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

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.