisco, Calif. Presented at the meeting of The Pacific Coast Fertility Society, Oct. 30, Supported by a grant from The Population Council, Inc., New York, N. Y. The author gratefully acknowledges the assistance of Dr. Robert R. Morris in preparing the illustrations. 467

2 468 SCHMIDT FERTILITY & STERILITY vances in the technics of vasovasostomy~2, 31 have made successful reanastomosis highly probable if vasectomy has been done high in the straight portion of the vas without resection of a segment of the vas. This paper presents reports of a series of patients having elective vasectomy, a comparison of complications after the use of various technics, and an explanation of the basic role of spermatic granuloma in the process of spontaneous recanalization. A technic is presented that was evolved when personal cases showed a large number of postoperative recanalizations and other complications. The technic was designed to minimize such complications while ensuring successful birth control and facilitating future vasovasostomy. Elective vasectomy offers the opportunity to study vasectomy and its results without other complicating factors. The conclusions which are drawn from this study will apply equally to vasectomy when done to prevent epididymitis. CLINICAL MATERIAL The series consists of 432 patients operated upon over a period of 10 years. All patients choosing vasectomy for birth control during that period are included. All patients were observed for a period of 5 months or longer, and 417 were observed for more than 1 year. Neither the age of the patient or his mate, nor the number of children were significant factors in determining if the operation would be done. If the couple seemed emotionally mature and if they had given the procedure careful consideration, the husband was operated upon. If the wife was pregnant, operation was usually deferred until after delivery. In all cases, a preoperative interview was held with both husband and wife. The operation was carefully discussed from the physiological and psychological aspects and an attempt was made to dissuade any undecided or reluctant couples. The fact that spermatogenesis continues after vasectomy was stressed and the possibilities of reanastomosis were discussed. The importance of postoperative examination of semen for spermatozoa was explained and all patients were told that contraceptives could be discontinued only after 2 semen examinations, 1 month apart, had yielded negative results. (The words "factories," "roadblocks," and "reservoirs" permit me to explain this operation in language familiar to the patients.) The average age of the patients at the time of operation was 33.7 years. The age span is shown in Fig. l. Six patients had had previous and unsuccessful vasectomies performed

3 VOL. 17, No.4, 1966 ELECTIVE VASECTOMY 469 by other physicians. Three patients had congenital absence of one vas. One patient had an untreated undescended testis. All operations were done in the office under local anesthesia. All were done through bilateral scrotal incisions. In 288 operations, the vasa were., :~ "- ~ ld h "I Q. ~~ t !l.., ~ ~ ~ ':~ o -L,.., I II."'T""'""! I!: ii", I,,: i:, j i: t I, I,: iii Il---r-r:l ZI Z AGE IN YEARS Fig. 1. Age distribution for 431 patients at time of elective vasectomy; average age, 33.7 years. divided and the cut ends were doubly ligated with cotton. In 144 operations, the vasa were divided and the cut ends were not ligated, but were fulgurized with a needle electrode introduced 2 mm. into the lumen of the vas. In 155 operations, the cut ends of the vasa were dropped back into the wound after ligation or fulguration; in the other 277, the sheath was closed over the distal stump of the vas so that a barrier of fascia was placed between the cut ends. RESULTS Psychological complications are difficult to assess directly. One means is to note the requests for reanastomosis. Of the 432 patients reported here, 1 requested reanastomosis during a subsequent marriage; one discussed it but did not follow through with his plans; and the wife of a third patient has discussed it. One patient complained of postoperative impotence, his complaint being made 18 months after operation during a period of marital discord. Pain prevented only one man from returning to work promptly after operation. Delayed postoperative pain, diagnosed as not due to granuloma or other complications, occurred in 4 men: in 1 after 1 month, in 2 after 2 months, and in 1 after 8 months. The cut ends of the vas had been ligated in all 5 patients.

