The evolution and refinement of vasoepididymostomy techniques

Obstructive azoospermia secondary to epididymal obstruction can be corrected by microsurgical reconstruction with vasoepididymostomy （VE）. Although alternative management such as epididymal or testicular sperm aspiration in conjunction with intracytoplasmic sperm injection is feasible, various studies have established the superior cost-effectiveness of VE as a treatment of choice. Microsurgical VE is considered one of the most technically challenging microsurgeries. Its success rate is highly dependent on the skills and experience of the surgeons. Various techniques have been described in the literature for VE. We have pioneered a technique known as longitudinal intussusception VE （LIVE） in which the epididymal tubule is opened longitudinally to obtain a larger opening to allow its tubular content to pass through the anastomosis. Our preliminary data demonstrated a patency rate of over 90%. This technique has been widely referenced in the recent literature including robotic-assisted microsurgery. The history of the development of different VE approaches, the oreoDerative evaluation along with the techniaues of various VE will be described in this article.

A modified single-armed technique for microsurgical vasoepididymostomy

This study is to evaluate the effectiveness of a modified single-armed suture technique for microsurgical vasoepididymostomy （VE） in patients with epididymal obstructive azoospermia. From September 2011 to December 2011, microsurgical two-suture longitudinal intussusception VEs were performed using our modified single-armed suture technique in 17 men with epididymal obstructive azoospermia at our hospital. Two of these patients underwent repeated VEs after previous failed VEs, and one patient underwent unilateral VE because of an occlusion of the left abdominal vas deferens. The presence of sperm in the semen sample at 3 months postoperation was used as the preliminary endpoint of this study. Each patient provided at least one semen sample at the 3-month time point, and the patency was assessed by the reappearance of sperm （〉 104 m I- 1） in the semen. The mean operative time for the modified technique was 219 min. Patency was noted in 10 men （58.8%）, including one patient who underwent repeated VE. The patient who underwent unilateral anastomosis manifested no sperm postoperatively in his semen. Sperm granulomas were not detected in this cohort. The results of this study demonstrate that our modified technique for microsurgical longitudinal intussusception VE is effective. We believe that it is a practical alternative that may reduce operation time and obviate the suture crossing.

Clinical observation of loupe-assisted intussusception vasoepididymostomy in the treatment of obstructive azoospermia(analysis of 49 case reports)

To evaluate the clinical outcomes of loupe-assisted intussusception vasoepididymostomy(VE)in the treatment of epididymal obstructive azoospermia(EOA),we retrospectively analyzed data from 49 patients with EOA who underwent two-suture longitudinal intussusception vasoepididymostomy(LIVE)between 2000 and 2007.The data included the surgical method,postoperative motile sperm count per ejaculation,percentage of progressive motile sperm and patency and pregnancy outcomes.There were a total of 49 men undergoing scrotal exploration,and epididymal obstruction was found in all cases.Bilateral or unilateral anastomoses were performed in 40 and 6 men,respectively.The postoperative courses of 42 patients were followed up for more than 6 months,and the courses of 38 patients were followed up for more than 1 year.The overall patency and pregnancy rates were 71.4%and 26.3%,respectively.Moreover,progressive motile sperm was more frequently present in those patients who had undergone anastomosis at cauda than at corpus or caput.Pregnancy was achieved only in those patients who had undergone anastomosis at least on one side of the cauda epididymis.We think that the loupe-assisted method,with a lower overall cost and a simplified surgical procedure,can achieve satisfactory patency outcomes and pregnancy results.Data from this paper also suggest that paternity outcomes occur more frequently after anastomoses at cauda than at corpus or caput.

The effect of BMI and age on the outcomes of microsurgical vasoepididymostomy: a retrospective analysis of 181 patients operated by a single surgeon

