Cornell University

NEW YORK
CORNELL
Cornell University
Weill Medical College

Cornell Institute for Reproductive Medicine

Center for Male Reproductive Medicine and Microsurgery

"State-of-the-Art Compassionate Care for the Infertile Couple"

What's New in Male Infertility Treatment at Cornell
Microsurgical Vasoepididymostomy

Introduction: Surgical Techniques: Current results of using the triangulation end-to-side technique for microsurgical vasoepididymostomy at Cornell
  1. Special Report in Urology Times (December 1999): Evidence supporting the end-to-side triangulation technique
  2. 1999 AUA Meeting Abstract (initial clinical report)
  3. 1999 AUA Meeting Abstract (Initial Animal Experimental Studies Report)
  4. 1999 AUA meeting Video Presentation and Abstract
WebTV Video Clips

References


Introduction

In the past 5 to 10 years, very few fields in modern medicine have changed as dramatically as reproductive medicine, especially, for the treatment of the male infertility. These advances include intracytoplasmic sperm injection (ICSI), refined microsurgical reconstructive techniques (vasovasostomy and vasoepididymostomy), and microsurgical techniques of surgical sperm retrieval from the epididymis and testis. All men with epididymal obstruction now have the opportunity to father their own biological children.

What is the vasoepididymostomy?

Vasoepididymostomy is the microsurgical procedure for treatment of epididymal obstruction. It is the most difficult microsurgical procedures for the treatment of male infertility. Surgeons must have excellent microsurgical skills and extensive experience to be able to perform this anastomosis procedure between the vas deferens and epididymis.

What is the etiology of epididymal obstruction?

The causes of epididymal obstruction include:
  • Congenital abnormalities: absence of the distal part of the epididymis (cauda) with absence of the vas deferens.
  • Young's Syndrome.
  • Infection or inflammation: history of epididymitis (tuberculosis or chlamydia)
  • Iatrogenic injury: accidental injury from prior surgery such as hydrocele repair, orchiopexy (for undescended testes or torsion or testis biopsy.
  • After vasectomy.

What are the advantages of vasoepididymostomy versus IVF-ICSI?

The advantages of the vasoepididymostomy for treatment for the epididymal obstruction are:
  • Patients can father their own children through natural intercourse.
  • In vitro fertilization (IVF) with ICSI is a very intense procedure for the female partner and very costly. Also, conception through natural intercourse does not pose ethical issues and it minimizes the risk of multiple births substantially.
  • Return of sperm rates (52% to 92%) and pregnancy rates (11% to 56%) are competitive with IVF/ICSI.
  • If an experienced surgeon performs the microsurgical procedure, the results (patency rate and pregnancy rates) are better. More importantly, the actual overall cost per live baby is lower than the IVF-ICSI related procedure.
  • Insurance companies may cover the expense for correction of an epididymal obstruction
  • Sperm can be collected during the procedure and frozen (cryopreserved) for future IVF/ICSI attempts if the microsurgical procedure fails.
Please review the sections of "
Microsurgical retrieval of epididymal sperm" and "Surgical sperm retrieval -which method to use?" in this website.


Physical Examination and Laboratory Tests:

Physical examination of men with epididymal obstruction may reveal a somewhat full, indurated epididymis. Men with epididymal obstructions are typically azoospermic ( zero sperm count) and have normal semen volume, an alkaline pH, and are fructose positive. A post-ejaculate urine sample should be evaluated on men with semen volumes less than 1.5 ml to rule out retrograde ejaculation. Normal serum follicle-stimulating hormone (FSH) levels and normally sized testis with epididymal fullness suggest normal sperm production. However, this can only be confirmed with a testicular biopsy.

Surgical Indications:

The indication for recommending and performing a vasoepididymostomy is the presence of active spermatogenesis (sperm production) in the testis, evidence of an epididymal obstruction and a patent (open) vas deferens. A general anesthesia or regional (continuous epidural block) is preferred when performing a vasoepididymostomy.

Testis Biopsy:

A testis biopsy is necessary to confirm normal sperm production prior to performing a vasoepididymostomy. Testicular biopsy performed using an operating microscope allows identification of subtunical blood vessels and reduces operative morbidity. Bouin's solution, the most widely used fixative, minimizes distortion of the testicular architecture. Other options include Zenker's solution or buffered glutaraldehyde, which are used when electron microscopy is desired.

