Name: vessel-sparing microsurgical longitudinal intussusception vasoepididymostomy to treat epididymal obstructive azoospermia
Uploaded: 2022-05-27T14:30:00.000+00:00
Duration: 6 min 28 s
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. Instruments for operation
<ol>
	<li>Ensure the availability of sterilized instruments and other equipment mentioned in the Table of Materials.</li>
</ol>
2. Preparation for operation
<ol>
	<li>Prepare the bowel prior to surgery (by defecation).</li>
	<li>Prepare the perineal skin before surgery (by shaving off the hair).</li>
	<li>Administer intramuscular scopolamine (20 mg) or atropine (0.5 mg) and an intravenous infusion of cefazolin sodium (1 g) with 100 mL of 0.9% sodium chloride solution 30 min before surgery.</li>
	<li>Place the patient in the supine position on the operating table after combined spinal-epidural anesthesia.</li>
	<li>Disinfect the surgical area with 1% iodophor and cover it with surgical towels.</li>
</ol>
3. Vessel-sparing modified single-armed LIVE
<ol>
	<li>Insert a 16 French or 16Fr Foley catheter, and mark the incision sites with a skin marker.</li>
	<li>Deliver the testis through a 3-4 cm vertical scrotal incision.</li>
	<li>Expose the vas deferens with a vas-fixation clamp 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, separate the connective tissue with microhemostatic forceps under the operating microscope, and cut with an electric knife. Carefully dissociate deferential vessels with the microhemostatic forceps by 1 cm from the vas deferens under the operating microscope (Figure 1).</li>
	<li>After hemisecting the vas deferens with a knife (Figure 2A), confirm the patency of the vas deferens by injection of diluted methylene blue with a 24 G irrigating needle connected to a 1 mL syringe and observation of dye in the urine, or by injection of 0.9% sodium chloride solution with no resistance or reflux (Figure 2B).</li>
	<li>Separate the adhesion between the tunica vaginalis and the testis with microhemostatic forceps, and cut 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. Cut a 5 mm diameter piece of the epididymal tunic using ophthalmic scissors at this position.</li>
	<li>Completely transect the vas deferens with a knife, and ligate the broken end of the vas deferens 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 (Figure 3A). Fix the vas deferens and epididymis tunic using two interrupted 8-0 polypropylene sutures, and ensure the vas deferens is not twisted at the same time. Use microscopic bipolar coagulation to stop the vas deferens from bleeding to keep the operative field clear (Figure 3B).</li>
	<li>After marking four suture sites on the vas deferens (equidistant distribution on the section of the vas deferens, Figure 4A), perform this modified single-armed suture technique for LIVE using two single-armed 10-0 polypropylene sutures7. Pass two needles through the inferior points of the vasal mucosal layer separately in an outside-in fashion (Figure 4A: a1, b1), using a microneedle holder to slightly dilate the vasal lumen and accurately control the needle under the microscope. Avoid hooking the needle into the back wall of the lumen (Figure 4B). Move the two needles in parallel and longitudinally through the same epididymal tubule.</li>
	<li>Place two needles in the epididymal tubule, opened longitudinally between the two needles using a 15&#176; ophthalmic knife (Figure 5A). Aspirate the epididymal fluid flowing from the incision in the tubule with a 24 G irrigating needle connected to a 1 mL syringe, and hand it to an examiner to check for sperm (Figure 5B).</li>
	<li>Gently pull out two needles in the epididymal tubule separately and pass them through the superior points (Figure 6A: a2, b2) of the vasal mucosal layer in an inside-out fashion. Suture the adventitia of the vas deferens and the epididymal tunic with an 8-0 polypropylene suture to reduce tension before intussusception of the epididymal tubule into the vas deferens can be performed (Figure 6B).</li>
	<li>Suture the muscularis edge of the vas deferens and the epididymal tunic using 10-12 interrupted sutures of 9-0 polypropylene (Figure 7).</li>
</ol>
4. Postoperative care
<ol>
	<li>Ensure that the patient waits for 6 h after the operation before eating, takes bed rest for 3 days, and avoids standing or walking.</li>
	<li>Continue intravenous antibiotics (cefazolin sodium, 1 g with 100 mL of 0.9% sodium chloride solution) after the surgery to avoid genitourinary tract infection or epididymitis.</li>
</ol>

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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. 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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>

The authors have no conflicts of interest to disclose.

