Microsurgical epididymovasostomy by tubule intussusception: a new technique in rat model**Presented at the American Urological Association 83rd Annual Meeting, Boston, Massachusetts, June 3 to 7, 1988

Rat model and validation of a modified single-armed suture technique for microsurgical vasoepididymostomy: Guo's SA-LIVE

BACKGROUND

Double-armed suture longitudinal intussusception vasoepididymostomy (DA-LIVE) has been widely adopted owing to its simplicity and high success rate; however, specialized double-armed microsutures are required.

OBJECTIVE

To provide a novel single-armed suture longitudinal intussusception vasoepididymostomy (SA-LIVE) technique using only two single-armed sutures, named Guo's SA-LIVE.

MATERIALS AND METHODS

Four weeks after vasectomy in male adult Wistar rats, vasoepididymostomies were performed using DA-LIVE, SA-LIVE, or Guo's SA-LIVE. After 12 weeks, functional patency was functionally assessed by evaluating for motile spermatozoa distal to the anastomosis. If no motile spermatozoa were visible, the mechanical patency of the anastomosis was tested by the ability of methylene blue to pass through the surgical anastomosis. The key procedure in Guo's SA-LIVE was cutting each needle with over 1cm attaching suture and making a flat overhand bend knot to tie the needle to the other end of the suture, after the needles were passed through the epididymal tubule and then the vasal lumen in an inside-out fashion, and then, the needles were passed through the vasal lumen in an inside-out fashion.

RESULTS

The proportions of functional patency were 50.0% (3/6), 33.3% (2/6), and 50% (3/6) for the DA-LIVE, SA-LIVE, and Guo's SA-LIVE groups, respectively (P = .799). The proportions of mechanical plus functional patency for the three methods were 83.3% (5/6), 66.7% (4/6), and 83.3% (5/6), respectively (P = .725). The mean anastomosis times for the three LIVE techniques and the proportions of complications were similar (P = .150 and .758, respectively).

CONCLUSIONS

Guo's single-armed suture technique is a potentially effective alternative to perform vasoepididymostomy when specialized double-armed microsutures are not available based on the current animal experiment.

[Surgery of male infertility: an update]

Surgery for male infertility includes three main areas: varicocele surgery, recanalization of seminal tract, sperm retrieval.Varicocele treatment in infertily is still controversial. Recent scientific evidence appears to demonstrate that in selected cases varicocele treatment is beneficial in improving semen parameters and pregnancy rate. The key for the success of treatment seems to be a correct indication. It is our opinion that varicocele should be treated in presence of abnormal semen parameters, when clinically significant, and in adolescents with atrophy of the affected testis. So far, no specific technique, either surgical, microsurgical or sclerotherapic, can be considered the gold standard. Good results in our hands have been obtained with the microsurgical lymphatic sparing high ligation of internal spermatic vein.Innovations in surgery for seminal tract obstructions include the new tubular invagination techniques for epididimovasostomy, which showed excellent results with a simplified and time-saving microsurgical approach. In distal obstructions, a new transperineal ultrasound-guided approach has been proposed for the diagnostic work-up and treatment. Advantages of this technique and of the TURED must be balanced with those of immediate sperm retrieval for ART.In sperm retrieval, microTESE represents the most important surgical evolution in non-obstructive azoospermia. We have recently proposed a new stepwise approach starting with a minimal equatorial incision for conventional testicular biopsy which is extended to perform microTESE only when no sperm is retrieved. In this way microTESE is offered only to patients who really need it. Another field of innovation is sperm retrieval for ICSI in patients with Klinefelter Syndrome.

A new one-layer epididymovasostomy technique

OBJECTIVES

To describe and evaluate the outcomes of a new epididymovasostomy technique.

PATIENTS AND METHODS

Nine patients with obstructive azoospermia were treated at the Minia University Hospital using a new microsurgical bilateral epididymovasostomy technique. The technique involved the opening of a small window in the tunica of the epididymis, making an opening in the underneath epididymal tubule and keeping it open by fixing the edges of the epididymal opening to the edge of the epididymal tunica with four 10/0 nylon sutures. The abdominal cut end of the vas deferens was then anastomosed to the epididymal opening by suturing the epididymal tubule, fixed to its tunica in one layer, to the full thickness vas deferens. The main outcome measure was finding sperm in the ejaculate.

RESULTS

Sperm was found in the ejaculate in six out of nine patients after our new, one-layer, epididymovasostomy technique. Mean ± sd operating time was 176 ± 23 min.

