Microsurgical varicocelectomy： a review

Varicocelectomy is the most commonly performed surgical procedure for the treatment of male infertility. Although several different techniques for varicocele repair have been described in the literature, microsurgical varicocelectomy performed through a subinguinal or inguinal incision is recognized as the gold-standard approach for varicocelectomy, due to high success rates with minimal complications. Standard indications for varicocelectomy include palpable varicocele（s）, with one or more abnormal semen parameters, and, for the couple trying to conceive, in the setting of normal or correctable female infertility. However, varicocele repair is often recommended and undertaken for reasons other than infertility, including low serum testosterone, testicular pain, testicular hypotrophy and poor sperm DNA quality. This article reviews the technical aspects of microsurgical varicocelectomy, and its indications in adults and adolescents.

Can inhibin-B predict the outcome of microsurgical epididymal sperm aspiration in patients with suspected primary obstructive azoospermia？

Aim： To evaluate whether inhibin-B can predict the outcome of a microsurgical epidymal sperm aspiration （MESA） procedure in patients with suspected primary obstructive azoospermia （OA） and if inhibin-B can replace testicular biopsy in the diagnostic work-up of these patients. Methods： Inhibin-B levels and testicular biopsy scores were related to the outcome of MESA in 43 patients with suspected primary OA. MESA was considered to be successful when epididymal sperm could be identified during the procedure. Results： Spermatozoa were present in the epididymal aspirate in 28 out of the 43 patients （65%）. lnhibin-B values were not significantly different in patients with successful or unsuccessful MESA. The modified Johnsen score, however, was significantly lower in patients with unsuccessful MESA （P = 0.003）. A rete testis obstruction or epididymal malfunctioning was found in 15% of patients with suspected primary OA, reflected by unsuccessful MESA despite normal inhibin-B levels and normal testicular histology. Conclusion： Inhibin-B cannot replace testicular biopsy as a diagnostic tool in the work-up of patients with suspected primary OA. Testicular biopsy is useful in identifying patients with spermatogenic arrest, who might have normal inhibin-B values.

Microsurgical epididymal sperm aspiration： indications, techniques and outcomes

Microsurgical epididymal sperm aspiration （MESA） refers to retrieval of sperm-containing fluid from optimal areas of the epididymis that are selected and sampled using high-power optical magnification provided by an operating microscope. Retrieved sperm are subsequently used for intracytoplasmic sperm injection （ICSI） to induce fertilization and pregnancy. MESA is considered by many experts to be the gold standard technique for sperm retrieval in men with obstructive azoospermia given its high yield of quality sperm, excellent reported fertilization and pregnancy rates, and low risk of complications. However, MESA must be performed in an operating room, requires microsurgical skills and is only useful for reproduction using ICSI. Herein we present an overview of the evaluation of candidate patients for MESA, the technical performance of the procedure and the outcomes that have been reported.

Microsurgical reconstruction of hepatic artery in A-A LDLT:124 consecutive cases without HAT

AIM:To retrospectively investigate microsurgical hepatic artery(HA) reconstruction and management of hepatic thrombosis in adult-to-adult living donor liver transplantation(A-A LDLT).METHODS:From January 2001 to September 2009,182 recipients with end-stage liver disease underwent A-A LDLT.Ten of these patients received dual grafts.The 157 men and 25 women had an age range of 18 to 68 years(mean age,42 years).Microsurgical techniques and running sutures with back-wall first techniques were performed in all arterial reconstructions under surgical loupes(3.5 ×) by a group of vascular surgeons.Intimal dissections were resolved by interposition of the great saphenous vein(GSV) between the donor right hepatic artery(RHA) and recipient common HA(3 cases) or abdominal aorta(AA)(2 cases),by interposition of cryopreserved iliac vessels between the donor RHA and recipient AA(2 cases).RESULTS:In the 58 incipient patients in this series,hepatic arterial thrombosis(HAT) was encountered in 4 patients,and was not observed in 124 consecutive cases(total 192 grafts,major incidence,2.08%).All cases of HAT were suspected by routine color Doppler ultrasonographic examination and confirmed by contrast-enhanced ultrasound and hepatic angiography.Of these cases of HAT,two occurred on the 1st and 7th d,respectively,following A-A LDLT,and were immediately revascularized with GSV between the graft and recipient AA.HAT in one patient occurred on the 46th postoperative day with no symptoms,and the remaining case of HAT occurred on the 3rd d following A-A LDLT,and was cured by thrombolytic therapy combined with an anticoagulant but died of multiorgan failure on the 36th d after A-A LDLT.No deaths were related to HAT.CONCLUSION:Applying microsurgical techniques and selecting an appropriate anastomotic artery for HA reconstruction are crucial in reducing the high risk of HAT during A-A LDLT.

