This study was supported by health science and technology projects in Yunnan Province (NO.2018NS0256) and training objects of medical subject leaders in Yunnan Province (NO. D-2018039)

We performed retrospective analysis of the clinical data of male patients, initially diagnosed with epididymal cysts, admitted to the urology inpatient department of the Affiliated Hospital of Kunming University of Technology (the First People&#39;s Hospital of Yunnan Province). Written, informed consent must be obtained from patients before surgery.
1. Clinical inclusion and exclusion criteria
<ol>
	<li>Include patients who are below 45 years of age and have a need to preserve fertility. 
	&#8203;NOTE: The patient in this study was younger than 45 years old.</li>
	<li>Include patients with a clinician&#39;s preliminary diagnosis of epididymal cystic occupancy following examination with type-B ultrasound or computer tomography (CT) imaging.</li>
	<li>Exclude any patients with severe cardiopulmonary dysfunction, obvious sexual dysfunction, or anaspermia. Exclude patients with a testicular mass, epididymal tuberculosis, and patients who have difficulty to determine the relationship between the testis and the neoplasm.</li>
</ol>
2. Patient preparation
<ol>
	<li>After performing the relevant examination and active preoperative preparation, fully explain the relevant conditions, surgical plans, and related risks.</li>
	<li>Discuss with the patient and his family members the patient&#39;s condition, surgical plan, selection, and possible risks and complications. Obtain consent from the patient and his family members for testicular and epididymal exploration and microscopic cyst resection.</li>
	<li>Instruments for operation
	<ol>
		<li>Make sure that a surgical microscope and microsurgical instruments are available.</li>
	</ol>
	</li>
	<li>Preparation for operation
	<ol>
		<li>Clean and shave the inguinal/subinguinal skin and scrotum before surgery.</li>
		<li>The surgical site need not be sterilized before surgery. As a routine procedure, clean the scrotum with soap and shave the surgical area using a razor.</li>
		<li>Place the patient on the operating table in a supine position after general anesthesia. 
		&#8203;NOTE: Anesthesia is provided by the anesthetist. The anesthetist chooses the anesthetic agent and the dosage to be used.</li>
	</ol>
	</li>
</ol>
3. Procedure
<ol>
	<li>Expose and explore the testis and epididymis in the incision.
	<ol>
		<li>Perform a 2.5-3 cm scrotal skin incision with a surgical knife. Cut the scrotal flesh membrane and testicular sheath membrane layer by layer with an electric knife.</li>
		<li>Carefully explore the testis and epididymis to find and confirm the epididymal cyst. Change/stop the surgical plan if solid epididymal tumors or masses derived from the testis are found.</li>
		<li>Lift the epididymis out of the incision. Find the epididymal cyst.</li>
	</ol>
	</li>
	<li>Microscopic cyst resection
	<ol>
		<li>Bring an operating microscope into the operating field and examine the cord under a 6x-10x power magnification.</li>
		<li>Use an electric knife to cut the epididymal capsule at the base of the epididymal cyst and normal epididymal tissue. Open up the epididymal capsule carefully and avoid opening the epididymal cyst cavity (see Figure 1).</li>
		<li>Carefully explore the space between the epididymal cyst wall and the epididymal tissue (epididymal tubule). Based on this anatomical level, gradually microseparate the epididymal cyst along the cyst wall with microscissors and microscopic forceps. Carefully isolate the epididymal tissue (epididymal tubule) surrounding the epididymal cyst to the base of the epididymal cyst (see Figure 2).</li>
		<li>Microseparate the epididymal cyst from its base and the gap between the cyst and normal epididymal tissue. Excise the epididymal cyst from the base with microscissors or an electric knife after occlusion of the epididymal tissue with a microvascular clamp or ligation by a microsuture (7-0 or 6-0) (see Figure 3).</li>
		<li>Carefully dissect the separation and avoid epididymal cyst wall breakage, especially on blood epididymal cysts (see Figure 4) or large epididymal cysts with clear cystic fluid inside (see Figure 5). If the cyst wall is damaged, carefully clamp the breach with microvascular forceps to avoid fluid overflow in the cyst. Remove the epididymal cyst completely and preserve the noninvasive epididymal tubular patency as much as possible.</li>
	</ol>
	</li>
</ol>
4. Finish the operation
<ol>
	<li>Carefully perform micro hemostasis. Stitch the incisions on the epididymal capsule and periorchium in layers. Then suture the scrotal wound.</li>
	<li>Send the mass (cyst) to the pathology department for pathological examination.</li>
	<li>Leave the patients in bed for 1 day after surgery and discharge them 1-3 days after the surgery.</li>
</ol>
5. Postoperative follow-up
NOTE: The postoperative follow-up lasts for 3-50 months. Conduct the below tests/examinations in the follow-up.
<ol>
	<li>Check the patient for scrotal swelling, pain, and other clinical symptoms after surgery.</li>
	<li>Perform a detailed physical examination, Including checking the scrotal wound, testis, and epididymis.</li>
	<li>Perform type-B ultrasound examination on the testis and epididymis.</li>
</ol>

