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>
	<li>Salonia, , 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=European+Association+of+urology+guidelines+on+sexual+and+reproductive+health-2021+update:+male+sexual+dysfunction.">European Association of urology guidelines on sexual and reproductive health-2021 update: male sexual dysfunction.</a> European Urology. 80 (3), 333-357 (2021).</li><li>Chen, X. F., 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=Microsurgical+vasoepididymostomy+for+patients+with+infectious+obstructive+azoospermia:+cause,+outcome,+and+associated+factors.">Microsurgical vasoepididymostomy for patients with infectious obstructive azoospermia: cause, outcome, and associated factors.</a> Asian Jorunal of Andrology. 18 (5), 759-762 (2016).</li><li>Han, H., Liu, S., Zhou, X. G., Tian, L., Zhang, X. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Aetiology+of+obstructive+azoospermia+in+Chinese+infertility+patients.">Aetiology of obstructive azoospermia in Chinese infertility patients.</a> Andrologia. 48 (7), 761-764 (2016).</li><li>Chan, P. T. K., 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=Microsurgical+reconstruction+of+pre-epididymal+obstructive+azoospermia.">Microsurgical reconstruction of pre-epididymal obstructive azoospermia.</a> Journal of Urology. 163, 258 (2000).</li><li>Practice Committee of the American Society for Reproductive Medicine in collaboration with the Society for Male Reproduction and Urology. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+management+of+obstructive+azoospermia:+a+committee+opinion.">The management of obstructive azoospermia: a committee opinion.</a> Fertility and Sterility. 111 (5), 873-880 (2019).</li><li>Chan, P. 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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