Multiple Factors Affecting Human Repregnancy after Microsurgical Vasovasostomy

To determine the factors which might affect the recovery of fertility after an accurate microsurgical vasovasostomy, we conducted α 3-year-follow up study in 56 men after microsurgical vasovasostomy. Twenty-two variables as putative factors associated with recovery of fertility were measured. The results of Logistic regression and other statistical analyses suggest that 8 factors including age of husband, age of wife, history of past pregnancies of current wife, number of vasovasostomies, serum FSH, LH and T before vasovasostomy, and sperm granuloma of vas nodule are of no significance in recovery of fertility, whereas 14 factors including years after vasectomy, sperm concentration, progressive motility, sperm motility, viability, normal morphology, sperm-egg penetration rate, TAT and SIT before-and-after vasovasostomy, MAR, IBT adherent IgG and IgA after vasovasostomy are significantly associated with repregnancy.

The microsurgical treatment of glomus tumor at the nail bed of the finger

Objective： To discuss the diagnosis and treatment of glomus tumor at the nail bed of the finger. Methods： The course and therapeutic outcome of 12 cases of glomus tumor which were resected and confirmed by histology examination were analyzed. Results：All cases were followed up for six months up to 2 years, no recurrences were observed, the shape of the nait was normal. Conclusion： Microsurgical treatment of glomus tumors of the nail bed is effective.

Serum Total Testosterone Levels Pre- and Post-Subinguinal Microsurgical Varicocelectomy in Men with Clinical Varicoceles

Background: Varicocele is abnormal dilation and tortousity of the scrotal venous pampiniform plexus that drain blood from each testicle. Recently, it has been linked to low serum total testosterone (TT) levels by affecting the optimal functioning of the leydig cell via increasing the scrotal temperature. Varicocele repair has been found post-operatively to increase the serum levels of TT. This study looks at the pre and post-subinguinal microsurgical varicocelectomy serum TT levels in male patients with clinical varicocele. Methods: The study involved 88 male patients with clinical varicoceles who met the inclusion criteria. These patients after good history taking and physical examination had their serum TT levels measured pre varicocelectomy and 6 months post-subinguinal microsurgical varicocelectomy. The varicoceles were diagnosed by physical examination and use of scrotal color Doppler ultrasonography (US). Results: The number of patients with varicocele were 88 males. The mean age of the patients was 33.43 ± 7.82 years. There was isolated left varicocele in 57 (64.8%) patients and bilateral varicocele in 27 (30.7%) patients. Pre varicocelectomy, 61 (69.3%) patients had serum TT of between 100 - 290 nanogram/deciliter (ng/dl) and a mean value of 241 ± 0.91 ng/dl. Post varicocelectomy 56 (63.6%) patients had serum TT in the range of 300 - 490 ng/dl with a mean of 482 ± 2.87 ng/dl, showing a robust significant increase in the serum TT post-operatively (P < 0.001). Conclusion: There was statistically significant improvement in the serum TT levels with 55 (79%) patients exhibiting normalization of serum TT levels after subinguinal microsurgical varicocelectomy.

