Name: a modified vessel-sparing microsurgical vasoepididymostomy
Uploaded: 2022-06-08T14:20:00.000+00:00
Duration: 4 min 59 s
Description: Watch this Scientific Journal Video about A Modified Vessel-Sparing Microsurgical Vasoepididymostomy at JoVE.com

I would like to thank Professor Long Tian (Department of Urology, Beijing Chaoyang Hospital) for the technical instruction on vasoepididymostomy. This modified procedure I designed is inspired by his artery-sparing microsurgical vasoepididymostomy. I would also like to thank Dr. Moqi Lv (Medical School, Xi&#39;an Jiaotong University) for the help with polishing the present paper.

This study was approved by the Ethics Committee of Northwest Women&#39;s and Children&#39;s Hospital (No. 2021002).
1. Preparations
<ol>
	<li>Place the patient supine on the operating table and perform anesthesia as per the anesthetist&#39;s recommendations.</li>
	<li>Insert a 16Fr Foley catheter around the incision site after the field is disinfected and covered with surgical drapes.</li>
</ol>
2. Modified vessel-sparing LIVE
<ol>
	<li>Create a 3 cm vertical incision in the middle of the scrotum and deliver the testis from the incision.</li>
	<li>Open the tunica vaginalis. Carefully dissociate the vas deferens and adjacent vessels. The dissociated length is ~5 cm (Figure 1).</li>
	<li>Place an operating microscope and ready the micro instruments: a micro needle holder, micro scissors, and micro forceps. Execute the following steps using the operating microscope.</li>
	<li>Create a buttonhole of a diameter of 5 mm at the tunica of cauda epididymis using micro scissors. Identify a dilated epididymal tubule and carefully dissociate it using micro forceps. After that, keep it for anastomosis.</li>
	<li>Place two needles of double-armed 11-0 microsutures longitudinally in the selected epididymal tubule, and open the epididymal tubule longitudinally between the two needles using a 15&#176; ophthalmic knife. Ensure that the opening length does not exceed the length between the entry point and the exit point of the suture on the epididymal tubule (Figure 2).</li>
	<li>Sample some epididymal fluid flowing from the incision in the tubule with a glass slide and hand it to an examiner to check for sperm. Gently pull out two needles in the epididymal tubule separately if sperm are found.</li>
	<li>Make a puncture in the gap between the vas deferens and adjacent vessels using deferens separating forceps. The puncturing site is approximately 1 cm away from the junction of the cauda epididymis and the vas deferens. Completely transect the vas deferens above the deferens separating forceps with a knife, and preserve the vasal vessels below the deferens separating forceps (Figure 3).</li>
	<li>Cannulate the 24-G angiocatheter sheath into the vas deferens lumen on the distal testicular side, followed by a bolus injection of diluted methylene blue. Observe the color of the urine. Blue staining of the urine indicates distal patency.</li>
	<li>Dissociate the vas deferens on the proximal testicular side using micro scissors to separate it from the vasal vessels. Ensure that the dissociation is executed along the vas deferens side to avoid damage to the vasal vessels. The dissociated length is ~2-3 cm. Then, remove the dissociated vas deferens and ligate the broken end of the vas deferens. During the dissociation, stop the bleeding using bipolar electrocoagulation or by ligating some small branch vessels using a 5-0 silk thread. This operation is called retrograde dissociation (Figure 4 and Figure 5).</li>
	<li>Carefully separate the vas deferens on the distal testicular side from the vasal vessels using deferens separating forceps combined with micro scissors. The dissociated length is ~0.5 cm. Separate the vas deferens and the vasal vessels without damaging the vas deferens or the vasal vessels. This operation is called anterograde dissociation (Figure 4 and Figure 6).</li>
	<li>Fix the vas deferens to be anastomosed with the tunica vaginalis using 8-0 microsutures at the included angle between the vas deferens and adjacent vessels. After fixation, ensure that the lumen of the vas deferens reaches the anastomosis site with no significant tension. This is regarded as the first-stage tension reduction.</li>
	<li>Fix the muscularis edge of the vas deferens and epididymis tunica using 3-4 interrupted 8-0 microsutures. This is regarded as the second-stage tension reduction.</li>
	<li>Pass the four needles of 11-0 microsutures in the epididymal tubule through four points (Figure 7) on the cutting surface of the vas deferens in an inside-out fashion. Then, perform the intussusception of the epididymal tubule into the vas deferens8.</li>
	<li>Suture the muscularis edge of the vas deferens and the epididymal tunica using 10-12 interrupted sutures of 8-0 microsutures.</li>
	<li>Fix the broken end of the vas deferens on the tunica vaginalis using 3-4 interrupted sutures of 8-0 microsutures (Figure 4 and Figure 8). Ensure that the free vasal vessels are fixed and cannot move. This operation is called fixation of the vasal vessels.</li>
	<li>Check whether there is tension in the vas deferens and whether there is tension and bleeding in the preserved vasal vessels. Then, suture each layer of tissue sequentially and terminate the operation.</li>
</ol>
3. Postoperative management
<ol>
	<li>Avoid sexual intercourse for 1 month after surgery.</li>
	<li>Wear a scrotal supporter or tight underpants for 1 week after surgery, and avoid standing or walking for a long time.</li>
	<li>Take antibiotics for 1 week to prevent infection.</li>
</ol>

