Name: vessel-sparing microsurgical longitudinal intussusception vasoepididymostomy to treat epididymal obstructive azoospermia
Uploaded: 2022-05-27T14:30:00
Description: Watch this Scientific Journal Video about Vessel-Sparing Microsurgical Longitudinal Intussusception Vasoepididymostomy to Treat Epididymal Obstructive Azoospermia at JoVE.com

This study was supported by Clinical Research Training Program, the East Division of the First Affiliated Hospital of Sun Yat-Sen University (No.2019002, No.2019008), and the Foundation of National Health Commission of the People&#39;s Republic of China key laboratory of Male Reproduction and Genetics (No.KF202001).

The study was approved by the First Affiliated Hospital of Sun Yat-Sen University. Diagnostic criteria, surgical indications, and contraindications were in accordance with the Guidelines for Diagnosis and Treatment of Andrology and Expert Consensus of the Chinese Society of Andrology and the European Association of Urology Guidelines for Sexual and Reproductive Health. A patient would be excluded from this study if the female partner had medical conditions that affect fertility.
1. Instr...

<ol>
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T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+evolution+and+refinement+of+vasoepididymostomy+techniques.">The evolution and refinement of vasoepididymostomy techniques.</a> Asian Jorunal of Andrology. 15 (1), 49-55 (2013).</li><li>Lyu, K. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+novel+experience+of+deferential+vessel-sparing+microsurgical+vasoepididymostomy.">A novel experience of deferential vessel-sparing microsurgical vasoepididymostomy.</a> Asian Jorunal of Andrology. 20 (6), 576-580 (2018).</li><li>Fantus, R. J., Halpern, J. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Vasovasostomy+and+vasoepididymostomy:+indications,+operative+technique,+and+outcomes.">Vasovasostomy and vasoepididymostomy: indications, operative technique, and outcomes.</a> Fertility and Sterility. 115 (6), 1384-1392 (2021).</li><li>Baker, K., Jr, S. a. b. a. n. e. g. h. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Obstructive+azoospermia:+reconstructive+techniques+and+results.">Obstructive azoospermia: reconstructive techniques and results.</a> Clinics. 68, 61-73 (2013).</li><li>Monoski, M. A., Schiff, J., Li, P. S., Chan, P. T., Goldstein, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Innovative+single-armed+suture+technique+for+microsurgical+vasoepididymostomy.">Innovative single-armed suture technique for microsurgical vasoepididymostomy.</a> Urology. 69 (4), 800-804 (2007).</li><li>Zhao, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+modified+single-armed+technique+for+microsurgical+vasoepididymostomy.">A modified single-armed technique for microsurgical vasoepididymostomy.</a> Asian Journal of Andrology. 15 (1), 79-82 (2013).</li><li>Zhao, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Retrospective+analysis+of+early+outcomes+after+a+single-armed+suture+technique+for+microsurgical+intussusception+vasoepididymostomy.">Retrospective analysis of early outcomes after a single-armed suture technique for microsurgical intussusception vasoepididymostomy.</a> Andrology. 3 (6), 1150-1153 (2015).</li><li>Harrison, R. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+distribution+of+the+vasal+and+cremasteric+arteries+to+the+testis+and+their+functional+importance.">The distribution of the vasal and cremasteric arteries to the testis and their functional importance.</a> Journal of Anatomy. 83, 267-282 (1949).</li><li>Raman, J. D., Goldstein, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intraoperative+characterization+of+arterial+vasculature+in+spermatic+cord.">Intraoperative characterization of arterial vasculature in spermatic cord.</a> Urology. 64 (3), 561-564 (2004).</li><li>Mostafa, T., Labib, I., El-Khayat, Y., El-Rahman El-Shahat , A., Gadallah, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Human+testicular+arterial+supply:+gross+anatomy,+corrosion+cast,+and+radiologic+study.">Human testicular arterial supply: gross anatomy, corrosion cast, and radiologic study.</a> Fertility and Sterility. 90 (6), 2226-2230 (2008).</li><li>Student, V., Z&#225;tura, F., Scheinar, J., Vrtal, R., Vr&#225;na, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Testicle+hemodynamics+in+patients+after+laparoscopic+varicocelectomy+evaluated+using+color+Doppler+sonography.">Testicle hemodynamics in patients after laparoscopic varicocelectomy evaluated using color Doppler sonography.</a> European Urology. 33 (1), 91-93 (1998).</li><li>Matsuda, T., Horii, Y., Yoshida, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Should+the+testicular+artery+be+preserved+at+varicocelectomy.">Should the testicular artery be preserved at varicocelectomy.</a> The Journal of Urology. 149 (5), 1357-1360 (1993).</li><li>Li, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Vasal+vessel-sparing+microsurgical+single-armed+vasoepididymostomy+to+epididymal+obstructive+azoospermia:+A+retrospective+control+study.">Vasal vessel-sparing microsurgical single-armed vasoepididymostomy to epididymal obstructive azoospermia: A retrospective control study.</a> Andrologia. 53 (8), 14133 (2021).</li></ol>

