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

[Surgery to improve male fertility]

BACKGROUND

At a time when increasing attention is being paid to the limitations and risks of in vitro fertilisation techniques, surgeries to improve male fertility are attracting growing interest.

METHODS

Systematic review based on a Pubmed search of surgeries to improve male fertility.

RESULTS

Vasovasostomy (VV) gives patency rates of 70-97% and pregnancy rates of 30-76%. Vasoepididymostomy (VE) gives patency rates of 80-84%, with pregnancy rates of 40-44%. The duration of obstruction and the age of the partner are 2 predictive parameters for the occurrence of a natural pregnancy. In cases of obstructive azoospermia due to pelvic obstruction (prostatic cyst, obstruction of the ejaculatory ducts), several surgical procedures may be proposed. Transurethral resection of the ejaculatory ducts leads to an improvement in sperm parameters in 63-83% of patients, with spontaneous pregnancy occurring in 12-31% of cases. Microsurgical cure of varicocele by the subinguinal route is a benchmark technique with recurrence rates of less than 4%. It improves live birth and pregnancy rates, both naturally and by in vitro fertilization, as well as sperm count, motility and DNA fragmentation rates.

CONCLUSION

Whenever possible, the urologist should present the surgical options for improving male fertility to the ART team and to the couple, discussing the benefit/risk balance of the operation as part of a personalized approach.

Male infertility

Clinical infertility is the inability of a couple to conceive after 12 months of trying. Male factors are estimated to contribute to 30-50% of cases of infertility. Infertility or reduced fertility can result from testicular dysfunction, endocrinopathies, lifestyle factors (such as tobacco and obesity), congenital anatomical factors, gonadotoxic exposures and ageing, among others. The evaluation of male infertility includes detailed history taking, focused physical examination and selective laboratory testing, including semen analysis. Treatments include lifestyle optimization, empirical or targeted medical therapy as well as surgical therapies that lead to measurable improvement in fertility. Although male infertility is recognized as a disease with effects on quality of life for both members of the infertile couple, fewer data exist on specific quantification and impact compared with other health-related conditions.

Unilateral Versus Bilateral Vasoepididymal Anastomosis for Idiopathic Obstructive Azoospermia: A Randomised Controlled Trial

Background

Men with idiopathic obstructive azoospermia (OA) are candidates for surgical reconstruction with a vasoepididymal anastomosis (VEA) performed on one or both testis. There are no randomised trials comparing the success of unilateral versus bilateral VEA.

Objective

We conducted a randomised trial to compare the two surgical options.

Design setting and participants

Between April 2017 and March 2022, men with infertility due to idiopathic OA were randomised to a unilateral (group 1) or bilateral (group 2) VEA in an ethics committee-approved clinical trial, registered with the Clinical Trials Registry.

Outcome measurements and statistical analysis

The primary outcome was successful surgery, defined as appearance of sperm in the ejaculate, evaluated at 3 mo intervals after surgery. Additional outcomes were pregnancy rates and complications between the two groups. Men with successful surgery were compared with those without patency to identify the predictors of success.

Results and limitations

Fifty-four men fulfilled the criteria and 52 who completed follow-up were included in the analysis. The overall patency rate was 36.5% (19/52 individuals). This was higher in men with bilateral surgery (12/26 patients, 46%) than in those with unilateral surgery (7/26 patients, 27%) but was not statistically significant (p = 0.1). The overall pregnancy rate with ejaculated sperm was significantly higher in the bilateral surgery group (4 vs 0, p = 0.037), while the spontaneous conception rate was higher but not statistically significant (3 vs 0, p = 0.074). The complication rates in the two groups were similar (p = 0.7), and all complications were Clavien-Dindo grade 1. Although bilateral surgery and presence of sperm in epididymal fluid were higher in men with patency, these were not statistically significant.

Conclusions

A bilateral VEA was associated with higher patency and spontaneous pregnancy rates than unilateral surgery, but the results were not statistically significant. However, the overall pregnancy rate with ejaculated sperm, spontaneous and assisted, was significantly higher in the bilateral surgery group.