The surgeon must be comfortable in assessing biopsy slides to make a clear plan of action based on the results. The patient with normal spermatogenesis should have in the range of 20 mature spermatids per round tubule, whereas the patient with epididymal obstruction typically should have at least 30 mature spermatids per round tubule. Alternatively, a squash preparation can be performed at the time of reconstruction to assess for the presence of sperm. This procedure involves placing a small piece of testis on a slide, with a drop of Ringer's lactate; the specimen is then compressed under a glass coverslip. This wet preparation is examined for the presence of sperm using a high, dry (40 X) objective lens. After it has been established that active spermatogenesis is present, a reconstruction can be undertaken.

Vasography:

It is also important and necessary to ensure that no other sites of obstruction are present within the genitourinary tract.

This is accomplished by performing a vasogram at the time of the vasoepididymostomy. The vas is isolated at the junction of the straight and convoluted portions. Under an operating microscope, the vasal sheath is vertically incised and the vasal vessels carefully preserved. Clean segment of bare vas is delivered, and a straight clamp is placed beneath the vas to act as a platform. The vas is hemi-transected with a 15░ microknife until the lumen is revealed; the vasal fluid is examined for presence of sperm. The absence of sperm in the vasal fluid confirms epididymal obstruction. The seminal vesicle end of the vas is then cannulated with a 24-gauge angiocatheter sheath and injected with Ringer's lactate to confirm patency. If the Ringer's lactate passes easily, formal vasography is not necessary. If any doubt of the patency exists, 50% diluted indigo carmine dye may be injected and the bladder catheterized. The presence of blue dye in the urine confirms patency of the vas. If obstruction is suspected based on the Ringer's lactate and indigo carmine findings, then the site of obstruction is determined with formal vasography (use water-soluble radiographic contrast medium).

Surgical Preparation & Examination of Vas Deferens and Epididymis

The vas is exposed at the junction of the straight and convoluted portions and the vas deferens is opened. Vasal fluid is sampled. The presence of sperm in the vasal fluid signifies proximal vasal or ejaculatory duct obstruction and a vasogram is performed. If no sperm is found in the vasal fluid it means epididymal obstruction. Occasionally copious amounts of clear fluid without sperm are encountered. If no clear site of epididymal obstruction exists, a vasovasostomy should be performed. The tunica vaginalis is incised and the testes delivered. The epididymis is carefully visualized and palpated. Often a granuloma or area of relative induration above which dilated tubules are seen is present.

The incision and exposure for the vasoepididymostomy proceeds as with a vasovasostomy. It is performed to bypass the site of epididymal obstruction.


Surgical Techniques:

Dr. Edward Martin described the first successful vasoepididymostomy with subsequent pregnancy in 1903. He constructed a side-to-side vasoepididymal fistula using silver wire sutures in a man with epididymal obstruction secondary to a previous gonococcal infection. His reconstruction involved aligning the vas deferens adjacent to a slash made in multiple epididymal tubules. His surgical standard was used for over 70 years until Dr. Sherman Silber reported a new microsurgical technique for vasoepididymostomy in 1978. The success of Martin's technique depended on formation of a fistula between the epididymal tubule and the vas deferens. The average patency rates in the best cases were reported in literature between 1903 to 1980's less than 50%, with only 10% to 20% having normal semen analysis. Scarring with either partial or complete closure of the fistula is the major cause of failure of this procedure.

Vasoepididymostomy may be performed as an end-to-end or end-to-side procedure. It is the most technically demanding microsurgical procedure in urology. The outcome of this procedure is dependent on technical perfection. However, the decision as to which to do is highly based on the surgeon's abilities and familiarity with each procedure as well as intraoperative findings. The success rate of vasoepididymostomies continues to improve as a result of refinements in suture materials, better operating microscopes, and more innovative surgical techniques since 1978. Recently, Dr. Richard Berger from University of Washington reported an innovative triangulation end-to-side microsurgical vasoepididymostomy with patency rates over than 90% in 1998. At Cornell, we have achieved and reported similar results at the
1999 American Urologic Association Annual Meeting in Dallas, TX, by using this technique.

1. Standard Microsurgical End-to-end Vasoepididymostomy

Dr. Sherman Silber performed the first microsurgical vasoepididymostomy technique reported in the literature in 1978, he constructed an end-to-end anastomosis of a single epididymal tubule to the lumen of the vas deferens.