<ol>
	<li>Jelloul, L., Billerey, C., Ait Ali Slimane, M., Mboyo, A., Aubert, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Epididymal+cysts+in+adolescents.">Epididymal cysts in adolescents.</a> Annales d'Urologie. 33 (2), 104-108 (1999).</li><li>Boscarelli, A., Bellini, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Epididymal+cyst+in+children.">Epididymal cyst in children.</a> European Journal of Pediatrics. 180 (9), 2723-2729 (2021).</li><li>Yong-Bao, W., 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=The+efficacy+and+safety+of+scrotoscope+in+the+treatment+of+masses+in+caput+epididymidis.">The efficacy and safety of scrotoscope in the treatment of masses in caput epididymidis.</a> Journal of Trauma and Emergency Surgery. 6 (4), 208-211 (2018).</li><li>Erikci, V., 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=Management+of+epididymal+cysts+in+childhood.">Management of epididymal cysts in childhood.</a> Journal of Pediatric Surgery. 48 (10), 2153-2156 (2013).</li><li>Zhen-Chao, L., Xing-You, Q., Rong-De, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnosis+value+of+high+frequency+color+doppler+ultrasound+for+epididymis+cyst.">Diagnosis value of high frequency color doppler ultrasound for epididymis cyst.</a> China Modern Medicine. 20 (3), 102-103 (2013).</li><li>Sinha, V., Shankar, M., Sardana, N., Aggarwal, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+rare+case+of+epididymal+cyst+due+to+schistosomiasis.">A rare case of epididymal cyst due to schistosomiasis.</a> Cureus. 11 (9), e5755 (2019).</li><li>Mukendi, A. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bilateral+spontaneous+resolution.">Bilateral spontaneous resolution.</a> Clinical Case Reports. 8 (12), 2689-2691 (2020).</li><li>Patoulias, D., Kalogirou, M., Patoulias, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intraparenchymal+4+cm+in+diameter+in+a+15-year+old+male+patient;+a+case+report+and+review+of+the+literature.">Intraparenchymal 4 cm in diameter in a 15-year old male patient; a case report and review of the literature.</a> Acta Medica. 59 (4), 137-139 (2016).</li><li>Sun-Biao, L., Meng, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+analysis+of+43+epididymal+mass+patients.">Clinical analysis of 43 epididymal mass patients.</a> Fujian Medical Journal. 31 (3), 32-33 (2009).</li><li>Wang, J., 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=Treatment+for+childhood+herniorrhaphy.">Treatment for childhood herniorrhaphy.</a> Urology. 112, 80-84 (2018).</li><li>Ory, J., 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=Predictors+of+success+after+bilateral+during+vasectomy+reversal:+A+multi-institutional+analysis.">Predictors of success after bilateral during vasectomy reversal: A multi-institutional analysis.</a> Canadian Urological Association Journal. 16 (3), E132-E136 (2022).</li></ol>

The authors have nothing to disclose.