4 470 SCHMIDT FERTILITY & STERILITY Infection, necessitating administration of antibiotics, occurred in 17 patients (3.9%). Two of these infections required drainage; all others subsided uneventfully. No patient was hospitalized for infection. Hematomas, which subsided spontaneously, occurred in 8 patients ( 1.9%). Buried ligatures have been expelled from 8 patients (2.8% of those having had the ends of the vasa ligated), in 1 patient each at 2 weeks, 4 months, 8 months, and 1 year; and 2 patients each after 2 years and 3 years. No sutures have been expelled from the sheath of the vas. Recanalization occurred in 5 patients, in each of whom a section of the vas had been excised and the cut ends doubly ligated with cotton, but in whom the sheath had not been closed over the cut end. Recanalization has not occurred in patients in whom the sheath was closed or the lumen fulgurized. Spermatic granuloma arising from the cut end of the proximal vas occurred in 21 patients (4.9%) who had a total of 28 attacks. Two patients had two consecutive episodes of symptoms on the same side. Four patients had bilateral granulomas, not occurring in every case on both sides at the same time. The interval between vasectomy and occurrence of spermatic granuloma of the vas is shown in Fig. 2. Significantly, in 20 of the 21 patients, the cut ends of the vas had been ligated, an incidence of 7% among patients in whom ligation was performed. Postoperative bacterial epididymitis did not occur, although postoperative epididymitis, not of bacterial origin, occurred in 21 patients. Attacks occurred bilaterally (although not simultaneously) in 3 patients; 4 patients had recurrent attacks on the same side. No correlation with operative technic could be made. Spermatic granuloma of the epididymis was diagnosed 5 4 NUMBER 01' CASES 3 2 Z 2 '/2:3 6 "7 B II MONTI-IS POST VASECTOMY ULu 2 2'h:3 4 41'0. G YEARS POST VASECTOMY Fig. 2. Interval between vasectomy and appe!!.rance of spermatic granuloma of vas.

5 VOL. 17, No.4, 1966 ELECTIVE VASECTOMY 471 in 8 of the 21 patients; 1 granuloma was excised 6 years after operation. The interval between attacks of epididymitis and vasectomy is shown in Fig SP,QMATiC GRANULOMA -:. EPIDIDYMITIS NUMBER OF' CASES 2 I , \,~ 3 Y.z. G 8 WEEKS MONTHS YEARS FOLLOWING VASECTOMY. Fig. 3. Interval between vasectomy and appearance of epididymitis and/or spermatic granuloma of epididymis. Other Cases Spermatic granulomas may also occur in the older patient who undergoes vasectomy as an accompaniment to prostatectomy. During the 10-year period of the study, 3 patients were seen with spermatic granuloma of the vas and 2 patients with spermatic granuloma of the epididymis, in each of whom vasectomy had been done with prostatectomy. None of these cases is included in the series of 432 cases studied above. Many spermatic granulomas were excised and were examined microscopically. One section, made 3 years after vasectomy, showed a cotton ligature and typical pooling of sperm (Fig. 4). One section of an epididymis showed a break in the wall of an epididymal tubule with spermatozoa extravasating into the interstitial tissues (Fig. 5). Other areas of the epididymis showed the marked tubular dilatation known to follow vasectomy (Fig. 6). There were varying degrees of reaction to the extravasated spermatozoa, showing that development of a granulomatous reaction after extravasation is progressive. In two spermatic granulomas of the vas (Fig. 7 and 8), two instances of recanalization (Fig. 9 and 10) and one of vasocutaneous fistula complicating a spermatic granuloma of the vas (Fig. 11), multiple channels had been epithelialized. Blind channels were occasionally epithelialized, even where there was no possibility of recanalization, fistula, or other means of drainage. The channels were also seen on an X-ray film of a specimen injected with Renografin* (Fig. 12). *E. R. Squibb & Sons, New York, N. Y.

6 472 SCHMIDT FERTILITY & STERILITY Fig. 4. Spermatic granuloma of vas 3 years after vasectomy showing cotton ligature on right and typical pools of sperm at bottom. No reaction to cotton is evident. (X 400) DISCUSSION The complications of vasectomy may be divided into the psychological and the physiological ones. The German literature is filled with papers dealing with the psychological complications. A recent paper by Johnson reported that 20% of a series of 83 patients wished reanastomosis, but adds that all of these patients were seen on a psychiatric service. Jhaver and 0hri reported that 3 of 682 patients had postoperative sexual debility and required psychotherapy. They make no mention of preoperative interviews or of the socioeconomic status of their patients. It is generally agreed that a careful preoperative interview will prevent most psychological complications. Johnson stated that the desire for repair "seems to be related to the way in which the decision was made." Similarly, Guttmacher stated that "there will be no emotional difficulty later on if the reason for sterilization has been a valid one-and the couple sincerely desires it." He also stated that "if a man is certain that sterilization will take away his virility-there is a reasonable chance that he will be impotent." Stressing to the patient that spermatogenesis continues after operation and that vasectomy will be done in such a manner as to make future reanastomosis possible is important in the preoperative interview. The most common immediate physiological complications are infection, hematoma? and pain. As evidenced by the series reported here, careful