The epididymis is mobilized from testicular surface and then serially sectioned until an unobstructed segment is reached. Under the microscope, the bleeding vessels on the cut surface are cauterized with micro-bipolar electrocautery and the transected tubules are examined for the efflux of fluid. A touch preparation is made and the fluid is examined under a microscope for the presence of sperm. Repeated cuts are made until a gush of fluid containing sperm is detected. This fluid then continues to ooze only from the most proximal segment. This is the single tubule to which the vas will be anastomosed.

The anastomosis is fashioned with interrupted suture of 9-0 or 10-0 nylon double-armed with 70 Ám fishhook-shaped taper-point needles. The number of sutures used depends on the size of the dilated epididymal tubule. Typically, four to six sutures are placed. After the mucosal apposition has been completed, the outer muscularis of the vas is secured to the epididymal tunic with 10 to 12 interrupted 9-0 double-armed nylon sutures. The tunica vaginalis is closed in a running fashion, the scrotal contents are returned, and attention is next turned to the contralateral testis.

One of the advantages of the end-to-end technique is to allow rapid identification of the most distal level in the epididymis where sperm are found, thereby allowing preservation of maximal epididymal length. It is most useful for obstruction in the distal corpus or cauda and especially for obstructions near the vasoepididymal junction. The end-to-end technique is preferable when vasal length is compromised and the epididymis is obstructed distally. In these situations, the epididymis can be dissected off of the testis and flipped up to meet the short vas, allowing large gaps to be bridged.




The Advantages of the end-to-end technique include:
  • Enables rapid identification of the most distal level in the epididymis at which anastomosis is possible.
  • Useful for obstructive in the distal corpus, cauda or near the vasoepididymal junction.
  • Situations where vasal length is compromised and where the epididymal is obstructed distally.
The Disadvantages of the end-to-end technique include:
  • Difficulty and time consuming in identifying the single "proximal" tubule from which sperm are exuding for an anastomosis.
  • Sutures must be placed in a tubule, which is not distended.
  • Numerous bleeding sites must be controlled.
  • The numbers of sutures are limited by the small size of the collapsed tubule.
  • Extremely difficult to obtain a water tight leak-proof end-to-end anastomosis.

2. Standard Microsurgical end-to-side Vasoepididymostomy:

Dr. Wagenacht in Germany first described the microsurgical end-to-side vasoepididymostomy in 1985. Thomas popularized the end-to-side microsurgical vasoepididymostomy in the United States. He reported a patency rate of 66% and a pregnancy rate of 41% in his 1987 series.

In 1984, Marc Goldstein and his associates introduced the use of double-armed sutures with fishhook-shaped taper-point needles to ensure inside-out placement of the mucosal sutures. In 1993, Peter Schlegel and Marc Goldstein at Cornell reported on 107 patients who underwent either an end-to-end or end-to-side vasoepididymostomy. The patency rate achieved was 70% and independent of technique, with a pregnancy rate of 44%. They noted a delayed stricture rate of13%.

The end-to-side procedure requires no epididymal mobilization and is relatively bloodless. It is ideally suited for obstructions in the proximal to the mid-epididymis where the level of obstruction is clear and dilated tubules are visualized. The end-to-side is also ideal when adequate vasal length exists for a tension-free anastomosis with the testis situated dependently in the scrotum. If a decision has been made to proceed with an end-to-side anastomosis, a dilated tubule, well situated for anastomosis above the presumed level of obstruction, is localized. Using micro-scissors a 4- to 5-mm buttonhole is made in the epididymal tunic.

The vas is approximated to the opening in the tubule and fixed to the adjacent visceral tunic with three or four interrupted 6-0 polypropylene sutures. The epididymal tubule is prepared for anastomosis by microdissection. There either it is incised with a microknife or, employing a 10-0-nylon suture for traction, a 1-mm buttonhole is made with microscissors. If sperm are present, the vasal mucosa is approximated to the epididymal mucosa with four to six interrupted 10-0 sutures. The vasal adventitia is then approximated to the epididymal tunic with 9-0 nylon.




The advantages of the end-to side technique are:
  • It is easy to identify a single epididymal tubule to make the anastomosis. (Since it makes no difference which end of the tubule sperm are coming from.)
  • There is minimal bleeding.
  • It is a widely used technique
The disadvantages of the end-to-side technique are:
  • It is difficult to positively identify the correct level at which to perform the anastomosis until the epididymal tubule is open.
  • The sutures are placed in a collapsed empty epididymal tubule.
  • The numbers of sutures are limited by the small size of the collapsed tubule.
  • It is difficult to obtain a water tight leak-proof mucosal anastomosis.

