Name: a modified vessel-sparing microsurgical vasoepididymostomy
Uploaded: 2022-06-08T14:20:00
Description: Watch this Scientific Journal Video about A Modified Vessel-Sparing Microsurgical Vasoepididymostomy at JoVE.com

我要感谢龙田教授（北京朝阳医院泌尿外科）对血管附睾切开术的技术指导。我设计的这个改良程序的灵感来自他的动脉保留显微外科血管附睾造口术。我还要感谢吕莫琪博士（西安交通大学医学院）帮助润色本文。

这项研究得到了西北妇女儿童医院伦理委员会（第2021002号）的批准。
1. 准备工作
<ol><li>将患者仰卧在手术台上，并根据麻醉师的建议进行麻醉。</li>
	<li>在对区域进行消毒并用手术窗帘覆盖后，在切口部位周围插入 16Fr Foley 导管。</li>
</ol>2. 改装船舶备用 LIVE
<ol><li>在阴囊中间创建一个 3 厘米的垂直切口，并从切口输送睾丸。</li>...

<ol>
	<li>Wagenknecht, L. V., Klosterhalfen, H., Schirren, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microsurgery+in+andrologic+urology.+I.Refertilization.">Microsurgery in andrologic urology. I.Refertilization.</a> Journal of Microsurgery. 1 (5), 370-376 (1980).</li><li>Thomas, A. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Vasoepididymostomy.">Vasoepididymostomy.</a> Urologic Clinics of North America. 14 (3), 527-538 (1987).</li><li>Berger, R. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Triangulation+end-to-side+vasoepididymostomy.">Triangulation end-to-side vasoepididymostomy.</a> The Journal of Urology. 159 (6), 1951-1953 (1998).</li><li>Marmar, J. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Modified+vasoepididymostomy+with+simultaneous+double+needle+placement,+tubulotomy+and+tubular+invagination.">Modified vasoepididymostomy with simultaneous double needle placement, tubulotomy and tubular invagination.</a> The Journal of Urology. 163 (2), 483-486 (2000).</li><li>Chan, P. T., Li, P. S., 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+vasoepididymostomy:+A+prospective+randomized+study+of+3+intussusception+techniques+in+rats.">Microsurgical vasoepididymostomy: A prospective randomized study of 3 intussusception techniques in rats.</a> The Journal of Urology. 169 (5), 1924-1929 (2003).</li><li>Chan, P. T., Graham, S. D., Keane, T. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Vasoepididymostomy.">Vasoepididymostomy.</a> Glenn's Urologic Surgery, 7th ed. , 379-386 (2009).</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 Journal of Andrology. 15 (1), 49-55 (2013).</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>Zhang, Y., Wu, X., Yang, X. J., Zhang, H., Zhang, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Vasal+vessels+preserving+microsurgical+vasoepididymostomy+in+cases+of+previous+varicocelectomy:+A+case+report+and+literature+review.">Vasal vessels preserving microsurgical vasoepididymostomy in cases of previous varicocelectomy: A case report and literature review.</a> Asian Journal of Andrology. 18 (1), 154-156 (2016).</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 Journal of Andrology. 20 (6), 576-580 (2018).</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>

保留血管的显微外科血管附睾造口术可能具有一定的临床意义。虽然尚未证实该方法可以提高通畅率，但可能更好地模拟正常的生理结构，对接受精索静脉曲张切除术的患者具有一定的意义。这可以归因于以下事实：保留顺动脉和输精管静脉分别对精索静脉曲张切除术后睾丸的血液供应和睾丸静脉回流有积极影响。然而，存在血管血管保存的风险，这可能会增加吻合术的张力和术后出血的风险，?...