Genitourinary tract infections and epididymitis are common causes of epididymal OA. VE has become an important method to treat epididymal OA and has been applied in clinics since 20004. Anastomosis of the vas deferens and epididymis is performed with double-needle sutures without preserving vessels of the vas deferens in the classic MVE6,8,9. Because double-needle sutures are expensive and not readily ava...

The number of infertile couples has been increasing annually; OA occurs in 20%-40% of azoospermia cases in men of reproductive age1. Epididymal obstruction accounts for approximately 30% of OA cases and is one of the most common obstruction sites. However, this proportion may be higher in China2,3. The treatment for OA varies depending on the site of the obstruction. The common causes of OA include vasectomy, genitourinary tract infection, genitourinary tuberculosis, iatrogenic injury, and idiopathic obstruction. The etiology of OA in China is mostly epididymal obstruction caused by genitourinary tract infection or epididymitis, while vasectomy is the most common etiology in Western countries2,3. The two types of obstructions require slightly different surgical approaches.
Microsurgical vasoepididymostomy (MVE) has become an important method for treating epididymal OA since 20004. MVE is the most challenging operation in male microsurgery, including microsurgical end-to-end single-tubule anastomosis, end-to-side anastomosis, triangulation, tubular invagination, and tubular intussusception techniques5. Longitudinal intussusception vasoepididymostomy (LIVE) is more advantageous because of the wider opening of the epididymal tubule6,7,8. Based on the characteristics of this case (presented here) in China, an improved, vessel-sparing, modified, single-armed suture LIVE technique was proposed based on a modified single-armed suture MVE technique. This technique not only enables vasoepididymostomy (VE) to be performed in areas where double-needle sutures are not readily available, but also preserves the vasculature of the vas deferens and maintains the normal physiological structure.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>0.9% sodium chloride solution</td>
			<td>Guangdong Otsuka Pharmaceutical Co. LTD</td>
			<td>21M1204</td>
			<td>Dilute antibiotics, irrigate.</td>
		</tr>
		<tr>
			<td>1 mL syringe</td>
			<td>Kindly Medical, Shanghai</td>
			<td>K20210826</td>
			<td>inject diluted methylene blue or 0.9% sodium chloride solution</td>
		</tr>
		<tr>
			<td>1% iodophor</td>
			<td>Guangzhou Qingfeng Disinfection Products Co., LTD</td>
			<td>Q/QFXD2</td>
			<td>Disinfect the surgical area.</td>
		</tr>
		<tr>
			<td>10-0 polypropylene sutures</td>
			<td>Ethicon, LLC</td>
			<td>REBBES</td>
			<td>Used when anastomosing.</td>
		</tr>
		<tr>
			<td>3-0 polyglactin 910 sutures</td>
			<td>Ethicon, LLC</td>
			<td>RGMCLH</td>
			<td>Suture skin incisions at the end of surgery.</td>
		</tr>
		<tr>
			<td>5-0 polyglactin 910 sutures</td>
			<td>Ethicon, LLC</td>
			<td>RBMMPQ</td>
			<td>Suture skin incisions at the end of surgery.</td>
		</tr>
		<tr>
			<td>8-0 polypropylene sutures</td>
			<td>Ethicon, LLC</td>
			<td>RDBBLS</td>
			<td>Used when anastomosing.</td>
		</tr>
		<tr>
			<td>9-0 polypropylene sutures</td>
			<td>Ethicon, LLC</td>
			<td>RABDTE</td>
			<td>Used when anastomosing.</td>
		</tr>
		<tr>
			<td>F16 urinary catheter</td>
			<td>Well Lead Medical, Guangzhou</td>
			<td>20190612</td>
			<td>Drainage of urine due to long operation time.</td>
		</tr>
		<tr>
			<td>micro haemostatic forceps</td>
			<td>Shanghai Surgical Instrument Factory</td>
			<td>W40350</td>
			<td>Used in surgical procedures</td>
		</tr>
		<tr>
			<td>micro scissors</td>
			<td>Cheng-He,NingBo</td>
			<td>HC-A008</td>
			<td>Used in surgical procedures</td>
		</tr>
		<tr>
			<td>micro tweezers</td>
			<td>Cheng-He,NingBo</td>
			<td>HC-A002</td>
			<td>Used in surgical procedures</td>
		</tr>
		<tr>
			<td>microneedle holder</td>
			<td>Cheng-He,NingBo</td>
			<td>HC-GN006</td>
			<td>Used in surgical procedures</td>
		</tr>
		<tr>
			<td>ophthalmic scissors</td>
			<td>Shanghai Surgical Instrument Factory</td>
			<td>Y00040</td>
			<td>Used in surgical procedures</td>
		</tr>
		<tr>
			<td>polyglactin 910 sutures</td>
			<td>Ethicon, LLC</td>
			<td>RBMMPQ</td>
			<td>Suture skin incisions at the end of surgery.</td>
		</tr>
		<tr>
			<td>silk braided non-absorbable suture</td>
			<td>Ethicon, LLC</td>
			<td>SB84G</td>
			<td>ligate the broken end of the vas deferens</td>
		</tr>
		<tr>
			<td>skin marker</td>
			<td>Medplus Inc.</td>
			<td>21120206</td>
			<td>Mark surgical incisions and suture sites.</td>
		</tr>
		<tr>
			<td>surgical microscope Carl Zeiss S88</td>
			<td>Carl Zeiss</td>
			<td>Carl Zeiss S88</td>
			<td>Enlarge your field of vision during surgery.</td>
		</tr>
		<tr>
			<td>vas-fixation clamp</td>
			<td>Shanghai Surgical Instrument Factory</td>
			<td>JCZ220</td>
			<td>Used in surgical procedures</td>
		</tr>
	</tbody>
</table>

