Vasovasostomy

The microdot technique was developed at Cornell University as a means of improving the vasovasostomy procedure. It ensures precise suture placement by the exact mapping of each planned suture. When sperm are found in the fluid emanating from the testicular end of the vas, the patency rate of this technique for return of sperm to the ejaculate is 99.5%, and the 1-year cumulative pregnancy rate for partners of patients undergoing this procedure is 70%.³ The microdot method separates the planning of suture position from the physical act of suture placement. Much as an architect prepares blueprints before the builder constructs the house, the perioperative planning of suture placement is critical to a successful surgical outcome. This painstaking planning allows the surgeon to focus on one task at the time of suture placement, 'hitting the bulls eye'. In addition, the discrepancy in diameter between the proximal (obstructed) vasal lumen and the distal (nonobstructed) vasal lumen is typically 2:1 to 3:1, sometimes more; careful, even spacing of the sutures minimizes luminal discrepancy and limits 'dogears' and leaks, thus decreasing the risk of postoperative stricture, granuloma formation, and reconstructive failure. The microdot method results in substantially improved accuracy of suture placement and minimizes the discrepancy between luminal diameters of the proximal and distal vasal ends, allowing for a watertight anastomosis.

A microtip skin-marking pen is used to map out planned needle exit points. Exactly six monofilament 10-0 double-arm nylon mucosal sutures (first layer) are used for every anastomosis, because they are easy to map out and always result in a leak-proof closure, even when the lumen diameters are markedly discrepant. After completion of the mucosal layer, six 9-0 deep muscularis sutures are placed exactly in between each mucosal suture, just above, but not penetrating, the mucosa (second layer). Six additional 9-0 nylon interrupted sutures are then placed between each muscular suture (third layer). These sutures only involve the adventitial layer that covers the underlying mucosal suture. The anastomosis is finished by approximating the vasal sheath with six interrupted sutures of 7-0 PDS, completely covering the anastomosis and relieving it of all tension (fourth layer). All anastomoses consist of four layers of six sutures, for a total of 24 sutures (Figure 1). The dartos layer is approximated with interrupted 4-0 absorbable sutures and the skin with subcuticular sutures of 5-0 Monocryl^® (Johnson and Johnson, New Brunswick, NJ).

Figure 1 Microsurgical vasovasostomy with multilayer microdot method (25).

(A) Placement of 10-0 nylon suture inside the vasal lumen and through the microdot target. (B) The first three (of six) sutures of the anastomosis have been placed and tied down. The final three sutures have been placed and are ready to be tied. (C) Completed anastomosis. Reproduced with permission from reference 23 © (2002) Elsevier Inc.

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Vasoepididymostomy

Microsurgical vasoepididymostomy

Microsurgical vasoepididymostomy is considered the most technically challenging type of surgery for the male reproductive system. In virtually no other operation are results so dependent upon the surgeon's technical expertise. Surgeons who perform vasoepididymostomy, therefore, must have extensive experience in microsurgical techniques and carry out the procedure frequently. The indications for performing vasoepididymostomy at the time of vasectomy reversal, based on gross appearance of the vasal fluid,²³ are reviewed in Table 1. Although occasional discrepancies exist between gross and microscopic findings, they correlate approximately 80% of the time. It is, however, essential to view the vasal fluid under the microscope, in order to determine whether to proceed with vasovasostomy or with vasoepididymostomy. For obstructive azoospermia that is not due to vasectomy or absence of the vas deferens, vasoepididymostomy is indicated when the testis biopsy reveals complete spermatogenesis and scrotal exploration reveals the absence of sperm in the vasal lumen.

Table 1 Surgical recommendations based on gross appearance of vasal fluid and microscopic findings.

