Surgery

Our minimal invasive surgical team focuses on the following operations:

Microsurgical refertilization
(recovery of fertility)

The popularity of vasectomy as a form of male contraception, combined with high rates of divorce and remarriages as well as several other reasons led to an increasing number of vasectomy reversals. Professor Sommer is a nationally recognized expert in both the simple microsurgical vasectomy reversal called vasovasostomy and the more complex reversal procedure known as vasoepididymostomy.

These surgical procedures are designed to bypass an obstruction in the male genital tract and are usually performed to restore fertility, although they occasionally are undertaken to relieve pain, such as that elicited by post vasectomy pain syndromes.

Vasovasostomy involves the anastomosis of segments of the vas deferens above and below an obstruction. The vast majority of vasovasostomies are performed to reverse a prior vasectomy, but the procedure occasionally is indicated for repair of an iatrogenic vasal injury secondary to prior surgery (e.g. inguinal herniorrhaphy).

Vasoepididymostomy is a technically more demanding procedure than vasovasostomy. It involves anastomosis of the vas deferens to the epididymis in order to bypass an epididymal obstruction. This obstruction may be secondary to long-standing vasal obstruction resulting in damage to an epididymal tubule (epididymal blowout), or it may be the result of epididymal infections or trauma. These techniques have gained popularity in recent years because of advances in surgical techniques, optical magnification, and surgical instruments.

In experienced hands like ours the post-op results are encouraging. Should you have already had a reversal operation without success, we will develop a problem solving strategy with the best possible results (in combination with the previous “operation report” and an extensive physical examination).

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Artificial Insemination

At present two possible methods are used worldwide with good success for artificial insemination: In Vitro Fertilization (IVF) means the sperm of the man is brought together with the egg of the woman (fertilization) outside of the body in a test tube. In contrast Intra-Cytoplasmic Sperm Injection (ICSI) is a relatively new but well-established procedure first performed in 1992. The procedure involves injecting a single sperm into the cytoplasm of an egg under a microscope using a fine glass needle (pipette). In both procedures the resulting embryo is transferred into the uterus

Both methods require sperm from the man and eggs from the woman. During the IVF process, the ovaries are stimulated with injectable fertility medications to mature multiple eggs. Once monitoring with ultrasound and blood tests indicate that the eggs are ready, they are collected with an ultrasound-guided needle. This is best carried out by an experienced gynecologist or in a specialized center.

The sperm of the man can usually be collected by masturbation. If infertility is the result of a blocked or damaged epididymis, the duct carrying sperm from the testicle to the urethra, sperm is extracted from the epididymis by a technique known as MESA(Microsurgical Epididymal Sperm Aspiration). Sperm thus extracted may then be used for IVF or ICSI.

TESE (testicular Sperm Extraction) is the process of removing a small portion of tissue from the testicle and extracting the few viable sperm cells present in that tissue for the purpose of ICSI. TESE is recommended to men who are unable to produce sperm by ejaculation as a result of primary testicular failure, congenital absence of the vase deferens or non-reconstructed vasectomy.

Vasectomy reversal is an operation that reestablishes a connection between the two ends of the vas deferens that were separated at the time of a prior vasectomy. This procedure requires great microsurgical skills from an urological specialist.

Our institution of men’s health has an internationally (nationally) recognized expertise in the field of male infertility and in urological microsurgery. Should you have fertility problems, please address this issue to us. We will be more than happy to assist you.

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Transurethral Resection of Ejaculatory Duct (TURED)

Patients who present with azoospermia (no sperm) and even sometimes oligo-asthenospermia (little sperm), normal sized testes, and a normal testicular biopsy in conjunction with transrectal ultrasound findings of dilated ejaculatory ducts are good candidates for transurethral resection of the ejaculatory ducts. Sometimes these patients suffer from pain during orgasm. The orifices of the ejaculatory ducts exit within the prostatic urethra just lateral to the verumontanum. They can be inspected endoscopically and then incised or unroofed.

In select cases, transurethral resection of the ejaculatory ducts has resulted in marked improvement in pain, semen parameters, and pregnancies have been achieved.

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Vasectomy

In experienced hands vasectomy is a simple, effective and cost efficient method of male contraception

Vasectomy is a permanent method of contraception that's sometimes called "male sterilization". A vasectomy does not affect a man's sex drive or ability to enjoy sex. He will still have erections and produce the same amount of fluid when he ejaculates. The only difference is that the fluid will not contain sperm. The body will still produce sperm, but they can't travel to the penis and are naturally reabsorbed. Vasectomy is one of the most effective long-term contraceptive method, and is among the safest options for family planning. However men who choose to have a vasectomy should consider it irreversible.