Evaluation of 10-year Microsurgical Tubal Reversal after Tubal Sterilization

One thousand and twenty-nine women with microsurgical tubal reversal after tubal sterilization were followed up.The rate of intrauterine pregnancy was found to be 93.29%.The rate of intrauterine pregnancy was the highest(73.28%)in the first year after tubal reversal.In the first year,the chance of pregnancy in the first 6 months was higher (54.81%)than that(40.86%)in the second 6 months(P<0.01),and the chance in the first 3 months was higher(37.41%)than that(27.80%)in the second 3 months(P<0.01).The rates of ectopic pregnancy after tubal reversal in various stages were not significantly different(P>0.05).The rate of intrauterine pregnancy was not related with the period from sterilization to tubal reversal.Early postoperative hydropertubation can only decrease the rate of intrauterine pregnancy.The rate of intra uterine pregnancy of the tubal reversal after Uchida's method and clips tubal sterilization was higher than that after Pomeroy's tubal ligation.The reanastomosis of isthmus and isthmus resulted in the highest rate of intra uterine pregnancy,so we think that Uchida's or elips tubal sterilization in the isthmus of the tubal are ideal and reversible techniques at present.

Successful lower leg microsurgical reconstruction in homozygous sickle cell disease: Case report

We present an 18-year-old female with sickle cell disease, who presented with an extensive lower leg ulcer over a 12-year course of the disease. Definitive reconstruction was made using a free latissimus dorsi flap and split-skin grafts. One week before the surgery, the plasmapheresis protocol and blood transfusion were administered, in order to achieve a hemoglobin S level of ≤ 30%. Intraoperatively, the flap pedicle was rinsed with plasminogen activator inhibitor-1 until the thrombolytic agent was obtained from the comitant vein; after the arterial flow had been released, an intravenous bolus dose of heparin(2000 U) was administrated. No vascular complications occurred. Postoperatively, the patient received a 10-d course of hemodilution and a 14-d course of full-dose anticoagulation. After 8 mo postoperatively, the patient was able to walk and run, and showed complete wound healing. This case indicates that sickle cell disease is not a contraindication to free tissue transfer; however, the complications, their rate and overall outcomes for these cases are not yet clear. Herein, we provide an algorithm based on our clinical experience in this type of case and treatment, including several recommendations that may help to reduce thrombosis risk and systemic complications.

Microsurgical resection of ventral foramen magnum meningiomas via a far-lateral suboccipital approach

BACKGROUND: In recent years some reports have been published propagating microsurgical resection of ventral foramen magnum meningiomas (VFMMs). Operative approaches to these lesions have been studied by various authors, but remain controversial. OBJECTIVE: To discuss the operative technique and outcome in patients with VFMMs who had been treated via a far lateral suboccipital approach. DESIGN: Retrospectively clinic case investigation. SETTING: Department of Neurosurgery, the Ninth People's Hospital, Medical School of Shanghai Jiao Tong University. PARTICIPANTS: Between January 1997 and June 2003, 10 patients were treated surgically with VFMMs in Department of Neurosurgery, the Ninth People's Hospital, Medical School of Shanghai Jiao Tong University. In the series of 10 patients, ages ranged from 37 to 72 years, mean (53±10) years, were consisted of 6 males and 4 females. All the subjects were informed of the treatment plan and agreed to join the experiment. Early symptoms included headache and upper cervical pain. The time between the first occurrence of symptoms and the diagnosis ranged from 6 months to 17 months, mean (10.3±3.4) months. Main presenting symptoms were unilateral upper extremity sensory and motor deficits in 6 cases, swallowing difficulties in 2 and spastic quadriparesis in 2. VFMMs were demonstrated as round by the computed tomographic (CT) scan and magnetic resonance imaging (MRI) in all patients. The maximum diameter of tumors ranged from 2 to 4 cm, mean (2.55±0.57) cm, including 2 cm in one case, 2.0-3.0 cm in six and 3.0-4.0 cm in three. METHODS: ①All tumors were removed via the far lateral suboccipital approach. Resection of the posterior 5 mm of the condyle was necessary in one patient whose tumors' diameter were 2 cm. The patient was situated in the lateral decubitus position. The head was fixed in a Mayfield headrest. A C-shaped incision made behind the ear 2 cm medial to the mastoid process, turning vertically down to the level C4, to expose the extradural segment of the vertebral artery (VA). After the dura was opened longitudinally behind VA entry point, the tumor was revealed to identify the complete cranial nerves and the intracranial VA under magnification of the surgical microscope. Every attempt should be made to keep the arachnoid and the dentate ligament was sectioned. Then the tumor was debulked significantly, and dissected away from the cranial nerves and the blood vessels with microsurgical techniques. If it was risk to dissect tumor from the vertebral artery, its branches, or any cranial nerve, the progression was discontinued and portion of the tumor was left behind. After resection of the tumor, the site of its attachment was coagulated and the involved layer of dura was resected. ②The degree of tumor resection was classified based on Al-Mefty's grade into three categories: gross-total resection: excision of the dural attachment and drilling of adjacent bone; near-total resection: a few millimeters of insulated and cauterized tumor were left on the vertebral artery or other vital; subtotal resection: more than 50% of the tumor mass were removed. ③All patients underwent clinical examination for lower cranial nerves or long tract deficits on the first day postoperatively. CT or MRI and neurological examinations were performed at 3 months of follow-up. MAIN OUTCOME MEASURES: Operative effect. RESULTS: All ten patients with VFMMs were treated via a far lateral suboccipital approach. Gross total resection was achieved in 6 patients, near-total resection was carried out in 2 and subtotal resection in 2 patients. One patients died in the postoperative period due to acute respiratory distress syndrome, five patients kept normal neurological status, whereas other four patients suffered from lower cranial nerve deficits and aspiration pneumonia was observed in two of them. The data of following up for 3 months showed that 2 patients still had lower cranial nerve deficit and others recovered from their illness. No tumor relapse or increment was found in CT or MRI scans. CONCLUSION: Most of VFMMs could be totally removed via a far lateral suboccipital approach with or without resection of the occipital condyle according to the tumor size, allowing most of these patients to achieve a good outcome in a 3 months follow-up.