As we mentioned previously, epididymal cysts mostly occur in men aged 20 to 40 years, while there is also some literature on epididymal cysts in childhood1,2. To date, the cause of epididymal cysts is not clear, and there is no specific medicine for its treatment. In addition to a few reports that epididymal cysts can resolve spontaneously without surgery7, most epididymal cysts, although their progression and enlargement are relatively slow, are unable to be absorbed and eliminated by themselves. Although a benign lesion, a large epididymal cyst can cause damage to the proximal vas deferens, obstruction, and even secondary azoospermia. Due to the small diameter of the epididymal tube (about 0.5 mm), without the amplification effect of the surgical microscope, it is difficult to avoid traditional epididymal cyst resection, the destruction of the epididymal tube around the cyst, or obvious scar hyperplasia after surgery. As a result, patients who have undergone traditional (nonmicroscopic) epididymal cyst resection surgery or epididymectomy are prone to postoperative complications, including seminal tract obstruction, immune infertility, postoperative scrotal hematoma, persistent pain, and even testicular atrophy3,4,5. Therefore, some scholars believe that caution should be taken in the resection of epididymal cysts for young patients with fertility needs2,9.
We took the lead in carrying out microscopic epididymal exploration and cyst resection surgery in China. According to the follow-up data derived from the 41 patients included in this study, the visualization of the subtle tissue structure of the epididymis was greatly improved by microscopic manipulation, and the cysts could be clearly separated and completely removed. The high precision of microsurgical techniques and low damage to the surrounding tissue have achieved good results in the treatment of vas deferens and epididymal obstruction10,11. In addition, our experience suggested that microscopic epididymal exploration and cystectomy can effectively preserve epididymal patency with fine treatment, while achieving a better preservation of sperm delivery pipelines and unobstructed prognosis. At the same time, according to the follow-up data of this study, microscopic treatment significantly reduced the incidence of postoperative scrotal hematoma, edema, and long-term postoperative pain; thus, it also promises higher surgical success rates and the prevention of recurrence due to scar obstruction.
We have also noted the following limitations of this technique. Firstly, the operating surgeon needs to master microsurgical skills. Secondly, if the cyst wall of the epididymal cyst is destroyed during the operation, it will result in difficulty in the precise and complete removal of the cyst, which will increase the destruction of the surrounding epididymal tissue. Therefore, one should immediately close the rupture with a microvascular clamp and a microsuture (7-0 or 8-0 ) if finding that the cyst wall is damaged.
Based on our preliminary experience, we recommend that surgery be carried out before the epididymal cyst develops to 0.8 cm in diameter, for fear that a larger epididymal cyst (&#62;0.9 cm in diameter) could cause complete destruction of all tubules of the ipsilateral epididymis - a more severe case with damage to the testicular output network.
Finally, we hope that microscopic epididymis exploration and resection of microscopic epididymis cysts can be recognized and improved by more surgeons to treat patients diagnosed with epididymal cysts.

Epididymal cysts mostly occur in men aged 20-40 years old, although some literature also exists concerning epididymal cysts in childhood1,2. Previous reports have covered concerns about surgical destruction and postoperative scarring in patients undertaking nonmicroscopic epididymal cyst resection or epididymal resection3,4. Other postoperative complexes include seminal tract obstruction, immune infertility, and testicular atrophy. There is also a higher risk for postoperative occurrence, and even recurrence, of hematoma, edema, and a sustaining pain and cyst5,6. There are also reports that epididymal cysts can resolve spontaneously without surgery7. As a result, previous studies have concluded that epididymal cysts do not lead to testicular network expansion without intervention, and puncture or surgical treatment can be considered if epididymal cysts combine with testicular network expansion or damage of the proximal vas deferens2,4. Further, some investigators believe that patients with large epididymal cysts combined with pain are also suitable for surgical resection8. The treatment of epididymal cysts by puncture alone is prone to relapse. Traditional (nonmicroscopic) cyst resection or epididymectomy may destroy the epididymal canal, leading to epididymal obstruction, immune infertility, or even testicular atrophy; therefore, one should be cautious for young patients with fertility requirements2,9. Patients with childbirth plans are recommended to choose traditional (nonmicroscopic) epididymal cyst surgery as a cautionary measure. 
Microsurgical methods have been widely used in the treatment of vas deferens obstruction and epididymal obstruction, with excellent results10,11. The treatment of male epididymal cysts via microtechnology may be a beneficial option, however the necessity of extending microtechnology treatment to male epididymal cysts is questionable. We took the lead in carrying out microscopic epididymal exploration and cyst resection surgery in China. We carried out retrospective analysis of the clinical data of male patients, initially diagnosed with epididymal cysts, admitted to the urology inpatient department of the Affiliated Hospital of Kunming University of Technology (the First People's Hospital of Yunnan Province) between September 2017 and April 2019. The patients were younger than 45 years old and required fertility preservation. Based on microscopic manipulation, which largely improved visualization of the subtle tissue structures of the epididymis, the cyst could be clearly dissected apart and completely removed intact.