3. Microsurgical Triangulation end-to-side Vasoepididymostomy:

The average patency rates after end-to-end and end-to-side microsurgical vasoepididymostomies have been similar and vary from 60% to 88% with pregnancy rates varying from 25% to 57%. (See the following table.)

In 1997, Dr. Richard Berger from the University of Washington in Seattle reported a new innovative technique of microsurgical vasoepididymostomy, which involving pre-placement of sutures in a triangular configuration within the distended epididymal tubule, which resulted in intussusception of the epididymal tubule into the vas lumen.



His early results reported yielded patency rates of 92%. Our experience at Cornell with the technique thus far has been similar with the patency rates of 86%.

Surgical Technique: The vas and epididymis are prepared in the same fashion as previously described for the standard end-to-side technique, except that the tubule is not opened before placement of three sutures of 10-0 nylon double-armed with 70 Ám fishhook-shaped taper-point needles.

Using a micro-marking pen, six dots are placed on the cut surface of the vas deferens indicating the exit points of the sutures used for the anastomosis. A dot is placed at 3'Oclock, 9 o'clock, 5'o'clock, 7 o'clock and finally at the 1 o'clock and 11 o'clock position. Microdots are labeled according to the order in which the sutures will be placed. A1 is at the 5 o'clock position, A2 is at the 3 o'clock position, and B1 is at the 7 o'clock position and B2 at the 9 o'clock position. Cl is at the 1 o'clock position, C2 is at the 11 o'clock, The epididymal tubule and vasa are then stained with indigo carmine to facilitate suture placement.



The first two sutures ( a and b) are placed in a V-shaped configuration with the point of the V aimed at the 6 o'clock position of the vas deferens. The 70-Ám needle (a1) is larger than the 17 Ám diameter of the suture so that epididymal fluid will leak around the suture sites (a1 and a2). This epididymal fluid is placed on a sterile microscope slide diluted with saline or Ringer's lactate and assessed under a microscope for the presence of sperm. If sperm are present, the remaining two sutures (b1 and b2) are placed. If no sperm are found, anastomosis is taken down and a more cephalad site is chosen, repeating these steps until sperm is found. The third suture (c1 and c2) is then placed, completing the triangle. This suture goes transversely across the distended epididymal tubule closing the V and creating a triangular configuration of sutures. The point of the triangle is aimed at the 6 o'clock position on the vas deferens.

The epididymal tubule is then opened with a 9-0 cutting needle or with a micro-needle knife, which is currently under development at Cornell.

Once the epididymal tubule is opened, the epididymal fluid may be aspirated into multiple pipettes for cryopreservation and for future use with assisted reproductive techniques if anastomosis fails.

Needles from the double-armed sutures are then passed inside out into the vas deferens, exiting through the microdots previously placed. No more than one-third of the thickness of the muscularis is included in each bite.



The three double-armed sutures will provide six points of fixation. The sutures are arranged in a hexagonal pattern on the vas deferens. The mucosa of the vas and one third of the muscularis are included in the suture. The use of microdots on the vas deferens allows for accurate suture placement and lessens the chance of leakage caused by "dog ears."

The first sutures placed are at the 5 and 7 o'clock positions (a1 and b1). Then next sutures are positioned at the 9 and 3 o'clock positions (a2 and b2). The final sutures are placed at the 1 and 11 o'clock positions (c1 and c2).

The sutures are then tied in an organized fashion. First a1 and a2 are tied (not shown in the below figure), then b1 and b2, and finally c1 and c2. As for the classic end-to-side anastomosis, a second layer is closed to provide a tension-free anastomosis.



This is accomplished with 10 to interrupted double-armed 9-0 nylon sutures. The vas is further secured to the tunica vaginalis tunic of the epididymis with interrupted 9-0 nylon sutures, using a single armed cutting needle. This prevents any tension from being transmitted to the anastomosis.

The advantages of the triangulation end-to side technique are:
  • The sutures are easily placed in a distended tubule.
  • The three double-armed sutures provide six points of fixation.
  • The intussuseption of the epididymal tubule into the vasal lumen provide a watertight leakproof anastomosis. The flow of epididymal fluid is from the epididymis into the vas deferens, causing the epididymal tubule walls to plaster up against the inside of the vasal lumen.
  • There is minimal bleeding associated with the technique.
The disadvantages of the triangulation technique are:
  • Inability to determine if the correct tubule that contains sperm has been selected until the first suture is placed.
  • Great care and extreme caution must be taken to ensure that sutures are not cut when making the opening in the epididymal. The use of a micro cutting needle or the micro-needle knife, which is currently under development at Cornell, solves this problem.
The keys to successful employment of the triangulation end-to-side technique are:
  • Extensive microsurgical training and expertise.
  • A tension free accurate anastomosis
  • A very meticulous and organized approach to suture placement.