vessel-sparing microsurgical longitudinal intussusception vasoepididymostomy to treat epididymal obstructive azoospermia

The epididymis is a common site of obstruction in obstructive azoospermia (OA). Vasoepididymostomy has become an important method for the treatment of epididymal OA since 2000. There are two challenges in classic microscopic vasoepididymostomy. First, anastomosis of the vas deferens and epididymis is performed with double-needle sutures. However, there is a lack of good-quality and cost-effective double-needle sutures in China, which leads to increased difficulty and poor success rates of anastomosis. Second, the separation of the vas deferens does not retain vasculature, although the vas deferens vasculature plays an important role in the blood supply to the vas deferens, epididymis, and testis. This affects the blood supply to the anastomotic area and epididymis.
Therefore, this team has made innovative improvements to address these problems. Good-quality, cost-effective, single-needle sutures, which are easy to purchase in China and other countries, were used in microsurgical longitudinal intussusception vasoepididymostomy. This can optimize the operation procedure and shorten the operation time while ensuring the success rate of the anastomosis. The surgical method of preserving the vas deferens vessels was innovatively proposed because the etiology of epididymal OA is mostly inflammatory in China. The protection of the blood supply to the vas deferens and epididymis is maximized using microsurgical forceps to separate and protect the vasculature. Patency reached 81.7% in the postoperative follow-up, indicating a better surgical treatment effect.

A study included 92 men who were diagnosed with azoospermia secondary to epididymal obstruction in the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China, and who underwent operation between January 2017 and December 2018. The average age of the 92 males was 30.77 &#177; 5.38 years (range: 20-47 years) (Table 1). All men underwent the bilateral vessel-sparing, modified, single-armed technique for LIVE, and the mean operation time was 223.59 &#177; 31.73 min. No postoperative complicati...

Watch this Scientific Journal Video about Vessel-Sparing Microsurgical Longitudinal Intussusception Vasoepididymostomy to Treat Epididymal Obstructive Azoospermia at JoVE.com

Vessel-Sparing Microsurgical Longitudinal Intussusception Vasoepididymostomy to Treat Epididymal Obstructive Azoospermia

The present protocol describes a vessel-sparing, longitudinal intussusception vasoepididymostomy using readily available single-needle sutures in China, a safe and effective procedure, which may improve patients' patency and natural pregnancy rates.