CONCLUSIONS

This new, one-layer, epididymovasostomy technique provides a simple alternative method of epididymovasostomy, with reasonable outcomes. More cases and follow-up are needed to make meaningful comparisons with conventional epididymovasostomy.

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 preoperative evaluation along with the techniques of various VE will be described in this article.

Restructuring reconstructive techniques--advances in reconstructive techniques

Microsurgical reconstruction to correct male infertility, although usually performed for vasectomy reversal, also is performed to correct other types of iatrogenic, congenital, and postinflammatory obstruction. In an effort to improve success rates and facilitate performance of these complex microsurgical procedures, modifications are continually suggested. This article reviews some of these proposed modifications. The modifications can be divided into five general categories: (1) use of biomaterials/sealants, (2) laser soldering, (3) use of absorbable and nonabsorbable stents, (4) new intussusception vasoepididymostomy (VE) anastomotic techniques, and (5) use of robotics.

Innovative single-armed suture technique for microsurgical vasoepididymostomy

OBJECTIVES

Vasoepididymostomy outcomes are heavily dependent on the surgeon's microsurgical experience and skill. To avoid back-walling the tubular lumen, the needles are generally placed inside-out through the vasal lumen using double-armed microsutures. These double-armed sutures for infertility microsurgery are very expensive and may be difficult to obtain. We describe a randomized trial that used a novel single-armed suture placement pattern for vasoepididymostomy.

METHODS

Male adult Wistar rats underwent vasectomy. Two weeks later, vasoepididymostomies were performed using either a single-armed longitudinal intussusception vasoepididymostomy (n = 6) or a standard double-armed longitudinal intussusception vasoepididymostomy (n = 6) technique. After 9 weeks, patency was assessed functionally by evaluating for motile sperm distal to the anastomosis. If no motile sperm were visible, the mechanical patency of the anastomoses was tested by the ability of methylene blue to pass through the surgical anastomosis.

RESULTS

The patency rate for the double-armed vasoepididymostomy group was 100% (6 of 6) compared with 83.3% (5 of 6) for the single-armed vasoepididymostomy group. This difference was not significant (P = 0.50). Sperm granulomas were found in three (50%) of six anastomoses in the double-armed group and five (83%) of six anastomoses in the single-armed vasoepididymostomy group (P = 0.27). The mean operative times for the double and single-armed longitudinal intussusception vasoepididymostomy techniques were similar (35 minutes versus 43 minutes; P = 0.39).

CONCLUSIONS

The results of our study have shown that the single-armed suture technique to perform vasoepididymostomy is almost as effective as the double-armed technique. Although we still prefer to use double-armed sutures, we believe that this is a practical and effective alternative when specialized double-armed microsurgical sutures are not available.

Early patency rates after the two-suture invagination technique of vaso-epididymal anastomosis for idiopathic obstruction

OBJECTIVES

To prospectively evaluate the results of vaso-epididymostomy, using a two-suture microsurgical invagination technique, when used for men with azoospermia due to an obstruction at the vaso-epididymal junction.

PATIENTS AND METHODS

Between December 2002 and November 2004, 29 men with idiopathic obstructive azoospermia underwent vaso-epididymostomy with the two-suture invagination technique. The patency rate was assessed by return of sperm in the semen after surgery.

RESULTS

In all, 23 men provided at least one postoperative semen sample. The mean (range) follow-up was 7.6 (1.5-30) months. In 11 of these men (48%), patency was shown at a mean of 3.2 (1.5-7) months after surgery. The median sperm density was 17 (10-65) million/mL. Four men had normal sperm density and motility (>20 million/mL; >50% total motility).

CONCLUSIONS

Men with idiopathic vaso-epididymal junction obstruction can have significant sperm positivity after vaso-epididymostomy. With a patency rate of nearly half within a year of surgery, vaso-epididymostomy should be the first line of therapy for these men.

Clinical experience of vasoepididymostomy using a triangulation technique

Background: Although the number of patients receiving vasoepididymostomies is gradually increasing, these individuals are limited in the recent advanced assisted reproductive technology (ART) era. A novel technique involving vasoepididymostomy with epididymal tubular invagination has been reported. We attempted to define the results of this method and to compare them with the conventional end-to-side technique in patients with suspected epididymal obstruction and no previous history of vasectomy. Methods and Results: Eight eligible triangulation end-to-side vasoepididymostomy procedures performed on five azoospermic patients exhibiting either unilateral or bilateral epididymal obstruction are described. The overall patency rate following operation was 100% (five of five). Two pregnancies were achieved by natural intercourse and one was accomplished via artificial insemination. A single pregnancy was obtained with an intracytoplasmic sperm injection using frozen-thawed sperm collected during the operation. Conclusion: Vasoepididymostomy, using the triangulation technique for epididymal obstruction, resulted in an earlier patency in all patients. This method may afford advantages when compared with the conventional end-to-side approach; however, larger subject populations are required in order to assess further the efficacy of this procedure. In addition, long-term follow up is necessary. (Reprod Med Biol 2003; 2: 101-104).

