Efficacy of stepwise mini-incision microdissection testicular sperm extraction for nonobstructive azoospermia with varied etiologies

Stepwise mini-incision microdissection testicular sperm extraction(mTESE)is a procedure that attempts to minimize testicular damage.However,the mini-incision approach may vary in patients with different etiologies.Here,we performed a retrospective analysis of 665 men with nonobstructive azoospermia(NOA)who underwent stepwise mini-incision mTESE(Group 1)and 365 men who underwent standard mTESE(Group 2).The results showed that the operation time(mean±standard deviation)for patients with successful sperm retrieval in Group1(64.0±26.6min)was significantly shorter than that in Group2(80.2±31.3min),with P<0.001.The total sperm retrieval rate(SRR)was 23.1%in our study,and there was no significant difference between Group 1 and Group 2(P>0.05),even when the etiologies of NOA were taken into consideration.The results of consecutive multivariate logistic regression analysis(odds ratio[0R]:0.57;95%confidence interval[Cl]:0.38-0.87;P=0.009)and receiver operating characteristic(ROC)analysis(area under the ROC curve[AUC]=O.628)showed that preoperative anti-Mullerian hormone(AMH)level in idiopathic NOA patients was a potential predictor for surgical outcomes after initial three small incisions made in the equatorial region without sperm examined under an operating microscope(Steps 2-4).In conclusion,stepwise mini-incision mTESE is a useful technique for NOA patients,with comparable SRR,less surgical invasiveness,and shorter operation time compared with the standard approach.Low AMH levels may predict successful sperm retrieval in idiopathic patients even after a failed initial mini-incision procedure.

Clinical features and microsurgical reconstruction of congenital unilateral absence of the vas deferens with obstructive azoospermia:a tertiary care center experience

Patients with congenital unilateral absence of the vas deferens(CUAVD)manifest diverse symptoms from normospermia to azoospermia.Treatment for CUAVD patients with obstructive azoospermia(OA)is complicated,and there is a lack of relevant reports.In this study,we describe the clinical features and evaluate the treatments and outcomes of CUAVD patients with OA.From December 2015 to December 2020,33 patients were diagnosed as CUAVD with OA in Shanghai General Hospital(Shanghai,China).Patient information,ultrasound findings,semen analysis,hormone profiles,and treatment information were collected,and the clinical outcomes were evaluated.Of 33 patients,29 patients were retrospectively analyzed.Vasoepididymostomy(VE)or cross VE was performed in 12 patients,the patency rate was 41.7%(5/12),and natural pregnancy was achieved in one of the patients.The other 17 patients underwent testicular sperm extraction as the distal vas deferens(contralateral side)was obstructed.These findings showed that VE or cross VE remains an alternative treatment for CUAVD patients with OA,even with a relatively low rate of patency and natural pregnancy.

Vasectomy reversal in China during the recent decade:insights from a multicenter retrospective investigation

To date,there is little information about the demography of vasectomy reversal(VR)patients or the factors currently influencing VR effectiveness in China,especially after the universal two-child policy was released in 2015.In this research,demographic data and perioperative medical records of VR patients were extracted from seven major hospitals in different provinces or municipalities of China.Meanwhile,a telephone survey of the patients was conducted to collect follow-up information.Eventually,448 VR cases from the past 13 years were included.The results were analyzed by stratified comparison to investigate factors that can influence postoperative vas deferens patency and pregnancy rate.Appropriately statistical methods were used,and all of the protocols were approved by the Ethics Committees of the institutes in this research.The results showed that the annual operation volume of VR quadrupled after the two-child policy was implemented.Nonmicrosurgery and a long duration of vasectomy were significantly associated with a lower patency rate.A follow-up survey showed that the general postoperative pregnancy rate was 27.2%.For female partners over the age of 35 years,the postoperative pregnancy rate showed a more severe decline,but only 35.5%of them had been given a fertility examination before their husbands’VR surgery.Our work revealed that more patients in China have been demanding VR in recent years.High-quality microsurgery and a short duration of vasectomy are crucial for restoring patency by VR.Clinical andrologists should perform a preoperative fertility evaluation of the patients’female partners.