<table><tbody><tr><td>Ablation electrode</td><td>Baisheng Medical Devices Co., Ltd. China</td><td>OBS-Db</td><td></td></tr><tr><td>Anesthesia apparatus</td><td>Datex-Ohmeda,Inc.USA</td><td>Aespire View, Datex-Ohmeda</td><td></td></tr><tr><td>Compact Anesthesia Monitor</td><td>GE Healthcare Finland OY.Finland</td><td>S/5 Compact</td><td></td></tr><tr><td>&amp;nbsp;Electric knife</td><td>Valleylab.USA</td><td>Valleylab Force FX-8C</td><td></td></tr><tr><td>Surgical (operation) microscope</td><td>Lecia Microsysterms (Schweiz) AG. Germany</td><td>Lecia M525 F20</td><td></td></tr></tbody></table>

microscopic cyst resection for the treatment of patients diagnosed with epididymal cyst

Epididymal cysts mostly occur in men aged 20-40 years old. Previous reports have covered concerns about postoperative complexes, including postoperative asoedema, hematoma, sustaining pain, and seminal tract obstruction in patients who have undertaken nonmicroscopic epididymal cyst resection or epididymal resection. Nonmicroscopic epididymal cyst surgery is suggested for patients with childbirth plans as a precaution. The treatment of male epididymal cysts via microtechnology is obviously a beneficial option; we took the lead in carrying out microscopic epididymal exploration and cyst resection surgery in China. From September 2017 to April 2021, 41 young and middle-aged male patients diagnosed with epididymal cysts underwent microtechnology treatment in a program titled &#34;microscopic epididymal exploration and cystectomy&#34;. The postoperative follow-up lasted for 3-50 months. The results confirmed that, as microscopic manipulation largely improved visualization of the subtle tissue structures of the epididymis, the cyst could be clearly dissected apart and completely removed intact under the microscope. Bleeding during the operation was significantly reduced (2-3 mL) and wound drainage was not required. According to follow-up data, microscopic treatment significantly reduced the incidence of postoperative scrotal hematoma, edema, and long-term postoperative pain, thereby promising a higher surgical success rate as well as recurrence prevention. Besides, preliminary experience and reflection suggest that microscopic epididymal exploration and cystectomy provide efficient preservation of the epididymal patency through refined treatment, while a better prognosis can be achieved. We recommend that surgery be carried out before the epididymal cyst develops to 0.8 cm in diameter, for fear that a larger epididymal cyst (&#62;0.9 cm in diameter) could cause the complete destruction of all tubules of the ipsilateral epididymis - a more severe case with damage to the testicular output network.

