Retrospective analysis of early outcomes after a single-armed suture technique for microsurgical intussusception vasoepididymostomy

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

ABSTRACT

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.

Comparative evaluation of double- and single-armed two-suture longitudinal intussusception techniques in microsurgical vasoepididymostomy: An updated systematic review and meta-analysis

BACKGROUND

This study aimed to compare the outcomes of double-armed two-suture longitudinal intussusception microsurgical vasoepididymostomy (LIVE) and single-armed two-suture LIVE techniques in patients with epididymal obstructive azoospermia (EOA). The main outcomes assessed were patency rates, patency time, semen quality and natural pregnancy rates.

METHODS

Data from patients with EOA who underwent two-suture LIVE were obtained from databases including PubMed, EMBASE, and Web of Science. Weighted data were analyzed using a random-effects model, and weighted mean differences were reported.

RESULTS

A total of 1574 patients with EOA from 24 studies were included. The overall patency rate was approximately 68% (95% confidence interval [CI]: 63-72%), with a patency time of approximately 4.63 months (95% CI: 4.15-5.12). The sperm concentration reached 26.90 million/ml and the sperm motility was 23.74%. The natural pregnancy rate was 38% (95% CI: 31-46%). The different definitions of patency do not seem to have any meaningful impact when comparing patency rates. There was no significant difference in patency rates, patency time, semen quality and natural pregnancy rates between the double-armed and single-armed LIVE techniques.

CONCLUSION

The single-armed LIVE is a potential alternative surgical option when high quality double-needle sutures are not easily accessible.

The pregnancy outcomes in patients with epididymal obstructive azoospermia after microsurgical vasoepididymostomy: a systematic review and meta-analysis

Purpose

Pregnancy outcomes (overall patency rate, overall pregnancy rate, natural pregnancy rate, and the ratio of patients with pregnancy by assisted reproductive technology) after microsurgical vasoepididymostomy (MVE) in patients with epididymal obstructive azoospermia (EOA) were assessed through meta-analysis.

Method

We searched PubMed, Embase, Web of Science, and the Cochrane Library databases up to 28 September 2022 for published literature related to retrospective or prospective clinical studies of obstructive azoospermia after apparent microsurgical vasoepididymostomy. Our search terms included obstructive azoospermia, epididymis obstruction, epididymal obstruction and vasoepididymostomy, and epididymovasostomy. Two researchers independently performed the literature search and assessed the eligibility of selected studies according to established inclusion criteria. The meta-analysis was performed using RevMan 5.4 software.

Result

A total of 504 patients with EOA were included in 10 studies (including 2 prospective clinical studies and 8 retrospective clinical studies). The mean patency rate after MVE was 72% (95% CI 68-76%). The overall pregnancy rate was 34% (95% CI 30-38%). The natural pregnancy rate is 21% (95% CI 17-24%). The ratio of patients with pregnancy by assisted reproductive technology (ART) was 34.9%. For the factors affecting pregnancy outcomes after MVE, the overall pregnancy rates in patients receiving bilateral MVE were significantly higher than those receiving unilateral MVE (75.4 vs. 24.6%). The mean best sperm count and sperm motility in patients with overall pregnancy were significantly higher than those with failing pregnancies. For the subgroup meta-analysis of microsurgical vasoepididymostomy, there were no statistically significant differences in the overall patency rate (68 vs. 70%), the overall pregnancy rate (33 vs. 37%), the natural pregnancy rate (20 vs. 23%), the ratio of ART (30 vs. 28%) in end-to-side or end-to-end anastomosis, and longitudinal or triangular intussusception MVE.

Conclusion

Vasectomy patency rates are higher, but natural pregnancy rates are lower in EOA male infertility patients after MVE. Altering the MVE procedures alone does not significantly improve pregnancy outcomes, but ART after MVE could improve the chance of pregnancy regardless of sperm parameters. We recommended that human sperms from EOA male infertility patients should be cryopreserved during intraoperative MVE for application in the subsequent ICSI treatment procedure.

