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 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.
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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
- Ensure the availability of sterilized instruments and other equipment mentioned in the Table of Materials.
2. Preparation for operation
- Prepare the bowel prior to surgery (by defecation).
- Prepare the perineal skin before surgery (by shaving off the hair).
- 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.
- Place the patient in the supine position on the operating table after combined spinal-epidural anesthesia.
- Disinfect the surgical area with 1% iodophor and cover it with surgical towels.
3. Vessel-sparing modified single-armed LIVE
- Insert a 16 French or 16Fr Foley catheter, and mark the incision sites with a skin marker.
- Deliver the testis through a 3-4 cm vertical scrotal incision.
- 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).
- 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).
- 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.
- 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).
- 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.
- 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).
- 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).
- 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
- Ensure that the patient waits for 6 h after the operation before eating, takes bed rest for 3 days, and avoids standing or walking.
- 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.
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Representative 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 severe adverse events were noted. A regular follow-up plan was established, with the first semen analysis at 6 weeks postoperatively and then every 3 months thereafter.
In this study, natural pregnancy or follow-up to 18 months after the operation were the endpoints of the follow-up. The follow-up dates of 82 (89.1%, 82/92) cases were included in the final statistical analysis. The patency rate was 81.7% (67/82). The average time of patency was 4.63 ± 3.29 months (range: 1-12 months), and the semen revealed oligospermia or asthenospermia at the time of first patency. One of the patients was unmarried. The average age of the others' spouses was 28.83 ± 5.05 years (range: 20-46 years). None of these spouses had any diseases that affected their fertility. The natural pregnancy rate was 35.8% (29/81). One pregnancy was achieved by in vitro fertilization using testicular aspiration to obtain sperm. The partners of the remaining 29 patients became pregnant naturally, and 25 (86.2%) were pregnant within 12 months after surgery (Table 2).
Figure 1: Dissociate the deferential vessels. Please click here to view a larger version of this figure.
Figure 2: Confirm patency of the distal vas deferens. (A) The vas deferens was hemisected. (B) The distal patency of the vas deferens was confirmed by injection of diluted methylene blue or 0.9% sodium chloride solution, with no resistance or reflux. Please click here to view a larger version of this figure.
Figure 3: Fix the vas deferens and epididymis tunic. (A) The isolated part of the vas deferens was passed through a tunnel in the tunica vaginalis. (B) Microscopic bipolar coagulation was used to stop the vas deferens bleeding. Please click here to view a larger version of this figure.
Figure 4: The first two steps of modified single-armed suture LIVE technique. (A) Mark four suture sites on the vas deferens. (B). Two needles were respectively placed outside-in (a1 and b1) through the inferior points of the vasal mucosal layer. Abbreviation: LIVE = longitudinal intussusception vasoepididymostomy. Please click here to view a larger version of this figure.
Figure 5: Detect epididymal fluid. (A) Open the epididymal tubule using a 15° ophthalmic knife. (B) Aspirate the epididymal fluid around the epididymal tubule for examination. Please click here to view a larger version of this figure.
Figure 6: The last two steps of modified single-armed suture LIVE technique. (A) Two needles were respectively passed through the superior points (a2 and b2) of the vasal mucosal layer in an inside-out fashion. (B) The adventitia of the vas deferens and the epididymal tunic were sutured to reduce the tension followed by intussusception of the opening of the epididymal tubule into the vasal lumen. Abbreviation: LIVE = longitudinal intussusception vasoepididymostomy. Please click here to view a larger version of this figure.
Figure 7: Suture the muscularis edge of the vas deferens and the epididymal tunic. Please click here to view a larger version of this figure.
| Items | Value |
| Age (years) | Mean ± standard deviation (range) |
| Patients | 30.77 ± 5.38 (20-47) |
| Female partners | 28.83 ± 5.05 (20-46) |
Table 1: Age of the patients and their partners.
| Items | Value |
| Operation time, Mean ± standard deviation | 223.59 ± 31.73 |
| Follow-up rate, n (%) | 82 (89.1) |
| Patency rate, n (%) | 67 (81.7) |
| Patency time, Mean±standard deviation (range) | 4.63 ± 3.29 (1-12) |
| Natural pregnancy rate, n (%) | 29 (35.8) |
| Natural pregnancy rate at one year, n (%) | 25 (86.2) |
Table 2: Surgical outcomes in patients.
