Abstract：
BACKGROUND: Obstructive azoospermia occurs when there is a blockage in the male reproductive tract, leading to a complete absence of sperm in the ejaculate. It constitutes around 40% of all cases of azoospermia (1, 2). Blockages in the male reproductive tract can arise from either congenital or acquired factors, affecting various segments such as the epididymis, vas deferens, and ejaculatory ducts (3). Examples of congenital causes encompass conditions like congenital bilateral absence of the vas deferens and unexplained epididymal blockages (4). Acquired instances of obstructive azoospermia may result from factors like vasectomy, infections, trauma, or unintentional injuries caused by medical procedures (5). This complex condition affecting male fertility, presents two main treatment options: microsurgical reconstruction and surgical extraction of sperm followed by in vitro fertilization (IVF). Microsurgical reconstruction proves to be the most cost-effective option for treating obstructive azoospermia when compared with assisted reproductive techniques (6, 7). However, success rates of reconstruction defined by patency are as high as 99% for vasovasostomy (VV) but decline to around 65% if vasoepididymostomy (VE) is required (8, 9). Thus, continued refinement in technique is necessary in order to attempt to improve patency for patients undergoing VE. In this video, we show a comprehensive demonstration of microsurgical VE, highlighting the innovative epididymal occlusion stitch. The goal of this innovative surgical technique is to improve outcomes for VE.
METHODS: The patient is a 39-year-old male diagnosed with obstructive azoospermia who presents for surgical reconstruction via VE. His partner is a 37-years-old female with regular menstrual cycles. The comprehensive clinical data encompasses a range of factors, including FSH levels, results from semen analysis, and outcomes from testicular sperm aspiration. This thorough exploration aims to provide a thorough understanding of our innovative surgical technique and its application in addressing complex cases of obstructive azoospermia.
RESULTS: The procedure was started on the right, the vas deferens was identified and transected. The abdominal side of the vas was intubated and a vasogram performed, there was no obstruction. There was no fluid visible from the testicular side of the vas for analysis, thus we proceeded with VE. Upon inspection of the epididymis dilated tubules were identified. After selecting a tubule for VE, two 10-0 nylon sutures were placed, and it was incised. Upon inspection of the fluid motile sperm was identified. After VE, we performed a novel epididymal occlusion stitch technique. This was completed distal to the anastomosis by placing a 7-0 prolene through the tunica of the epididymis from the medial to lateral side. This stitch was then tightened down with the goal to largely occlude the epididymis so that sperm will preferentially travel through the anastomosis. The steps were then repeated on the left. At 3-month follow up, the patient had no change in testicular size as compared with preoperative size (18cc), he had no testicular or incisional discomfort, and on semen analysis he had presence of motile sperm. After 3 months post-surgery, the patient had motile sperm seen on semen analysis.
CONCLUSIONS: The introduction of a novel epididymal occlusion stitch demonstrates a targeted strategy to enhance the success of microscopic VE. Encouragingly, a 3-month post-surgery follow-up reveals the presence of motile sperm, reinforcing the potential efficacy of our approach. This is promising given the historical lower patency, delayed time to patency, and higher delayed failure rates that patients who require VE experience (10). In total, 40% of all azoospermia cases can be attributed to obstruction. The conventional treatments for obstructive azoospermia involve microsurgical reconstruction and surgical sperm retrieval followed by IVF. While microsurgical reconstruction has proven to be economically viable, the quest for enhanced success rates has led to the exploration of innovative techniques. Historically, the evolution of VV and VE procedures, initially performed in the early 20th century, laid the foundation for contemporary microsurgical approaches (11). Notably, the microscopic VV demonstrated significant improvements in patency rates and natural pregnancy likelihood, as evidenced by the seminal Vasovastomy Study Group study in 1991 (8). In contemporary literature, success rates particularly for VE remain unchanged for the past three decades since the original published success rates by the Vasectomy Reversal Study Group (12). VE is associated with a longer time to patency as well with patients taking 2.8 to 6.6 months to have sperm return to ejaculate as compared to 1.7 to 4.3 months for those undergoing VV. Additionally, of those patients who successfully have sperm return to the ejaculate after VE up to 50% will have delayed failure compared to 12% for those undergoing VV who are patent. Finally, of those who experience delayed failure after undergoing VE it usually occurs earlier with studies reporting as early as 6 months post-operatively (10). Given the lack of improvement and significantly worsened outcomes with VE further surgical refinement is a constant goal for surgeons performing this procedure.