The epididymis is a common site of obstruction in obstructive azoospermia (OA). Vasoepididymostomy has become an important method for the treatment of ...

This protocol enables successful anastomosis using readily available single needle sutures. It may improve patient's patency and natural pregnancy rates by preserving the vas deferens vessels. Single needle sutures in this technique are readily available in most countries.Preservation of the vas deferens vessels protects blood supply to anastomotic stomas and epididymis. And it's more consistent with the physiological structure. This technique is suitable for epididymal obstructive azoospermia and vasectomy without damage to vasculature of vas deferens and it requires specialized microsurgical training.Visual demonstration is important for this procedure as it makes this technique easier to understand and learn. Begin by inserting a 16 French Foley catheter into the urethra and marking the incision sites with a skin marker. Make a three to four centimeter vertical scrotal incision and deliver the testis through the incision.Using a vas-fixation clamp, expose the vas deferens next to the spermatic cord near the testis. Pass a vascular sling through the space between the vas deferens and the vas deferens vasculature. Apply traction to the vascular sling.Under the operating microscope, separate the connective tissue with micro hemostatic forceps and cut with an electrical knife, then carefully dissociate the differential vessels with the micro hemostatic forceps one centimeter from the vas deferens. Hemisect the vas deferens. Then confirm it's patency by injecting diluted methylene blue with a 24 gauge irrigating needle connected to a one milliliter syringe and observing the dye in the urine.Alternatively, inject 0.9%sodium chloride solution with no resistance or reflux. Separate the adhesion between the tunica vaginalis and the testis with micro hemostatic forceps and cut it with an electric knife after opening the tunica vaginalis. Examine the epididymis under the operating microscope and select the site of dilated epididymal tubule for anastomosis.Using ophthalmic scissors, cut a five millimeter diameter piece of the epididymal tunic. Completely transect the vas deferens with a knife and ligate the broken ends near the epididymis with silk braided nonabsorbable suture. Perforate the tunica vaginalis using hemostatic forceps and pass the isolated part of the vas deferens through the tunnel to reach the anastomosis site.Fix the vas deferens and epididymis tunic using two interrupted 8-0 polypropylene sutures. Ensure the the vas deferens is not twisted. Use microscopic bipolar coagulation to stop the vas deferens from bleeding to keep the operative field clear.After marking four equidistant suture sites on the vas deferens, perform this modified single armed suture technique for live using two single armed 10-0 polypropylene sutures. Using a microneedle holder, pass two needles through the inferior points of the vasal mucosal layer separately and an outside in manner to slightly dilate the vasal lumen. Accurately controlled the needle under the microscope and avoid hooking the needle into the back wall of the lumen.Move the two needles in parallel and longitudinally through the same epididymal tubule. Using a 15 degree ophthalmic knife, place two needles in the epididymal tubule opened longitudinally between the two needles. Aspirate the epididymal fluid flowing from the incision in tubule with a 24 gauge irrigating needle connected to a one milliliter syringe.Hand it to an examiner to check for sperm. Gently pull out two needles in the epididymal tubule separately and pass them through the superior points of the vasal mucosal layer in an inside out manner. Suture the a adventitia of the vas deferens in the epididymal tunic with an 8-0 polypropylene suture to reduce tension before performing intussusception of the epididymal tubule into the vas deferens.Suture the muscularis edge of the vas deferens and the epididymal tunic using 10 to 12 interrupted 9-0 polypropylene sutures. This study included 92 males aged between 20 to 47 years. All men underwent the bilateral vessel-sparing modified single armed technique for live.And the mean operation time was approximately 224 minutes. No post operative complications or severe adverse effects were noted. A regular follow up plan was established with the first semen analysis at six weeks after surgery followed by a checkup every three months.The patency rate was 81.7%And the average time of patency was approximately 4.64 months. The semen revealed oligospermia or asthenospermia at the time of first patency. The average age of the spouses ranged from 20 to 46 years.None of these spouses had any diseases that affected their fertility. The natural pregnancy rate was 35.8%In vitro fertilization using testicular aspiration to obtain sperm was achieved in one pregnancy. The partners of the remaining 29 patients became pregnant naturally and 86.2%were pregnant within 12 months post-surgery.The most important part of this procedure is to avoid hooking the needle into the back wall of the vas deferens lumen and keep the anastomosis free of tension. The critical steps include vessel separation and live performance. The technique can be used by andrologist to develop better treatment of obstructive azoospermia making surgery safer and more effective.