7 VOL. 17, No.4, 1966 ELECTIVE VASECTOMY 473 technic can keep all of these complications at a minimum. Jhaver and Ghri mentioned 2 cases of gangrene of the testis after vasectomy, but added that, in these cases, vasectomy was done' by "junior doctors." Deodhar and Fig. 5 (top), Epididymal tubule 6 years after vasectomy showing spermatozoa extravasating into interstitial tissues. (X 1000) Fig. 6 (bottom). Typical dilated epididymal tubules 8 months after vasectomy with prostatectomy. Spermatozoa are seen in interstitial tissues in this case of spermatic granuloma of the epididymis. (X 100)

8 474 SCHMIDT FERTILITY & STERILITY Nadkarni mentioned a case of gangrene of the testis after ligation of the entire spermatic cord. Spermatic granuloma of the vas, a complication peculiar to vasectomy, is easily diagnosed by the finding of a tender nodule at the point of interruption of the vas after the immediate postoperative tenderness has sub- Fig. 7 (top). Spermatic granuloma of vas, lower right, 5 years after vasectomy. One of multiple channels lined with epithelium at top center contains spermatozoa. Areas of pooled extravasated sperm at left. (X 400) Fig. 8 (bottom). Spermatic granuloma 1 year after vasectomy, vas at upper left. Epithelialized channels, center, with spermatozoa at top center and right. (X 100)

9 VOL. 17, No.4, 1966 ELECTIVE VASECTOMY 475 sided. Variations of this sign occur, ranging from an associated acute pain resembling renal colic in its severity and distribution to vasocutaneous fistulas appearing as clusters of small pimples, which break and drain. Awareness of the possibility of spermatic granuloma aids in rapid diagnosis. After vasectomy, the lumen of the vas dilates due to a continued in- Fig. 9 (top). Spontaneous recanalization. Vas is at right. Multiple, tiny passages at left proved to be patent on serial section. (X 100) Fig. 10 (bottom). Spontaneous recanalization. Multiple, patent passages contain spermatozoa in many instances. Areas of spermatic granuloma are at left center and top right. (X 100)

10 476 SCHMIDT FERTILITY & STERILITY ternal pressure. 21 If the proximal end of the vas is ligated, the ligature may either cut through or dissolve, allowing a blowout or expulsion of spermatozoa. While a ligated blood vessel will thrombose back to the nearest branching, the vas remains patent and dilated to the point of obstruction. Singh stated that this dilatation reaches a maximum 75 days after operation. It does not regress appreciably. Van de Velde states that in the rat violent contractions of the vas occur during ejaculation, even after vasectomy. He feels that these contractions playa role in causing ligatures to cut into the lumen of the vas. Fig. 11 (top). Vasocutaneous fistula 8 years after vasectomy (skin at top). Spermatozoa are present, both extravasated and within epithelium-lined tubules. (X 400) Fig. 12 (bottom). Spontaneous recanalization. Specimen was injected with Renografin and X-rayed to show tract between ends of vas. (Retouched for clarity.)