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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 MVE6,8,9. Because double-needle sutures are expensive and not readily available, and the etiology of most patients in China is different from that in western countries, the single-needle suture of vessel preservation technique was proposed. A safe and more effective VE can be achieved by separating and protecting the vessels of the vas deferens, using easily available single-needle sutures and keeping the anastomosis tension-free.
In classic MVE, the needle is placed inside-out through the mucosal layer of the vas deferens, which has certain protective effects on the mucosal layer of the vas deferens. However, the prices of imported double-needle sutures are high in China and many other countries. The quality of domestic double-needle sutures is poor, which leads to increased difficulty and a poor success rate of anastomosis. A single-needle suture technique has been described and demonstrated to be safe and effective in a study by Monoski et al.10. This team proposed a modified single-armed technique for MVE in humans, which was first reported internationally by Zhao et al.11. Readily available, good quality, single-needle sutures were used in LIVE. In Monoski's technique10, the needle first passed through the superior points of the vasal mucosal layer in an outside-in fashion, through the epididymal tubule, and finally through the inferior points of the vasal mucosal layer in an inside-out fashion. In this protocol, the first stitch was passed through the inferior points of the vasal mucosal layer in an outside-in fashion, which did not cause any significant damage to the mucosal layer of the vas deferens. A microneedle holder was used to slightly dilate the vasal lumen and accurately control the needle under the microscope. The patency rate of MVE was 50%-80% at that time6, and this modified single-armed technique for MVE achieved an early 6-month patency rate of 61.5% contemporaneously12, which proved the safety and effectiveness of the modified single-armed technique.
Tension-free anastomosis is crucial for the success of VE6,8,9. Additional vas deferens mobilization is necessary in the presence of tension during the anastomosis. However, overmobilization of the vas deferens may prevent the vessels of the vas deferens from being preserved. Tension-free anastomosis can also be achieved by suturing an 8-0 tension-reducing suture through the adventitia of the vas deferens and epididymal tunic. This 8-0 suture was tied loosely so that the anastomosis could be seen when tying 10-0 sutures. Then, 10-12 interrupted sutures of 9-0 were used to close the muscularis edge of the vas deferens and the epididymal tunic to reduce tension and avoid epididymal fluid leakage. The leakage of epididymal fluid could lead to sperm granuloma formation.
The surgical method of preserving the vas deferens vessels has been innovatively proposed because the etiology of patients with epididymal OA is mostly inflammatory in China2,3. The vas deferens artery has anastomotic branches with the testicular artery in the epididymis, which also plays an important role in the blood supply to the vas deferens, epididymis, and testis13,14,15. This role of the vas deferens artery has been shown to not cause testicular atrophy during unintentional ligation of the testicular artery during varicocelectomy16,17. Protection of the blood supply to the vas deferens, anastomotic stomas, and epididymis is maximized using microsurgical forceps to separate and protect the vas deferens vessels. The patency rate reached 81.7% during the postoperative follow-up in this study, compared with a patency rate of 61.5% for those undergoing nondeferential vessel-sparing LIVE performed by the same surgeon12, which shows a better surgical treatment effect. A retrospective controlled study by Li et al.18 also showed that vessel-sparing LIVE could achieve better patency and pregnancy rates, especially natural pregnancy rate in the early stages.
Implementation of MVE is limited because it is one of the most complex and challenging technologies. Specialized training is required to perform this operation. The technique in this study is suitable for epididymal obstructive azoospermia and vasectomy without damage of the vasculature of the vas deferens. It also has stringent requirements because the vessels of the vas deferens are separated under the operating microscope, which is necessary to avoid damage of the vessels during separation. Although the significance of vessel-sparing during LIVE has not been documented, vasculature preservation can protect the blood supply of the vas deferens, epididymis, and testis, and it is more consistent with the physiological structure. The early clinical follow-up demonstrated its effectiveness and improved recurrence and pregnancy rates7. In summary, the modified single-armed technique for LIVE with preserved vascular vasculature was safe and effective. This innovation is worth disseminating and will improve patients' patency and natural pregnancy rates.
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Disclosures
The authors have no conflicts of interest to disclose.
Acknowledgments
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's Republic of China key laboratory of Male Reproduction and Genetics (No.KF202001).
Materials
| 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 |
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