OBJECTIVE: Vasovasostomy is a cost-effective procedure for the reversal of vasectomy. A water-tight adequately blood-supplied mucosal anastomosis is required for better outcomes. This review aimed to compare the outcome of vasovasostomy performed by three different techniques: macroscopic, pure microsurgical, and robot-assisted microsurgical techniques.
METHODS: Scopus, Web of Science, PubMed, Embase, and Cochrane library databases were searched for relevant studies from January 1901 to June 2023. We conducted our quantitative syntheses using the inverse variance method in OpenMeta software. The study\'s protocol was registered on PROSPERO.
RESULTS: This review involved 95 studies of different designs, with a total sample size of 48,132. The majority of operations were performed bilaterally, and participants were monitored for up to 10 years. The pooled patency rate was the highest following robot-assisted vasovasostomy (94.4%), followed by pure microsurgical vasovasostomy (87.5%), and macroscopic vasovasostomy (83.7%). The pooled pregnancy rate following purely microsurgical vasovasostomy was higher than that of macroscopic vasovasostomy (47.4 vs. 43.7%). Definitive pregnancy rates in robotic vasovasostomy are yet to be determined.
CONCLUSIONS: Patency outcomes for vasovasostomy were best with robot-assisted microsurgical technique, followed by pure microsurgical technique, and conventional macroscopic technique. Further investigations of robot-assisted microsurgical vasovasostomy outcomes and randomized control trials are required to support this evidence.

Robot-assisted surgery is the gold standard of treatment in many fields of urology. In this systematic review, we aim to report its usage in andrology and to evaluate any advantages. A systematic search of the PubMed and Cochrane Library databases was conducted to identify articles referring to robotic-assisted microsurgery in andrology. The search strategy was in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane Handbook. The articles were then reviewed by two authors. A qualitative analysis of the articles that met the inclusion criteria was performed. Thirty-one articles that met the inclusion criteria were reviewed. The first results for robot-assisted vasovasostomy (RAVV) are encouraging as excellent patency rates, short operative times, and learning curves were achieved. Interestingly, patency rates were greater in some case series for RAVV than for microsurgical vasovasostomy, with a statistically significant difference. In addition, robot has been shown to be of great use in bypassing fibrotic changes in cases of iatrogenic vasal injuries, difficulties encountered with traditional microsurgery. In addition, the feasibility of robot-assisted microsurgery has been proven for varicocelectomy and microsurgical denervation of the spermatic cord, with acceptable improvement in sperm parameters and pain, respectively. The current evidence suggests that there are potential advantages of the use of robots in andrology. However, for robotic surgery to become incorporated into the daily use of the andrologists, large, multicenter randomized trials are needed. As robotics systems are becoming standard in urology practice, it is reasonable for one to believe that they will also find their place in andrology.

Chronic scrotal pain (CSP) may be due to an identifiable cause, may be multifactorial, or may be idiopathic. Successful treatment often requires multimodal therapy with a multidisciplinary approach. Conservative options may be offered initially, but if symptoms fail to improve with conservative interventions, more invasive therapies may be required. A nerve block may be attempted and patients who experience improvement in pain following nerve blocks may be good candidates for surgical denervation of the spermatic cord. Alternative surgical treatment options including proximal nerve blocks, neuromodulation, cryoablation, vasectomy reversal, varicocelectomy, and even orchiectomy have been described. The aim of this review is to discuss the treatment options for CSP with a focus on surgical treatment options.

The clinical need for magnified visualization during surgery spurred the evolution of microscope and microsuture technology. Innovative surgeons across various surgical specialties recognized the importance of utilizing and advancing these technologies. Operative microscopy allows human dexterity to perform beyond direct visual limitations. Microsurgery started in otolaryngology and ophthalmology, became popular in reconstruction and transplantation, and was then adopted in urology. Microsurgery in urology involves renal and penile revascularization, penile transplantation and free flap phalloplasty, testicular autotransplantation, reproductive tract reconstruction of the vas deferens and epididymis, varicocele repair, and sperm retrieval. By examining the peer reviewed and lay literature, this review discusses the history of microsurgery and its subsequent development as a subspecialty in urology.

Duplication of vas deferens is a very rare anomaly which two vasa deferentia are found in the spermatic cord. It can be recognised during autopsy or cadaveric dissection and also several surgical procedures which require spermatic cord dissection including inguinal hernia repair, orchiopexy, vasectomy, varicocelectomy, vasectomy reversal and radical prostatectomy. Recognition of the duplicated vas deferens is important to avoid surgical complications such as an unsuccessful vasectomy or transection of the vas. It was reported in only three cadavers and 31 patients since 1959. In this study, we describe a new case of duplicated vas deferens found incidentally during routine inguinal hernia repair in a 66-year-old patient. We also review all previously reported cases in the literature to draw attention to this rare but important anomaly.