11 VOL. 17, No.4, 1966 ELECTIVE VASECTOMY 477 Spermatic granulomas may occur years after vasectomy (Fig. 2 and 3). They are mentioned as occurring more frequently if the ends of the vas have been ligated. Banerji found "nodules in the cord" in 37 of 202 patients ( 18.6%). Other authors mention them with less frequency. As was seen in this series, fulguration of the vas is seldom followed by spermatic granulomas. An occasional acute pain accompanies spermatic granuloma,6,19 probably because the acute inflammation is confined within a walled-off area of scar tissue. Additional extravasation occurred into the granulomatous area in several patients in this series, a possibility that had been foreseen by Friedman and Garske. Epididymitis after vasectomy differs from classical epididymitis of bacterial origin; appearing after obstruction of the vas, it is seen in two different forms. No coltelation can be made between specific technic and the types of postvasectomy epididymitis. The first type, exemplified by a slightly swollen, diffusely tender epididymis, is probably due to engorgement of the epididymal tubules arising after obstruction, although this has not been proved. It usually occurs during the first few postoperative months and subsides fairly rapidly. The second type, spermatic granuloma of the epididymis, usually appears later and is characterized by a tender nodule in one area of the epididymis which persists for weeks or months. As tubules of the obstructed epididymis are dilated, minor trauma easily produces rupture which may result in a granuloma. In addition to the discomfort such a granuloma causes, the tubule may be permanently obstructed and later restoration of fertility thereby prevented. While most patients eliminate stored spermatozoa within 1-2 months of operation, others retain them for surprisingly long periods. When spermatozoa persist, the surgeon must consider the possibility of duplication of vas, surgical failure (failure to divide the vas), spontaneous reanastomosis, or just the very slow normal release of spermatozoa from the reservoirs. In this series, spermatozoa persisted for over 5 months in 1 patient in whom the vas had been covered over by the sheath so that recanalization could not have occurred. Both Rieser and Rugna cited cases in which spermatozoa were seen 1 year after vasectomy, although it is not clear whether reanastomosis had occurred. Howard noted spermatozoa in the ejaculate of one of his patients 6 months after bilateral epididymectomy. Because of the possibility of persistence of spermatozoa, the patient's seminal fluid should be periodically examined until all spermatozoa are gone. It is remarkable that spermatozoa can persist intact for such long periods.

12 478 SCHMIDT FERTILITY & STERILITY They have been reported by some authors 14 to be nonmotile after 2 months' storage. Mullaney described in a rat spermatic granuloma spermatozoa that had survived for 7 months, but she did not exclude the possibility that some could have been new. In experiments where new supplies of spermatozoa have been blocked off for 9 months, Schmide 3 has recognized spermatozoa in rat spermatic granulomas. An increase in the spermatozoa in the postoperative ejaculate may be an indication of reanastomosis of the cut ends of the vas or recanalization. In 1 patient in whom recanalization occurred, Stokes found no spermatozoa 3 months after operation, and many 5 months later. A few spermatozoa were present at all times in other patients in whom recanalization had occurred. One of the patients discussed in the present report who experienced regeneration of the vas showed only a few spermatozoa 2~~ months after operation, and a normal number 5 months after operation. I therefore require 2 negative semen examinations, 1 month apart, before I will assure a patient that he is sterile. The test has never failed. That regeneration may follow ligation of the ends of the vas even when a segment of the vas is excised, is shown by patients in this series and in a series reported by Rugna. The mechanism of such regeneration has been earnestly sought for, but never fully explained. Van Neiderhausern stated that fluid pressure in the proximal vas plays an important role; Chaset postulated that the ligatures cut through the vas. Glassy and Mostofi reported that spermatic granuloma may help in postvasectomy recanalization. Strode found that recanalization did not occur if a fascial barrier was interposed between the cut ends of the vas. AIken and Ferner reported a case of regeneration in which the ends of the vas were connected by a thin tube lined with epithelium; there was no evidence of muscular regeneration. Several patients in this series have shown similar tubing. In other cases, a spermatic granuloma of the vas was clearly in the process of re-establishing epithelium-lined tubes through its center. Sections through both granulomas and recanalized vasa show that multiple channels are frequently epithelialized. The association of spermatic granuloma of the vas and recanalization of the vas after 1 of the 2 technics used in this series points to a significant relationship. On the basis of a study of the patients in this series and patients reported in the literature, it is assumed that recanalization occurs in the following manner. Fluid pressure builds up in the proximal vas after obstruction bv ligation. Tissue beneath the ligatures becomes necrotic, and occasionally the ligatures cut into the lumen of both cut ends of the vas. Spermatozoa then leak into the area between the ends of the vas and a spermatic granuloma results. When the lumen of the distal vas is open and is involved in