Current Results of using the Triangulation end-to-side Technique for Microsurgical Vasoepididymostomy at Cornell

1. Special Report by Urology Times

(Source: This article was reported by Mr. Charles D. Bankhead, Urology Times CONTRIBUTING EDITOR, Urology Times, Vol.27.No.12, December 1999.)

Evidence Support End-to-side Triangulation Technique

At a Glance

Higher patency rates: During vasoepididymostomy a simple-to-perform end-to-side triangulation procedure showed patency rates of 83% and 91% in two separate studies.
Dallas - Two studies reported at the American Urologic Association (AUA) meeting-one clinical and one experimental-showed patency rates of 83% and 91% when using an end-to-side triangulation technique during vasoepididymostomy (VE). The triangulation technique also has proved simpler to perform than conventional VE techniques, said Roy A. Brandell, MD, a urology fellow at Cornell University in New York working under Marc Goldstein, MD professor of urology.

"Our results were especially encouraging in light of our relatively brief follow-up." Dr. Brandell said. "We expect the patency rates will be even higher with longer follow-up."

Another experimental study reported by German investigators provided additional confirmation for a similar technique, which investigators describe as invaginated end-to-side technique.

The triangulation technique used by Dr. Brandell, Dr. Goldstein, and colleagues was described last year by University of Washington (Seattle) urologist Richard E. Berger, MD (J Urol 1998; 159:1951-3). Initial results showed patency rate exceeding 90% with a minimum 6-month follow-up.

The Cornell researchers reported findings from 18 patients with epididymal obstruction. The patients included five men who had epididymal obstruction secondary to vasectomy, four who had idiopathic obstruction, three who had iatrogenic obstruction, three who had failed vasovasostomy, two who had obstruction associated with epididymitis, and one who had congenital obstruction.

The triangulation technique involves intussusception of the epididymal tubule into the lumen of the vas deferens to create a leak-proof anastomosis.

As described by Dr.Brandell and Dr.Goldstein, the technique's advantages include easy placement of sutures in a distended tubule, six points of fixation provided by three double-armed sutures, leak-proof anastomosis, and minimal bleeding.

At a mean follow-up of 6 months, the patency rate was 83% in the 18 patients. Notably, all eight patients with obstruction secondary to vasectomy or who had failed vasovasostomy were patent. Also at 6 months' follow-up, sperm count averaged 30 million/ml. One patient had late failure at 10 months of follow-up.

Procedure of choice
"Even though we haven't seen a significant decline in operative time, the triangulation technique is simpler to perform than conventional vasoepididymostomy techniques, and is has become our procedure of choice, including for men who have complex etiologies that have had a poor prognosis in the past. " Dr. Brandell said.

Stewart McCallum, MD, also a urology fellow of Dr. Goldstein at Cornell reported a 91% patency rate with the triangulation technique in a randomized study involving laboratory rats. The animals were randomized to a sham operation, control (vasectomy), conventional VE, or the triangulation technique, and then followed for 24 weeks after surgery.

At 24 weeks, the triangulation technique was associated with a 91% patency compared with 54% for the conventional technique. The triangulation technique also led so a lower incidence of granuloma formation.

"The triangulation technique results in a significantly higher patency rate and a lower granuloma rate," said Dr. McCallum. "We have been offering the technique to our patients and have seen similar results at 6 months. The opening time appears to be much less than with conventional techniques. We think the triangulation technique is a significant advance in vasoepididymal surgery and deserves evaluation in clinical trials."

Gralf Popken, MD, a urologist at the University of Freiberg in Germany, reported an 87% patency rate with invaginated end-to-side procedures and 90% patency with invaginated and-to-end procedures in laboratory animals, A conventional end-to-side VE resulted in an 83% patency rate. Conception rates were 13% with the conventional technique versus 13% with each of the invaginated techniques.

Dr.Popken described the invaginated technique as end-to-side adaptation of the epididymal lumen to the lumen of the ductus deferens wish four anastomotic sutures. The epididymal loop is invaginated into the lumen of ductus for a distance equal to three times the diameter of the epididymal tubule by means of a suture. The end-to-end technique involves a similar procedure.