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><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 ...

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3.6K Views.  The East Division of the First Affiliated Hospital of Sun Yat-Sen University. 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.

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

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 ...

Microvascular Doppler Assisted Microsurgical Denervation of the Spermatic Cord in Treating Chronic Orchialgia

Chronic orchialgia is a common disease in department of urology and andrology. The etiology is complex, and the treatment is difficult. In severe cases, orchiectomy is even necessary. In recent years, microsurgical denervation of the spermatic cord (MDSC) is a minimally invasive and effective surgical method for the treatment of chronic orchialgia. Its greatest advantage is to preserve the testis and epididymis, avoid the possible organ resection. The key of the operation is to dissect all the fibrous tissues in the spermatic cord, while protecting the arteries (especially the testicular arteries) and several lymphatic vessels. Combined with the use of microvascular doppler in the operation, when separating the structure of spermatic cord under the microscope, the testicular arteries can be objectively and accurately protected (pulse &#8220;whistle&#8221; sound can be heard when the microvascular doppler probes the arterial surface), while artery injury and venous missed ligation can be avoided. The postoperative blood supply of the testis is also maximumly safeguarded. At the same time, we can be more fearless to cut the cremaster muscle, fatty and connective tissues surrounding the spermatic cord blood vessels and vas deferens after the arteries and lymphatic vessels being accurately protected under the microscope, finally achieve the spermatic cord completely &#34;skeletonized&#34; (only the testicular arteries, lymphatic vessels and vas deferens remained after the surgery). Thus we can better ensure the clinical curative effect (denervation thoroughly), avoid serious complications (testicular atrophy), and achieve better surgical results.

Here, we present a protocol to treat chronic orchialgia by microsurgical denervation of the spermatic cord. Combined with the use of a microvascular doppler, the procedures can be more easily implemented.

Chronic orchialgia is a common disease in department of urology and andrology. The etiology is complex, and the treatment is difficult. In severe cases, ...

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, ...

Clinical Application of 24 G Cannula Needle and 3-0 Polypropylene Suture in Vas Deferens Exploration

The goal of this article is to present the application of a 24 G cannula and 3-0 polypropylene suture as a simple method for the exploration of the vas deferens. During the exploration of the vas deferens, a 24 G cannula needle was used to puncture it. The fluid in the smear confirmed the presence of sperm, to determine whether or not there was concomitant obstruction at the junction of the epididymis and the vas deferens. Then, a 3-0 polypropylene suture (this suture specification has the advantages of a smooth surface, robust quality, and can be passed through a 24 G cannula needle) was passed through the cannula needle to probe the location of the obstructed site. With this technique, exploration of the vas deferens could be more targeted and accurate.

This protocol presents the clinical application of a 24 G cannula and 3-0 polypropylene suture as a simple and effective method for the exploration of the vas deferens.

The goal of this article is to present the application of a 24 G cannula and 3-0 polypropylene suture as a simple method for the exploration of the vas ...

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 ...

Seminal Vesiculoscope Laser-Assisted Surgery to Treat Ejaculatory Duct Blockage

Treatment of Ejaculatory Duct Obstruction by Seminal Vesiculoscopy Assisted Flow Modification