13 VOL. 17, No.4, 1966 ELECTIVE VASECTOMY 479 the granuloma, the spermatozoa will drain out through the distal vas. One or more tracts develop within the granuloma. These become lined with epithelium originating from both ends of the vas, and patency is restored. If fascia is interposed between the cut ends of the vas, recanalization cannot occur even should a spermatic granuloma arise. Similarly, electrocoagulation of the vas will lessen the occurrence of spermatic granuloma of the vas (and thereby recanalization) by creating a firm scar at each end of the vas. Recanalization is not limited to cases of elective vasectomy, and undoubtedly occurs after vasectomy in association with prostatectomy. The occasional case of delayed bacterial epididymitis after prophylactic vasectomy may well be due to recanalization of the vas, which permits an ascending infection to reach the epididymis. The technic of vasectomy should thus be the same whatever the reason for the vasectomy. RECOMMENDED TECHNIC 1. The operation is done in the office. If necessary, it should be scheduled when the patient can be away from work for 1 or 2 days, perhaps at the start of a weekend. 2. The patient should shave his entire scrotal and pubic area and then shower to remove all loose hairs. 3. The patient lies supine with his hands beneath his head. An electrosurgical grounding pad should be placed beneath his hips. 4. The skin of the scrotal and pubic areas is scrubbed with germicidal soap, rinsed with water, and coated with an aqueous antiseptic. Strong germicides, including tinctures, should never be used. 5. Each ligation is done through a separate skin incision. The use of a single skin incision to expose both vasa is to be condemned since it increases the chance that the same vas will be cut twice. The vas is grasped between the fingers at the point where the scrotum joins the body. It may be necessary to relax the tunica dartos and cremaster by gentle traction to make the vas more accessible. 6. First the overlying skin and then the tissue of the vas is infiltrated with Xylocaine* (lidocaine) for a distance of 2-3 cm. Epinephrine is unnecessary and may be dangerous. The skin in this area is highly movable and if the penile skin is carelessly drawn laterally, the injection and incision may be made through it. 7. The skin is incised, bleeding vessels are fulgurized, and the skin and * Astra Pharmaceutical Products, Inc., Worcester, Mass.

14 480 SCHMIDT FERTILITY & STERILITY subcutaneous tissues are spread apart with a mosquito clamp. It may be necessary to incise the cremaster along (not across) its fibers to expose the sheath of the vas. 8. The vas is cautiously grasped through its sheath with an Allis clamp. If pain occurs at this stage, more Xylocaine should be injected into the tissue immediately adjacent to the vas. 9. The sheath of the vas is incised longitudinally until the vas itself is exposed. The wall of the vas should not be cut so deeply that its lumen is entered. 10. With mosquito forceps, the vas is separated from the sheath and its accompanying vessels. The sheath of the vas is grasped with a hemostat to keep it from slipping away. Hemostasis must be complete at this stage. 11. The vas is then divided with scissors. While the cut end is held with smooth forceps, a needle electrode is introduced into the lumen of the vas for about 2 mm. The mucosa of the vas is destroyed by fulguration as the electrode is slowly withdrawn and then the cut surface is thoroughly fulgurized. Both cut ends should be so treated. 12. The sheath of the vas is closed over the distal cut end of the vas with a running cotton suture. Care must be taken that this suture does not enter one of the spermatic veins to cause a hematoma. 13. When bleeding has stopped, the skin of the first side is closed with a cotton suture, after which the skin on the second side is closed. Since this nonabsorbable skin suture must be removed, the surgeon is ensured a chance to check on the patient's wound 1 week after operation. 14. A sterile dressing is placed over the incisions and held in place with a suspensory having leg straps. The patient is given a prescription for codeine sulfate to be used for pain. 15. The patient is directed to lie down for 1 or 2 hr. at home and to place an icebag over the operative site. After that, he may resume full activity. He is instructed to leave the suspensory in place until he is seen again in 2 days. When the dressing and suspensory are removed, the patient may shower whenever he wishes. He is cautioned to carry the suspensory with him for 1 or 2 days in case he wishes to replace it for comfort. Application of heat to the operative site is recommended as needed after the third postoperative day. 16. The patient is cautioned that he is still fertile and that he must use contraceptives until he has submitted 2 negative semen specimens, 1 month apart. Sexual intercourse may be resumed as soon as the dressings are removed. l7. The w(mnd shquld again be examined 7 and 14 days after operation.