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Research

JoVE Journal

Medicine

The Helsinki Rat Microsurgical Sidewall Aneurysm Model

Experimental saccular aneurysm models are necessary for testing novel surgical and endovascular treatment options and devices before they are introduced into clinical practice. Furthermore, experimental models are needed to elucidate the complex aneurysm biology leading to rupture of saccular aneurysms.
Several different kinds of experimental models for saccular aneurysms have been established in different species. Many of them, however, require special skills, expensive equipment, or special environments, which limits their widespread use. A simple, robust, and inexpensive experimental model is needed as a standardized tool that can be used in a standardized manner in various institutions.
The microsurgical rat abdominal aortic sidewall aneurysm model combines the possibility to study both novel endovascular treatment strategies and the molecular basis of aneurysm biology in a standardized and inexpensive manner. Standardized grafts by means of shape, size, and geometry are harvested from a donor rat&#39;s descending thoracic aorta and then transplanted to a syngenic recipient rat. The aneurysms are sutured end-to-side with continuous or interrupted 9-0 nylon sutures to the infrarenal abdominal aorta.
We present step-by-step procedural instructions, information on necessary equipment, and discuss important anatomical and surgical details for successful microsurgical creation of an abdominal aortic sidewall aneurysm in the rat.

Microsurgical sidewall aneurysms in rats are created by end-to-side anastomosis of an aortic graft to the abdominal aorta. We present step-by-step instructions and discuss anatomical and surgical details for successful experimental saccular aneurysm creation.

Experimental saccular aneurysm models are necessary for testing novel surgical and endovascular treatment options and devices before they are introduced ...

Longitudinal In Vivo Imaging of the Cerebrovasculature: Relevance to CNS Diseases

Remodeling of the brain vasculature is a common trait of brain pathologies. In vivo imaging techniques are fundamental to detect cerebrovascular plasticity or damage occurring overtime and in relation to neuronal activity or blood flow. In vivo two-photon microscopy allows the study of the structural and functional plasticity of large cellular units in the living brain. In particular, the thinned-skull window preparation allows the visualization of cortical regions of interest (ROI) without inducing significant brain inflammation. Repetitive imaging sessions of cortical ROI are feasible, providing the characterization of disease hallmarks over time during the progression of numerous CNS diseases. This technique accessing the pial structures within 250 &#956;m of the brain relies on the detection of fluorescent probes encoded by genetic cellular markers and/or vital dyes. The latter (e.g., fluorescent dextrans) are used to map the luminal compartment of cerebrovascular structures. Germane to the protocol described herein is the use of an in vivo marker of amyloid deposits, Methoxy-O4, to assess Alzheimer&#39;s disease (AD) progression. We also describe the post-acquisition image processing used to track vascular changes and amyloid depositions. While focusing presently on a model of AD, the described protocol is relevant to other CNS disorders where pathological cerebrovascular changes occur.

Longitudinal In Vivo Imaging of the Cerebrovasculature: Relevance to CNS Diseases

This manuscript describes a procedure to track the remodeling of the cerebrovasculature during amyloid plaque accumulation in vivo using longitudinal two-photon microscopy. A thinned-skull preparation enables the visualization of fluorescent dyes to assess the progression of cerebrovascular damage in a mouse model of Alzheimer&#39;s disease.

Remodeling of the brain vasculature is a common trait of brain pathologies. In vivo imaging techniques are fundamental to detect cerebrovascular ...

Development of Recombinant Proteins to Treat Chronic Pain

Chronic pain is difficult to treat and new approaches to resolve persistent pain are urgently needed. Anti-inflammatory cytokines are promising candidates for treating debilitating pain conditions due to their capacity to regulate aberrant neuro-immune interactions. However, physiologically they work in a network of various cytokines, and therefore their therapeutic effect may not be optimal when used as stand-alone drugs. To overcome this limitation, we developed a fusion protein of the anti-inflammatory cytokines IL4 and IL10. Here, we describe the methods for production and quality control of IL4-10 recombinant fusion protein and we test the effectiveness of the IL4-10 fusion protein to resolve pain in a mouse model of persistent inflammatory pain.

