Tuesday, May 13, 2014

Historical Contribution: 1928, Colston, Vas Ligation for the Prevention of... Epididymitis


Vas ligation for the prevention of preoperative and postoperative epididymitis J. A. C. Colston Journal of the American Medical Association 1928  90: 526-527

In the early 1900's, epididymitis was a common problem for men dealing with obstructive uropathy from both benign and malignant conditions of the prostate and bladder.  Colston comments on the sequelae of epididymitis:

"... while it is rarely a dangerous complication, it plays an important part in increasing the length of hospitalization of the patient and usually has a markedly depressing effect on the morale. In some extremely sick patients with lowered resistance, the added effect of this infection may prove to be too much for the individual to withstand, and in such cases, fortunately rare, the fatal outcome may be directly attributed to the added burden of the epididymitis. Then, too, in the very rare case in which a blood stream infection develops, either during the preparatory treatment or postoperative course, the septicemia often appears directly after the epididymitis, so that in some of these cases, at least, the epididymis may be considered as the portal of entry of the infection into the circulation."

It the modern era, it is rare to think about epididymitis as a cause of sepsis and mortality, however without modern diagnostics and antimicrobials, this was a very real clinical scenario.

The development of epididymitis was of particular interest following prostatectomy (for both benign and malignant disease), where the rate of epididymitis was approximately 20% regardless of approach (suprapubic or perineal).  To address this issue, a number of other urologists advocated open ligation of the vas deferens through a small scrotal incision, and dropped the rate of epididymitis to 4%.

To improve upon this technique, Colston described a method of temporary ligation that removed the need for an incision and had fewer complications.  Dr. Colston used an Allis clamp to isolate the vas deferens and then ligated it, externally, with a silk suture.  The suture was tied to the scrotal skin, treated daily with antibiotic and removed after 7-8 days.

At the suggestion of his resident, Edwin Alyea, Colston transitioned from performing the ligation in the operating room while under anesthesia and prior to prostatectomy to performing the ligation at the bedside prior to surgery without local anesthetic.  He described no complications (other than suture irritation at the skin) and a dramatically reduced rate of epididymitis.

This may represent the first description of the "no scalpel vasectomy" -- although for dramatically different indications than we perform that operation today!!

Read the entire manuscript using the link above or here.

HISTORICAL CONTRIBUTIONS highlight the greatest academic manuscripts from the Brady Urological Institute over the past 100 years.  As the Brady Urological Institute approaches its centennial, we will present a HISTORICAL CONTRIBUTION from each of the past 100 years.  In the most recent experience, the most highly cited article from each year is selected; older manuscripts were selected based on their perceived impact on the field.  We hope you enjoy! 


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