附睾梗阻是梗阻性无精子症的最常见原因。显微外科附睾造口术（MVE）是附睾梗阻的主要手术治疗方法。尽管之前已经描述了各种MVE技术1，2，3，4，但Chan等人描述的双针纵向肠套叠血管附睾造口术（LIVE）技术5，6已被公认为实现卓越通畅率的金标准7.血管通常在 LIVE 中结扎。血管结扎术简化了手术并降低了吻合口的张力，而无张力吻合术对于获得成功的结果至关重要。
输精管动脉主要供应附睾和输精管8.输精管动脉保留是否能改善术后通畅率仍不清楚。然而，在MVE期间保留血管可能更好地模拟正常的生理结构。此外，对于接受过精索静脉曲张切除术的患者，进行血管保留MVE可能有意义，因为血管血管系统的完整性在精索静脉曲张切除术后血液供应和睾丸静脉回流中起着至关重要的作用。一些研究9，10，11试图在MVE期间保存血管，并表明该程序可能有一定的益处。然而，保留血管会使吻合术的操作更加困难，并增加吻合术的张力。此外，输精管的张力可能传递到血管，并导致血管小分支术后出血。此外，现有的血管保留程序可能会影响输精管的血液供应。因此，我们改进了血管保留MVE的手术技术，使其更安全。我们称这种新手术为显微外科血管附睾造口术，通过使用逆行 - 顺行解离来保存血管。

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>11-0 microsutures</td>
			<td>Ningbo Medical Needle Co.,Ltd</td>
			<td>211115</td>
			<td>Double-armed microsurgical nylon suture length: 5 cm</td>
		</tr>
		<tr>
			<td>15&#176; ophthalmic knife</td>
			<td>pearsalls limited</td>
			<td>72-1501</td>
			<td>&#160;open the epididymal tubule</td>
		</tr>
		<tr>
			<td>2-0 silk braided non-absorbable suture</td>
			<td>Coated</td>
			<td>1604-51</td>
			<td>Ligation of the vas deferens</td>
		</tr>
		<tr>
			<td>24-Gangiocatheter sheath</td>
			<td>Melsungen AG</td>
			<td>4253523-03</td>
			<td>injection</td>
		</tr>
		<tr>
			<td>5-0 silk braided non-absorbable suture</td>
			<td>Johnson &#38; Johnson</td>
			<td>SA82G</td>
			<td>Ligation of blood vessels</td>
		</tr>
		<tr>
			<td>8-0 microsutures</td>
			<td>Johnson &#38; Johnson</td>
			<td>W2908</td>
			<td>Single-armed microsurgical nylon suture length: 13 cm</td>
		</tr>
		<tr>
			<td>Deferens separating forceps</td>
			<td>Shanghai Medical Instrument Co., Ltd</td>
			<td>JCZ210</td>
			<td>Separation of vas deferens</td>
		</tr>
		<tr>
			<td>Micro scissors</td>
			<td>Shanghai Medical Instrument Co., Ltd</td>
			<td>WA1040</td>
			<td>Microsurgical operation</td>
		</tr>
		<tr>
			<td>Microforceps</td>
			<td>Shanghai Medical Instrument Co., Ltd</td>
			<td>WA3090</td>
			<td>Microsurgical operation</td>
		</tr>
		<tr>
			<td>Microneedle holder</td>
			<td>Shanghai Medical Instrument Co., Ltd</td>
			<td>WA2040</td>
			<td>Microsurgical operation</td>
		</tr>
		<tr>
			<td>Operating microscope</td>
			<td>Leica Microsystems(Sch weiz) AG</td>
			<td>M525MS3</td>
			<td>Microsurgical operation</td>
		</tr>
	</tbody>
</table>

a modified vessel-sparing microsurgical vasoepididymostomy

显微外科附睾造口术（MVE）是附睾梗阻的主要手术治疗方法。血管在MVE期间结扎。然而，在MVE期间保留血管可能更好地模拟正常的生理结构，并且对接受精索静脉曲张切除术的患者有意义。然而，保留血管可能会增加吻合张力的风险，影响通畅率并导致术后出血延迟。因此，我们开发了一种新型的船舶备用MVE，使其更安全。以下是对该过程的改进的摘要。1）以睾丸近端血管逆行解离为主要方法，以睾丸远端血管顺行解离为辅，解离待保存的血管。这种改进确保了输精管的血液供应，这些输精管将用于吻合术，并提供更长的血管，从而降低吻合口的张力。2）通过固定待吻合输精管和输精管断端，固定游离血管血管，解决了输精管张力传递到血管的问题，降低了血管出血的风险。3）打开被膜阴道后输精管解离会增加输精管的活动，这也使新手术更容易完成。对这种新手术结果的评估表明，患者术后未发生明显的并发症，通畅率与常规手术无差异。因此，这种新的改进程序可以被认为是安全的，具有令人满意的术后结果。