<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>

The authors have nothing to disclose.

Vessel-sparing microsurgical vasoepididymostomy might have some clinical significance. Although it is not confirmed that this approach can improve the patency rate, it might better simulate the normal physiological structure and has certain significance for patients who have undergone varicocelectomy. This can be attributed to the fact that preservation of the deferential artery and vas deferens vein have positive effects on the blood supply to the testis after varicocelectomy and the venous return of the testis, respectively. However, there is a risk of vasal vessel preservation, which may increase the tension of anastomosis and the risk of postoperative bleeding and affect the blood supply to the vas deferens due to the separation of the artery from the vas deferens. Therefore, we improved the surgical technique of vessel-sparing MVE to make it safer.
We redesigned the vessel-sparing vasoepididymostomy procedure using retrograde-anterograde dissociation of the vasal vessels and innovatively adopted the method of fixing the vasal vessels, which increased the safety of the surgery and reduced the tension of the anastomosis. The specific surgical improvements were as follows. Firstly, the vasal vessels to be preserved were dissociated using retrograde dissociation of the vasal vessels on the proximal testicular side as the main method and the anterograde dissociation of the vasal vessels on the distal testicular side as a supplement. This improvement ensured the blood supply to the vas deferens that was used for anastomosis and also provided longer vasal vessels, which reduced the tension of anastomosis. Secondly, the vas deferens to be anastomosed and the broken end of the vas deferens were fixed on the tunica vaginalis, respectively, to make sure that the free vasal vessels cannot move. The transmission of vas deferens tension to the vasal vessels was avoided, and the risk of vasal vessel hemorrhage was reduced. Thirdly, the vas deferens was dissociated after opening the tunica vaginalis. This increased the mobilization of the vas deferens so that, theoretically, some obstructions close to the caput epididymal could also be resolved using our modified procedure.
The dissociation and protection of the vasal vessels are key steps for the success of this novel procedure. Particularly, the vasal vessels may be occasionally damaged during dissociation of the vas deferens on the proximal testicular side&#160;and the vasal vessels, resulting in decreased efficacy of the novel procedure. Hence, the micromanipulation skills of the surgeon should be continuously improved. Besides, as the vas deferens on the proximal testicular side is the last tissue to be removed, the dissociation should be executed at the vas deferens side during the separation of the vas deferens on the proximal testicular side and the vasal vessels to avoid damage to the vasal vessels. This would facilitate the successful protection of the vasal vessels. Additionally, the vas deferens on the proximal testicular side should be fixed on the tunica vaginalis instead of the epididymis to avoid epididymal obstruction. In our study, an inspection of the vasal fluid was not part of the regular examination for these patients, since all cases were epididymal obstruction but not obstruction of the vas deferens. For patients prepared for vasectomy reversal, an inspection of the vasal fluid would be recommended to explore the possibility of vasovasostomy; however, vasectomy is seldom conducted in China today.
No significant postoperative complications have occurred in the patients who received this modified procedure until the submission of this manuscript, and there was no significant difference in the postoperative patency rate between the modified and conventional procedures. Therefore, the modified procedure is safe, with a satisfactory postoperative patency effect. It may not only preserve the vasal vessels and simulate the normal physiological structure but also achieve a satisfactory patency rate. In addition, there was no significant difference in total motile sperm count (TMSC) between the two groups (P = 0.869). However, there is a possibility that an increased sample size may provide different results.
The new procedure may prolong the surgical time and exhibit increased difficulty. In order to ensure the operation quality, the criteria for selecting the procedure are that the new procedure will be performed if there is only one operation on the day; otherwise, the traditional procedure will be performed if there are two or more operations on the same day or the patients refuse to try the new procedure. Moreover, although theoretically, the obstruction of the caput epididymal can be resolved using the modified procedure; however, tension may be generated as the anastomotic site moves toward the caput epididymal owing to the limited dissociated lengths of the vasal vessels, so we still recommend the modified procedure for only those patients with the obstruction of the corpus or caudal epididymal.
In summary, the modified procedure, microsurgical vasoepididymostomy by preserving the vasal vessels using retrograde-anterograde dissociation, is safe and effective for vasoepididymostomy. This modified procedure can complete vasoepididymostomy without destroying the normal physiological structure. It is a safe procedure and may enhance blood supply and venous return to the testis. Hence, we recommend it for patients with obstruction of the corpus or caudal epididymal. Future studies shall further clarify the advantages of the proposed procedure using a randomized control trial.