Microsurgical subinguinal varicocelectomy with spermatic cord double traction and vein stripping

We retrospectively reviewed data for 286 patients with varicocele who underwent microsurgical subinguinal varicocelectomy from March 2015 to May 2017 in Shanghai General Hospital(Shanghai,China).In this surgical approach,the testis was delivered,and the gubernacular and external cremasteric veins were stripped.In addition,the spermatic cord was delivered downward with continuous double traction away from the external ring.The remaining procedure was similar to the conventional approach.We followed patients for at least 3 months and evaluated postoperative semen parameters,pain symptoms,and complications.We excluded data for 32 men due to inadequate follow-up(<3 months).Of the remaining 254 patients,73 had oligoasthenospermia,121 had nonobstructive azoospermia,and 60 had symptomatic varicoceles.Total progressive sperm counts increased in the oligoasthenospermic patients from a median preoperative value of 9.15×10^6 ml^?1 to 25.33×10^6 ml^?1(n=34),and 35.6%(26/73)initially oligoasthenospermic men contributed to unassisted pregnancies.Sperm returned to the ejaculate in 12.4%(15/121)azoospermia patients.In patients with scrotal pain(n=60),43(71.7%)reported complete resolution of pain,16(26.7%)reported partial resolution,and 1(1.7%)reported no change.No patients experienced varicocele recurrence.This doubletraction strategy avoids opening the external oblique aponeurosis,and results in less damage and faster recovery.In addition,the stripping strategy eliminates potential damage to the testis caused by the varicose veins.Our results showed that microsurgical subinguinal varicocelectomy using spermatic cord double traction in conjunction with testicular delivery for vein stripping is a safe and effective approach for varicocele repair.

分步法小切口改良睾丸显微取精术在隐睾下降固定术后非梗阻性无精子症的临床应用研究（英文）

目的:探讨分步法小切口改良睾丸显微取精术在隐睾下降固定术后非梗阻性无精子症的有效性。创新点:既往有隐睾下降固定术手术史的非梗阻性无精子症的患者睾丸局部粘连严重,所以睾丸显微取精术时睾丸暴露困难,因此手术难度明显增大。术者将常规睾丸显微取精术改良为分步法小切口睾丸显微取精术,术中无需完全游离暴露睾丸,仅通过小切口睾丸显微取精术就可使一半的患者成功获取精子。因此分步法小切口改良睾丸显微取精术可在不降低睾丸取精成功率的前提下缩短手术时间和减少手术创伤。方法:收集2015年5月至2017年3月于上海交通大学附属第一人民医院泌尿中心男科接受睾丸显微取精术的20例既往有隐睾下降固定术手术史的非梗阻性无精子症,采用分步法小切口改良睾丸显微取精术获取睾丸精子。分步法小切口改良睾丸显微取精术具体步骤为:第一步,小切口睾丸取精术;第二步,将小切口延长为标准切口,行标准睾丸显微取精术;第三步,对侧睾丸标准睾丸显微取精术。结论:小切口睾丸显微取精术可快速有效获取睾丸内表浅位置饱满的生精小管,标准的睾丸显微取精术可作为小切口睾丸显微取精术失败时的补救措施。分步法小切口睾丸显微取精术可降低睾丸损伤前提下,快速有效地获取睾丸精子。这种手术方式特别适用于睾丸内存在表浅饱满生精小管的非梗阻性无精子症,如隐睾下降固定术后的非梗阻性无精子症。

Seminal plasma miR-192a： a biomarker predicting successful resolution of nonobstructive azoospermia following varicocele repair

