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From Androlog

From time to time, male reproductive microsurgeons are reminded that even the most seemingly banal surgery may lead to undesired effects on fertility. Such may be the case, for example, with hernia repair using artificial mesh as architectural support. Dr Arnold Belker posted a message querying the Androlog group regarding azoospermia possibly resulting from one of the most common scrotal procedures, hydrocelectomy:

I was called today by a urologist who asked me about the frequency with which ductal obstruction may follow hydrocelectomy. His patient had contralateral testicular atrophy and a normal or near-normal sperm count preoperatively and was azoospermic after hydrocelectomy was performed on his normal-sized testicle. A testicular biopsy at the time of hydrocelectomy was interpreted as showing normal spermatogenesis. Does anyone have information concerning the occurrence of vasal or epididymal injury associated with hydrocelectomy?

Dr Teoman Cem Kadioglu of Istanbul University replied:

I encountered 2 cases of patients becoming azoospermic following hydrocelectomy in the last 10 years. The first was a 23-year-old man who was born without a right testicle and had a hydrocelectomy when he was 12 years old. No cause was identified at the time. The other was a 45-year-old man who had had a bilateral hydrocele operation elsewhere just a year before, due to a moderate hydrocele—as he described it. Both had normal biopsy results. I believe the absence of tunics leaves the epididymis wide open for scarring that obstructs the tubules (even though the epididymis has its own fine tunica). This may be the reason that some patients who have had orchidopexy operations eventually become azoospermic but do have spermatogenesis. Of course, a tight hydrocele causes thermal and/or pressure effects on spermatogenesis, but I still try to avoid or postpone performing hydrocelectomy if fertility is a concern—at least performing it bilaterally.

Dr Hussein Ghanem of Cairo University wrote:

Dr Belker presented a case of functional azoospermia that might be related to hydrocelectomy. Dr Kadioglu described 2 cases of obstructive azoospermia with no risk factors apart from a history of hydrocelectomy. He also suggested that a tight hydrocele might be related to thermal and/or pressure effects on spermatogenesis.

These are interesting concepts. We do occasionally encounter cases of functional or obstructive azoospermia with a history of hydrocelectomy. One had assumed that the hydrocelectomy was probably a coincidence rather than a factor in the infertility. It is, however, conceivable that blunt techniques or inadvertent use of diathermy might result in injury to the epididymis, the vas deferens, or the blood supply. I am also not aware of any literature supporting the notion that a hydrocele or "a tight hydrocele" might be an etiologic factor in male infertility.

Finally, Dr Marc Goldstein of Cornell reported:

I have explored 4 men with iatrogenic injuries to the epididymis from hydrocelectomy (2 cases of bilateral hydrocelectomy and 2 unilateral with contralateral atrophy or vasal obstruction from hernia repair). Three of the 4 got sperm back after vasoepididymostomy (VE). Two pregnancies occurred naturally and one with intraoperatively cryopreserved epididymal sperm and in vitro fertilization. I also did VE on a patient with epididymal obstruction from a silk stitch through the epididymis from prophylactic orchiopexy for torsion (torted side was removed). We are putting together these iatrogenic epididymal obstructions and will report this series. We had previously reported 34 iatrogenic injuries to the vas and epididymis mostly from hernia repairs, but one of those patients had epididymal obstruction from prior spermatocelectomy (Sheynkin YR, Hendin BN, Schlegel PN, Goldstein MJ. Microsurgical repair of iatrogenic injury to the vas deferens. Urology. 1998;159:139-141).

Thus, it appears that even the seemingly innocuous hydrocelectomy may result in significant ductal obstruction. In many of the cases reported by these Androlog participants, the obstruction was unmasked by contralateral testicular dysfunction. Readers may speculate how many cases of unilateral obstruction might occur with sufficient contralateral function to render obstruction unnoticed. These reports serve as a potent reminder of the veracity of the surgical dogma that surgery, no matter how small, is attendant with risk.

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