Abstract
Objective:
To document a step-by-step guide of crossed transeptal vasoepididymostomy with prioritization of crossover vas deferens measurement.
Design:
Video presentation.
Setting:
University of Miami Lennar Surgical Center.
Patient(s):
The patient undergoing this procedure signed a written, informed consent for video and audio recording.
Results:
No intraoperative complications were seen during the surgery, and the patient was discharged 6 h after the procedure. Through the steps detailed in the video and manuscript, a proper tubule into vas deferens invagination was formed.
Conclusions:
Anatomical indications for crossed vasoepididymostomy exists in 6% of azoospermic males and procedural prevalence is increasing. With a standardized step-by-step procedural approach that prioritizes crossover vas deferens measurement, crossed vasoepididymostomy can be considered in couples desiring natural conception, with previous complications of ART or failed ART.
Keywords: Male, Infertility, Microsurgery, Anatomy
1. Introduction
The use of vasoepididymostomy is typically reserved for vasectomy reversal. About 6–10% or 30,000 vasectomies are reversed annually [1] and as a result, vasoepididymostomies are relatively common. The majority of these well documented and common cases are corrected by traditional ipsilateral vas to epididymis anastomosis. This is where a patent abdominal vas deferens and a dilated epididymal tubules are found ipsilaterally and able to be conjoined without much worry of anatomic differences risking proper anastomosis. In cases where a vas deferens is not patent or dilated epididymal tubules are not seen, reconstruction on the same side is not possible, and a crossed vasoepididymostomy can be considered.
To date, there is no standardized technique for this procedure because of its unpredictable indication. We present a step-by-step procedure of a crossed vasoepididymostomy using a 4K3D video microscope [2] and introduce principles of abdominal vas deferens measurement to increase success rate.
1.1. Surgical procedure
Procedural approach to a traditional vasoepididymostomy is identical to the crossed variation. During sequential assessment of vas deferens patency and epididymis dilation, real time microscopic evaluation for viable sperm is required. The decision to commit to a crossed vasoepididymostomy is then made, and 10–0 sutures are thrown into side ends of the dilated epididymis for later anastomosis. For this case, a diagnosis of obstructive azoospermia via epididymal obstruction was established. One of the vasa were not patent despite serial examinations likely due to extensive use of cautery at the time of vasectomy. The epididymal tubules were flat and scarred on the contralateral side likely due to multiple attempts at needle passage during a prior percutaneous epididymal sperm retrieval.
Measurement of crossover vas deferens is then prioritized. Following septal crossover of patent vas deferens, it is marked, and 9–0 sutures are passed into the seromuscular layer. The inside-out 10–0 sutures of the dilated epididymis are then used for dilated epididymal tubule intussusception into the crossed vas deferens lumen. Tension-free anastomosis is secured with multiple parallel 9–0 suture ties around the invagination point marking crossover union.
2. Results
Intraoperatively, the estimated blood loss was 10 mL and total operative time of 110 min. There were no intraoperative complications, and the patient was discharged 6 h after surgery. The step-by-step procedure detailed above and, in the video, showed the steps needed to create tubule invagination into vas deferens and successful anastomosis. Following six weeks of anti-inflammatory prednisone treatment, semen analysis results at the 3-month showed azoospermia. Another semen analysis is planned at the 6-month follow-up.
3. Discussion
Although sperm retrieval and IVF can be more straight-forward as compared to complex reconstructions, there could be a need for an operation like crossed vasoepididymostomy. Longer time to patency is expected for the crossed vasoepididymostomy procedure, based on a systematic review of standard vasoepididymostomy procedures [3]. With a standardized step-by-step assessment of bilateral vasa and epididymides and prioritization of crossover vas deferens measurement, crossed vasoepididymostomy can be considered in couples desiring natural conception, with previous complications of ART or failed ART.
The video related to this article can be found online at: doi:10.1016/j.urolvj.2021.100090.
Supplementary Material
Footnotes
Declaration of Competing Interest
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests.
Patient consent statement
Written, informed consent agreeing to publication of audio and video was obtained from all patients prior to any intervention.
References
- [1].Patel AP, Smith RP, Vasectomy reversal: a clinical update, Asian J. Androl 18 (3) (2016) 365–371, 10.4103/1008-682X.175091. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [2].Best JC, Gonzalez D, Alawamlh OAH, Li PS, Ramasamy R, Use of 4K3D video microscope in male infertility microsurgery, Urol. Video J 7 (2020), 100046, 10.1016/j.urolvj.2020.100046. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [3].Farber NJ, Flannigan R, Li P, Li PS, Goldstein M, The kinetics of sperm return and late failure following vasovasostomy or vasoepididymostomy: a systematic review, J. Urol 201 (2) (2019) 241–250, 10.1016/j.juro.2018.07.092. [DOI] [PubMed] [Google Scholar]
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