Patient summary

In this study, we compared between unilateral and bilateral reconstructive surgery in azoospermic men and found better overall success with bilateral surgery. However, these results were not statistically significant.

Current progress on the curative effects of vasoepididymostomy for patients with obstructive azoospermia: An updated systematic review and meta-analysis of human studies

BACKGROUND

Obstructive azoospermia (OA) is an important cause of male infertility, and epididymal OA (EOA) is a common disease. Microsurgical reconstruction is a common technique used in the treatment of EOA. In the present study, we analyzed the effectiveness of microsurgical vasoepididymostomy (MVE) at different levels and compared the differences among several MVE techniques.

MATERIALS AND METHODS

A literature search was conducted in the PubMed, Web of Science, and Embase databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The included studies were published in English until May 14, 2021. The R 4.1.2 software was utilized to evaluate the event rate, risk ratio (RR), and 95% confidence interval (CI).

RESULTS

A total of 51 studies involving 2853 patients with OA were included in our meta-analysis. The overall mean patency rate of patients who underwent MVE was 67.20% (95% [CI]:63.30%-71.10%), and the overall mean natural pregnancy rate of their partners was 40.05% (95% [CI]: 35.30%-45.60%). The pooled results showed that the patency rate of bilateral MVE was higher than that of unilateral MVE (RR = 1.42; 95% [CI]:1.25-1.61; p < 0.00). A comparison of the anastomotic site of MVE showed that the caudal/corpus area was favorable for the patency rate (RR = 1.17; 95% [CI]:1.04 - 1.32; p < 0.00). The caudal area was also advantageous for the patency rate (RR = 1.20; 95% CI:1.03 - 1.41; p < 0.04). Compared with typical MVE (65.20%, 95% [CI]:61.40%-69.10%), deferential vessel-sparing MVE with a higher overall mean patency rate (83.60%, 95% [CI]:75.40%-91.70%).

CONCLUSIONS

The meta-analyses indicated that MVE is a high- and cost-effective therapeutic method for patients with EOA, and deferential vessel-sparing MVE could be mainstream in the near future.

Vasovasostomy and vasoepididymostomy: indications, operative technique, and outcomes

The basic principles of vasal reconstruction have endured since their initial description over a century ago, yet the nuances and technical approaches have evolved. Prior to performing vasectomy reversal, the clinician should perform a focused history, physical and laboratory assessment, all of which are critical for patient counseling and preoperative planning. Operative success is contingent on appropriate intraoperative decision making and technical precision in completing a tension-free, watertight, and patent anastomosis. Outcomes of vasectomy reversal differ on the basis of the type of reconstruction required, reconstructive technique, and patient-specific factors. Here we review the indications, surgical techniques, and outcomes of vasectomy reversal.

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.

Outcomes of partial intussusception and endo-to-side vasoepididymostomy in men with epididymal obstructive azoospermia

OBJECTIVES

Vasoepididymostomy is an ideal surgical approach for epididymal obstructive azoospermia. The aim of the present study was to compare reproductive outcomes of vasoepididymostomy with several anastomotic techniques, including end-to-side and longitudinal intussusception vasoepididymostomy, and partial intussusception and endo-to-side vasoepididymostomy.

METHODS

A case-control study including 110 infertile men with epididymal obstructive azoospermia with mean age of 35 years was carried out. Univariate and multivariate analyses using clinical factors were carried out to predict patency and non-assisted reproductive technology pregnancy. Johnsen score count and proliferating cell nuclear antigen expression were used as surrogates for spermatogenic function. Operative time, number of 10-0 sutures and late failure rates were also compared.

RESULTS

The overall patency and non-assisted reproductive technology pregnancy rates were 70% and 32%, respectively. Multivariate analyses showed that the presence of motile sperm in the epididymis and a higher spermatogenic function (P < 0.05) were independent predictors for patency, and that a higher spermatogenic function and anastomosis at the caput/corpus (P < 0.001) were predictors for non-assisted reproductive technology pregnancy. The operative time was significantly shorter with partial intussusception and endo-to-side than with the other techniques (P < 0.001), and the number of 10-0 sutures was significantly less with partial intussusception and endo-to-side than with longitudinal intussusception vasoepididymostomy (P < 0.01).