To design a treatment plan for patients with epididymal obstruction,we explored the potential impact of factors such as body mass index(BMI)and age on the surgical outcomes of vasoepididymostomy(VE).In this retrospective study,181 patients diagnosed with obstructive azoospermia(OA)due to epididymal obstruction between September 2014 and September 2017 were reviewed.All patients underwent single-armed microsurgical intussusception VEs with longitudinal two-suture placement performed by a single surgeon(KH)in a single hospital(Peking University Third Hospital,Beijing,China).Six factors that could possibly influence the patency rates were analyzed,including BMI,age,mode of anastomosis,site of anastomosis,and sperm motility and quantity in the intraoperative epididymal fluid.Single-factor outcome analysis was performed via Chi-square test and multivariable analysis was performed using logistic regression.A total of 159(87.8%,159/181)patients were followed up.The follow-up time(mean±standard deviation[s.d.])was 27.7±9.3 months,ranging from 12 months to 48 months.The overall patency rate was 73.0%(116/159).The multivariable analysis revealed that BMI and age significantly influenced the patency rate(P=0.008 and 0.028,respectively).Younger age(≤28 years;odds ratio[OR]=3.531,95%confidence interval[95%CI]:1.397–8.924)and lower BMI score(<26.0 kg m−2;OR=2.352,95%CI:1.095–5.054)appeared to be associated with a higher patency rate.BMI and age were independent factors affecting the outcomes of microsurgical VEs depending on surgical expertise and the use of advanced technology.

Multiple factors affecting surgical outcomes and patency rates in use of single-armed two-suture microsurgical vasoepididymostomy： a single surgeon＇s experience with 81 patients

Vasoepididymostomy （VE）, as the most challenging procedure in microsurgeries, is often carried out with a double-armed two-suture technique. In this study, we evaluated the efficacy and safety of the single-armed two-suture VEs on humans and studied the factors that could possibly affect the patency rates. From July 2012 to July 2013, we reviewed 81 patients with consecutive primary epididymal obstruction who underwent single-armed two-suture longitudinal intussusception microsurgical VEs by a single surgeon, Kai Hong （KH）. At the same time, we analyzed seven factors that possibly related to the patency rates. With the single-armed technique, a total of 81 men underwent the microsurgical VEs. Data on 62 patients were completely recorded. 19 patients were lost to follow-up. Mean age was 31 years old. Mean follow-up time was 8.8 （2-17） months. The patency rate was 66.1% （41/62）. Natural pregnancy rate was 34.1% （14/41）. Overall pregnancy rate was 22.6% （14/62）. No severe surgical complications were noted. With logistic regression test analysis, there were two factors related to a higher patency rate： anastomosis sites （P = 0.035） and motile sperm found in the epididymal fluid （P = 0.006）. Motile sperm found in the epididymal fluid were associated with a higher patency rate （OR = 11.80, 95% CI = 1.79, 77.65）. The single-armed two-suture longitudinal VE technique is feasible for microsurgical practice. The patency and pregnancy rates are comparable to the doubled-armed technique. Anastomosis sites and motile sperm found in the epididymal fluid were the most two important factors related to higher patency.

Microsurgical vasoepididymostomy for patients withinfectious obstructive azoospermia, cause, outcome,and associated factors

Azoospermia is of great importance to male infertility. Obstructive azoospermia （OA） due to infection is the most prevalent form of OA in China and has been less studied. We aim to observe the treatment outcome of microsurgical vasoepididymostomy （VE） and also to identify the factors relative to the result after reconstructive surgery. Two hundred and eight men presenting with OA due to infection during the study period from July 2010 to July 2013 were prospectively evaluated. Clinical examination, semen analysis, serum follicle stimulating hormone （FSH）, and scrotal ultrasound were done before surgical exploration. Among the 198 men who were selected for surgical procedures, 159 candidates underwent microsurgical VE with sperm detected in the epididymal fluid. As for the other 39 cases, reconstruction was not feasible. The average age was 28.5 ＋ 3.9 years （range 22-38）, with average follow-up being 16.5 ~ 5.9 months （range 4-28）. According to the 150 cases being followed after VE procedures, the total patency rate was 72% （108/150）. During follow-up, 38.7% （58/150） natural pregnancies occurred, with overall live birth rate being 32.7% （49/150）. Our data suggested that microsurgical VE is an effective therapy for postinfectious epididymal OA. Individualized counseling with prognosis based on etiology should be offered to patients to select optical therapy.