This study was performed to investigate a potential marker for the presence of spermatozoa in the ejaculate following varicocelectomy in Chinese men with nonobstructive azoospermia and varicoceles. The micro-RNA （miR）-192a levels in seminal plasma and testicular tissue were evaluated by quantitative real-time polymerase chain reaction from 60 men with nonobstructive azoospermia and varicoceles （Group A： 27 men with spermatozoa found in the ejaculate after surgery; Group B： 33 men without spermatozoa found in the ejaculate after surgery） and 30 controls. The seminal plasma and testicular tissue miR-192a levels were higher in Group B than in Group A and the controls （P〈 0.001）, and there was no significant difference between Group A and the controls （P〉 0.05）. Apoptosis and proliferation assays with miR mimics and inhibitors showed that miR-192a induced GC-2 cell apoptosis through the activation of Caspase-3 protein. Thus, seminal plasma miR-192a appears to be a potential marker for successfully indicating spermatozoa in the ejaculate following microsurgical varicocelectomy in men with nonobstructive azoospermia and varicoceles. Seminal plasma miR-192a may be a useful clinical marker for prescreening to determine which patients with nonobstructive azoospermia and varicoceles would benefit from varicocelectomy.

3D digital image microscope system-assisted vasovasostomy and vasoepididymostomy in rats

Optimal vision and ergonomics are essential factors contributing to the achievement of good results during microsurgery.The three-dimensional(3D)digital image microscope system with a better 3D depth of field can release strain on the surgeon's neck and back,which can improve outcomes in microsurgery.We report a randomized prospective study of vasoepididymostomy and vasovasostomy using a 3D digital image microscope system(3D-DIM)in rats.A total of 16 adult male rats were randomly divided into two groups of 8 each:the standard operating microscope(SOM)group and the 3D-DIM group.The outcomes measured included the operative time,real-time postoperative mechanical patency,and anastomosis leakage.Furthermore,a user-friendly microscope score was designed to evaluate the ergonomic design and equipment characteristics of the microscope.There were no differences in operative time between the two groups.The real-time postoperative mechanical patency rates were 100.0%for both groups.The percentage of vasoepididymostomy anastomosis leakage was 16.7%in the SOM group and 25.0%in the 3D-DIM group;however,no vasovasostomy anastomosis leakage was found in either group.In terms of the ergonomic design,the 3D-DIM group obtained better scores based on the surgeon's feelings;in terms of the equipment characteristics,the 3D-DIM group had lower scores for clarity and higher scores for flexibility and adaptivity.Based on our randomized prospective study in a rat model,we believe that the 3D-DIM can improve surgeon comfort without compromising outcomes in male infertility reconstructive microsurgery,so the 3D-DIM might be widely used in the future.

A novel approach:successful management of vasectomy reversal with a three-dimensional digital image microscope system

Dear Editor,Microsurgical vasovasostomy,most commonly performed for vasectomy reversal,remains the most successful procedure for restoring patency to the vas deferens with the return of sperm to the ejaculate.Although the excellent results depend on the surgeons skill and technique,optimal vision and ergonomics are also crucial factors contributing to the achievement of good results during male infertility microsurgery.

Relationship between self-reported residential indoor remodeling and semen quality： a case-control study

The present study examined the association between residential indoor remodeling and poor semen quality. Sperm donors aged 18-45 years old were recruited in Shanghai, China. Semen specimens were collected and analyzed. An in-person interview was conducted to obtain information on the history of indoor remodeling and potential confounders. A total of 70 participants with abnormal semen quality （case group） and 68 controls were examined. A total of 20 subjects reported indoor remodeling in the recent 24 months, and among them 17 subjects reported indoor remodeling in the recent 12 months. Compared with participants with no history of indoor remodeling, participants with a history of indoor remodeling in the recent 24 months were more than three times as likely to have poor sperm quality （adjusted odds ratio = 3.8, 95% confidence interval： 1.3-12.0） after controlling for potential confounders. The association was strengthened when the analysis was restricted to those who had indoor remodeling in the recent 12 months. Our findings provide preliminary evidence that indoor remodeling has an adverse effect on semen quality.

Successful microsurgical vasoepididymostomy for a case of cryptozoospermia

Dear Editor,Cryptozoospermia is defined as the apparent absence of spermatozoa from fresh semen samples,but they can.be found in centrifuged pellets.1 It is usually caused by a spermatogenic disorder,while cryptozoospermia associated with seminal duct obstruction is less common.2 Because of the extremely low sperm counts in semen samples,men with cryptozoospermia are often reliant on intracytoplasmic sperm injection(ICSI)for paternity.