Piotr Dobronski MD PhD, FEBU. Associate Professor of Urology
Who am I? I graduated from Medical University of Warsaw(MUW) in 1989 with distinction, most of my Professional life has been linked to Chair and Department of Urology of MUW. Doctoral thesis on the long term results of vagial reconstruction from bladder flap in Mayer-Rokitansky syndrome defended cum laude (2002) at MUW and achieved two awards. Also at MUW in 2013 I got a postdoctoral degree for a series of publications on female urinary incontinence as main achievement. In 1994 I passed the board exams in general surgery (1 st degree) and in 1998 in urology, both Polish and European Board of Urology. My overseas scholarships included these in university and private departments of urology in Paris (France) , Innsbruck (Austria) , Perugia (Italy), Vienna (Austria) and San Francisco (CA,USA) . The list of my publications encompasses ca 60 papers (incl in Eur Urol, BJU Int, Urology, J Urol), 17 book chapters and monographs and ca 130 congress presentations. I am involved in everyday urologic surgery, pre and post graduate university education. Andrology has been my long time fascination, especially surgical treatment of male infertility. Laparoscopic and open varicocelectomy , TURED for ejaculatory ducts obstruction I have performed since 1990 ies. In recent years I have started microscopic/microsurgial treatment of andrologic problems including vasectomy reversal and varicocelectomy. I am also involved in surgery of pathologies of the testis such as hydrocele, epidydymal cysts as well as foreskin and frenular plastic surgery.
I am a member of European Association of Urology, and I was a member of its scientific committee (2000-2008). My memberships also include Polish Urologic Association (member of board of its Mazovian Division) and Polish Association of Andrology. Conslutations in Polish and English.
Although vasectomy is a quick and outpatient procedure done under local anesthesia by one surgeon , vasectomy reversal is a time consuming (3,4-4 h), complex procedure done under general or regional anesthesia by at least two people. In short, the principle bilateral steps are: scrotal skin incision, finding of both ends of the vasa, excision of the blind ends of them, confirmation of patency of the abdominal portion of vas, reaproximation of its ends and tension free watertight 3 layer end-to-end anastomosis with sutures 10/0-7/0. Drains are usually not left unless extensive dissection in search for the abdominal stump of a vas.
The success rate in terms of patency depends also upon the time elapsed from vasectomy . On one hand the longer the time the higher the risk of so called epidydymal block (secondary stricture of epidydymal duct due to high pressure) requiring even more fine surgery called epidydymovasostomy, on the other hand even if patency is regained after “old” vasectomy, the motility of sperms is lower. The risk of epidydymal block is ca 3%/year in the first 22 years after vasectomy and reaches plateau at the level of 72% thereafter. The decreased motility may be related to presence of antisperm antibodies, which develop in up to 75% men after vasectomy but disappear only in 30-60% after reversal. Other prognostic factors are : the presence and appearance of fluid in the testicular stump of a vas intraoperatively ( which is predictive of presence of sperms, its fragments or spermatids) and the length of testicular stump.
Varicocele Is the most common cause of male infertility – a surgically correctable or at least improvable form of infertility. They are present in 15% up to 20% of the normal male population and in up to 40% of patients with male infertility. It is believed to be the cause of up to 35% of primary infertility and 69-81% of secondary infertility. The causes of varicocele are multifactorial, but at the end the result is a pathological dilatation of the veins draining the testicles.
Infertility affects 13–20% of couples in Poland. It is estimated that the male factor of couple infertility is between 25-50%. The pattern of infertility in Poland shows an increase in the rate of the male factor.
In the meta- analysis, a 33% pregnancy rate was reported in patients who underwent the surgical treatment of varicocele in comparison to the 15.5% pregnancy rate in the control groups receiving no treatment. Due to this fact varicocele is nowadays recognized as the most surgically correctable cause of male infertility.
Microsurgical varicocelectomy seems to have only one disadvantage – operation duration which is sig-nificantly longer than other surgical techniques that require training. The microscope is brought into the operating field in order to improve the ability in differing arteries, veins and lymphatic vessels (Figure 1) which is considered to significantly decrease the incidence of hydrocele formation, testicular artery injury (and testicular atrophy) and recurrence (Figure 2). Microsurgical varicocelectomy results in the return of sperm in the ejaculate in up to 60% of azoospermic men with palpable varicocele.
|Pregnancy rate||Recurrence||Hydrocele formation|
|Open surgery||33.57-37.6%||5.51-14.97% (Palomo) 2.63% (Ivanissevich)||8.24-9.09% (Palomo) 7.3% (Ivanissevich)|
|Radiological embolization||31.93-33.2%||4.29-12.7%||Not available – not typically seen|
The subinguinal microscopic varicocelectomy technique is believed to be a gold standard in menagement of male infertility. It’s popularity has been growing for thirty years in all over the world. Now has been finally brought to Poland.