Vasectomy will not chance your hormonal status or erections. Your sexual drive will not change. Your erections and climaxes will be the same. Some men say that without the worry of accidental pregnancy and the bother of other family planning methods, they and their partners find sex more pleasurable and spontaneous.

This operation is usually performed in local anesthesia as an outpatient procedure.

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Penile implant

“Experience sexuality to fulfillment“

Progress in the treatment of impotence has experienced a wide range of therapeutic options. Besides the most common use of medication (e.g. Phosphodiesteras-5-inhibitors), intraurethral inserts (MUSE), vacuum tumescence/constriction devices and self-injection of the erectile tissues with a medication that improves penile blood flow, such as Prostaglandin E-1 some patients might require the implantation of a penile prosthesis.

A penile implant is an internal device that is permanent and makes the penis hard enough for penetration. There are several types with different features. With the currently available state-of-the-art implants, a success rate of almost 95% may be expected.

Penile implant surgery requires the placement of two implants in the penis; one in the left erectile chamber and one in the right. The implants and the pump which fills the implants are totally concealed inside the body and give excellent cosmetic and functional results in most patients.

There are two categories of implants: - the non-inflatable rods which are bendable and can be manipulated to give an erection, and inflatable implants which contain fluid to give a more natural erection. This fluid is transferred within or to cylinders in the penis to give hardness. With our expertise your sexuality can become natural again and help improve your quality of life.

“As we know – love keeps us young!“

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Plastic surgery on the external genitalia
Peyronie's disease

We can help you: “don’t worry be happy!“

Peyronie's disease is due to a plaque (scar) of the tunica albuginea lining the erectile chambers resulting in a tethering and curving of the erect penis. Sometimes this condition is accompanied with pain.

From time to time it is best treated with oral medication, injections into the penis or “shockwave“ treatment. However now and again surgery is the best solution.

If erections are normal but only a slight curve is present, plication or removal of a wedge of the tunica albuginea may be performed to straighten the penis. If erections are normal but more than a slight curve is present, incision or excision of the plaque with placement of a graft is frequently performed. In this situation penile shortening is less likely than after plication or removal of wedges of the tunica albuginea. If erectile impairment is present, a penile prosthesis might be best to insert at the time that the plaque is incised or excised.

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Penile enlargement

Penile length has a wide variety. In some cases it is so pronounced that a surgical procedure is the option of choice.

Surgical techniques used for penile enlargement (enhancement phalloplasty) - penis lengthening and penis widening (girth enhancement) - have been performened for many years.

There are various ways of enlarging the penis.

We personally consult all of our patients before and after surgery and perform all the surgical procedures ourselves in a “state-of-the-art” fashion. Our cosmetic results are exceptional.

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Hydrocele

What is a hydrocele?

A hydrocele occurs from an accumulation of fluid in the tunica vaginalis (a thin pouch that holds the testes within the scrotum). In the fetes, the tunica vaginalis is formed in the abdomen and then migrates into the scrotum with the testes. After the pouch is in the testes, it seals off from the abdomen. Hydroceles can be communicating or non-communicating.

Communicating hydrocele

A communicating hydrocele occurs from the incomplete closure of the tunica vaginalis, so that a small amount of abdominal fluid may flow in and out of the thin pouch. It is distinctive because the fluid fluctuates throughout the day and night, altering the size of the mass.

Non-communicating hydrocele

A non-communicating hydrocele may be present at birth and usually resolves on its own spontaneously within one year. A non-communicating hydrocele in an older child or male may indicate other problems, such as infection, trauma, torsion (twisting of the testes), or a tumor. Always consult your physician for a diagnosis. A hydrocele is present in as many as half of all full-term male live births; however, in most cases, it disappears without treatment within the first year.

What are the symptoms of a hydrocele?

The following are the most common symptoms of hydrocele. However, each patient may experience symptoms differently. Symptoms may include the following:

  • A mass that is usually smooth and not tender.
  • A communicating hydrocele will fluctuate in size, getting smaller at night while lying flat, and increasing in size during more active periods.
  • If the hydrocele is large and tense, it may require more immediate attention.
  • The symptoms of a hydrocele may resemble other conditions or medical problems. Always consult your physician for a diagnosis.

How is a hydrocele diagnosed?

Diagnosis of a hydrocele is usually made by a physical examination, a complete medical history and an ultrasound of the testes. A physician may need to determine if the mass is a hydrocele or an inguinal hernia (a weakened area in the lower abdominal wall or inguinal canal where intestines may protrude). Transillumination (the passage of a strong light through a body structure to permit inspection on the opposite side) of the scrotum can differentiate a hernia from a hydrocele as well as a stethoscope to listen for bowel sounds.