CONCLUSIONS

Partial intussusception and endo-to-side as well as end-to-side and longitudinal intussusception vasoepididymostomy are feasible vasoepididymostomy techniques for epididymal obstruction. Spermatogenic function plays important roles in patency and non-assisted reproductive technology pregnancy after vasoepididymostomy. Depending on the surgeon's expertise, partial intussusception and endo-to-side provides similar functional outcomes to those of more established vasoepididymostomy techniques, such as end-to-side and longitudinal intussusception vasoepididymostomy, and it could therefore be considered an effective technique for seminal reconstruction in patients with epididymal obstructive azoospermia.

The management of obstructive azoospermia: a committee opinion

Infertility due to obstructive azoospermia may be treated effectively by surgical reconstruction or by retrieval of sperm from the epididymis or testis, followed by in vitro fertilization with intracytoplasmic sperm injection. This replaces the ASRM documents titled "Sperm retrieval for obstructive azoospermia" and "The management of infertility due to obstructive azoospermia," last published in 2008.

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 of training and skill in microsurgical techniques.

[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.

Predictive factors for natural pregnancy after microsurgical reconstruction in patients with primary epididymal obstructive azoospermia

Primary epididymal obstructive azoospermia (OA) is the most prevalent form of OA in nonvasectomized patients and has been less studied. We aim to assess the results with microsurgical vasoepididymostomy used in the treatment of men diagnosed with primary epididymal obstructive azoospermia and to identify the factors associated with natural pregnancy occurring after microsurgical reconstruction. This prospective study included consecutive patients with epididymal OA who underwent microsurgical reconstruction in our center. Clinical and biological data were obtained every three months during follow-up. Occurrence of natural pregnancy was the primary study outcome. In total, 36 patients underwent microsurgical reconstruction. The mean age was 34 ± 4.5 years (range 24-46 years). Median follow-up time was 15 [IQR 12-21] months. The total patency rate was 77.7% (n = 28). During follow-up, 8 (22.2%) natural pregnancies occurred. The overall live birth rate was 100%. Low FSH levels (HR: 0.22; 95% CI: 0.052-0.88; P = 0.032) and higher total motile sperm count (TMSC) (HR: 1.001; 95% CI 1-1.001; P = 0.012) were associated with a higher rate of natural pregnancy. Our data suggest that microsurgical vasoepididymostomy is an effective therapy of primary epididymal OA. Baseline lower FSH and higher TMSC were independent predictors for natural pregnancy occurrence.

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.

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 (>10(4) ml(-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.

European Association of Urology guidelines on Male Infertility: the 2012 update

CONTEXT

New data regarding the diagnosis and treatment of male infertility have emerged and led to an update of the European Association of Urology (EAU) guidelines for Male Infertility.

OBJECTIVE

To review the new EAU guidelines for Male Infertility.

EVIDENCE ACQUISITION

A comprehensive work-up of the literature obtained from Medline, the Cochrane Central Register of Systematic Reviews, and reference lists in publications and review articles was developed and screened by a group of urologists and andrologists appointed by the EAU Guidelines Committee. Previous recommendations based on the older literature on this subject were taken into account. Levels of evidence and grade of guideline recommendations were added, modified from the Oxford Centre for Evidence-based Medicine Levels of Evidence.

EVIDENCE SUMMARY

These EAU guidelines are a short comprehensive overview of the updated guidelines of male infertility as recently published by the EAU (http://www.uroweb.org/guidelines/online-guidelines/), and they are also available in the National Guideline Clearinghouse (http://www.guideline.gov/).