Outcomes of microsurgical vasoepididymostomy using intussusception technique: a systematic review and meta‑analysis

A systematic review and meta-analysis of microsurgical vasoepididymostomy (MVE) for treating epididymal obstructive azoospermia (EOA) with different intussusception techniques. We conducted a comprehensive literature search using PubMed, Embase, and the Cochrane Central Register of Controlled Trials, retained literature related to obstructive azoospermia or male infertility and vasoepididymostomy, proactively reviewed other relevant literature, supplemented valuable references, and excluded studies that did not use intussusception and where valuable statistical data were difficult to obtain. Event rate and risk ratio (RR) were estimated. Patency rates were investigated. The influence of motile sperms found in the epididymal fluid, anastomotic sides and sites on patency was evaluated. 273 articles were comprised in this analysis, and 25 observational studies were eventually included, with a total patient sample of 1400. The overall mean patency rate was 69.3% (95% confidence interval [CI] 64.6-73.6%; I² = 63.735%). We conducted a meta-analysis of the factors affecting patency after microsurgical IVE, finding that the presence of motile sperms in epididymal fluid (RR = 1.52; 95% CI 1.18-1.97%; P = 0.001), anastomosing bilaterally (RR = 1.32; 95% CI 1.15-1.50%; P < 0.0001) and distally (RR = 1.42; 95% CI 1.09-1.85%; P = 0.009) lead to higher patency rates. IVE is an effective treatment for EOA. The presence of motile sperms found in the epididymal fluid, anastomosing bilaterally and distally are significantly correlated with higher patency rates.

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.

Vasal vessel-sparing microsurgical single-armed vasoepididymostomy to epididymal obstructive azoospermia: A retrospective control study

This study aimed to evaluate the efficacy and safety of vasal vessel-sparing modified single-armed 2-suture longitudinal intussusception vasoepididymostomy (SA-LIVE) to epididymal obstructive azoospermia patients. Forty consecutive epididymal obstructive azoospermia cases, who underwent microsurgical vasoepididymostomy in Shanghai General Hospital from January 2019 to October 2019, were included in this study. Twenty cases underwent SA-LIVE (group A), and 20 cases underwent vasal vessel-sparing SA-LIVE (group B). Until March 2021, the mean follow-up period was 16.9 ± 4.1 (12-23) months. The overall patency rate was 82.5%, and 80% and 85% for group A and group B respectively. The mean time to achieve patency was 4.11 ± 2.74 months. The overall natural pregnancy rate was 51.5%(17/33) at the mean follow-up of 16.9 months. The natural pregnancy rate was 50.0% for group A and 52.9% for group B (p > .05). At the time of 6 months post-operation, the patency rate was 70% for group A and 80% for group B (p = .465); the natural pregnancy rate was 0% for group A and 31.3% for group B (p = .022). Vasal vessel-sparing SA-LIVE is safe and effective to achieve favourable patency and pregnancy rates. Preserving vasal vessel would improve natural pregnancy rate at a very early stage.

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.

A modified single-armed microsurgical vasoepididymostomy for epididymal obstructive azoospermia: intraoperative choice and postoperative consideration

Background

To evaluate the clinical outcomes and the duration required for the sperm to return to the ejaculate after a modified single-armed 2-suture longitudinal intussusception vasoepididymostomy (SA-LIVE).

Methods

From March 2015 to December 2018, 134 patients with epididymal obstruction azoospermia underwent the modified single-armed vasoepididymostomy at Shanghai General Hospital. The outcomes and clinical findings were documented and evaluated. The mean follow-up period was 17 (range: 3–36) months.