Treatment for a hydrocele:

In children a non-communicating hydrocele usually resolves spontaneously by the time the child reaches his first birthday. Resolution occurs as the fluid is reabsorbed from the pouch. Children with a hydrocele that persists longer than 12 to 18 months usually have a communicating hydrocele. A communicating hydrocele usually requires surgical repair to prevent an inguinal hernia from occurring. The surgery involves making a small incision in the groin or inguinal area and then draining the fluid and closing off the opening to the tunica vaginalis.

In adults with larger hydroceles an operation is frequently considered for cosmetic reasons or because of complaints while sitting or walking. Simple needle aspiration is seldom therapeutic because the cause of the problem is not addressed and the fluid typically reaccumulates.

Operation technique

Surgical excision is perhaps the most effective form of treatment. In surgery, the bulk of the hydrocele sac is cut away, and what remains is turned inside out. As a result, the fluid-secreting surface is now in contact with the inner skin of the scrotum rather than that of the testicle with which it made previous contact. Mostly this operation is performed from the scrotum; in special cases however from the groin.

It should be noted that rarely reoccurrences can occur which could make a further operation necessary.

Our institute or men’s health is a competent partner for this type of surgery. At request we will be more than glad to assist you.

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Phimosis
(foreskin narrowing)

What is a phimosis?

A phimosis is an abnormal tightness of the male foreskin preventing retraction over the glans penis. Sometimes the foreskin is coalesced with the glans. Basically one can differentiate between a complete and incomplete phimosis. In this context complete means it is impossible to retract the foreskin over the glans when the penis is flaccid. Incomplete refers to the impossibility of retracting the foreskin during an erection.

How does a foreskin narrowing arise

A foreskin narrowing is normal in newborns and during infancy. By the third year of life the foreskin can usually be easily pushed back. If not one speaks of a phimosis. Approximately one percent of the 16 to 18 year-old males still have a narrowing of the foreskin. This percentage can further increase during adulthood. This often requires an operation: on the one hand for hygienic reasons, on the other hand, a phimosis can impair an unhindered urine flow. Moreover, it is well known that the collection of physical secretions under the foreskin can cause cancer. Mostly however a phimosis in adulthood impairs sexual intercourse.

Other causes of a foreskin narrowing are inflammations and in very rare cases a genetic disposition seems to play a role e.g. the Kindler syndrome, a hereditary skin disease. Lichen Sclerosis (often a white, scar-like skin alteration), a chronic, non-contagious skin disease, producing an infection, which is most likely caused by an autoimmune illnesses. One should not try to pull the foreskin back by force. This can cause small injuries or incipient cracks in the foreskin which in turn can lead to a further narrowing of the foreskin.

Symptoms

A phimosis can exist a whole live without problems arising. However, frequent symptoms are an impairment of voiding or recurrent inflammations. A scarred narrowness of the foreskin should however be operatively corrected before the enrolment in elementary school.

In cases of foreskin narrowing which lead to a decrease of the urine stream and provoke a so-called balloon phenomenon of the foreskin during voiding should be operated at any age.

An erection can be impaired by a phimosis so that pulling the foreskin back to the original position can cause pain. Or the foreskin cannot be replaced again until the penis is flaccid. In severe cases a constriction of the glans penis can be caused by a phimotic foreskin, which has been retracted behind the corona and cannot be replaced. This condition is called a paraphimosis and it should be corrected quickly, if necessary by a physician. In cases of inflammation (redness, swelling, pain or voiding problems) a physician should be consulted.

What other problems can be caused by a foreskin narrowing? The risk of penis cancer is increased with the presence of a phimosis since the glans penis can not be cleaned regularly.

How is a phimosis diagnosed?

A physician recognizes a foreskin narrowing on physical examination: because of the narrowed foreskin which cannot be retracted the glans can not be seen (or only partly).

How is a phimosis treated?

Operation: This operation is called a circumcision. In adults it is mostly carried out under a local anesthesia. However, in some cases, usually upon request, it is performed under general anesthesia.

Depending on the situation and the condition of the foreskin or the wish of the patient the foreskin is either removed partly or completely. While various operative methods exist they only differ in detail. The principle is always the same. All most always self-dissolving sutures are used.

At our institution of men’s health we carry out all types of circumcisions and would be glad to consult you on this issue.