In this paper we provide details for the methods of production and quality control of an IL4-10 recombinant fusion protein. We also show how to test the effectiveness of this protein to resolve pain in a mouse model of inflammatory pain.

Chronic pain is difficult to treat and new approaches to resolve persistent pain are urgently needed. Anti-inflammatory cytokines are promising candidates ...

Vessel-sparing Excision and Primary Anastomosis

Urethroplasty is considered to be the standard treatment for urethral strictures since it provides excellent long-term success rates. For isolated short bulbar or posterior urethral strictures, urethroplasty by excision and primary anastomosis (EPA) is recommended. As EPA only requires the excision of the narrowed segment and the surrounding spongiofibrosis, a full-thickness transection of the corpus spongiosum, as performed in the traditional transecting EPA (tEPA), is usually unnecessary. Jordan et al. introduced the idea of a vessel-sparing approach in 2007, aiming to reduce surgical trauma, especially to the dual arterial blood supply of the urethra, and, thus, potentially reducing the risk of postoperative erectile dysfunction or glans ischemia. This approach could also be beneficial for subsequent urethral interventions such as redo urethroplasty using a free graft, in which a well-vascularized graft bed is imperative. Nevertheless, these potential benefits are only assumptions as prospective studies comparing the functional outcome of both techniques with validated questionnaires are currently lacking. Moreover, vessel-sparing EPA (vsEPA) should at least be able to provide similar surgical outcomes as tEPA. The aim of this paper is to give an elaborate, step-by-step overview of how to manage patients with isolated short bulbar or posterior urethral strictures with vsEPA. The main objective of this manuscript is to outline the surgical technique and to report the representative surgical outcome. A total of 117 patients were managed according to the described protocol. The analysis was performed on the entire patient cohort and on the bulbar (n = 91) and posterior (n = 26) vsEPA group separately. Success rates were 93.4% and 88.5% for the bulbar and posterior vsEPA, respectively. To conclude, vsEPA, as outlined in the protocol, provides excellent success rates with low complication rates for isolated short bulbar and posterior urethral strictures.

Here, we present an elaborate and efficient protocol to treat isolated short bulbar or posterior urethral strictures with vessel-sparing excision and primary anastomosis.

Urethroplasty is considered to be the standard treatment for urethral strictures since it provides excellent long-term success rates. For isolated short ...

Fat-Covered Islet Transplantation Using Epididymal White Adipose Tissue

Islet transplantation is a cellular replacement therapy for severe diabetes mellitus. The intraperitoneal cavity is typically the transplant site for this procedure. However, intraperitoneal islet transplantation has some limitations, including poor transplant efficacy, difficult graft detection ability, and a lack of graftectomy capability for post-transplant analysis. In this paper, "fat-covered islet transplantation", an intraperitoneal islet transplantation method that utilizes epididymal white adipose tissue, is used to assess the therapeutic effects of bioengineered islets. The simplicity of the method lies in the seeding of islets onto epididymal white adipose tissue and using the tissue to cover the islets. While this method can be categorized as an intraperitoneal islet transplantation technique, it shares characteristics with intra-adipose tissue islet transplantation. The fat-covered islet transplantation method demonstrates more robust therapeutic effects than intra-adipose tissue islet transplantation, however, including the improvement of blood glucose and plasma insulin levels and the potential for graft removal. We recommend the adoption of this method for assessing the mechanisms of islet engraftment into white adipose tissue and the therapeutic effects of bioengineered islets.

This fat-covered islet transplantation method is suitable for the detection of engrafted islets in the intraperitoneal cavity. Notably, it does not require the use of biobinding agents or suturing.

Islet transplantation is a cellular replacement therapy for severe diabetes mellitus. The intraperitoneal cavity is typically the transplant site for this ...