Microsurgical vasoepididymostomy: a prospective randomized study of 3 intussusception techniques in rats

PURPOSE

Vasoepididymostomy is a technically challenging but cost-effective treatment for obstructive azoospermia. We evaluated the outcomes of 3 intussusception vasoepididymostomy techniques, namely 3 suture triangulation, 2 suture transverse and a new 2 suture longitudinal technique.

MATERIALS AND METHODS

Male Wistar rats were randomized into 4 experimental and 1 control groups. After 3 weeks of vasal obstruction bilateral vasoepididymostomy was performed. In group I, 3 sutures were placed in triangular fashion. In group II, 2 sutures were placed perpendicular to the tubule. In group III, 2 sutures were placed longitudinal to the tubule. The tubules were then opened in the direction of the needles and anastomosed to the vasa. After 5 months patency was evaluated in blinded fashion.

RESULTS

The functional patency rate (presence of motile sperm in the vas) was 64%, 64% and 93% in groups I to III, respectively (p <0.001). As evaluated by methylene blue retrograde vasography toward the epididymis, the mechanical patency rate was similar for the 3 techniques, that is 86%, 86% and 93% in groups I to III, respectively. The sperm granuloma rate was significantly lower in group III (36%, 21% and 0% in groups I to III, respectively, p <0.001).

CONCLUSIONS

Transverse 2 suture vasoepididymostomy has a patency rate similar to that of the 3 suture technique. Our new 2 suture longitudinal technique, which allows a larger opening in the epididymal tubule for anastomosis, is superior to the 2 and 3 suture techniques with respect to the patency and sperm granuloma rates.

Reconstruction of seminal ducts in obstructive azoospermia

Depending on the localization of the obstruction of the seminal ducts, either a microsurgical reconstruction (tubulovasostomy, vasovasostomy) or a transurethral resection of the ejaculatory ducts is carried out. We have compared the effectiveness and economic advantages of reconstructive microsurgery of the epididymis and vas deferens with standard procedures in animal experiments. Microsurgical invagination techniques in tubulovasostomy are equal to the standard procedure from the point of view of the patency and fertility rates. They are also easier to learn and carry out. Less time is required for the invagination technique, and also less microsurgical suture material. The double-layer technique in vasovasostomy is equal to the one-layer microsurgical technique from the point of view of patency and fertility rates. The one-layer technique requires less time and suture material. It seems that the discrepancy between the patency and the fertility rate is related to immunological processes after reconstruction of the seminal ducts. In cases of obstructive azoospermia it is necessary to investigate the individual conditions and possibilities of the infertile couple. As a result of the high success rate obtainable today by surgical reconstruction of the seminal ducts, this must constitute the first type of treatment to be considered, before any of the procedures of reproductive medicine are undertaken.

Modified vasoepididymostomy with simultaneous double needle placement, tubulotomy and tubular invagination

PURPOSE

Recently a new technique for vasoepididymostomy was described which included tubular invagination by the triangulation method with a patency rate of 92%. Although these early data were encouraging, some technical problems were noted with the technique. After placing the first suture there was often tubular leakage and collapse. The tubulotomy was difficult and in some cases a suture was inadvertently cut. A modified technique is presented for vasoepididymostomy with tubular invagination, including some methods described in rat models. Only 2 sutures are used with simultaneous double needle placement.

MATERIALS AND METHODS

The 2-suture technique was used on 19 men who had undergone at least 1 vasoepididymostomy during vasectomy reversal procedures.

RESULTS

Patency was demonstrated in 7 of 9 men (77.7%) who underwent modified bilateral vasoepididymostomy and 6 of 7 (85.7%) who underwent unilateral vasoepididymostomy and unilateral vasovasostomy. Pregnancies were reported in both groups. The overall operating time for the modified technique was about 35 to 45 minutes per side.

CONCLUSIONS

Modified vasoepididymostomy with simultaneous needle placement, tubulotomy and invagination resulted in early patency in a high percentage of patients. Tubular invagination may have advantages compared to other conventional methods of vasoepididymostomy but more followup is needed.