From September 2017 to April 2021, 41 young and middle-aged male patients diagnosed with epididymal cysts underwent microtechnology treatment in a program titled "microscopic epididymal exploration and cystectomy."
Here, we show the data from a single patient as a representative example. The patient was operated on for descending surgery (testicular and epididymal exploration and microscopic cyst removal) under general anesthesia. A scrotal incision was made, the testicular sheath was cut, the scrotum was explored, and the epididymis on the surgical side was isolated under a microscope. The epididymal mass (cyst) was sought, and the epididymal capsule was cut microscopically and carefully microseparated along the boundary of the normal epididymal tubular tissue. The base part of the epididymal mass (cyst) and the mass were completely removed. The noninvasive epididymal tubular patency was preserved as much as possible. After achieving micro hemostasis carefully, the incisions on the epididymal capsule and periorchium were stitched in layers. Then the scrotal wound was routinely sutured. The mass (cyst) was sent for disease examination. The patients were left in bed for 1 day after surgery and were discharged 1 to 3 days after surgery.
The following data are all derived from the 41 patients included in this study. The procedure time was 30-50 min (38.9 ± 8.5 min). All epididymal cysts were completely removed. Bleeding during the operation was significantly reduced (2-3 mL); wound drainage was no longer required. The postoperative follow-up lasted for 3-50 months. It must be noted that the operation time is longer than the traditional operation because of the use of the surgical microscope and fine microscopic operation.This may present as a limitation to the widespread use of the technique. No patient had a recurrence of the epididymal cyst by type-B ultrasound, and no patient developed postoperative scrotal hematoma. Only one patient had scrotal surgical site pain. The results confirmed that, as microscopic manipulation largely improved visualization of the subtle tissue structures of the epididymis, the cyst could be clearly dissected apart and completely removed intact under the microscope. According to follow-up data, microscopic treatment significantly reduced the incidence of postoperative scrotal hematoma, edema, and long-term postoperative pain, thereby promising a higher surgical success rate as well as recurrence prevention3 (see Table 1 and Table 2).
<img alt="Surgical dissection of tissue using forceps; anatomical study technique in veterinary research." class="xfigimg" src="/files/ftp_upload/64083/64083fig01.jpg" data-altupdatedat="1747911167000" data-alt="Figure 1"> 
Figure 1: Opening the epididymal capsule. The epididymal capsule is opened, avoiding opening the epididymal cyst cavity <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/64083/64083fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Surgical procedure with retractors on tissue, demonstrating incision technique in medical context." class="xfigimg" src="/files/ftp_upload/64083/64083fig02.jpg" data-altupdatedat="1747911167000" data-alt="Figure 2"> 
Figure 2: Epididymal cyst isolation. The tissue surrounding the epididymal cyst was isolated carefully. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/64083/64083fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Surgical dissection process in experimental medical study, close-up microscope image with tools." class="xfigimg" src="/files/ftp_upload/64083/64083fig03.jpg" data-altupdatedat="1747911167000" data-alt="Figure 3"> 
Figure 3: Epididymal cyst excision. The epididymal cyst was excised from the base. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/64083/64083fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Biological tissue close-up, showing vascular structures; microscopy image, anatomy focus." class="xfigimg" src="/files/ftp_upload/64083/64083fig04.jpg" data-altupdatedat="1747911167000" data-alt="Figure 4"> 
Figure 4: Blood epididymal cyst. Separation of the blood epididymal cyst without cyst wall breakage. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/64083/64083fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Surgical procedure dissection; medical training, anatomical study, precision tools used." class="xfigimg" src="/files/ftp_upload/64083/64083fig05.jpg" data-altupdatedat="1747911167000" data-alt="Figure 5"> 
Figure 5: Large epididymal cyst. A large epididymal cyst with clear cystic fluid inside was carefully separated without cyst wall breakage. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/64083/64083fig05large.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>Clinical data</td>
			<td>Median</td>
			<td>Least value</td>
			<td>Maximum value</td>
		</tr>
		<tr>
			<td>Enrolled No.</td>
			<td>41</td>
			<td>/</td>
			<td>/</td>
			<td>/</td>
		</tr>
		<tr>
			<td>Age (years) </td>
			<td>24.89 ± 4.46</td>
			<td>25</td>
			<td>18</td>
			<td>40</td>
		</tr>
		<tr>
			<td>Operation time (min)</td>
			<td>38.95 ± 8.51</td>
			<td>40</td>
			<td>30</td>
			<td>50</td>
		</tr>
		<tr>
			<td>Bleeding during operation (mL)</td>
			<td>2.50 ± 0.46</td>
			<td>2.5</td>
			<td>2</td>
			<td>3</td>
		</tr>
		<tr>
			<td>Follow-up time (months)</td>
			<td>22.73 ± 14.56</td>
			<td>18</td>
			<td>3</td>
			<td>50</td>
		</tr>
		<tr>
			<td>Recurrence of epididymal cysts</td>
			<td>0</td>
			<td>/</td>
			<td>/</td>
			<td>/</td>
		</tr>
		<tr>
			<td>Scrotal hematoma</td>
			<td>0</td>
			<td>/</td>
			<td>/</td>
			<td>/</td>
		</tr>
		<tr>
			<td> Scrotal edema</td>
			<td>0</td>
			<td>/</td>
			<td>/</td>
			<td>/</td>
		</tr>
		<tr>
			<td>Short-term Scrotal surgical site pain</td>
			<td>1(2.44%)</td>
			<td>/</td>
			<td>/</td>
			<td>/</td>
		</tr>
		<tr>
			<td>Long-term postoperative pain</td>
			<td>0</td>
			<td>/</td>
			<td>/</td>
			<td>/</td>
		</tr>
	</tbody>
</table>
Table 1: Clinical data of epididymal cyst patients.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Surgical method</td>
			<td>Microtechnology Treatment of Male Epididymal Cysts</td>
			<td>Non-microscopic surgery(by  scrotal mirror) </td>
		</tr>
		<tr>
			<td>Enrolled No.</td>
			<td>41</td>
			<td>57</td>
		</tr>
		<tr>
			<td>Recurrence of epididymal cysts</td>
			<td>0</td>
			<td>2(3.4%)</td>
		</tr>
		<tr>
			<td>Scrotal hematoma</td>
			<td>0</td>
			<td>2(3.4%)</td>
		</tr>
		<tr>
			<td> Scrotal edema</td>
			<td>0</td>
			<td>7(12.3%)</td>
		</tr>
		<tr>
			<td>Short-term Scrotal surgical site pain</td>
			<td>1(2.44%)</td>
			<td>10(17.54)</td>
		</tr>
		<tr>
			<td>Long-term postoperative pain</td>
			<td>0</td>
			<td>2(3.4%)</td>
		</tr>
	</tbody>
</table>
Table 2: Table of surgical complications.