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Microsurgical end-to-side two-suture intussusception vasoepididymostomy

The intussusception technique, originally known as the three-suture triangulation technique, was developed by Berger.²⁶ Marmar described a modified technique that consists of two sutures with transverse double-needle placement within the epididymal tubule.²⁷ At Cornell University, a longitudinal two-suture intussusception vasoepididymostomy approach (Figure 2A) was developed in order to further improve the procedure.⁷ With this method, four microdots are marked on the cut surface of the vas deferens and two parallel double-arm sutures are placed in the distended epididymal tubule; however, the needles are not pulled through. After the epididymal fluid is tested for sperm and aspirated into micropipettes for cryopreservation, the two needles within the epididymal tubule are pulled through, and all four needles are placed through the vas lumen at the marked locations. Tying down the sutures allows the epididymal tubule to be intussuscepted into the vasal lumen, completing the anastomosis (Figure 2B). The patency rate with the longitudinal intussusception vasoepididymostomy approach was over 90% in a recent clinical series, and intussusception is the preferred method for all vasoepididymostomies.⁶

Figure 2 Microsurgical end-to-side two-suture intussusception vasoepididymostomy.

(A) Two parallel sutures are placed in the selected epididymal tubule, oriented longitudinally, then the tubule is incised between the two needles (top inset). Once the epididymal tubule has been incised, the sutures are pulled through (bottom inset). The double-arm needles are placed in-to-out through the vasal lumen. The suture points are labeled to indicate where they run (a1 to a1, etc.). (B) Completed anastomosis. The suture points at the completed anastomosis are indicated by a1, a2, b1 and b2. Reproduced with permission from reference 7 © (2003) Elsevier Inc.

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All successful vasovasostomy and vasoepididymostomy techniques rely on adherence to surgical principles that are universally applicable to anastomoses of all tubular structures: an accurate mucosa-to-mucosa approximation; leak-proof anastomosis; tension-free anastomosis; good blood supply; healthy mucosa and muscularis; and atraumatic anastomotic technique.

When to perform sperm extraction

Although most postvasectomy patients are candidates for microsurgical reconstruction, not all obstructive-azoospermic men can be managed surgically. In order that these men can become biological fathers, various sperm-retrieval techniques have been developed for use in conjunction with in vitro fertilization (IVF). Before the introduction of ICSI, sperm retrieval was performed with IVF and limited forms of micromanipulation, such as partial zona dissection. ICSI has now replaced all other types of assisted reproduction.

Congenital bilateral absence of the vas deferens (CBAVD) is an abnormality related to cystic fibrosis. In patients with mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene, segments of the excurrent ductal system anywhere from the midportion of the epididymis to the seminal vesicles are missing.²⁸ Only a minority of patients with a CFTR gene mutation have enough healthy tissue for reconstruction to be feasible.²⁹ The majority of patients with CBAVD, therefore, will need epididymal sperm aspiration for IVF via ICSI.^{30, 31, 32} Before IVF is performed, it should be determined whether both partners are carriers of the CFTR gene mutation.

There are various surgical techniques for sperm retrieval; their advantages and disadvantages are summarized in Table 2. These techniques are also useful for intraoperative retrieval of sperm during reconstructive procedures such as vasoepididymostomy, which have failure rates high enough that intraoperative cryopreservation of sperm for a future IVF cycle should be considered, in the event that the reconstructive surgery is unsuccessful.

Table 2 Advantages and disadvantages of surgical techniques for sperm retrieval.

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Sperm obtained from patients with chronically obstructed reproductive systems usually have poor motility and decreased fertilization capacity. The use of ICSI is essential to achieve optimal results in most cases. One notable exception is chronic obstruction secondary to previous vasectomy. Female partners of men who underwent vasovasostomy more than 15 years after their initial vasectomy still achieved a natural pregnancy rate of 44%.²⁰ The sperm of patients with chronic epididymal obstruction in this setting will take longer to regain motility; however, even if natural conception does not occur, ejaculated sperm could be used for intrauterine insemination or ICSI.