Robotic approaches for male infertility and chronic orchialgia microsurgery

PURPOSE OF REVIEW

Since its inception in early 2000, robotic assistance with urologic procedures continues to expand. The magnification, three-dimensional visualization, and surgical control offered by the latest daVinci Si-HD system has led to its integration into microsurgical procedures for male infertility. The addition of robotic assistance may allow an improvement in outcomes similar to when the operating microscope was introduced in microsurgery. Though the use of robotics in microsurgery is still in its early phases, initial findings are encouraging.

RECENT FINDINGS

This review covers robotic microsurgical procedures and tools for infertility and chronic orchialgia/testicular pain such as vasovasostomy, vasoepididymostomy, varicocelectomy, testicular sperm extraction and targeted denervation of the spermatic cord. Preliminary human clinical studies appear to show improved operative efficiency and comparable outcomes. The use of robotic assistance during robotic microsurgical vasovasostomy appears to decrease operative duration and improve the rate of return of postoperative sperm counts compared to the pure microsurgical technique.

SUMMARY

Long-term prospective controlled trials are necessary to assess the true benefit for robotic-assisted microsurgery. The preliminary findings are promising, but further evaluation is warranted.

Robotic microsurgery 2011: male infertility, chronic testicular pain, postvasectomy pain, sports hernia pain and phantom pain

PURPOSE OF REVIEW

The use of robotic assistance during microsurgical procedures has evolved from its early beginnings in the early 2000s. Currently, its use is expanding in the treatment of male infertility and patients with chronic testicular or groin pain. The addition of this technology may allow an improvement in outcomes as when the operating microscope was introduced in microsurgery. However, this is yet to be proven.

RECENT FINDINGS

This review covers new robotic microsurgical tools and applications of the robotic platform in microsurgical procedures such as vasectomy reversal, varicocelectomy, microsurgical denervation of the spermatic cord for chronic testicular or groin pain, post-vasectomy pain, sports hernia pain, postnephrectomy, donor nephrectomy and phantom groin pain. Preliminary animal studies show an advantage in terms of improved operative efficiency and improved surgical outcomes. Preliminary human clinical studies appear to support these findings. The use of robotic assistance during robotic microsurgical vasovasostomy appears to decrease operative duration and improve early postoperative sperm counts compared to the pure microsurgical technique.

SUMMARY

Long-term prospective controlled trials are necessary to assess the true cost-benefit ratio for robotic assisted microsurgery. The preliminary findings are promising and evidence is mounting, but further evaluation is warranted.

Surgical treatment of male infertility in the era of intracytoplasmic sperm injection - new insights

Assisted reproductive technology is an evolving area, and several adjuvant procedures have been created to increase a couple's chance of conceiving. For male infertility, the current challenges are to properly accommodate old and new techniques that are both cost-effective and evidence-based. In this context, urologists are expected to diagnose, counsel, provide medical or surgical treatment whenever possible and/or correctly refer male patients for assisted conception. Urologists are sometimes part of a multiprofessional team in an assisted reproduction unit and are responsible for the above-cited tasks as well as the surgical retrieval of sperm from either the epididymides or testicles. We present a comprehensive review of the surgical treatment options for infertile males, including the perioperative planning and prognostic aspects, with an emphasis on the role of microsurgery in the optimization of treatment results. This review also discusses current techniques for sperm retrieval that are used in association with assisted reproductive technology and includes sperm retrieval success rates according to the technique and the type of azoospermia. New insights are provided with regard to each surgical treatment option in view of the availability of assisted conception to overcome male infertility.

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.

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.

Mini-incision microsurgical vasoepididymostomy: a new surgical approach

A less-invasive approach for vasoepididymostomy is described. The technique might decrease postoperative discomfort and swelling by obviating the need to make a large scrotal incision for complete exteriorization of the testis to perform an accurate and successful anastomosis.

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.

[Male infertility: management strategies]

Although the objective of the urologist is to correct the factors of male infertility and to favour natural procreation, the strategy must consider also the couple and the female aspects of infertility. Some types of male infertility require specific treatment. In severe cases, recent advances in medical assistance to procreation have changed the prognosis of male infertility. Pregnancy can be obtained by the means of gamet manipulation and spermatozoid selection. Nevertheless, such techniques expose to genetic disorders transmission. Subsequently, genetic assessment is required during male infertility management, especially for difficult cases.