Like the Cornell investigators, Dr. Popken has found the invaginated technique simpler to perform than conventional VE techniques.

Invagination involves less manipulation, trauma, and laceration of the ductus deferens and epididymal tubules. He and his colleagues have found the procedure takes less time to perform and requires less suture material.


2. 1999 AUA Meeting Abstract (Initial Clinical Report)

(Source: 1999 American Urologic Association Meeting, Abstract #1355. J. Urology Vol.161., No.4. Supplement Wednesday, May 5, 1999. Dallas, TX)

RECONSTRUCTION OF THE MALE REPRODUCTWE TRACT USING THE MICROS URGICAL TRIANGULATION TECHNIQUE FOR VASOEPIDIDYMOSTOMY. Roy A. Brandell, M.D. and Marc Goldstein, M.D., The New York Presbyterian Hospital-Weill Medical College of Cornell University, New York, NY 10065

INTRODUCTION:
The highest patency rates following vasoepididymostomy (VE) have been reported in men with secondary epididymal obstruction ("blow-outs") following vasectomy. Recently, Berger described a new approach to VE in this patient population using an end-to-side triangulation technique (J Urol 1998). He reported patency rates over 90% with a minimum 6-month follow-up. Like Berger, we have used the triangulation technique when VE is needed for vasectomy reversal. However, we have also applied the technique to more complex cases of epididymal obstruction stemming from a variety of etiologies. We report our results.

METHODS:
After identifying a distended epididymal tubule, 3 double-armed 10-0 nylon sutures are placed in a triangular pattern. The epididymal tubule is opened between these sutures and the six needles are then passed inside-out through the vasal mucosa using microdots for guidance. When tied, the epididymal tubule becomes intussuscepted into the vasal lumen creating a watertight anastomosis.

RESULTS:
Eighteen patients have undergone VE by one surgeon (MG) at our Center using the triangulation technique. All patients had either a bilateral VE or a unilateral VE in a functionally solitary testis. The obstructive etiology was post-vasectomy epididymal obstruction (5), failed vasovasostomy (3), iatrogenic injury (3), congenital (1), epididymitis (2), and idiopathic (4). Four patients had one or more anastomoses performed at the efferent ductule level. The overall patency rate was 78% with a mean follow-up of 6 months. Thirty-nine percent of men had achieved patency one month postoperatively. All of the men with epididymal blow-outs secondary to vasectomy were patent. There was a 71% patency rate for epididymal obstruction from other etiologies. One natural pregnancy has already resulted.

CONCLUSIONS:
The patency rates reported herein are especially encouraging in light of the short follow-up. Traditional methods for VE can take 12 to 18 months to "open-up." The triangulation technique is now our procedure of choice for VE, including complex cases involving obstructive etiologies that have, in the past, portended a poorer prognosis. (SOURCE OF FOUNDING: Frederick J. and Theresa Dow Wallace Fund.)


3. 1999 AUA Meeting Abstract (Animal experimental Report):

(Source: 1999 American Urologic Association Meeting, Abstract #1196, J. Urology Vol.161, and No.4. Supplement Tuesday, May 4, 1999. Dallas, TX)

COMPARISON OF TRIANGULATION END-TO-SIDE AND CONVENTIONAL END-TO-SIDE MICROSURGICAL VASOEPIDIDYMOSTOMY: A RANDOMIZED CONTROLLED STUDY IN RAT. Stewart McCallum, M.D., Philip Shihua Li, M.D., Li-Ming Su, M.D., Yefim Sheynkin, M.D. and Marc Goldstein, M.D. The New York Presbyterian Hospital-Weill Medical College of Cornell University, New York, NY 10065

INTRODUCTION:
Berger described a triangulation end-to-side microsurgical vasoepididymostomy (T-VE) that intussuscepts the epididymal tubule into the vasal lumen. He reported higher patency rates (92%) and lower operative time (156▒14 min. bilaterally) in humans. No controlled studies have compared conventional end-to-side vasoepididymostomy (C-VE) with the T-VE. We compare patency, sperm granuloma rates and operative time between the C-VE and T-VE microsurgical techniques in previously vasectomized rats.