Open epididymal tubule sperm retrieval technique

Microsurgical epididymal sperm aspiration can be employed either for intraoperative sperm retrieval at the time of vasoepididymostomy or as an isolated procedure in men with congenital absence of the vas deferens or unreconstructable obstructions.³³ Under the operating microscope, the epididymal tunic is incised and a dilated epididymal tubule is selected, isolated and incised with a 15° microknife (Figure 3A). The fluid is touched to a slide, a drop of saline or Ringer's solution is added, a cover slip is placed over the slide, and the fluid is immediately examined under a bench microscope. As soon as motile sperm are found, a dry micropipette is placed adjacent to the effluxing epididymal tubule (Figure 3B). A standard hematocrit pipette is less satisfactory, but can be used if a micropipette is not available. Sperm are drawn into the micropipette by simple capillary action. Negative pressure, as is generated by the action of an in-line syringe, should not be applied during sperm retrieval as this can disrupt the delicate epididymal mucosa. Two micropipettes can be employed simultaneously in order to increase the speed of sperm retrieval. The highest rate of flow is observed immediately following incision of the tubule. Progressively better-quality sperm are often found following the initial washout. Gentle compression of the testis and epididymis enhances flow from the incised tubule. With patience, 25–50 l of highly concentrated epididymal fluid, containing approximately 75 million sperm, can be recovered. This is diluted in multiple aliquots of 2–3 ml of human tubal-fluid medium, so that there are 5–10 million sperm per ml. Those specimens not used immediately for ART are cryopreserved for possible future use. If no sperm are obtained, the epididymal tubule and tunic are closed with 10-0 and 9-0 monofilament nylon sutures, respectively, and an incision is made more proximally in the epididymis, or even at the level of the efferent ductules, until motile sperm are obtained.

Figure 3 Microsurgical epididymal sperm aspiration.

(A) Selection and isolation of dilated tubule (10). (B) Aspiration of sperm into micropipette by capillary action (15). Reproduced with permission from reference 23 © (2002) Elsevier Inc.

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Success of sperm extraction techniques

Sperm retrieval from the epididymides of men with obstructive azoospermia is possible in over 99% of patients when performed by experienced microsurgeons.^{34, 35} Success rates such as these are possible even if multiple prior procedures have been performed and extensive scarring is present in the scrotum. If the epididymis is obliterated because of previous procedures or infection, the most proximal efferent ductules of the testis can be exposed by reflection of the caput epididymis to uncover the 7 to 11 dilated tubules. One should be able to aspirate sperm from at least one of these tubules.

In a study of 76 attempts at sperm retrieval using MESA and ICSI in men with obstructive azoospermia, clinical pregnancies were detected by a fetal heartbeat after 75% of attempts, with ongoing pregnancy or delivery achieved for 64% of attempts.³⁶ For men with CBAVD, the success rate is even higher.³⁷ Optimal fertilization and pregnancy rates are obtained with a technique of agressive immobilization of spermatozoa prior to ICSI. It is possible that aggressive immobilization acts by enhancing sperm membrane permeability to improve the ability of immature spermatozoa to fertilize oocytes.³⁸ The teamwork and collaborative effort of reproductive endocrinologists, embryologists, and male reproductive surgeons is of paramount importance for successful results.

Testicular-sperm extraction

Testicular sperm can be found within the testicular tissue of many men with NOA. The optimal technique of sperm extraction would be minimally invasive and avoid destruction of testicular function, without compromising the chance of retrieving enough spermatozoa with which to perform ICSI.

Microdissection testicular sperm extraction

Microdissection TESE is an advanced version of TESE that applies microsurgical techniques to the retrieval of sperm from the seminiferous tubules. Although microdissection TESE is not a minimally invasive technique, it results in the removal of a minimal amount of testicular tissue with maximal sperm yield, and minimizes the negative impact on testicular function. This method was developed by Schlegel,⁴⁰ and is an effective method for the retrieval of sperm from men with NOA, for use in ICSI. The seminiferous tubules from different areas of the testis are often associated with different states of maturation of spermatogenesis. In other words, in some areas of the testis, the Sertoli-cell-only pattern might be present, whereas other areas might show maturation arrest, hypospermatogenesis, or even normal spermatogenesis. Under the operating microscope (25), an experienced surgeon can usually distinguish between 'more active' and 'less active' seminiferous tubules by their appearance; tubules that appear full, opaque, and are larger in comparison to other tubules are more likely to contain sperm (Figures 4A and 4B).