Transurethral resection of ejaculatory duct (TURED) is a primary surgical approach to treat ejaculatory duct obstruction (EDO) caused by the ejaculatory duct cyst. Intraoperative excision of the verumontanum is usually required to expose the ejaculatory ducts. However, preserving the verumontanum structure allows for a better simulation of normal physiological anatomy. Maintaining the verumontanum may increase the risk of postoperative distal ejaculatory duct scarring, leading to recurrent obstruction or reduced semen volume. Therefore, we attempted a novel technique that preserves the verumontanum, which is relatively easier and safer compared to TURED. The following were the procedural steps: 1. A 6F seminal vesiculoscope was introduced through the external urethral orifice to the vicinity of the verumontanum, locating the opening of the affected-side ejaculatory duct and introducing a guidewire into the cyst. This successful step preserved the verumontanum, maximizing the retention of the anti-reflux mechanism in the distal ejaculatory duct. 2. The holmium laser enlarged the affected-side ejaculatory duct opening to 5 mm, decreasing the likelihood of postoperative closure of the ejaculatory duct opening and simplifying the procedure. 3. A window was created within the cyst to access the contralateral seminal vesicle, and then a holmium laser was used to burn and dilate the opening to 5 mm, redirecting the contralateral ejaculatory duct into the cystic cavity. This modification preserved the opening of the healthy-side ejaculatory duct and provided a new outflow passage for semen, reducing the risk of decreased semen volume postoperatively. The patients experienced no complications postoperatively, had shorter hospital stays, and showed improvement in semen volume. Hence, this surgical approach is simple yet effective.

Author Spotlight: Advanced Treatment of Seminal Duct Blockage Employing Endoscopy-Mediated Semen Channel Refluviation 

This protocol introduces the clinical application of seminal vesicle endoscopy combined with holmium laser in the treatment of ejaculatory duct obstruction caused by ejaculatory duct cyst.

Transurethral resection of ejaculatory duct (TURED) is a primary surgical approach to treat ejaculatory duct obstruction (EDO) caused by the ejaculatory ...

Combination of High Ligation and Intraoperative Embolization using Polidocanol for Treatment of Varicoceles

Varicoceles are dilated veins within the pampiniform plexus and are relatively common in the general male population. The spermatic vein has many branches in the scrotal segment and then gradually merges into 1-2 trunks after passing through the internal inguinal ring. The key to a successful varicocelectomy is to ligate all the spermatic veins while protecting the testicular arteries and spermatic lymphatic vessels from damage. The small veins, including the branches of spermatic veins and collateral veins, are easily missed for ligation during conventional high ligation of varicocele, which has been suggested as a major cause of postoperative recurrence. Although microsurgery effectively reduces the risk of missing ligation of the spermatic veins during surgery, it has several shortcomings, such as long operation time and a steep learning curve. More importantly, this technique is difficult to carry out in primary hospitals due to the requirement of specialized equipment. Therefore, an attempt to modify the traditional high ligation aiming to reduce the postoperative recurrence rate has been carried out here. The protocol here combines traditional high ligation with intraoperative embolization to seal off the branches of the spermatic vein and collateral veins. We rapidly injected foamed sclerosant into the internal spermatic vein under direct observation after separation of the spermatic vein and then ligated all the veins. The foamed sclerosant through the varicose vein hampers endothelial cell growth, promotes the growth of thrombus and fibrosis, and ultimately forms fibrous streaks that permanently fill the venous. The results showed a more satisfactory effect on reducing the postoperative recurrence rate compared with traditional high ligation. Since this protocol is simple to carry out and has better results in reducing the recurrence rate, this can be an alternative surgical method for the treatment of varicocele, especially in primary hospitals.

To reduce the postoperative recurrence rate of varicocelectomy, we combined high ligation of varicocele with intraoperative embolization. We injected polidocanol from the spermatic vein during surgery to embolize the branches of the spermatic vein and collateral veins. This is an alternative surgical method for the treatment of varicocele.

Varicoceles are dilated veins within the pampiniform plexus and are relatively common in the general male population. The spermatic vein has many branches ...

Grade III Varicocele Surgical Treatment using Spermatic Vein-Superficial Abdominal Vein Shunt