A Modified Vessel-Sparing Microsurgical Vasoepididymostomy

Microsurgical vasoepididymostomy (MVE) is the main surgical treatment for epididymal obstruction. The vasal vessels are ligated during MVE. However, preserving the vasal vessels during MVE might better simulate the normal physiological structure and be meaningful for patients who have undergone varicocelectomy. Nevertheless, preserving the vasal vessels might elevate the risk of increasing the tension of anastomosis, affecting the patency rate and leading to delayed postoperative bleeding. Therefore, we developed a novel vessel-sparing MVE to make it safer. Here is a summary of the improvements to the procedure. 1) The retrograde dissociation of the vasal vessels on the proximal testicular side was adopted as the main method, and the anterograde dissociation of the vasal vessels on the distal testicular side was adopted as a supplement to dissociate the vasal vessels to be preserved. This improvement ensures the blood supply to the vas deferens that will be used for anastomosis and also provides longer vasal vessels, which reduces the tension of anastomosis. 2) By fixing the vas deferens to be anastomosed and the broken end of the vas deferens, the free vasal vessels get fixed, which resolves the problem of transmission of vas tension to the vasal vessels and reduces the risk of vasal vessel hemorrhage. 3) Dissociation of the vas deferens after opening the tunica vaginalis increases the mobilization of the vas deferens, which also makes the new procedure easier to complete. The evaluation of the outcomes of this new procedure showed that no significant postoperative complications occurred in the patients, and the patency rate was no different from that of the conventional procedure. Therefore, this new, improved procedure can be considered safe, with satisfactory postoperative results.

Here, we present a protocol to preserve the vasal vessels in microsurgical vasoepididymostomy. The surgical security is enhanced by preserving the vasal vessels using a retrograde-anterograde dissociation and fixing the vasal vessels.

Microsurgical vasoepididymostomy (MVE) is the main surgical treatment for epididymal obstruction. The vasal vessels are ligated during MVE. However, ...

Exploring the Two Herb Combination Strategy to Treat Injured PC12 Cells

In view of the advantages of the combination of traditional Chinese medicine (TCM) in the treatment of cerebral ischemia, we studied the differences in the efficacy and mechanism between the preparation combination and the component combination in order to explore the two herb combination strategy to treat injured PC12 cells. Cobalt chloride (CoCl2) combined with a glucose-free medium was employed to induce oxidative damage of PC12 cells. Then, the optimal combination of Astragalus mongholicus (Ast) and Erigeron breviscapus (Eri) injection was selected and combined following uniform design methods after screening their safe and effective concentration on PC12 cells. Further, the component combination screened comprises 10 &#181;M astragaloside A, 40 &#181;M scutellarin, and 75 &#181;M chlorogenic acid in two herbs. Then, MTT, Annexin V-FITC/PI, immunofluorescence, and Western blot analysis were used to evaluate the efficacy and mechanism of the preparation combination and the component combination on injured PC12 cells. The results showed that the optimal preparation combination for cell pro-survival was Ast injection and Eri capsule with a concentration of 6:1.8 (&#181;M). The component combination (10 &#181;M astragaloside A, 40 &#181;M scutellarin, and 75 &#181;M chlorogenic acid) was more effective than the preparation combination. Both combinations remarkably reduced apoptotic rate, the fluorescence intensity of caspase-3, and intracellular reactive oxygen species (ROS) level; meanwhile, they upregulated the expression levels of p-Akt/Akt, Bcl-2/Bax, and Nrf2. These effects were more evident in the component combination. In conclusion, both combinations can inhibit the injury induced by CoCl2 combined with a glucose-free medium on PC12 cells, thus promoting cell survival. However, the efficiency of the component combination over the preparation combination may be due to its stronger regulation of the PI3K/Akt/Nrf2 signaling pathway related to oxidative stress and apoptosis.

This protocol provides a combination strategy of two herbs to treat injured PC12 cells. The protocol provides a reference for optimizing the best application mode of traditional Chinese medicine (TCM).

In view of the advantages of the combination of traditional Chinese medicine (TCM) in the treatment of cerebral ischemia, we studied the differences in ...