CONCLUSIONS: In conclusion, this video is both a demonstration and a call to action for commitment to surgical innovation. We aim to raise the bar in VE success rates, ultimately bringing tangible benefits to patients and contributing to the ongoing evolution of reproductive medicine. The novel epididymal occlusion stitch emerges as a beacon of progress, promising not only enhanced safety but also potential reductions in patency time. Surgical excellence and methodological refinement, as exemplified in this video, lay the foundation for a future where male reproductive surgery continues to break new ground.
METHODS: The patient is a 39-year-old male diagnosed with obstructive azoospermia who presents for surgical reconstruction via VE. His partner is a 37-years-old female with regular menstrual cycles. The comprehensive clinical data encompasses a range of factors, including FSH levels, results from semen analysis, and outcomes from testicular sperm aspiration. This thorough exploration aims to provide a thorough understanding of our innovative surgical technique and its application in addressing complex cases of obstructive azoospermia.
RESULTS: The procedure was started on the right, the vas deferens was identified and transected. The abdominal side of the vas was intubated and a vasogram performed, there was no obstruction. There was no fluid visible from the testicular side of the vas for analysis, thus we proceeded with VE. Upon inspection of the epididymis dilated tubules were identified. After selecting a tubule for VE, two 10-0 nylon sutures were placed, and it was incised. Upon inspection of the fluid motile sperm was identified. After VE, we performed a novel epididymal occlusion stitch technique. This was completed distal to the anastomosis by placing a 7-0 prolene through the tunica of the epididymis from the medial to lateral side. This stitch was then tightened down with the goal to largely occlude the epididymis so that sperm will preferentially travel through the anastomosis. The steps were then repeated on the left. At 3-month follow up, the patient had no change in testicular size as compared with preoperative size (18cc), he had no testicular or incisional discomfort, and on semen analysis he had presence of motile sperm. After 3 months post-surgery, the patient had motile sperm seen on semen analysis.
CONCLUSIONS: The introduction of a novel epididymal occlusion stitch demonstrates a targeted strategy to enhance the success of microscopic VE. Encouragingly, a 3-month post-surgery follow-up reveals the presence of motile sperm, reinforcing the potential efficacy of our approach. This is promising given the historical lower patency, delayed time to patency, and higher delayed failure rates that patients who require VE experience (10). In total, 40% of all azoospermia cases can be attributed to obstruction. The conventional treatments for obstructive azoospermia involve microsurgical reconstruction and surgical sperm retrieval followed by IVF. While microsurgical reconstruction has proven to be economically viable, the quest for enhanced success rates has led to the exploration of innovative techniques. Historically, the evolution of VV and VE procedures, initially performed in the early 20th century, laid the foundation for contemporary microsurgical approaches (11). Notably, the microscopic VV demonstrated significant improvements in patency rates and natural pregnancy likelihood, as evidenced by the seminal Vasovastomy Study Group study in 1991 (8). In contemporary literature, success rates particularly for VE remain unchanged for the past three decades since the original published success rates by the Vasectomy Reversal Study Group (12). VE is associated with a longer time to patency as well with patients taking 2.8 to 6.6 months to have sperm return to ejaculate as compared to 1.7 to 4.3 months for those undergoing VV. Additionally, of those patients who successfully have sperm return to the ejaculate after VE up to 50% will have delayed failure compared to 12% for those undergoing VV who are patent. Finally, of those who experience delayed failure after undergoing VE it usually occurs earlier with studies reporting as early as 6 months post-operatively (10). Given the lack of improvement and significantly worsened outcomes with VE further surgical refinement is a constant goal for surgeons performing this procedure.