回顾性分析了2018年2月至2020年11月期间在本中心接受血管附睾切开术的51例患者。考虑到吻合口张力，修改后的手术仅在附睾体或尾部梗阻患者中进行，这些患者被纳入目前的研究中。术后1.5个月进行精液检查，随访1年以上。本研究纳入了术后随访期间至少一次精液检测结果的患者的相关数据。精子浓度>1 x 104 精子/mL被定义为成功的通畅。记录术后并发症，特别是术后1周内阴囊血肿、术?...

Watch this Scientific Journal Video about A Modified Vessel-Sparing Microsurgical Vasoepididymostomy at JoVE.com

A Modified Vessel-Sparing Microsurgical Vasoepididymostomy

在这里，我们提出了一种在显微外科血管附睾造口术中保存血管的方案。通过使用逆行-顺行解离术保留血管并固定血管来增强手术安全性。

一种改良的血管保留显微外科血管附睾造口术

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

该协议描述了一种新型船舶备用MVE的开发。该手术不仅保证了通畅率，而且提高了手术的安全性。该程序可以在不破坏正常生理结构的情况下完成MVE。这是一种安全的程序，可以增强血液供应和静脉回流睾丸。首先，在阴囊中间做一个三厘米的垂直切口，并从切口输送睾丸。打开被膜阴道。小心地分离输精管和相邻血管。解离的长度约为五厘米。使用微型剪刀在附睾尾部的被膜上创建一个直径为五毫米的扣眼。识别扩张的附睾小管，并使用微镊子小心地将其解离。将两根双臂11-0微缝合线的针纵向放置在选定的附睾小管中，并使用15度眼科刀在两根针之间纵向打开附睾小管。用载玻片对从小管切口流出的一些附睾液进行采样。轻轻拔出附睾小管中的两根针，如果发现精子，则分别拔出。使用分离镊子在输精管和相邻血管之间的间隙中穿刺。用刀完全横穿分镊上方的输精管，并保留分镊下方的血管。将 24 号血管导管鞘插入睾丸远端的输精管腔中，然后推注稀释的亚甲蓝。观察尿液的颜色。使用微型剪刀将睾丸近端侧的输精管与血管分离。然后结扎输精管的断端并移除解离的输精管。使用分离镊子和微型剪刀小心地将睾丸远端侧的输精管与血管血管分开。使用8-0将输精管固定在与被膜阴道吻合口处在输精管和相邻血管之间以包含的角度进行微缝合。固定后，确保输精管管腔到达吻合部位，没有明显的张力。固定输精管和附睾的肌肉边缘使用三个四中断8-0微缝合线。将附睾小管中11-0微缝合线的四根针以由内而外的方式穿过输精管切割表面上的四个点。然后将附睾小管的肠套叠插入输精管。使用10至12条8-0的中断缝合缝合输精管的肌肉库拉边缘和附睾微缝合线。使用三到四条8-0的中断缝合线固定被膜阴道输精管的断端微缝合线。确保自由血管固定且不能移动。51例中，采用新方法治疗22例，术后精液检出精子19例。术后通畅率为86.4%29例常规手术中，25例发现精子，术后通畅率为86.2%两组术后通畅率差异无统计学意义，术后无阴囊血肿、阴囊疼痛或睾丸萎缩。在尝试此程序时，血管的固定是最重要的事情。可以尝试改善血管的解离，并可能缩短手术时间。这种新手术不仅保证了通畅率，还提高了手术的安全性。

Research

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