METHODS:
Forty-two Wistar rats, 6 weeks old, were randomized into 4 groups: sham, control, C-VE and T-VE. Except for sham group, all rats underwent bilateral two-clip vasectomy. One group (n=12) underwent bilateral microsurgical C-VE and one group (n=12) T-VE to the cauda epididymis. For the T-VE, 3 double-armed 10-0 sutures are placed in a triangular configuration in the distended epididymal tubule. A 9-0 cutting needle was used to open the tubule, and the six needles were passed inside out the vas and tied, intussuscepting the epididymal tubule into the vasal lumen and forming a watertight seal. Control group included 12 vasectomized rats. In the sham group, the testis was mobilized out of the scrotum and returned back. Rats were killed at 8, 12, 16 and 24 weeks. Anastomotic sites were inspected for sperm granulomas. The abdominal end of the vas was transected and intraluminal fluid was microscopically examined for presence of motile sperm at 400x to assess patency. Patency was also confirmed by performing an indigo carmine vasogram through the anastomoses.

RESULTS:
Patency rates (P%), sperm granuloma (G%) and operative time (T, min.)



Overall patency for T-VE group was 91.7% vs. 54.2% for C-VE group (p=0.004). Sperm granuloma rate was 20.8% for T-VE group vs. 58.4 % (p=0.035) for C-VE group. The average operative time was 65.8 min. for T-VE vs. 67.7 min. for C-VE.

CONCLUSIONS:
The patency rates with the T-VE technique were significantly higher than with C-VE. Moreover, the T-VE technique resulted in significantly fewer sperm granulomas than the C-VE group. (Microsurgical suture materials provided by Sharpoint.)


4. 1999 AUA meeting Video Presentation and Abstract

(Source: 1999 American Urologic Association Meeting, Abstract #V 17, J. Urology Vol.161., No.4. Supplement, Sunday, May 2, 1999. Dallas, TX)

MICROSURGICAL VASOEPIDIDYMOSTOMY: END-TO-SIDE TRIANGULATION TECHNIQUE. Marc Goldstein, M.D., Stewart McCallum, M.D. and Philip Shihua Li, M.D. The New York Presbyterian Hospital-Weill Medical College of Cornell University, New York, NY 10065

INTRODUCTION AND OBJECTIVES:
Microsurgical vasoepididymostomy is the most technically demanding and time-consuming procedure for the treatment of obstructive azoospermia. Even in the hands of well-trained and experienced microsurgeons, the patency rates following vasoepididymostomy varies from 30% to 70%. We have reported no difference in the patency rates between end-to-end and end-to-side techniques. However, with the end-to-side anastomosis, it is easier to identify which tubule to use for anastomosis and there is minimal bleeding. The disadvantage of the end-to-side technique is that sutures are placed in an opened, collapsed and empty tubule. It is also difficult to achieve a watertight, leak-proof mucosal anastomosis. Berger first reported a simplified triangulation end-to-side microsurgical technique that intussuscepts the epididymal tubule into the vas lumen. He reported patency rates of 92%, with reduced operating times.

METHODS:
The posterior adventitial edge of the vas is fixed to a 3 mm buttonhole opening in the tunic of the epididymis with 2 to 3 interrupted sutures of 9-0 nylon. Three double-armed 10-0 sutures are placed in a triangular configuration in the distended epididymal tubule. A 9-0 cutting needle, or a newly designed micro-needle knife (MNK), is used to open the tubule, and the six needles are passed inside-out the vas. The sutures are positioned symmetrically around the vas lumen, and when tied, the epididymal tubule is intussuscepted into the vas lumen forming a watertight seal.

RESULTS:
We (MG) have performed end-to-side triangulation anastomoses in 36 men. The patency rate is 86% with 3 to 12 months follow-up.

CONCLUSIONS:
Microsurgical triangulation vasoepididymostomy is easier to perform and a more efficient technique with higher patency rates than with previously described techniques. This video uses detailed illustrations and provides step by step instruction in performing a triangulation vasoepididymostomy.