Microscopic Cyst Resection for the Treatment of Patients Diagnosed with Epididymal Cyst

Epididymal cysts mostly occur in men aged 20-40 years old. Previous reports have covered concerns about postoperative complexes, including postoperative asoedema, hematoma, sustaining pain, and seminal tract obstruction in patients who have undertaken nonmicroscopic epididymal cyst resection or epididymal resection. Nonmicroscopic epididymal cyst surgery is suggested for patients with childbirth plans as a precaution. The treatment of male epididymal cysts via microtechnology is obviously a beneficial option; we took the lead in carrying out microscopic epididymal exploration and cyst resection surgery in China. From September 2017 to April 2021, 41 young and middle-aged male patients diagnosed with epididymal cysts underwent microtechnology treatment in a program titled &#34;microscopic epididymal exploration and cystectomy&#34;. The postoperative follow-up lasted for 3-50 months. The results confirmed that, as microscopic manipulation largely improved visualization of the subtle tissue structures of the epididymis, the cyst could be clearly dissected apart and completely removed intact under the microscope. Bleeding during the operation was significantly reduced (2-3 mL) and wound drainage was not required. According to follow-up data, microscopic treatment significantly reduced the incidence of postoperative scrotal hematoma, edema, and long-term postoperative pain, thereby promising a higher surgical success rate as well as recurrence prevention. Besides, preliminary experience and reflection suggest that microscopic epididymal exploration and cystectomy provide efficient preservation of the epididymal patency through refined treatment, while a better prognosis can be achieved. We recommend that surgery be carried out before the epididymal cyst develops to 0.8 cm in diameter, for fear that a larger epididymal cyst (&#62;0.9 cm in diameter) could cause the complete destruction of all tubules of the ipsilateral epididymis - a more severe case with damage to the testicular output network.

Here, we present a protocol to treat patients diagnosed with an epididymal cyst using microscopic cyst resection. Based on microscopic manipulation, a largely improved visualization of the subtle tissue structures of the epididymis was obtained, so the cyst could be clearly dissected apart and completely removed intact.

Epididymal cysts mostly occur in men aged 20-40 years old. Previous reports have covered concerns about postoperative complexes, including postoperative ...

Preparation for Ear Plaster Therapy to Treat Pregnancy Vomiting

Begin by preparing the ear plasters for ear plaster therapy. To do so, cut a medical adhesive tape into squares, each measuring 0.6 by 0.6 square centimeters. Then position one or two smooth cow herb seeds at the center of each tape square.Next, instruct the patient to assume a comfortable seated position. Examine the skin on the patient's ear to ensure that it is intact and free from any abnormalities before selecting the acupoints. To locate the potential acupoints, stabilize the ear oracle by pinching and lifting the ear helix backward and upward using the thumb and index finger of one hand, making sure the area is fully exposed.Then, using the sterile probe in the other hand, gently examine the patient's ear to identify sensitive pressure points near the six auricular points. The stomach or CO4, cardia or CO3, belly or AH8, shenmen or TF4, subcortex or AT4, and liver or CO12.

Application of Seminal Vesiculoscopy and Holmium Laser to Treat Ejaculatory Duct Blockage Caused by Cysts

To begin, position the patient in lithotomy for anesthesia induction. Perform tracheal intubation to support breathing. Inject rocuronium bromide intermittently for inotropic relaxation.Disinfect the lower abdomen and the perineal area three times with iodophor. Connect the seminal vesiculoscope to the display system and insert the endoscope through the external urethral opening. Then carefully advance it towards the posterior urethra.To confirm the accurate position, observe the smooth and reddish urethral mucosa. Note the visibility of the colliculus seminalis and spot the two small openings of the ejaculatory ducts on either side. Guide a wire to the ejaculatory duct cyst through the opening on the affected side to reach the area filled with cloudy fluid.After flushing the cyst with saline, look for abnormal opening in the seminal canal. Then enter the ipsilateral seminal vesicle through the abnormal ejaculatory duct cyst opening, revealing multiple honeycombed ductal lumens. Using a 40-watt holmium laser, expand the ejaculatory duct diameter.To preserve the anti-urine reflux mechanism, cut the ejaculatory duct opening along the direction of urine flow. Explore the symmetrical position of the abnormal ejaculatory duct opening on the affected side as well as the seminal vesicle of the healthy side. Then gently insert the wire into the seminal vesicle at the lower left and right of the cyst.Finally using the holmium laser, incise and widen the contralateral artificial opening. To prevent blood clots from blocking, indwell an 18-French catheter and rinse it continuously with physiological saline. Postoperative examination after a month showed the open ejaculatory duct on the affected side and the preserved verumontanum.Endoscopy confirmed the presence of lateral ductus openings within the ejaculatory cyst. The semen parameters of patients improved significantly in the third month after the surgery.