Watch this Scientific Journal Video about Microscopic Cyst Resection for the Treatment of Patients Diagnosed with Epididymal Cyst at JoVE.com

Microscopic Cyst Resection for the Treatment of Patients Diagnosed with Epididymal Cyst

Here, we present a protocol to treat patients diagnosed with an epididymal cyst using microscopic cyst resection. Based on microscopic manipulation, a largely improved visualization of the subtle tissue structures of the epididymis was obtained, so the cyst could be clearly dissected apart and completely removed intact.

Epididymal cysts mostly occur in men aged 20-40 years old. Previous reports have covered concerns about postoperative complexes, including postoperative ...

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7.7K Views.  The First People’s Hospital of Yunnan Province (Medical College of Kunming University of Science and Technology). Here, we present a protocol to treat patients diagnosed with an epididymal cyst using microscopic cyst resection. Based on microscopic manipulation, a largely improved visualization of the subtle tissue structures of the epididymis was obtained, so the cyst could be clearly dissected apart and completely removed intact.

Video: Microscopic Cyst Resection for the Treatment of Patients Diagnosed with Epididymal Cyst

Endoscopy Guided Photoablation of Endometrial Cysts using a 980 nm Laser with a Contact Fiber in Mares

In mares, endometrial cysts are associated with endometriosis and can cause maternal recognition failure or compromise and delay pregnancy diagnoses. Historical treatments were invasive and had adverse effects on the endometrium. Hysteroscopically guided laser therapy is easy and effective for endometrial cysts resection, with no deleterious effects for the endometrium.
A 110 cm long and 1.0 cm wide endoscope is sterilely introduced in the uterus through the open cervix of an estrous mare after vulvar cleaning. The uterus is slowly infused with less than 1 L of physiologic solution and the laser fiber is inserted in the biopsy canal of the endoscope. Cysts are then cauterized with the 980 nm diode laser with a contact fiber set at 20&#8210;2 5W in continuous mode. Each cyst is punctured&#160;until complete voiding of the cyst and shrinking of the cyst wall around the fiber. Uterine lavages with sterile saline solution are performed directly after the surgery and for one or two days as non-inflammatory fluid can be observed.
This procedure is easy and quickly performed, with no obvious deleterious effects. Cysts resection makes ultrasound pregnancy diagnosis easier and, in some cases, could restore proper embryo migration in the uterine horns between day 6.5 and 17. However, this treatment does not improve the underlying histological lesions related to endometriosis. These considerations should be clearly expressed to the breeder before this procedure.

The aim of this report is to describe the photoablation of endometrial cysts in the mare using an endoscopic laser device, and to discuss the interest and limitations of this new approach to deal with low fertility issues.

In mares, endometrial cysts are associated with endometriosis and can cause maternal recognition failure or compromise and delay pregnancy diagnoses. ...

Surgical Techniques to Optimize Ovarian Reserve during Laparoscopic Cystectomy for Ovarian Endometrioma

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts to spare normal ovarian cortex. Optimization of tubal anatomy is another frequent consideration. Fertility-sparing laparoscopic techniques at the time of cystectomy for ovarian endometrioma seek to limit iatrogenic surgical damage to the ovarian cortex and strategically assess and respond to genital tract patency. Surgical candidates frequently desire relief from endometriosis-associated pain while also seeking to optimize spontaneous or assisted conception rates. Operative benefits include potential for surgical and histopathologic diagnosis of endometriosis, evaluation of genital tract patency, and treatment of visualized lesions. Resection of ovarian endometrioma nonetheless poses significant risks, including surgical injury, blood loss, post-surgical decline in ovarian reserve and post-operative inflammation with adhesion formation, both of which may impair folliculogenesis.
We present the case of a 32-year-old woman with known endometriosis and continued pain refractory to medical management who opted for surgical management of her disease tailored toward optimizing her chances at future conception. Using this case as an example, we describe techniques and considerations for diagnostic laparoscopy, adhesiolysis, ovarian cystectomy, chromopertubation, and salpingectomy with a focus on maintaining a fertility-preserving approach.

This protocol presents techniques to laparoscopically excise ovarian endometrioma, to perform adhesiolysis with sparing electrosurgical application, and to employ intraoperative chromopertubation to assess for genital tract patency. This systematic approach will facilitate optimal endometriosis management, guide concomitant adnexal surgeries, and enhance post-surgical fertility outcomes.

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts ...