BACKGROUND: Vasectomy is a popular choice of contraception worldwide. In the UK, vasectomy reversal is not usually licensed under the NHS with reports on outcomes being limited. Microsurgical reversal is a technique commonly performed under the operating microscope. Loupe magnification, however, is emerging as a safe and reliable technique to perform microsurgery.
METHODS: Loupe-assisted microsurgical vasovasotomies were performed on 14 men in a 3-year period. Indications for the procedure were for fertility only. Semen analysis variables were measured against European Association of Urologists (EAU) guidelines at six weeks. Patients were followed-up at clinic in three months. Data were collated using operation notes and cytology results, and analysed using descriptive statistics. Pearson\'s correlation coefficient was used to compare years after vasectomy, and age to sperm count.
RESULTS: The average sperm count in our group was 41.3 million per millilitre (median 29.95, range 2.7-107.8) at 6 weeks. Seventy-five per cent were found to have positive sperm motility, and all had acceptable sperm morphology at follow-up. A very low to weak correlation between time after vasectomy and age, with sperm count.
CONCLUSIONS: We have demonstrated that fertility and post-operative outcomes using a loupe-assisted microsurgical vasovasotomy approach are favourable as per EAU guidelines.

BACKGROUND: In the era of improving assisted reproductive technology (ART), patients with obstructive azoospermia (OA) have 2 options: vasal repair or testicular sperm extraction with intracytoplasmic sperm injection. Vasal repair, including vasovasostomy (VV) and vasoepididymostomy (VE), is the only option that leads to natural conception.
METHODS: This article reviews the surgical techniques, outcomes, and predictors of postoperative patency and pregnancy, with a focus on articles that have reported over the last 10 years, using PubMed database searches.
RESULTS: The reported mean patency rate was 87% and the mean pregnancy rate was 49% for a patient following microscopic VV and/or VE for vasectomy reversal. Recently, robot-assisted techniques were introduced and have achieved a high rate of success. The predictors and predictive models of postoperative patency and pregnancy also have been reported. The obstructive interval, presence of a granuloma, and intraoperative sperm findings predict postoperative patency. These factors also predict postoperative fertility. In addition, the female partner\'s age and the same female partner correlate with pregnancy after surgery.
CONCLUSIONS: In the era of ART, the physician should present and discuss with both the patient with OA and his partner the most appropriate procedure to conceive by using these predictors.

Vasovasostomy and vasoepididymostomy are technically challenging microsurgical reconstructive procedures necessary for men with obstructive azoospermia at the level of the vas deferens or epididymis. Patency rates following vasovasostomy or vasoepididymostomy have been widely described in the literature. However, few reports have discussed the timing of sperm return to the ejaculate after reconstruction as well as the proportion of men in whom late failure develops following vasovasostomy or vasoepididymostomy. Therefore, the objective of this article was to review the rates and predictors associated with late failure and the timing of sperm returning to the ejaculate after vasovasostomy and vasoepididymostomy.
A literature search was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines via the PubMed®/MEDLINE® database. We included relevant articles published in English in peer reviewed journals from 1960 to 2017 which reported outcomes regarding time to patency, time to late failure or the late failure rate after vasovasostomy or vasoepididymostomy. Macroscopic reconstructions were excluded from study.
A total of 24 articles were included in the review. Mean time to patency after vasovasostomy and vasoepididymostomy ranged from 1.7 to 4.3 and 2.8 to 6.6 months, respectively. The late failure rate after microsurgical vasovasostomy and vasoepididymostomy ranged from 0% to 12% and 1% to 50%, respectively. Mean time to late failure after vasovasostomy and vasoepididymostomy ranged from 9.7 to 13.6 and 6 to 14.2 months, respectively. There was significant heterogeneity in the available data, limiting comparisons between series.
Sperm returns to the ejaculate sooner in men who undergo vasovasostomy compared to vasoepididymostomy. Late failures are heterogeneously defined in the literature but they occur at a rate that is not insignificant. Thus, clinicians should discuss considerations for sperm cryopreservation.

Vasovasostomy (VV) for iatrogenic infertility is commonly employed for patients with obstructive intervals of less than 15 years, with the microsurgical technique gaining favor over use of loupe magnification due to precision suture placement. We present our technique of a robot-assisted VV and compare surgical times of staff to resident. Twenty patients with iatrogenic infertility and obstructed intervals of less than 10 years underwent robot-assisted VV, 17 utilizing a single-layer reapproximation and 3 using a double-layer reapproximation. Average patient age was 32.9 years. Following vasal exposure, the staff performed the robot-assisted anastomosis on one side followed by the resident on the opposite side. Reanastomosis times and semen analyses were recorded. Twenty patients underwent successful single- or double-layer robot-assisted vasovasostomy. Mean console time for staff to complete the vasal reconstruction was 37.6 min compared to the resident time of 54 min. Mean total operative time for all procedures was 187 min (single-layer procedure averaged 182 min compared to double-layer repair which averaged 238 min). Thirteen patients returned for follow-up semen analysis, with twelve patients demonstrating sperm within the ejaculate. Additionally, two patients reported pregnancies for a patency rate of 93%. Mean sperm density was 14 million/ml with motility of 26.4%. Robot-assisted vasovasostomy is a technically feasible procedure demonstrating adequate results on follow-up semen analysis, and can be included in training residents in robotic surgery. Additional data are needed to determine its role in the management of iatrogenic infertility.

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