Repeat vasectomy reversal yields high success rates

We retrospectively reviewed our experiences with repeat vasectomy reversal and report the patency and natural pregnancy rates. Our data demonstrate that repeat vasectomy reversal is a valid option in patients with a failed initial reversal, although the suitability of repeat reversal should be based on the obstructive interval, the original reversal, the experience of the reversal surgeon, and any female factors, as well as the couple's wishes.

Microsurgical management of male infertility

The introduction of microsurgical techniques has revolutionized the treatment of male infertility. As a result of technical advances and innovation over the past 10-15 years, previously infertile couples are now able to conceive naturally or to parent their own biological children with the aid of assisted reproductive technologies. This article reviews the indications, techniques, and outcomes of the various microsurgical procedures currently used to optimize male fertility. The most up-to-date methods of microsurgical vasal and epididymal reconstruction, sperm retrieval, and varicocele repair are discussed.

Prediction of candidates for seminal tract reconstructive surgery among patients with clinically suspected idiopathic or inflammatory obstructive azoospermia

Background and Aim:  We reviewed the findings of scrotal exploration, histological examination and clinical parameters in patients with clinically suspected idiopathic or inflammatory obstructive azoospermia without confirmation by isolated testis biopsy in advance. Methods:  The present study included 27 patients who underwent scrotal exploration for the purpose of vasoepididymostomy, with simultaneous testicular sperm extraction. Results:  Sperm in the epididymis was proven in 11 patients (40.7%). In two of these patients, the vas deferens was obstructed on the seminal vesicle side. Histologically, normal spermatogenesis was seen in all patients. The 16 (59.2%) patients with no sperm in the epididymis included two with normal spermatogenesis. Serum follicle stimulating hormone (FSH) levels were significantly higher in men with no sperm in the epididymis in contrast to those in men with sperm proven in the epididymis (P = 0.0057). By using a cut-off point of 6.02 mIU/mL, serum FSH can predict the existence of sperm in the epididymis, with a sensitivity of 81.8%, a specificity of 81.2% and a positive predictive value of 75.0%. Conclusion:  No more than a third of the patients in the present study who had clinically suspected obstructive azoospermia were actual candidates for vasoepidydimostomy. A serum FSH level cut-off point of 6.02 mIU/mL might be useful to determine its indication. (Reprod Med Biol 2006; 5: 211-214).

Outcome and late failures compared in 4 techniques of microsurgical vasoepididymostomy in 153 consecutive men

PURPOSE

Vasoepididymostomy remains one of the most technically challenging procedures in all of microsurgery. The technique has evolved from an end-to-end, to an end-to-side technique, then to intussusception end-to-side methods. We recently reported the superiority of 2-suture longitudinal and 3-suture triangulation intussusception techniques in rats. In the present study we report our results in humans. We evaluated all vasoepididymostomies performed by 1 surgeon from January 1992 until the present for patency, pregnancy and for disappearance of sperm after initial return of sperm to the ejaculate.

MATERIALS AND METHODS

We recorded the results of 153 consecutive vasoepdidymostomies done by 1 surgeon (MG) from January 1992 until February 2004. Four techniques were used, namely end-to-end (EE), end-to-side (ES), 3-suture triangulation intussusception (TIVE) and 2-suture longitudinal intussusception (LIVE). Data collected included technique, months of followup, sperm density, motility and morphology (WHO 1992 criteria), pregnancy outcome and late failures. Late failures were defined as having return of sperm to the ejaculate after vasoepididymostomy and then becoming azoospermic on at least 2 subsequent semen analyses.