Epididymal obstruction is the most common cause of obstructive azoospermia. Microsurgical vasoepididymostomy (MVE) is the main surgical treatment for epididymal obstruction. Although various MVE techniques1,2,3,4 have been described previously, a two-needle longitudinal intussusception vasoepididymostomy (LIVE) technique described by Chan et al.5,6 has been recognized as the gold standard for achieving a superior patency rate7. The vasal vessels are typically ligated in LIVE. Ligation of the vasal vessels simplifies the procedure and reduces the tension of anastomosis, and a tension-free anastomosis is critical to achieving a successful outcome.
The vas artery primarily supplies the epididymis and vas deferens8. Whether preservation of the vas artery improves the postoperative patency rate remains unclear. However, preserving the vasal vessels during MVE might better simulate the normal physiological structure. Also, for patients who have undergone varicocelectomy, it may be meaningful to perform the vessel-sparing MVE, because the integrity of vasal vasculature plays a vital role in post-varicocelectomy blood supply and the venous return of the testis. A few studies9,10,11 have attempted to preserve the vasal vessels during MVE and suggested that the procedure may have certain benefits. However, preserving the vasal vessels makes the operation of anastomosis more difficult and increases the tension of anastomosis. In addition, the tension of the vas deferens may be transmitted to the vasal vessels and cause postoperative bleeding of the little branches of the vessels. Besides, the existing vessel-sparing procedure may affect the blood supply of the vas deferens. Therefore, we improved the surgical technique of vessel-sparing MVE to make it safer. We called this new procedure microsurgical vasoepididymostomy by preserving the vasal vessels using a retrograde-anterograde dissociation.

<table><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&amp;deg; ophthalmic knife</td><td>pearsalls limited</td><td>72-1501</td><td>&amp;nbsp;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 &amp;amp; Johnson</td><td>SA82G</td><td>Ligation of blood vessels</td></tr><tr><td>8-0 microsutures</td><td>Johnson &amp;amp; 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

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.

