The evolution and refinement of vasoepididymostomy techniques

Abstract

Obstructive azoospermia secondary to epididymal obstruction can be corrected by microsurgical reconstruction with vasoepididymostomy (VE). Although alternative management such as epididymal or testicular sperm aspiration in conjunction with intracytoplasmic sperm injection is feasible, various studies have established the superior cost-effectiveness of VE as a treatment of choice. Microsurgical VE is considered one of the most technically challenging microsurgeries. Its success rate is highly dependent on the skills and experience of the surgeons. Various techniques have been described in the literature for VE. We have pioneered a technique known as longitudinal intussusception VE (LIVE) in which the epididymal tubule is opened longitudinally to obtain a larger opening to allow its tubular content to pass through the anastomosis. Our preliminary data demonstrated a patency rate of over 90%. This technique has been widely referenced in the recent literature including robotic-assisted microsurgery. The history of the development of different VE approaches, the preoperative evaluation along with the techniques of various VE will be described in this article.

Figure 1

Triangulation intussusception end-to-side vasoepididymostomy (VE). Three double-armed microsutures are placed in a triangulation fashion on the epididymal tubule which is opened in the center of the triangle formed. The ends of the sutures are placed on the vasal end to complete the anastomosis.

Figure 2

Two-needle intussusception vasoepididymostomy (VE). This technique allows the use of two double-armed sutures to provide a four-point fixation on the vasal end for the anastomosis.

Figure 3

A high scrotal incision (solid lines) for vasoepididymostomy (VE) allows option to extend the incision (dotted lines) towards the external inguinal ring (marked by ‘X') for mobilization of the abdominal vas to bridge a larger gap for the anastomosis.

Figure 4

Longitudinal intussusception vasoepididymostomy (LIVE): (a) the vas is secured on the edge of the tunica epididymis with two to three 9-0 sutures with its lumen opposing the mid-portion of the isolated epididymal tubule; (b) placement of the two double-armed 10-0 mucosal sutures in a longitudinal fashion on the tubule which is opening with a longitudinal incision between the needles; (c,d) the sutures are pulled through and placed in an inside-out fashion on the vasal ends; (e,f) a 9-0 tension reducing suture is placed to position the vasal lumen in direct opposition with the epididymal lumen prior to tying the mucosal sutures. Both mucosal sutures can be tied to their own ends complete the anastomosis.

Figure 5

The corpus and caudal epididymis can be dissected off from the testis tunica albugenia and brought superiorly to bridge a massive vasal gap.

Figure 6

Placement of a single-armed microsuture for longitudinal intussusception vasoepididymostomy (LIVE). The arrows indicated the placement of the first bites of the two sutures.

Figure 7

Placement of a long double-armed microsuture for longitudinal intussusception vasoepididymostomy (LIVE). The arrows indicated the placement of the first bites of the two needles.