RESULTS

A total of 153 men underwent bilateral vasoepididymostomies. The most recent 17 were LIVE, preceeded by 38 TIVE, 32 ES and 66 EE. Mean followup for the groups were 17.2 (LIVE), 70.8 (TIVE), 116.7 (ES) and 140.2 (EE) months, respectively. Intact sperm were seen in the ejaculates of 12 men (80%) in the LIVE group, 16 in the TIVE group (84%), 20 in the ES group (74%) and 30 men in the EE group (73%). Motile sperm were found in the ejaculates of 10 of 15 (67%) in the LIVE group, 13 of 19 (68%) in the TIVE group, 10 of 27 (37%) in the ES group and 20 of 41 (49%) in the EE group (p =0.2). Mean times for return of sperm to the ejaculate were 2.9, 2.8, 2.8 and 3.5 months, respectively. Pregnancies were reported by 4 men in the LIVE group all before 12 months, 6 in the TIVE group and 3 were by 12 months, and 4 each by the ES and EE groups with 3 and 2 by 12 months (p =0.07). Thus far, there have been no late failures in the LIVE group, only 1 in the TIVE group (8%), 5 in the ES group (50%) and 6 in the EE group (30%) (p =0.04).

CONCLUSIONS

Although vasoepididymostomy remains a technically demanding microsurgical procedure, recent technical innovations of TIVE and LIVE offer better or comparable outcomes compared with EE and ES procedures with the use of fewer sutures, which simplifies the performance of the anastomosis. In addition, the late failure rate is lower with the use of the intussusception techniques (LIVE and TIVE) with only 1 late failure in 22 men with return of sperm to the ejaculate procedures (4%) compared with 11 of 30 (37%) in the nonintussusception groups (p =0.006).

Model to predict if a vasoepididymostomy will be required for vasectomy reversal

PURPOSE

We devised a model to predict, preoperatively, the need for a vasoepididymostomy (VE) when performing a vasectomy reversal. Urologists could use it to identify those patients who need a referral to an experienced VE surgeon.

MATERIALS AND METHODS

We performed a retrospective review of 483 patients who underwent vasectomy reversal by a single surgeon (AJT) including 393 vasovasostomies and 90 vasoepididymostomies. Selection was based on chart availability. Established criteria were used in deciding the type of reversal (eg gross appearance and microscopic examination of vasal fluid). Type of reversal, patient age and time since vasectomy were recorded. Univariate analysis revealed that patient age (p <0.001) and time since vasectomy (p <0.001) were significant predictors of reversal type. On multivariate logistic regression analysis, time since vasectomy (p <0.001) was the only significant independent predictor. We designed a linear regression algorithm based on time since vasectomy and patient age to predict if a VE would be performed. The model was designed using 433 patients and then tested on a separate randomly selected 50 patient group. The model was designed to be 100% sensitive in detecting patients requiring VE.

RESULTS

In the test group the model was 100% sensitive in predicting VE with a specificity of 58.8%. The area under the ROC curves for the design and test groups was 0.8. Palm (PalmSource Inc., Sunnyvale, California) and Windows (Microsoft Corporation, Redmond, Washington) versions are available as free shareware from www.uroengineering.com.

CONCLUSIONS

The model is 100% sensitivity in detecting those patients who may require a VE during vasectomy reversal (specificity of 58.8%). It may allow urologists to preoperatively identify these patients.

Current techniques in microsurgical reversal surgery

Microsurgical reversal surgery for the treatment of vasal and epididymal obstruction represents one of the most challenging procedures in urology. An awareness of the latest information surrounding these procedures is essential to success. This article discusses current techniques in preparation, anastomosis, and investigational methods.

The epididymal slide technique: a tension-free anastomosis in a vasoepididymostomy

PURPOSE

Vasoepididymostomy is a technically demanding procedure that requires excellent positioning of the abdominal vas deferens at the epididymal tubule as well as a tension-free anastomosis. We describe a novel technique of securing the vas deferens to the testicle that allows manipulation of the epididymis and ensures a tension-free anastomosis.