A total of 51 patients who underwent vasoepididymostomy at our center between February 2018 and November 2020 were retrospectively analyzed. Considering the anastomotic tension, the modified procedure was performed only in patients with obstruction at the corpus or caudal epididymal, and these patients were included in the current study. Semen examination was performed 1.5 months after the surgery, and the patients were followed up for more than 1 year. Relevant data of patients with the results of at least one semen test during the postoperative follow-up were included in the current study. Sperm concentrations &#62;1 x 104 sperm/mL was defined as successful patency. Postoperative complications, especially scrotal hematoma within 1 week after surgery, pain or discomfort in the scrotal area after exercise 1 month after surgery, and testicular atrophy after surgery, were recorded. The patency rate was also evaluated.
Among the 51 cases, 22 were treated using the new method, and spermatozoa were detected in the postoperative semen in 19 cases. The postoperative patency rate was 86.4%. Among the 29 cases who underwent the conventional procedure, spermatozoa were detected in 25 cases, and the postoperative patency rate was 86.2%. There was no statistically significant difference in the postoperative patency rate between the two groups (P = 0.997, using the Chi-square test). For the two groups, the recovery was good, and there was no postoperative scrotal hematoma, scrotal pain, or testicular atrophy. Considering there were a few patients who did not complete the follow-up, the current study did not include an evaluation of the postoperative natural pregnancy rate (Table 1).
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/63894/63894fig01.jpg" /> 
Figure 1: Dissociation of the vas deferens and the vasal vessels. Open the tunica vaginalis. Carefully dissociate the vas deferens and adjacent vessels. The dissociated length is ~5 cm. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/63894/63894fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/63894/63894fig02.jpg" /> 
Figure 2: Preparation of the epididymal tubule. Place two needles of double-armed 11-0 microsutures longitudinally in the selected epididymal tubule, and open the epididymal tubule longitudinally between the two needles using a 15&#176; ophthalmic knife. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/63894/63894fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/63894/63894fig03.jpg" /> 
Figure 3: Separation of the vas deferens from the vasal vessels. Make a puncture in the gap between the vas deferens and adjacent vessels using a deferens separating forceps. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/63894/63894fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/63894/63894fig04.jpg" /> 
Figure 4: Schematic diagram of the modified 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. 2) By fixing the vas deferens to be anastomosed and the broken end of the vas deferens, the free vasal vessels get fixed. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/63894/63894fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/63894/63894fig05.jpg" /> 
Figure 5: Retrograde dissociation. Separate the vas deferens on the proximal testicular side from the vasal vessels. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/63894/63894fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/63894/63894fig06.jpg" /> 
Figure 6: Anterograde dissociation. Separate the vas deferens on the distal testicular side from the vasal vessels. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/63894/63894fig06large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 7" class="xfigimg" src="/files/ftp_upload/63894/63894fig07.jpg" /> 
Figure 7: Schematic diagram of LIVE. Pass the four needles of 11-0 microsutures in the epididymal tubule through four points (a1-2, b1-2) on the cutting surface of the vas deferens in an inside-out fashion. Then, perform the intussusception of the epididymal tubule into the vas deferens. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/63894/63894fig07large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 8" class="xfigimg" src="/files/ftp_upload/63894/63894fig08.jpg" /> 
Figure 8: The fixation of the vasal vessels. Fix the vas deferens to be anastomosed and the broken end of the vas deferens on the tunica vaginalis, respectively, to make sure that the free vasal vessels cannot move. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/63894/63894fig08large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td></td>
			<td>Modified procedure (n = 22)</td>
			<td>Conventional procedure (n = 29)</td>
			<td>P-value</td>
		</tr>
		<tr>
			<td>Age(year)</td>
			<td>30.5 &#177; 4.8</td>
			<td>30.8 &#177; 5.5</td>
			<td>0.825</td>
		</tr>
		<tr>
			<td>Patency rate (%)</td>
			<td>86.4 (19/22)&#160;</td>
			<td>86.2 (25/29)</td>
			<td>1.000</td>
		</tr>
		<tr>
			<td>Postoperative scrotal hematoma</td>
			<td>0</td>
			<td>0</td>
			<td>/</td>
		</tr>
		<tr>
			<td>Postoperative scrotal pain</td>
			<td>0</td>
			<td>0</td>
			<td>/</td>
		</tr>
		<tr>
			<td>Postoperative testicular atrophy</td>
			<td>0</td>
			<td>0</td>
			<td>/</td>
		</tr>
	</tbody>
</table>
Table 1: Comparison of postoperative results between the modified procedure and the conventional procedure. There was no statistically significant difference in the postoperative patency rate between the two groups (P = 0.997). There was no postoperative scrotal hematoma, scrotal pain, or testicular atrophy in the two groups.