Microsurgical vasovasostomy:An option for men with post vasectomy psychological distress

Vasectomy is a practical and straightforward approach to birth control.This paper presented a 31-year-old patient who desired to restore his fertility five years after being vasectomized.He met several obstacles.He developed severe psychological distress with symptoms of stress,anxiety,and aggression.He underwent microsurgical vasovasostomy,and vassal patency was confirmed by return of spermatozoa in semen samples 6 and 10 weeks after surgery,and symptoms of psychological distress disappeared.Preoperative vasectomy counseling should include information about vasectomy reversal.At the most,vasectomy reversal can be considered in selected men with psychological problems due to vasectomy.Microsurgical training should be offered to more urological surgeons,especially those who are interested in andrology.

Microsurgical treatment on distal anterior cerebral artery aneurysms (9 cases report)

Objective To report the clinical diagnosis and microsurgical treatment of ruptured distal anterior cerebral artery aneurysm (DACAA) patients treated over the last 3 years. Methods 9 consecutive cases of ruptured DACAA operated from October 2007 to March 2010 were reviewed and followed up. Results 11 aneurysms were clipped

Diagnosis and microsurgical treatment of intracranial subependymoma:report of 33 cases

Objective To explore the clinical characteristics and treatment of intracranial subependymoma. Methods 33 patients with intracranial subependymoma treated with microneurosurgical management at Beijing Tiantan Hospital from 1998 to 2008 were analyzed retrospectively. Results In this serials,19 patients were male and 14 patients female.

Microsurgical treatment of neurilemmoma in upper cervical spinal canal:59 cases report

Objective To explore surgical techniques and curative effects of microsurgical treatment for neuriemmoma in upper cervical spinal canal. Methods Form Jan. 2004 to Nov. 2007. 59 cases of schwannoma was resected through microoperation, the operation was conducted through a posteromedial approach,using German Laika microscope resection

Microsurgical anatomy of the ambient cistern and its related arachnoidal membranes

Objective To study microanatomy features and clinical significance of ambient cisterns and their arachnoidal membranes in detail. Methods Ambient cisterns including their shapes,borders,contents and arachnoidal membranes were observed in 20 cadaveric brains using an operating microscope. Results The

Facial nerve preservation following microsurgical removal of large and huge acoustic neuroma