MATERIALS AND METHODS

After the vas deferens and epididymis are isolated in the usual fashion the vas is brought to the lateral portion of the testicle. A stay stitch is placed on the abdominal vas. This stay stitch is then placed through the tunica albuginea immediately posterior to the corpus or cauda epididymis. This allows the epididymis to slide in cephalad and caudad fashion prior to vasoepididymostomy and allows a tension-free anastomosis.

RESULTS

We have used this technique routinely for vasoepididymostomy without any associated complications and have found it to be technically feasible in our last 50 cases.

CONCLUSIONS

Although it is simple, the epididymal slide technique allows minimal to no distortion of the epididymal tubule, secure and safe fixation of the vas deferens, flexibility in choosing an appropriate epididymal tubule and tailoring of tension at the conclusion of the procedure. This technique is now used routinely at our center to allow a tension-free anastomosis during vasoepididymostomy and it has been technically feasible in all of our last 50 cases.

Robotic microsurgical vasovasostomy and vasoepididymostomy: a prospective randomized study in a rat model

PURPOSE

Microsurgical vasovasostomy and vasoepididymostomy remain technically challenging procedures. Refinements in technique have continually improved patency and pregnancy rates for the 2 procedures in experienced hands. Advances in surgical robotics produced the Da Vinci robot (Intuitive Surgical, Inc., Sunnyvale, California) with motion reduction and no tremor, features that may improve outcomes in microsurgery. We report a randomized prospective study of vasoepididymostomy and vasovasostomy using the Da Vinci robot in rats.

MATERIALS AND METHODS

A total of 24 adult male Wistar rats underwent vasectomy through a midline abdominal incision. Two weeks later the animals were randomized to microsurgical multilayer vasovasostomy, longitudinal vasoepididymostomy or robotic vasovasostomy and vasoepididymostomy groups. Outcomes measured included surgical time, complications, patency and sperm granuloma formation at 9 weeks.

RESULTS

Animals were sacrificed 9 weeks after microsurgery. There were no significant differences in complications among the groups. Robotic vasovasostomy was significantly faster than the conventional microsurgical technique (68.5 vs 102.5 minutes, p = 0.002). The robotic and microsurgical vasoepididymostomy groups did not differ significantly in time. Patency rates were 100% for the robotic vasovasostomy and vasoepididymostomy groups, and 90% in the microsurgical vasovasostomy and vasoepididymostomy groups. These differences were not significant. Sperm granulomas were found in 70% of microsurgical vasovasostomy anastomoses and 27% of robotic vasovasostomy anastomoses (p = 0.001). No significant difference in the sperm granuloma rate was found between the robotic or microsurgical vasoepididymostomy groups (42% and 50%, respectively, p = 0.37).

CONCLUSIONS

To our knowledge we report the first randomized prospective study using the Da Vinci robot for microsurgery. We believe that the improved stability and motion reduction during microsurgical suturing with the robot helped achieve excellent patency rates for vasovasostomy and vasoepididymostomy. The robot may also allow experienced microsurgeons to perform microsurgical procedures in patients at remote locations where no experienced microsurgeons are available.

Causes of azoospermia and their management

Azoospermia may occur because of reproductive tract obstruction (obstructive azoospermia) or inadequate production of spermatozoa, such that spermatozoa do not appear in the ejaculate (non-obstructive azoospermia). Azoospermia is diagnosed based on the absence of spermatozoa after centrifugation of complete semen specimens using microscopic analysis. History and physical examination and hormonal analysis (FSH, testosterone) are undertaken to define the cause of azoospermia. Together, these factors provide a >90% prediction of the type of azoospermia (obstructive v. non-obstructive). Full definition of the type of azoospermia is provided based on diagnostic testicular biopsy. Obstructive azoospermia may be congenital (congenital absence of the vas deferens, idiopathic epididymal obstruction) or acquired (from infections, vasectomy, or other iatrogenic injuries to the male reproductive tract). Couples in whom the man has congenital reproductive tract obstruction should have cystic fibrosis (CF) gene mutation analysis for the female partner because of the high risk of the male being a CF carrier. Patients with acquired obstruction of the male reproductive tract may be treated using microsurgical reconstruction or transurethral resection of the ejaculatory ducts, depending on the level of obstruction. Alternatively, sperm retrieval with assisted reproduction may be used to effect pregnancies, with success rates of 25–65% reported by different centres. Non-obstructive azoospermia may be treated by defining the cause of low sperm production and initiating treatment. Genetic evaluation with Y-chromosome microdeletion analysis and karyotype testing provides prognostic information in these men. For men who have had any factors potentially affecting sperm production treated and remain azoospermic, sperm retrieval from the testis may be effective in 30–70% of cases. Once sperm are found, pregnancy rates of 20–50% may be obtained at different centres with in vitro fertilisation and intracytoplasmic sperm injection.