CONCLUSIONS: In conclusion, this video is both a demonstration and a call to action for commitment to surgical innovation. We aim to raise the bar in VE success rates, ultimately bringing tangible benefits to patients and contributing to the ongoing evolution of reproductive medicine. The novel epididymal occlusion stitch emerges as a beacon of progress, promising not only enhanced safety but also potential reductions in patency time. Surgical excellence and methodological refinement, as exemplified in this video, lay the foundation for a future where male reproductive surgery continues to break new ground.
摘要：
背景：阻塞性无精子症发生在男性生殖道阻塞时，导致射精中完全没有精子。它约占所有无精子症病例的40％（1，2）。男性生殖道的阻塞可能来自先天性或获得性因素，影响各种节段，如附睾，输精管,和射精管（3）。先天性原因的例子包括先天性双侧输精管缺失和原因不明的附睾阻塞(4)。获得性梗阻性无精子症可能是输精管结扎术等因素造成的，感染,创伤,或医疗程序造成的意外伤害（5）。这种影响男性生育能力的复杂状况，提出了两种主要的治疗选择：显微外科手术重建和手术提取精子，然后进行体外受精（IVF）。与辅助生殖技术相比，显微手术重建被证明是治疗阻塞性无精子症的最具成本效益的选择（6，7）。然而,血管血管造口术(VV)的通畅性定义的重建成功率高达99%,但如果需要血管附睾造口术(VE)则下降到65%左右(8,9).因此，为了尝试改善接受VE的患者的通畅性，有必要继续改进技术。在这个视频中,我们展示了显微外科VE的全面演示，突出创新的附睾咬合缝合。这种创新手术技术的目标是改善VE的结果。
方法：患者是一名39岁男性，诊断为梗阻性无精子症，通过VE进行手术重建。他的伴侣是一名37岁的女性，月经周期规律。全面的临床数据涵盖了一系列因素，包括FSH水平，精液分析的结果，和睾丸精子抽吸的结果。这项彻底的探索旨在全面了解我们的创新外科技术及其在解决阻塞性无精子症复杂病例中的应用。
结果：程序从右侧开始，对输精管进行了鉴定和横切.对血管的腹部侧进行了插管并进行了血管造影，没有障碍物。从血管的睾丸侧没有可见的液体进行分析，因此，我们继续与VE。检查附睾后，确定了扩张的小管。为VE选择细管后，放置了两条10-0尼龙缝线，它被切开了。在检查流体活动精子时,鉴定。VE之后,我们进行了一种新的附睾咬合缝合技术。通过将7-0prolene从内侧到外侧穿过附睾膜来完成吻合远端。然后将此缝线收紧，目的是在很大程度上阻塞附睾，以便精子优先穿过吻合口。然后在左边重复这些步骤。在3个月的随访中，患者的睾丸大小与术前大小（18cc）相比没有变化，他没有睾丸或切口不适，根据精液分析，他有活动精子。术后3个月,在精液分析中，患者有活动精子。