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Varicocele
(Varicose veins of the testicle)

A varicocele is a swelling in the scrotum caused by varicose veins of the spermatic cord which usually appears on the left-hand side. Approximately fifteen per cent adult men are affected. Among infertile couples, the incidence of varicoceles increase to 30 percent. In teenagers the occurrence is about five per cent.

How and why does a varicocele develop?

Veins contain one-way valves that work to allow blood to flow from the testicles and scrotum back to the heart. When these valves fail, the blood pools and enlarges the veins around the testicle in the scrotum to cause a varicocele. This phenomenon can clinically be seen as a swelling of the scrotum (“bag of worms”).

The most probable explanation for the more frequent development of a varicocele on the left side alone is because the left spermatic vein is longer than the right. The left vein enters the left renal vein at a right angle near a site of compression by the mesenteric artery while the right spermatic vein drains at a softer angle into the vena cava. These anatomical factors (and the aid of gravity) promote backflow of blood in the left spermatic vein, resulting in pooling of blood and increased temperature and congestion in the testicle.

However there are also other theories for the development of a varicocele:

The kidney vein can be narrowed by the aorta or one of its branches

Cystic, good-natured and malignant tumors in the kidney

Vessel injuries or blood clots in the vein complex of the spermatic cord which hinders the blood drain.

What symptoms are there?

As in the case of a hydrocele the testicle can swelling and cause discomfort in the scrotum with a feeling of pain especially while standing or running. Most commonly a varicocele is diagnosed by coincidence as a result of a physical examination frequently performed as a work-up of male infertility. Data seems to postulate that one cause of infertility might be due to a varicocele.

Which examinations should be carried out?

The diagnosis of a varicocele can usually be made on physical examination of the scrotum while the patient is standing. The varicocele feels like a "bag of worms" and disappears or becomes significantly reduced when the patient lies down. The patient is asked to bear down and frequently the backflow of blood can be felt in these veins. Occasionally a varicocele may be so prominent that it can be seen through the skin. Sometimes the testicle on the side of the varicocele is smaller than the other side. Ancillary tests such as the Doppler Stethoscope may be used in the diagnosis. Recently the scrotal ultrasound has been found to be an accurate way of confirming the presence of a varicocele. The size of the veins and abnormal blood flow can be seen and measured using the ultrasound. An ultrasound may also be performed to exclude a kidney tumor.

Since infertility can be caused by a varicocele usually a sperm count is performed.

Treatment

Repair of the varicocele is indicated depending on size and extend. In cases of documented infertility, testicular pain or discomfort or a significant discrepancy between the size of the two testicles treatment is required.

Ideally, the perfect procedure would be one that ligates both the veins contributing to the varix at the time of repair and those that could cause a recurrence in the future. However, some veins clearly must be preserved so as to allow drainage of blood from the testis and prevent vascular engorgement. Therefore, the ideal procedure should be one that leaves the testicular arteries, lymphatics, and vas deferens intact.

Treatment options to aid with fertility include surgical varicocele repair and sclerotherapy of the varicose vein.

There are several surgical approaches:

  • The classic operation is an approach in the groin in order to occlude the veins.
  • Another classical abdominal approach is a small abdominal incision at the height of the middle ureter.
  • A newer method is the antegrade or retrograde sclerotherapy of the testicular vein by inserting a small tube and injecting a special fluid to occlude (or sclerose) the varicose vein.
  • The laparoscopic approach is a new method performed in varicocele repair. Long-term studies are however needed before performed routinely.
  • In children the microsurgical approach is routinely carried out. At request we perform this operation in adults as well. The magnification makes the operation easier and helps preserve the testicular artery.

The treatment of a varicocele can in some cases improve fertility. Our Men’s health team offers the complete spectrum of varicocele treatment.

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Male to female Sex reassignment surgery

Modern medical advances have brought us a long way in the surgical treatments of transsexualism. Modern sex hormone therapy, vaginoplasty (SRS) surgery, and cosmetic surgeries can substantially modify a transsexual's body to properly match her innate gender. It is now possible for many "postop" women to feel totally gender-congruent in their transformed bodies, and to be able to very comfortably and passionately enter into loving relationships as sensual, sexually responsive women.

Our clinic provides a wide range of medical treatments and counseling for transsexuals and transvestites. We provide a confidential solution for those to whom privacy is of vital importance. Our experienced staff and I will assist you resolve your personal gender identity problem.

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Management of chronic testalgia by microsurgical testicular denervation

Chronic testicular pain represents a troublesome clinical entity whose diagnostic evaluation and effective treatment is a special challenge. This clinically unsatisfying situation sometimes requires a option known as microsurgical testicular denervation with the intent to cure the symptoms. Based on our experience with this procedure our results exceed the ordinary.

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