Weill Medical College
Cornell Institute for Reproductive Medicine
Center for Male Reproductive Medicine and Microsurgery
"State-of-the-Art Compassionate Care for the Infertile Couple"
Vasography is indicated in men with at least one palpable vas deferens azoospermia, and a testis biopsy indicating normal spermatogenesis, or in men with low-volume ejaculates with poorly motile sperm in whom ejaculatory duct obstruction is possible. Vasography should be performed only at the time of planned reconstruction. It should not be undertaken at the time of biopsy unless immediate reconstruction is planned, dictated by the presence of mature spermatids with tails and preferably motile on immediate cytological evaluation.
When the cause or site of the obstruction is unknown, the vas is approached through a vertical 3 - 4-cm incision in the upper scrotum, the testis is delivered, and the vas is separated from adjacent spermatic cord structures at the junction of the straight and convoluted portions. Care is taken to isolate the vas cleanly, preserving the vasal vessels. The isolated vas is stabilized using a straight clainp as a platform and hemitransected with a microknife under 15 power magnification. Any fluid exuding from the lumen is placed on a slide, mixed with a drop of saline, covered with a coverslip, and examined microscopically. If no sperm are found in the vasal fluid then an epididymal obstruction is likely. If sperm are present in the vasal fluid then a vasal or ejaculatory duct obstruction is likely, Copious thick white fluid, devoid of sperm in a dilated vas, indicates a vasal and epididymal obstruction. If no fluid is present and none can be expressed by gentle pressure on the testis and epididymis, then gentle barbitage of the testicular end is performed with 0.1-0.2 mL of saline or Ringer's solution. If an epididymal obstruction is suspected, this does not rule out the possibility of a secondary abdominal side obstruction and does not preclude the need for vasography. A 25-gauge angiocath is gently advanced into the abdominal side of the hemitransected vas. Gentle, low-pressure instillation of saline or Ringer's lactate will determine abdominal side patency. Easy flow confirms patency and requires no further vasal study. Resistance to flow indicates obstruction, the level of which must be determined. In this setting, the abdominal vas is usually dilated and a 3-Fr whistle tip ureteral catheter passed toward the seminal vesicles. The calibrations will determine the distance of the obstruction from the level of hemitransection. These catheters may also be employed to instill a 50% concentration of water-soluble contrast media for formal vasography. If the obstruction is determined to be at the ejaculatory ducts (Fig. 3), the ureteral catheters may be employed for the injection of,methylene blue contrast to aid in subsequent transurethral resection of the ejaculatory ducts. Vasography sites are carefully closed employing microsurgical technique with interrupted 10-0 nylon for mucosa and interrupted 9-0 nylon for the muscularis and adventitia.