WebTV Video Clips



References:

1. Martin E, Carnett JB, Levi JV, et al: The surgical treatment of sterility due to obstruction at the epididymis. Together with a study of the morphology of human spermatozoa. University of Pennsylvania Medical Bulletin 15:2-15, 1903

2. Lespinasse VD: Obstructive sterility in the male: treatment by direct vasoepididymostomy. JAMA, 70:448, 1918

3. Hagner FR: Operative treatment of sterility in the male. JAMA,107:1851-1854. 1936

4. Hanley HG., and Hodges RD: The epididymis in male sterility: A report of micro-dissection studies. J. Urol. 82:508, 1959

5. Silber SJ: Microscopic vasoepididymostomy: Specific microanastomosis to the epididymal tubule. Fertil Steril, 30:565.571, 1978

6. Silber SJ: Epididymal extravasation following vasectomy as a cause for failure of vasectomy reversal. Fertil Steril. 31:309, 1979

7. Wagenknecht LV and Klosterhalfen H: Microsurgery in andrologic urology. I. Refertilization. J. Microsurg.1:370,1980

8. Belker AM, Konnak JW Sharlip 0, Thomas AJ Jr.: Intraoperative observations during vasovasostomy in 334 patients. J Urol, 129:524-527, 1983

9. Silber SI: Microsurgery for vasectomy reversal and vasoepididymostomy. Urology; 23:505-524, 1984

10. Dubin L and Amelar RD: Magnifies surgery for epididymovasostomy. Urology, 23:525, 1984

11. Belker AM.: Microsurgical repair of obstructive cause of male infertility. Seminars in Urology 2:91, 1984

12. Wagenknecht LV: Epididymovasostomy: a new technique. In Microsurgery in Urology. New York: Thieme Verlag; 291-295, 1985

13. Thomas AJ, Jr.: Vasoepididymostomy. Urol Clin North Am 14:527-538. 1987.

14. Gilbert BR, Goldstein M: New directions in male reproductive microsurgery. Microsurgery, 9:281 -285,1988

15. Hirsch IH, Choi H: Quantitative testicular biopsy in congenital and acquired genital obstruction. J Urol. 143:311-312., 1990

16. Shekarriz M, Pomer S: Microsurgical vasoepididymostomy: a comparison between end-to-side anastomosis and the Invagination technique. Urol Res., 19:285-287. 1991

17. Fuchs, EF: Restoring fertility through epididymovasostomy. Contemporary Urology, pp.27-38, December, 1991

18. Schlegel PN, Goldstein M: Microsurgical vasoepididymostomy: refinements and results. J Urol , 150:1165-1168, 1993

19. Thomas AJ: Microsurgical end-to-side vasoepididymostomy: Analysis and outcome of 161 procedures. Presented at the 88th Annual meeting of American urologic Association, San Antonio, May 1993

20. Goldstein M: Microsurgical vasoepididymostomy: end-to-end anastomosis. In Goldstein M( ed.): Surgery of Male Infertility. Philadelphia: WB Saunders, pp120-127, 1995

21. Marmar LJ: management of the epididymal tubule during an end-to-side vasoepididymostomy. J. Urol 154:93-96, 1995

22. Matthews GJ, Schlegel PN and Goldstein M: Patency following microsurgical vasoepididymostomy and vasovasostomy: Temporal considerations. J. Urol 154:2070-2073, 1995

23. Berger RE: Triangulation end-to-side vasoepididymostomy. J Urol 159:1951-1953. 1998

24. Berardinucci D, Zini A, Jarvi K: Outcome of microsurgical reconstruction in men with suspected epididymal obstruction. J.Urol 159:831-834, 1998

25. Brandell AR and Goldstein M: Reconstruction of the male reproductive tract using the microsurgical triangulation technique for vasoepididymostomy. 1999 American Urologic Association Meeting, Abstract #1355. J. Urol Vol.161., No.4. Supplement Wednesday, May 5, 1999. Dallas, TX

26. McCallum S., Li PS., Su LM., .Sheynkin Y., Goldstein M: Comparison of triangulation end-to-side and conventional end-to-side microsurgical vasoepididymostomy: A randomized controlled study in rat. 1999 American Urologic Association Meeting, Abstract #1196, J. Urol Vol.161, and No.4. Supplement Tuesday, May 4, 1999. Dallas, TX

27. Goldstein M, McCallum S and Li PS: Microsurgical vasoepididymostomy: End-to-side triangulation technique. 1999 American Urologic Association Meeting, Abstract #V 17, J. Urol Vol.161., No.4. Supplement Sunday, May 2, 1999. Dallas, TX)

28. McCallum SW, Berger RE, Goldstein M.: : Vasoepididymostomy ( Chapter 13) in Tom F. Lue and Marc Goldstein ( Ed): Volume 1- Impotence and Infertility: Atlas of Clinical Urology by Series editors of E. Darracott Vaughan, Jr. and Aaron P. Perlmutter. Current Medicine, Inc. Philadelphia, 1999, ISBN# 1-57340-119-6


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