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).

Pregnancy outcomes after vasectomy reversal for female partners 35 years old or older

PURPOSE

We review the outcomes after vasectomy reversal for couples with female partners 35 years old or older.

MATERIALS AND METHODS

A retrospective review of experience at 2 institutions was performed. Patency was defined as the presence of motile sperm. Patients with less than 6 months of followup were excluded from the patency rate analysis unless they had sperm in the semen. Similarly, patients with less than 12 months of followup or no ongoing interest in establishing conception were excluded from the pregnancy rate analysis unless they had established a pregnancy or they were azoospermic with sufficient followup.

RESULTS

A total of 46 men with partners 35 years old or older underwent vasectomy reversal at 2 institutions. Mean partner age was 37 +/- 2 years, and median obstructive interval was 10 years. Bilateral vasovasostomy was performed in 43 men, unilateral vasovasostomy in 2 and vasovasostomy/vasoepididymostomy in 1. Of the 46 men 27 had followup semen analyses with a patency rate of 81% (22). Transient patency occurred in 2 cases (7%). Pregnancy occurred in 35% of the couples (14 of 40 patients) with sufficient followup. The ongoing/live delivery rate was 33% (13 of 40 cases). The pregnancy and ongoing/delivery rates were 46% (12 of 26 patients) and 46% (12 of 26) for female partners 35 to 39 years old, and 14% (2 of 14) and 7% (1 of 14) for female partners older than 40, respectively.

CONCLUSIONS

Vasectomy reversal offers reasonable chance for success when the female partner is 35 years old or older. The chance for success is similar to that of a single cycle of in vitro fertilization with intracytoplasmic sperm injection. These couples should not be eliminated from consideration for reversal simply because the female partner is 35 years old or older.

Outcomes of vasectomy reversal performed for men with the same female partners

OBJECTIVES

To review the fertility outcomes of patients who underwent vasectomy reversal and attempted conception with the same female partners.

METHODS

A retrospective review of two surgeons' experience was performed. Patency was defined as the presence of motile sperm. Patients with less than 6 months of follow-up were excluded from the patency rate analysis unless they had sperm in the semen sample. Similarly, patients with less than 6 months of follow-up or no ongoing interest in establishing conception were excluded from the pregnancy rate analysis unless they had established a pregnancy.

RESULTS

Of 200 consecutive men, 34 (17%) underwent microsurgical vasectomy reversal with the same female partner. All but two of the couples had previous proven fertility. The procedures performed for those who pursued fertility were bilateral vasovasostomy (n = 27), vasovasostomy/vasoepididymostomy (n = 4), and bilateral vasoepididymostomy (n = 1). The mean obstructive interval was 5 years (range 4 months to 10 years). The mean female partner age was 31.9 years (range 26 to 38). The median follow-up was 8 months (range 1 to 48). Patency was achieved in 27 (93%) of 29, and pregnancy occurred in 15 (60%) of 25 cases with sufficient follow-up. The ongoing or delivered rate was 56% (14 of 25). Female factor problems were present in three couples, and two miscarriages occurred for couples with known female factor problems.

CONCLUSIONS

Microsurgical vasectomy reversal may have higher success rates when performed for couples with the same female partner. These results may be related to a shorter obstructive interval and a history of previous fertility as a couple.

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.