结论：新的附睾咬合针法的引入证明了提高显微VE成功率的针对性策略。令人鼓舞的是，术后3个月的随访显示存在活动精子，加强我们方法的潜在功效。鉴于历史上较低的通畅性，这是有希望的，延迟开放时间，与需要VE经验的患者相比，延迟失败率更高（10）。总的来说,所有无精子症病例中有40％可归因于梗阻。梗阻性无精子症的常规治疗包括显微外科手术重建和手术精子取出，然后进行IVF。虽然显微外科重建已被证明在经济上是可行的，对提高成功率的追求导致了创新技术的探索。历史上,VV和VE程序的演变，最初演出于20世纪初，为当代显微外科手术方法奠定了基础(11)。值得注意的是,显微镜下的VV显着改善了通畅率和自然妊娠可能性，1991年的精索血管切开术研究组研究证明了这一点(8)。在当代文学中,自输精管切除术逆转研究组最初发表的成功率以来,在过去30年中,尤其是VE的成功率保持不变(12).与接受VV的患者的1.7至4.3个月相比，VE与更长的通畅时间以及需要2.8至6.6个月的精子返回射精的患者相关。此外,在VE后成功精子返回射精的患者中，高达50％的患者将延迟失败，而接受VV的患者为12％。最后,在接受VE后出现延迟失败的患者中,通常发生时间较早,研究报告早在术后6个月(10).鉴于VE缺乏改善和明显恶化的结果，进一步的手术改进是执行此手术的外科医生的恒定目标。
结论：结论：这段视频既是一个示范，也是对外科创新承诺的行动呼吁。我们的目标是提高VE成功率的标准，最终为患者带来切实的利益，并为生殖医学的持续发展做出贡献。新的附睾咬合缝合作为进步的灯塔出现，不仅有希望提高安全性，而且有可能减少通畅时间。手术的卓越和方法的完善，正如这个视频中的例子，为男性生殖手术继续开辟新领域的未来奠定基础。
方法：患者是一名39岁男性，诊断为梗阻性无精子症，通过VE进行手术重建。他的伴侣是一名37岁的女性，月经周期规律。全面的临床数据涵盖了一系列因素，包括FSH水平，精液分析的结果，和睾丸精子抽吸的结果。这项彻底的探索旨在全面了解我们的创新外科技术及其在解决阻塞性无精子症复杂病例中的应用。
结果：程序从右侧开始，对输精管进行了鉴定和横切.对血管的腹部侧进行了插管并进行了血管造影，没有障碍物。从血管的睾丸侧没有可见的液体进行分析，因此，我们继续与VE。检查附睾后，确定了扩张的小管。为VE选择细管后，放置了两条10-0尼龙缝线，它被切开了。在检查流体活动精子时,鉴定。VE之后,我们进行了一种新的附睾咬合缝合技术。通过将7-0prolene从内侧到外侧穿过附睾膜来完成吻合远端。然后将此缝线收紧，目的是在很大程度上阻塞附睾，以便精子优先穿过吻合口。然后在左边重复这些步骤。在3个月的随访中，患者的睾丸大小与术前大小（18cc）相比没有变化，他没有睾丸或切口不适，根据精液分析，他有活动精子。术后3个月,在精液分析中，患者有活动精子。
结论：新的附睾咬合针法的引入证明了提高显微VE成功率的针对性策略。令人鼓舞的是，术后3个月的随访显示存在活动精子，加强我们方法的潜在功效。鉴于历史上较低的通畅性，这是有希望的，延迟开放时间，与需要VE经验的患者相比，延迟失败率更高（10）。总的来说,所有无精子症病例中有40％可归因于梗阻。梗阻性无精子症的常规治疗包括显微外科手术重建和手术精子取出，然后进行IVF。虽然显微外科重建已被证明在经济上是可行的，对提高成功率的追求导致了创新技术的探索。历史上,VV和VE程序的演变，最初演出于20世纪初，为当代显微外科手术方法奠定了基础(11)。值得注意的是,显微镜下的VV显着改善了通畅率和自然妊娠可能性，1991年的精索血管切开术研究组研究证明了这一点(8)。在当代文学中,自输精管切除术逆转研究组最初发表的成功率以来,在过去30年中,尤其是VE的成功率保持不变(12).与接受VV的患者的1.7至4.3个月相比，VE与更长的通畅时间以及需要2.8至6.6个月的精子返回射精的患者相关。此外,在VE后成功精子返回射精的患者中，高达50％的患者将延迟失败，而接受VV的患者为12％。最后,在接受VE后出现延迟失败的患者中,通常发生时间较早,研究报告早在术后6个月(10).鉴于VE缺乏改善和明显恶化的结果，进一步的手术改进是执行此手术的外科医生的恒定目标。
结论：结论：这段视频既是一个示范，也是对外科创新承诺的行动呼吁。我们的目标是提高VE成功率的标准，最终为患者带来切实的利益，并为生殖医学的持续发展做出贡献。新的附睾咬合缝合作为进步的灯塔出现，不仅有希望提高安全性，而且有可能减少通畅时间。手术的卓越和方法的完善，正如这个视频中的例子，为男性生殖手术继续开辟新领域的未来奠定基础。