Results

Patency was assessed by the return of sperm in the ejaculate. The overall patency rate was 55.2%, and the patency rates were 58.9, 40.7, 36.4, and 58.9% for bilateral surgery, unilateral surgery, proximal anastomosis, and distal anastomosis, respectively. The average time to achieve patency was 4.11 ± 2.74 months. In the first 6 months, 87.8% (65/74) patency patients reported sperm in the ejaculate. The overall pregnancy rate was 40.9% (29/66) at the follow-up of 3–36 months, and the natural pregnancy rate was 30.3% (20/66). The natural pregnancy rate was 32.1% post-bilateral surgery and 33.3% for the site of distal anastomosis; surprisingly, it was 0% for the site of proximal anastomosis.

Conclusion

Modified SA-LIVE is safe and may achieve favorable patency and pregnancy rates. When double-armed sutures are not accessible, single-armed may be preferable. The expected patency time was within 1 year. Moreover, because of the low natural pregnancy rate for proximal anastomosis, sperm banking is preferred to SA-LIVE.

A novel experience of deferential vessel-sparing microsurgical vasoepididymostomy

Microsurgical longitudinal intussusception vasoepididymostomy (LIVE) has been widely used to treat epididymal obstructive azoospermia since 2004. Although the deferential vasculature plays an important role in supplying blood to the testis and epididymis, little attention has been paid to the potential benefits of sparing the deferential vessels during the anastomosis in LIVE. This study aimed to evaluate the efficacy and safety of deferential vessel-sparing LIVE in humans. From December 2013 to December 2015, 69 azoospermic men with epididymal obstruction due to a genital infection, trauma, or idiopathic factors underwent deferential vessel-sparing LIVE in the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China. The outcomes of these patients were analyzed retrospectively. The mean age was 31.1 years for men and 28.3 years for their partners. Fifty-nine (85.5%, 59/69) men were followed up after surgery for approximately 16 months. Patency was noted and confirmed by semen analysis (>10 000 sperm/ml) in 83.1% (49/59) of men. The natural pregnancy rate was 40.7% (24/59) by the end of the study, with 87.5% (21/24) of these natural pregnancies achieved within 12 months after surgery. No severe adverse events or complications were observed. In this study, we present a novel technique for sparing the deferential vessels during LIVE. The preliminary outcomes show this technique to be safe with favorable patency and pregnancy rates.

Seminal plasma neutral alpha-glucosidase activity as an early predictor of patency and natural pregnancy after microsurgical vasoepididymostomy

Microsurgical vasoepididymostomy (MVE) is recommended as a first-line option for treatment of epididymal obstructive azoospermia (EOA). However, early indicators for predicting patency and natural pregnancy are unclear. Our aim was to explore the early predictive value of seminal plasma neutral alpha-glucosidase (NAG) activity for patency and natural pregnancy after MVE. Eighty-four patients with EOA who underwent MVE were enrolled in this study. The post-operative patency and natural pregnancy rates were 60.71% and 33.33% respectively. The presence of motile epididymal spermatozoa at the anastomosis site and NAG activity measured at the first month after MVE were early and independent predictors of patency and natural pregnancy. The areas under the receiver operating characteristic curves (AUCs) of NAG activity for prediction of patency and natural pregnancy were 0.78 (95% confidence interval [CI]: 0.68-0.88) and 0.82 (95% CI: 0.73-0.92). The best cut-off values of NAG activity for predicting patency and pregnancy were 15.9 and 17.0 m IU/ejaculate respectively. In conclusion， NAG activity measured at the first month after MVE is an early and independent predictor of patency and natural pregnancy.

