would radically change his career path, pushing him to

specialize in urologic microsurgical techniques in male

infertility where he felt there was more opportunity for

discovery.

The collaboration between Owen and Silber would

bear fruit the following year at the University of Cali-

fornia at San Francisco, when Silber performed a 2-layer

vasovasostomy using 9-0 and 10-0 nylon sutures and a

Zeiss operating microscope, the

rst such procedure in the

United States.

However, controversy would arise as to

whether Silber or Owen was truly the

rst to perform

microsurgical vasovasostomy. Although Owen failed to

publish his approach until 1977, 2 years after Silber

published his procedure, most believe the

rst vaso-

vasostomy was indeed performed by Owen in 1971.

Regardless, both men were foundational in the advent

urologic

microsurgery.

Silber

’

microsurgical

approach achieved higher success rates compared with

nonmicroscopic techniques

—

a spontaneous pregnancy

rate of

71% was reported compared with 40% using

nonmicroscopic

techniques.

14,15

After

the

success

and growing acceptance of the microsurgical vaso-

vasostomy, in 1978, Silber described an end-to-end

epididymovasostomy,

allowing

surgeons

bypass

obstruction in the 1-2 mm epididymis and achieve greater

success than prior approaches. The end-to-end procedure

produced a patent connection between the vas deferens

and the epididymis, rather than the

stulous tract that

was previously obtained by grossly approximating the vas

deferens to the epididymis. In 1983, L.V. Wagenknect at

the University of Hamburg introduced the end-to-side

technique currently used by many urologic micro-

surgeons,

which would be further expounded on in

1986 by Ingemar Fogdestam, a Swedish plastic surgeon

and former fellow at St. Vincent

’

s Hospital in Mel-

bourne.

The epididymovasostomy would later be further

developed by Larry I. Lipshultz, who used the microsur-

gical technique for correction of epididymal pathology

not related to prior vasectomy, pushing microsurgery into

more urologic areas.

Comparable advancements were

made to the vasovasostomy by several others, including

Joel Marmar and Anthony Thomas, who described the

trans-septal crossed vasovasostomy in 1985.

recently, Richard Berger described the triangulation end-

to-side vasoepididymostomy, a broadly used advancement

in surgical technique.

Marc Goldstein would later

describe the 2-stitch longitudinal intussusception tech-

nique now preferred by many microsurgeons for its

simplicity and high patency rate.

22,23

Although microsurgery was revolutionizing vasectomy

reversal techniques, it was transforming orchidopexy as

well. In 1975, Silber described a microsurgical orchid-

opexy in a 9-year-old boy in Melbourne where the sper-

matic artery and vein were reanastomosed to the inferior

epigastric artery and saphenous vein.

This technique

would be further developed by Marc Goldstein, a physi-

cian mentored by Silber for 4 months in 1978-1979 who,

after practicing vascular anastomoses on human pla-

centas,

published his work on the microsurgical trans-

plantation of rat testes.

This research, combined with

Silber

’

s work, would establish the use of microsurgery in

treating testicular pathologies. Goldstein

’

s expertise

would later serve as the foundation for urologic micro-

surgery training in New York.

Reimplantation of an amputated penis was also vastly

aided by microsurgical technique, facilitating anastomosis

of neurovascular bundles to restore penile sensation after

amputation. In the summer of 1976, the Japanese or-

thopedic surgeon Susumu Tamai

and the American

plastic surgeon Benjamin E. Cohen

independently

assisted urologists in penile reimplantation procedures,

using binocular magni

cation for the delicate vascular

and neural anastomoses necessary for successful recovery

of penile function. In 1981, Andrew Novick used

microvascular reconstruction to manage intrarenal arte-

rial lesions.

That same year, Ira Sharlip used microsur-

gical technique for penile revascularization by implanting

the inferior epigastric artery into the corpora cavernosa of

men with vasculogenic erectile dysfunction, improving

erectile function in

40% of treated men.

The use of microsurgical technique in varicocele

treatment using an inguinal approach was

rst presented

by Marc Goldstein in 1983 at the Ferdinand C. Valentine

Urology Essay Contest of the New York Academy of

Medicine.

In 1985, the subinguinal approach to

microsurgical varicocelectomy was described by Joel

Marmar,

representing another popular approach and

the

rst published account of microsurgical varicocele

repair. By allowing clear visualization of all spermatic cord

vessels, selective ligation of veins with lymphatic sparing

could be achieved, resulting in excellent outcomes with

lower recurrence and complication rates than non-

microsurgical approaches.

The results of Goldstein

’

work would not be published until 1992 but would

facilitate acceptance of microsurgical varicocele repair as

the standard.

Furthermore, this work paved the way to

understanding the relationship between varicocele and

testicular endocrine function.

33,34

In 1993, Goldstein demonstrated motile sperm in testis

biopsy specimens, whereas previously such sperm were

thought to only be present in the epididymis,

making

possible the use of testicular biopsy to treat non-

obstructive azoospermia. During the same year, the

rst

testicular sperm extractions (TESE) were performed

independently by Craft

and Schoysman

without the

use of an operating microscope. The TESE, although

effective, required large amounts of tissue, sometimes

leading to obliteration of the testis but was improved by

Peter N. Schlegel, who performed the

rst microdissec-

tion TESE in 1998.

Using the operating microscope to

identify seminiferous tubules most likely to contain

sperm, Schlegel improved sperm retrieval rates of TESE

from 45% to 63% while decreasing the amount of tissue

removed. This set a new standard in facilitating

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UROLOGY 85 (5), 2015