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

Summary

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.

Abstract

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.

Introduction

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 China^2,3. 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 countries^2,3. 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 tubule^6,7,8. 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.

Protocol

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

1. Ensure the availability of sterilized instruments and other equipment mentioned in the Table of Materials.

2. Preparation for operation

1. Prepare the bowel prior to surgery (by defecation).
2. Prepare the perineal skin before surgery (by shaving off the hair).
3. 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.
4. Place the patient in the supine position on the operating table after combined spinal-epidural anesthesia.
5. Disinfect the surgical area with 1% iodophor and cover it with surgical towels.

3. Vessel-sparing modified single-armed LIVE

1. Insert a 16 French or 16Fr Foley catheter, and mark the incision sites with a skin marker.
2. Deliver the testis through a 3-4 cm vertical scrotal incision.
3. 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).
4. 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).
5. 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.
6. 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).
7. 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.
8. Place two needles in the epididymal tubule, opened longitudinally between the two needles using a 15° 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).
9. 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).
10. Suture the muscularis edge of the vas deferens and the epididymal tunic using 10-12 interrupted sutures of 9-0 polypropylene (Figure 7).

4. Postoperative care

1. Ensure that the patient waits for 6 h after the operation before eating, takes bed rest for 3 days, and avoids standing or walking.
2. 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.

Results

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 ± 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 ± 31.73 min. No postoperative complications or sev...

Discussion

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 MVE^6,8,9. Because double-needle sutures are expensive and not readily ava...

Materials

List of materials used in this article

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