Fertility Sparing Procedure using Carbon Dioxide Fiber Laser Vaporization of Ovarian Endometrioma

The surgical management of endometrioma is still a matter of debate. Cystectomy, which is recognized as the standard technique, seems to be associated with a potential reduction in the ovarian reserve due to the inadvertent removal and thermal damage of healthy ovarian tissue. New ablative techniques with reduced tissue penetration depth and less thermal spread to the surrounding parenchyma may represent a viable alternative to cystectomy. For these reasons, the aim of this manuscript is to demonstrate the ablation of the endometrioma capsule using a CO2 fiber laser technique and discuss the clinical outcomes. Once the cyst has been drained and washed, a biopsy is taken. After cyst eversion, vaporization of the inner surface of the cyst is performed using a CO2 fiber laser. The technique is simple and reproducible as even young surgeons without any surgical experience were more confident in performing laser CO2 vaporization instead of cystectomy. The positive effects of CO2 technology are reported in a randomized controlled trial, where the postoperative changes in the antral follicular count (AFC) and antimullerian hormone (AMH) levels were compared between patients who had their endometrioma excised (cystectomy) and those who had undergone endometrioma vaporization with CO2 laser. The patients treated with CO2 laser showed significantly increased AFC without a reduction in serum AMH levels as compared to the cystectomy group, in which both parameters were significantly reduced. The postoperative pregnancy rate was also assessed, and comparable pregnancy rates were found after both treatments. On the contrary, patients treated with the CO2 fiber laser technique had more favorable in-vitro fertilization (IVF) outcomes compared to cystectomy.
In conclusion, the CO2 fiber laser technique may represent a viable alternative to cystectomy in the surgical treatment of endometrioma in terms of ovarian preservation, pregnancy rates, and IVF outcomes. Moreover, it has the advantage of being independent of the surgeon's skills and personal experience.

In this protocol, CO2 fiber laser technique is demonstrated for the surgical treatment of ovarian endometriosis, which represents a viable alternative in terms of fertility preservation with the major advantage of not being dependent on the surgeon's skills and personal experience.

The surgical management of endometrioma is still a matter of debate. Cystectomy, which is recognized as the standard technique, seems to be associated ...

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 ...

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.

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, ...

Arthroscopic Double Posteromedial Approach for PCL Cyst Excision

Arthroscopic Excision of Posterior Cruciate Ligament Cysts Using a Double Posteromedial Approach

Cruciate ligament cysts of the knee are a rare condition. Posterior cruciate ligament cysts of the knee are less common than anterior cruciate ligament cysts. In patients with asymptomatic isolated cruciate ligament cysts of the knee, conservative treatment is recommended. Symptomatic cruciate ligament cysts of the knee are mostly manifested as knee hyperflexion pain, straightening pain, knee discomfort after standing for a long time or walking for a long time, etc., which seriously affects the quality of life, surgical treatment can be performed. The surgical treatments can be divided into ultrasound-guided cyst puncture and fluid extraction procedure and arthroscopic cystectomy. Cysts are mostly lobulated with a multi-layer cyst wall, cyst fluid extraction does not remove the cyst wall completely but simply extracts cyst fluid, leading to a high recurrence rate. Arthroscopic surgery can completely remove the cyst wall with little trauma, a low recurrence rate, and fast postoperative recovery, so arthroscopic resection is the most common and preferred method of treatment. Since posterior cruciate ligament cysts mostly occur posterior to the ligament, we remove the cyst wall by adding a double posteromedial approach to the knee joint, and the cyst wall is removed under direct vision, which is simple to operate, the cyst wall is completely cleared, the trauma is small, the postoperative recovery is fast, and there is no recurrence. Here, 8 posterior cruciate ligament cysts were removed with complete postoperative symptom relief, no surgical complications, and no recurrence at 1-year follow-up.

Author Spotlight: Double Posteromedial Approach for Treating Posterior Cruciate Ligament Cysts

We present a surgical approach to treat posterior cruciate ligament cysts by an arthroscopic double posteromedial approach.

Cruciate ligament cysts of the knee are a rare condition. Posterior cruciate ligament cysts of the knee are less common than anterior cruciate ligament ...

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 ...