15 VOL. 17, No.4, 1966 ELECTIVE VASECTOMY 481 SUMMARY AND CONCLUSIONS A series of 432 patients who underwent elective vasectomy is reported; several technics of vasectomy and the resulting complications are reviewed. It is recommended that vasectomy be done through bilateral incisions, that both ends of the sectioned vas be fulgurized, and that the sheath of the vas be closed over the cut end of the distal vas. This technic should be employed in both elective and prophylactic vasectomy. Spermatic granuloma is the most significant complication and may occur at the cut end of the vas or in the epididymis shortly after, or years after vasectomy. Its occurrence at the cut end of the vas can be reduced noticeably if the cut ends of the vas are fulgurized rather than ligated. Recanalization, or reanastomosis, occurs most frequently if the cut ends of the vas are ligated rather than fulgurized. The presence of a spermatic granuloma increases the chances of a recurrence of patency. Recanalization can be prevented if the sheath of the vas is closed over the cut end of the distal vas. Most psychological complications (e.g., impotence, and decrease in sexual desire) can be prevented if the patient and his wife both want the operation done, if they are fully informed of the steps in the procedure before it is done, and if they are assured that spermatogenesis continues and that reanastomosis is possible. REFERENCES 707 K St. Eureka, Calif. 1. ALKEN, C. E., and FERNER, H. Morphologic study of spontaneous restoration of freedom of passage in the spermatic cord of humans after section and ligation. UrolInt 10:66, BANERJI, T. P. A study of male sterilization at Kanpur. A report on 202 cases of vasectomy. J Indian Med Ass 36:578, Vasectomy: A panel discussion. California GP (Jan./Feb.) p. 15, CHASET, N. Male sterilization. JUral 87:512, DEODHAR, N. S., and NADKARNI, M. G. Early morbidity after vasectomy-a study of 137 cases. Indian J Med Sci 16:391, FRIEDMAN, N. B., and GARSKE, G. L. Inflammatory reactions involving sperm and the seminiferous tubules: Extravasation, spermatic granulomas and granulomatous orchitis. JUral 62:363, GLASSY, F. J., and MosToFI, F. K. Spermatic granulomas of the epididymis. Arner J Clin Path 26: 1303, GUTTMACHER, A. F. Surgical birth control. True Story, Feb. 1960, p HOWARD, F. S. Personal Communication, ]HAVER, P. S., and OHRI, B. B. Vasectomy: Difficulties and complications. J Indian Med Ass 32:193, ]HAVER, P. S. Surgery of the epididymis and vas. Read at the meeting of the Associated Surgeons of India, Dec. 27, 1964.

16 482 SCHMIDT FERTILITY & STERILITY ] 2. JOHNSON, M. H. Social and psychological effects of vasectomy. Amer ] Psychiat 121:482, MULLANEY, J. Experimental production of spermatic granuloma in rats. Nature (London) 194:487, ] 4. REIMANN-HuNZIKER, R., and HEIMANN-Hui'lZIKER, C. Eigene Erfahrungen an iiber 1000 Vasektomierten del' letzten 20 Jahre. Z Praeventivmed 7:537, RIDGEWAY, J. Birth control by surgery. The New Republic, Nov. 14, RIESER, C. Vasectomy: Medical and legal aspects. ] Ural 79:138, ROLNICK, H. C. Regeneration of the vas deferens. ] Ural 9: 188, RUGNA, D. The problem of the procreative capacity of the male after sterilization. Praxis 48:400, RUSSELL, M., and FRIEDMAN, N. B. Studies in general biology of sperm: Experimental production of spermatic granuloma. ] Ural 65:650, SAYEGH, E., CASTEEL, B., and SACHER, E. The occurrence of spermatic granuloma after vasectomy. Delivered at the meeting of the Mid-Atlantic Section of the AUA, November SCHMIDT, S. S. Anastomosis of the vas deferens: An experimental study. III. Dilatation of the vas following obstruction. ] Ural 81 :206, SCHMIDT, S. S. Anastomosis of the vas deferens: An experimental study. IV. The use of fine polyethylene tubing as a splint. ] Urol 85:838, SCHMIDT, S. S. Unpublished data. 24. SINGH, R. C. Quantitative studies of spermatogenesis in normal rats. Cited by Jhaver STOKES, W. R. Delayed anastomosis of the vas deferens following vasectomy. Hum Fertil 6:79, STRODE, J. E. A technique of vasectomy for sterilization. ] Ural 37:733, SZKODNY, A. A simplified method of ligating the vas deferens. Pol Przegl Chir 36: 1309, Time, Jan. 15, 1965, p VAN DE VELDE, R L., and RISLEY, P. L. Unpublished data. 30. VON NIEDERHAUSERN, W. La repermeabilisation spontanee du canal deferent. Helv Chir Acta 23:1939, WINER, J. Unpublished data.