A novel experience of deferential vessel-sparing microsurgical vasoepididymostomy

Microsurgical longitudinal intussusception vasoepididymostomy （LIVE） has been widely used to treat epididymal obstructive azoospermia since 2004. Although the deferential vasculature plays an important role in supplying blood to the testis and epididymis, little attention has been paid to the potential benefits of sparing the deferential vessels during the anastomosis in LIVE. This study aimed to evaluate the efficacy and safety of deferential vessel-sparing LIVE in humans. From December 2013 to December 2015, 69 azoospermic men with epididymal obstruction due to a genital infection, trauma, or idiopathic factors underwent deferential vessel-sparing LIVE in the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China. The outcomes of these patients were analyzed retrospectively. The mean age was 31.1 years for men and 28.3 years for their partners. Fifty-nine （85.5%, 59/69） men were followed up after surgery for approximately 16 months. Patency was noted and confirmed by semen analysis （〉10 000 sperm/ml） in 83.1% （49159） of men. The natural pregnancy rate was 40.7% （24/59） by the end of the study, with 87.5% （21124） of these natural pregnancies achieved within 12 months after surgery. No severe adverse events or complications were observed. In this study, we present a novel technique for sparing the deferential vessels during LIVE. The preliminary outcomes show this technique to be safe with favorable patency and pregnancy rates.

The role of vasoepididymostomy for treatment of obstructive azoospermia in the era of in vitro fertilization:a systematic review and meta-analysis

This study comprises a systematic review and meta-analysis of micmsurgical vasoepididymostomy outcomes in epididymal obstructive azoospermia.A comprehensive literature search was performed using Medline,Embase,and the Cochrane library that included all studies related to microsurgical vasoepididymostomy.Keywords included “vasoepididymostomy,”“epididymovasostomy,”“epididymal obstruction,”and “epididymis obstruction.”Event rate and risk ratio (RR)were estimated.Patency rate and pregnancy rate were investigated.The analysis comprised 1422 articles,including 42 observational studies with 2298 enrolled patients performed from November 1978 to January 2017.The overall mean patency rate was 64.1%(95%confidence interval [CI]:58.5%-69.3%;F=83.0%),and the overall mean pregnancy rate was 31.1%(95%CI:26.9%-35.7%;I^2=73.0%).We performed a meta-analysis comparing the patency rate of bilateral microsurgical vasoepididymostomy and unilateral microsurgical vasoepididymostomy and found an RR of 1.38%(95%CI: 1.21%-1.57%;P <0.00001).A comparison of the site of microsurgical vasoepididymostomy showed that caudal or corpus area was favorable for patency rate (RR =1.17%;95%CI: 1.01%-1.35%;P =0.04).Patients with motile sperm in epididymal fluid exhibited an RR of 1.53%(95%CI:1.11%-2.13%;P =0.01)with respect to patency rate. Microsurgical vasoepididymostomy is an effective treatment for epididymal obstructive azoospermia that can improve male fertility. We find that performing microsurgical vasoepididymostomy bilaterally,anastomosing a larger caudal area,and containing motile sperm in epididymis fluid can potentially achieve a superior patency rate.

Microsurgical transverse 2-suture intussusception vasoepididymostomy： effectiveness and rationality

Background 2-Suture longitudinal vasoepididymostomy shows superiority to transverse technique in an animal study; to date, this has not been consistently confirmed in human body. In the present study, we evaluated the effectiveness of 2-suture transverse intussusception vasoepididymostomy and compared the rationality between transverse and longitudinal techniques. Methods From May 2007 to December 2008, we performed 2-suture transverse vasoepididymostomy in 19 consecutive patients, as described by Marmar with modification. Between March 2009 and January 2010, the internal diameter of the vas lumen and the outer diameter of the epididymal tube were measured using microruler （21 patients and 37 sides）. Results Three patients lost to follow-up. At the first follow-up period （ranged from 10 to 24 months）, the patency rate was 56.3% （9/16） and the natural pregnancy rate was 25% （4/16）. At the second follow-up period （ranged from 46 to 63 months）, the patency rate was 68.8% （11/16）, the natural pregnancy rate was 37.5% （6/16）, respectively, and the take- home baby rate was 31.3% （5/16）. The diameter of the vas lumen and the outer diameter of the epididymal tubule were （0.512±0.046） mm and （0.572±0.051） mm （P 〈0.001）, respectively. Conclusion Transverse 2-suture intussusception vasoepididymostomy is still an effective technique in treating obstructive azoospermia.

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.

Male infertility microsurgical training

Microsurgical training is imperative for urologists and clinical andrologists specializing in male infertility. Success in male infertility microsurgery is heavily dependent on the surgeon＇s microsurgical skills. Laboratory-based practice to enhance microsurgical skills improves the surgeon＇s confidence, and reduces stress and operating time, benefiting both the patient and the surgeon. This review provides guidelines for setting up a microsurgical laboratory to develop and enhance microsurgical skills using synthetic and animal models. The role of emerginE techniaues, such as robotic-assisted microsureerv, is also discussed.