Objective To evaluate the long-term facial nerve funtion of patients following microsurgical removal of large and huge acoustic neuroma,and to indentify the factors that influence these outcomes. Methods A retrospective review was performed,which included 176 consecutive patients with a

Microsurgical resection of bilateral falcine meningiomas in central gyrus region

Objective To investigate microsurgical techniques in bilateral falcine meningiomas of central gyrus region surgery. Methods Sixteen patients with bilateral falcine meningiomas in central gyrus region were treateded with a series of microsurgical techniques,including midline crossing craniotomy,dural cut in a strip fashion

Factors affecting patency time and semen quality in a single-armed microsurgical vasoepididymostomy

Although microsurgical vasoepididymostomy(MVE)is an effective treatment for epididymal obstructive azoospermia,some patients may experience delayed patency or suboptimal semen parameters after patency.However,research into patency time,semen quality postpatency,and associated influencing factors remains limited.This study aimed to address these issues by evaluating 181 patients who underwent at least one-sided MVE employing asingle-armed longitudinal intussusception vasoepididymostomy technique,with a follow-up period of over 12 months for 150 patients.The overall patency rate was 75.3%,with 86.0%of patients achieving patency within 6 months following MVE.Unexpectedly,factors such as age,history of epididymitis,duration of surgery,side of anastomosis,sperm motility in epididymal fluid,and the site of anastomosis showed no correlation with patency time.Nonetheless,our univariate and multivariate linear regression analysis indicated that only the site of anastomosis was positively correlated with and could independently predict postoperative total motile sperm count.Therefore,the site of anastomosis might serve as a predictor for optimal postoperative semen quality following the MVE procedure.

Predictors of microsurgical varicocelectomy efficacy in male infertility treatment:critical assessment and systematization

In this review,we tried to systematize all the evidence(from PubMed[MEDLINE],Scopus,Cochrane Library,EBSCO,Embase,and Google Scholar)from 1993 to 2021 on the predictors of microsurgical varicocelectomy efficacy in male infertility treatment.Regarding the outcomes of varicocele repair,we considered semen improvement and pregnancy and analyzed them separately.Based on the 2011 Oxford CEBM Levels of Evidence,we assigned a score to each trial that studied the role of the predictor.We systematized the studied predictors based on the total points,which were,in turn,calculated based on the number and quality of studies that confirmed or rejected the studied predictor as significant,into three levels of significance:predictors of high,moderate,and low clinical significance.Preoperative total motile sperm count(TMSC)coupled with sperm concentration can be a significant predictor of semen improvement and pregnancy after varicocelectomy.In addition,for semen improvement alone,scrotal Doppler ultrasound(DUS)parameters,sperm DNA fragmentation index(DFI),and bilateral varicocelectomy are reliable predictors of microsurgical varicocelectomy efficacy.

Classification and microsurgical treatment of foramen magnum meningioma

Background To investigate the classification and microsurgical treatment of foramen magnum meningioma(FMM).Methods We retrospectively analyzed 76 patients with FMM and classified them into two classifications,classification ABS according to the relationship between the FMM and the brainstem and classification SIM according to the relationship between the FMM and the vertebral artery(VA).All patients underwent either the far lateral approach(54 cases)or the suboccipital midline approach(22 cases).Results Of the 76 cases,47 cases were located ahead of the brainstem(A),16 cases at the back of the brainstem(B),and 13 cases were located laterally to the brainstem(S).There were 15 cases located superior to the VA(S),49 cases were inferior(I),and 12 cases were mixed type(M).Among 76 cases,71 cases were resected with Simpson grade 2(93.42%),3 with Simpson grade 3(3.95%),and 2 with Simpson grade 4(2.63%).We summarized four anatomical triangles:triangles SOT,VOT,JVV,and TVV.The mean postoperative Karnofsky performance score was improved in all patients(p<0.05).However,several complications occurred,including hoarseness and CSF leak.Conclusion ABS and SIM classifications are objective indices for choosing the surgical approach and predicting the difficulty of FMMs,and it is of great importance to master the content,position relationship with the tumor,and variable anatomical structures in the four"triangles"for the success of the operation.