Microsurgical varicocelectomy is the most commonly used method for the treatment of varicocele (VC) in recent years. However, it is technically demanding with the risk of damaging the normal anatomical structure of the spermatic cord, such as the cremaster muscle, testicular artery, and vas deferens during the pampiniform plexus ligation. Also, traditional varicocelectomy hinders the drainage of the stagnant venous blood of the affected testicle, resulting in a persistent scrotal appearance of varicose veins and slower remission of swelling sensation in postoperative patients with grade III VC. Therefore, we developed a retroperitoneal varicocelectomy with a microscopical spermatic venous-superficial vein of the abdominal wall bypass procedure. The spermatic vein was transected and ligated proximally through the retroperitoneal space. Then, the distal spermatic vein was freed and passed through the internal ring; under the skin of the groin, a microscopic vascular anastomosis was performed to build the bypass of the distal spermatic vein and proximal inferior epigastric vein. The high ligation facilitates the protection of the normal anatomy of the spermatic cord, and the venous bypass allows rapid testicular blood drainage, which can effectively improve the degree of varicocele, testicular pain, and even spermatogenic function. In conclusion, the present protocol describes a promising way to reconstruct the spermatic return through high retroperitoneal ligation of the spermatic vein and anastomosis of the spermatic vein-inferior epigastric vein, which resulted in faster and more obvious improvement in symptoms and better prognosis of grade III VC.

Here, we present a protocol for grade III varicocele surgical treatment that aims to rebuild the venous drainage of the spermatic cord by a spermatic vein-superficial abdominal vein shunt performed under the microscope.

Microsurgical varicocelectomy is the most commonly used method for the treatment of varicocele (VC) in recent years. However, it is technically demanding ...

Electrical Stimulation Therapy: Non-Surgical Remedy for Varicocele-Induced Pain

Transcutaneous Neuromuscular Electrical Stimulation for Treating Varicocele-Induced Scrotal Pain

Varicocele is a prevalent vascular disorder affecting the male reproductive system, leading to scrotal pain and testicular dysfunction. Epidemiological studies have shown that varicocele occurs in approximately 10% to 15% of adult males, while scrotal pain affects 2% to 10% of the population. Currently, clinical treatment options for varicocele-induced scrotal pain include general therapy, medication, and surgery. Among these, surgical intervention is considered the most effective method, boasting a success rate of 80%. However, it carries risks such as postoperative bleeding, infection, and recurrence, making it less desirable for some patients. In recent years, transcutaneous neuromuscular electrical stimulation has gained wide acceptance for treating various andrological conditions, including erectile dysfunction and premature ejaculation, yielding positive outcomes. This non-invasive technique offers a promising alternative for managing varicocele-induced scrotal pain, potentially reducing the need for surgical intervention and its associated risks. Its growing popularity underscores the need for further research and clinical trials to validate its efficacy and safety in treating this condition.

Author Spotlight: Advancing Varicocele Treatment with Neuromuscular Electrical Stimulation

This protocol outlines the use of transcutaneous neuromuscular electrical stimulation for treating varicocele-induced scrotal pain. It compares visual analog scale (VAS) scores and imaging changes before and after treatment to assess effectiveness. Results indicate that patients experienced improved scrotal pain symptoms following the treatment.

Varicocele is a prevalent vascular disorder affecting the male reproductive system, leading to scrotal pain and testicular dysfunction. Epidemiological ...

Bilateral Spermatic Nerve Blocks and Vasectomy Procedures in Males

Optimizing the Modified No-Scalpel Vasectomy Technique

No-scalpel vasectomy (NSV) is a commonly used contraceptive method for males. In previous applications of this surgical method, issues such as knot detachment and postoperative recanalization resulted in a reduced contraceptive success rate after vasectomy. This new technique innovatively modifies the ligation procedure during NSV to address knot detachment and postoperative recanalization. Two ligations of the testicular end of the vas deferens and one ligation of the abdominal end are completed before transection of the vas deferens. A fourth ligation of the abdominal end is performed using the suture tails of the third ligature of the testicular end after transection of the vas deferens. The fifth ligation of the abdominal end is performed using the suture tails of the first ligature of the testicular end. These modifications strengthen the ligations and reduce the postoperative recanalization rate. Additionally, the two stumps are gathered together, creating better conditions for a possible vasovasostomy in the future, thereby achieving overall better outcomes with vasectomy.

A modified no-scalpel vasectomy technique reduces the postoperative recanalization rate. This protocol describes a modified no-scalpel vasectomy technique that can reduce the postoperative recanalization rate.

No-scalpel vasectomy (NSV) is a commonly used contraceptive method for males. In previous applications of this surgical method, issues such as knot ...