Impact of surgical volume and resident involvement on patency rates after vasectomy reversaldA 14-year experience in an open access system

Objective:Evaluate the influence of fellowship training,resident participation,reconstruction type,and patient factors on outcomes after vasectomy reversals in a high volume,open access system.Methods:Retrospective review of all vasectomy reversals performed at a single institution from January 1,2002 to December 31,2016 was conducted.Patient and spouse demographics,patient tobacco use and comorbidities,surgeon training and case volume,resident participation,reconstruction type,and postoperative patency were collected and analyzed.Results:Five hundred and twenty-six vasectomy reversals were performed during the study period.Follow-up was available in 80.6%of the cohort and overall patency,regardless of reconstruction type was 88.7%.The mean time to reversal was 7.87 years(range of 0-34 years).The majority of cases included resident participation.Case volume was high with faculty and residents logging a mean of 37.0 and 38.7(median 18 and 37)cases respectively.Bilateral vasovasostomy was the most common reconstruction type(83%)and demonstrated a significantly better patency rate(89%)than all other reconstructions(p=0.0008).Overall patency and patency by reconstruction type were not statistically different among faculty surgeons and were not impacted by fertility fellowship training,resident participation or postgraduate year.Multivariate analysis demonstrated that increased time to reversal and repeat reconstructions had a negative impact on patency(p=0.0023 and p=0.043,respectively).Conclusions:Surgeons with a high volume of vasectomy reversals have outcomes consistent with contemporary series regardless of fellowship training in fertility.Patency was better for bilateral vasovasostomies.Patency was not negatively impacted by tobacco use,comorbidities,resident participation,or post-graduate year.

Vasectomy reversal: A review of the evaluation, techniques, and outcomes

This review highlights the evaluation and treatment of men who have undergone vasectomy and desire vasectomy reversal to father children. For surgeons offering this treatment, the appropriate evaluation and treatment are crucial for acceptable outcomes. Although variations on surgical approaches have evolved over the years, one constant is the need for a high level o training and skill in microsurgical techniques.

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.

Validation of robot-assisted vasectomy reversal

Vasectomy reversal （VR） has traditionally been performed with the operative microscope. Recently, robot assistance has been applied to VR. Retrospective chart review from a single VR center included men who underwent either robot-assisted VR （RAVR） or microsurgical VR （MVR） by a single fellowship trained microsurgeon between 2011 and 2013 and had a 6 weeks postoperative semen analysis. Fifty-two men who were interested in VR were counseled and given the option of RAVR versus MVR. Twenty-seven men elected to have MVR while 25 men elected RAVR. These included vasovasostomies and vasoepididymostomies in both groups, as well as redo VRs in men who had failed previous VR attempts by other surgeons. There was no statistically significant difference between the microsurgical group and the robot-assisted group, respectively, in overall patency rates （89% vs 92%）, 6 weeks post-VR mean sperm concentrations （28 million m1-1 vs 26 million m1-1） or total motile counts （29 million vs 30 million）, or mean operative times （141 min vs 150 min）. There was a statistically significant difference in anastomosis time （64 min vs 74 min）, however, clinically this only represented a 10 min longer anastomosis time in the early robotic experience, which was found to be decreasing as the case series continued. Transitioning from MVR to RAVR is feasible with comparable outcomes.

Vasectomy reversal： a clinical update

Vasectomy is a safe and effective method of contraception used by 42-60 million men worldwide. Approximately 3%-6% of men opt for a vasectomy reversal due to the death of a child or divorce and remarriage, change in financial situation, desire for more children within the same marriage, or to alleviate the dreaded postvasectomy pain syndrome. Unlike vasectomy, vasectomy reversal is a much more technically challenging procedure that is performed only by a minority of urologists and places a larger financial strain on the patient since it is usually not covered by insurance. Interest in this procedure has increased since the operating microscope became available in the 1970s, which consequently led to improved patency and pregnancy rates following the procedure. In this clinical update, we discuss patient evaluation, variables that may influence reversal success rates, factors to consider in choosing to perform vasovasostomy versus vasoepididymostomy, and the usefulness of vasectomy reversal to alleviate postvasectomy pain syndrome. We also review the use of robotics for vasectomy reversal and other novel techniques and instrumentation that have emerged in recent years to aid in the success of this surgery.