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

This study comprises a systematic review and meta.analysis of microsurgical vasoepididymostomy outcomes in epididymal obstructive azoospermia. A comprehensive literature search was performed using Medline, Embase, and the Cochrane library that included all studies related to microsurgical vasoepididymostomy. Keywords included "vasoepididymostomy" "epididymovasostomy" "epididymal obstruction" and "epididymis obstruction" Event rate and risk ratio (RR) were estimated. Patency rate and pregnancy rate were investigated. The analysis comprised 1422 articles, including 42 observational studies with 2298 enrolled patients performed from November 1978 to January 2017. The overall mean patency rate was 64.1% (95% confidence interval [CI]: 58.5%.69.3%; I2 =83.0%), and the overall mean pregnancy rate was 31.1% (95% CI: 26.9%.35.7%; I2 =73.0%). We performed a meta-analysis comparing the patency rate of bilateral microsurgical vasoepididymostomy and unilateral microsurgical vasoepididymostomy and found an RR of 1.38% (95% CI: 1.21%-1.57%; P < 0.00001). A comparison of the site of microsurgical vasoepididymostomy showed that caudal or corpus area was favorable for patency rate (RR = 1.17%; 95% CI: 1.01%-1.35%; P = 0.04). Patients with motile sperm in epididymal fluid exhibited an RR of 1.53% (95% CI: 1.11%-2.13%; P = 0.01) with respect to patency rate. Microsurgical vasoepididymostomy is an effective treatment for epididymal obstructive azoospermia that can improve male fertility. We find that performing microsurgical vasoepididymostomy bilaterally, anastomosing a larger caudal area, and containing motile sperm in epididymis fluid can potentially achieve a superior patency rate.

Pregnancy and live birth rates after microsurgical vasoepididymostomy for azoospermic patients with epididymal obstruction

STUDY QUESTION

Can microsurgical vasoepididymostomy (MVE) be an effective treatment for azoospermic men with epididymal obstruction?

SUMMARY ANSWER

MVE is an effective treatment for epididymal obstruction, with overall patency and live birth rates of 76.3% and 34.8%, respectively.

WHAT IS KNOWN ALREADY

We showed that MVE was an effective treatment for non-vasectomized patients with epididymal obstruction and prior failed sperm retrieval for ICSI. ICSI is the preferred treatment for obstructive azoospermia in some reproductive centers. Some small studies documented that MVE could achieve high patency and pregnancy rates.

STUDY DESIGN, SIZE, DURATION

This retrospective study was designed to investigate the natural pregnancy and live birth rates after MVE and to identify possible predictors of pregnancy. From January 2011 to July 2013, 241 patients underwent MVE for epididymal obstruction in our andrology center.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All patients underwent scrotal exploration and MVE. Semen was analyzed every 3 months postoperatively until pregnancy was achieved. Patency, pregnancy and live birth rates were evaluated. Preoperative and intraoperative data were compared between patent and non-patent groups to identify factors affecting the patency rate. Predictors of pregnancy were identified by univariate and multivariate analyses with Cox regression models.

MAIN RESULTS AND THE ROLE OF CHANCE

Data from 198 males (82.2%) were analyzed. The mean (±SD) age of males and female partners was 31.0 ± 5.8 and 28.4 ± 4.4 years, respectively. Sperm was present in the ejaculate of 151 patients (76.3%) postoperatively. Patency rates were increased for patients with bilateral anastomosis, distant anastomosis and motile sperm in epididymal fluid. Overall, 81/198 males (40.9%) reported pregnancy in partners and 73 newborns were delivered. The overall live birth rate was 34.8%. Male age (hazard ratio (HR) [95% CI] 0.407 [0.203-0.816], P = 0.011), sperm concentration (HR [95% CI] 4.988 [2.777-8.957], P < 0.001) and forward motility (HR [95% CI] 1.751 [1.042-2.945], P = 0.035) were predictors of pregnancy.

LIMITATIONS, REASONS FOR CAUTION

A randomized control trial comparing pregnancy rates, live birth rates, risks and medical costs of MVE and IVF/ICSI is needed. The sample size of females >35 years old was small, so we could not determine whether female age was a predictor of pregnancy.

WIDER IMPLICATIONS OF THE FINDINGS

MVE is an effective therapy for azoospermic patients with epididymal obstruction. Sperm concentration and forward motility may predict pregnancy after the procedure. Microsurgical reconstruction could be a first choice for epididymal obstruction.

STUDY FUNDING/COMPETING INTERESTS

No external funding was received. The authors have no competing interests.

TRIAL REGISTRATION NUMBER

Not applicable.