Microsurgical Varicocele Removal Under Local Anesthesia

Microscopic Varicocelectomy under Local Anesthesia as the Treatment of Varicocele

Varicocele, characterized by the dilation of veins within the spermatic cord, is a prevalent disease in males, accounting for 35%-40% of infertility cases among men of reproductive age. This condition may disrupt normal neuroregulation, blood supply, and temperature regulation in the testicles, thereby impacting sperm count, quality (morphology, fragmentation rate), and functionality (motility). It may even induce symptoms such as pain and testicular atrophy. The international standard treatment method is microscopic varicocelectomy, typically performed under general anesthesia. This requires patients to fast before surgery and necessitates recovery and fasting care postoperatively. The arterial blood pressure drop caused by anesthesia may obscure the fluctuation of the spermatic artery, making the precise intraoperative isolation and protection of the spermatic artery more challenging. Therefore, this study proposes and implements microscopic varicocelectomy under local anesthesia. This method facilitates rapid and precise identification of the fluctuating spermatic artery, reducing the risk of spermatic artery damage. It also provides more humane care for patients, reduces economic burden, and offers a new perspective on the treatment of varicocele.

Author Spotlight: Advancing Varicocele Treatment Through Enhanced Surgical Techniques

Varicocele accounts for 35%-40% of infertility cases among men of reproductive age. The international standard treatment method is microscopic varicocelectomy, typically performed under general anesthesia. This study proposes and implements microscopic varicocelectomy under local anesthesia, which provides more humane care for patients and reduces the economic burden.

Varicocele, characterized by the dilation of veins within the spermatic cord, is a prevalent disease in males, accounting for 35%-40% of infertility cases ...

Laparoscopic Choledochal Cyst Excision and Roux-en-Y Choledochojejunostomy in Adults

Choledochal cysts (CCs), known as congenital choledochal dilatations, are more prevalent in Asia. The majority of patients with abdominal symptoms are diagnosed and treated during early childhood, which results in a lower prevalence of CCs in adults. The treatment of choice for CCs is complete cyst excision followed by choledochojejunostomy. Laparoscopic surgery is now more widely accepted than traditional open surgery due to its smaller incisions, faster recovery, and less postoperative pain. However, there are few reports on laparoscopic excision of CCs in adults. This article presents a protocol that describes and demonstrates the complete procedure for laparoscopic excision of a choledochal cyst and Roux-en-Y choledochojejunostomy. A 32-year-old woman diagnosed with a 2.5 cm by 3 cm CC underwent surgery using a laparoscopic approach with post-colonic anastomosis. The procedure lasted 290 min with an estimated blood loss of approximately 100 mL. A follow-up abdominal CT scan on the sixth postoperative day showed a satisfactory recovery, leading to her discharge on the ninth day. This study aims to demonstrate the feasibility and safety of laparoscopically assisted excision of CCs in adults. This procedure is expected to become the preferred surgical option for CCs in adults due to its minimal surgical trauma and rapid postoperative recovery.

Choledochal cysts in adults are relatively rare, and few reports have detailed treatment options. Here, we present a case demonstrating laparoscopic resection of choledochal cysts and posterior colonic Roux-en-Y choledochojejunostomy in adults, offering an alternative for clinical management.

Choledochal cysts (CCs), known as congenital choledochal dilatations, are more prevalent in Asia. The majority of patients with abdominal symptoms are ...

Laparoscopic Common Bile Duct Exploration Followed by Primary Suture Using a Modified Bile Duct Incision

Cholecystolithiasis is a common clinical disease, and 10-15% of patients with cholecystolithiasis have common bile duct (CBD) stones. Laparoscopic CBD exploration (LCBDE) followed by primary closure has proven to be safe and cost-effective for treating CBD stones and is typically performed via transcystic and transductal approaches. However, traditional LCBDE with choledochotomy may lead to biliary stricture and leakage, and performing choledochoscopy in transcystic LCBDE may be challenging because of the narrow cystic duct. To reduce the incidence rate of biliary stricture and leakage and increase the success rate of choledochoscopy, we propose a modified technique for bile duct incision. We performed LCBDE via a micro longitudinal incision extended along the cystobiliary junction toward the CBD instead of the traditional anterior wall of the CBD or purely transverse transcystic incision. Our micro incision size on CBD only ranged from 5 to 10 mm according to the size of the CBD stones. Using this micro incision technique, which is less invasive, resulted in easier exploration of the CBD and preservation of the ductal wall integrity. This approach encourages surgeons to use primary closure and may be considered a viable alternative choice for patients with ductal stones in the future.

Cholecystolithiasis with common bile duct stones is a common disease; however, traditional common bile duct exploration has its own limitations. We propose a modified micro incision for laparoscopic common bile duct exploration aimed at reducing complication rates.

Cholecystolithiasis is a common clinical disease, and 10-15% of patients with cholecystolithiasis have common bile duct (CBD) stones. Laparoscopic CBD ...