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

A Modified Vessel-Sparing Microsurgical Vasoepididymostomy

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, ...

a-modified-vessel-sparing-microsurgical-vasoepididymostomy

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1.8K Views.  Northwest Women’s and Children’s Hospital. 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.

Video: A Modified Vessel-Sparing Microsurgical Vasoepididymostomy

Microvascular Decompression: Salient Surgical Principles and Technical Nuances

Trigeminal neuralgia is a disorder associated with severe episodes of lancinating pain in the distribution of the trigeminal nerve. Previous reports indicate that 80-90% of cases are related to compression of the trigeminal nerve by an adjacent vessel. The majority of patients with trigeminal neuralgia eventually require surgical management in order to achieve remission of symptoms. Surgical options for management include ablative procedures (e.g., radiosurgery, percutaneous radiofrequency lesioning, balloon compression, glycerol rhizolysis, etc.) and microvascular decompression. Ablative procedures fail to address the root cause of the disorder and are less effective at preventing recurrence of symptoms over the long term than microvascular decompression. However, microvascular decompression is inherently more invasive than ablative procedures and is associated with increased surgical risks. Previous studies have demonstrated a correlation between surgeon experience and patient outcome in microvascular decompression. In this series of 59 patients operated on by two neurosurgeons (JSN and PEK) since 2006, 93% of patients demonstrated substantial improvement in their trigeminal neuralgia following the procedure&#x2014;with follow-up ranging from 6 weeks to 2 years. Moreover, 41 of 66 patients (approximately 64%) have been entirely pain-free following the operation.
In this publication, video format is utilized to review the microsurgical pathology of this disorder. Steps of the operative procedure are reviewed and salient principles and technical nuances useful in minimizing complications and maximizing efficacy are discussed.

There are many available options for management of the patient with trigeminal neuralgia. Microvascular decompression, while the most invasive of all options, is also the most effective at achieving long term remission of symptoms. Video instruction on how to maximize efficacy and minimize complications with this procedure is described.

Trigeminal neuralgia is a disorder associated with severe episodes of lancinating pain in the distribution of the trigeminal nerve. Previous reports ...

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 ...

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.

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 ...

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, ...

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 ...

Fully Endoscopic Mitral Valve Repair with Percutaneous Cannulation of Groin Vessels

Endoscopic mitral valve surgery (EMS) has become a standard of care at specialized heart centers, further reducing surgical trauma compared to a traditional minimally invasive, thoracotomy-based approach. Exposure of the groin vessels for the establishment of cardiopulmonary bypass (CPB) via surgical cutdown in minimally invasive surgery (MIS) may result in wound healing disorders or seroma formation. The avoidance of surgical exposure of the groin vessels by using fully percutaneous techniques for the insertion of a CPB cannula with the implementation of vascular pre-closure devices has the potential to reduce these complications and improve clinical results. Herein, we present the utilization of a novel plug based vacsular closure device with a resobable collagen plug and the absence of suture material for closure of the arterial access for CPB in MIS. While this device was initially predominantly used in transcatheter aortic valve implantation (TAVI) procedures, with its safety and feasibility shown, we herein show that it can be used in CPB cannulation, since it is capable of closing arterial access sites up to 25 French (Fr.) in size. This device may be suitable to significantly reduce groin complications in MIS and simplify the establishment of CPB. Here, we describe the fundamental steps of EMS, including percutaneous groin cannulation and decannulation using a vascular closure device.

This protocol demonstrates in detail how to perform fully endoscopic mitral valve surgery (EMS) with percutaneous cannulation of the groin vessels, using a percutaneous plug-based vascular closure device. Fundamental steps and useful instructions are described in detail for each step.

Endoscopic mitral valve surgery (EMS) has become a standard of care at specialized heart centers, further reducing surgical trauma compared to a ...

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 ...

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 ...