Figure 4 Microdissection testicular sperm extraction.

(A) Comparison of full, white sperm-containing tubules (to left) with stringy-appearing, yellowish Sertoli-cell-only tubules (right) (25). An example is provided of what a sample might look like under microscopic histologic examination. (B) Excision of full tubules under microscopic assistance (25). (C) Conventional testis biopsy. Abbreviation: TB, testis biopsy. Reproduced with permission from reference 23 © (2002) Elsevier Inc.

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The conventional TESE technique requires multiple, blind testis biopsies with excision of large volumes (>500 mg) of testicular tissue, which can result in permanent damage to the testis (Figure 4C). The microdissection TESE technique of sequential excision of microdissected seminiferous tubules (10–15 mg, or 2 mm in length, of seminiferous tubule) has been shown to be more successful, compared with the results achieved by conventional TESE, or random biopsies of testicular tissue. In a sequential series of TESE attempts, Schlegel showed that sperm-retrieval rates improved from 45% (10 out of 22 patients) with conventional TESE to 63% (17 out of 27 patients) with microdissection TESE. Microdissection samples yielded an average of 160,000 spermatozoa per 9.4 mg sample, whereas only 64,000 spermatozoa were found in an average 720 mg conventional biopsy sample (P <0.05 for all comparisons).⁴¹

Outcomes of testicular sperm extraction

By using microdissection TESE in men with NOA, a sufficient number of spermatozoa can be retrieved with a minimal amount of testicular tissue being excised. In addition, optical magnification allows for the minimal disturbance of the testicular blood supply.⁴² Microdissection TESE is a more efficient technique for sperm retrieval in men with NOA than conventional TESE, and results in less postoperative intratesticular scarring.⁴³

The likelihood of sperm retrieval in patients with nonobstructive azoospermia can be estimated on the basis of the most advanced pattern of spermatogenesis (not the most predominant pattern) seen on histopathology, if a previous testis biopsy has been performed.⁴⁴ In men with at least one area of hypospermatogenesis, microdissection TESE resulted in successful sperm retrieval in 81% of patients. In men where the most advanced form of spermatogenesis was maturation arrest, the retrieval rate was 44%. Even those who exhibited a Sertoli-cell-only pattern had sperm retrieved in 41% of cases.⁴³

In an extension of the 1999 study by Palermo et al.,⁴⁵ the team at Cornell University made 684 attempts at sperm retrieval, using microdissection TESE for men with NOA, with encouraging results. Sperm were retrieved from 59% of the men. The fertilization rate from subsequent ICSI procedures using the extracted sperm was 59% per injected oocyte, and clinical pregnancy, as defined by detection of a fetal heartbeat, was achieved in 48% of the cycles in which sperm were retrieved (PN Schlegel, unpublished data).

Varicocelectomy

Varicocelectomy is the most common procedure for male infertility. Varicoceles are found in approximately 10–15% of unmarried, male military recruits,⁴⁶ in 35% of infertile men who have never fathered a child, and in 81% of men who were once fertile, as proven by previous conception, but who are now infertile (secondary infertility).⁴⁷ Repair of varicocele for treatment of male infertility is controversial;⁴⁸ however, any studies that have not shown an improved pregnancy rate after varicocele repair were small, were not stratified by grade of varicocele, and did not control for type of repair technique.⁴⁹

It is possible that varicocelectomy can halt further damage to testicular function and improve spermatogenesis, as well as enhancing Leydig-cell function (as reflected by an increase in postoperative serum testosterone levels in infertile men).⁵⁰ Urologists might, therefore, have a valuable role in preventing future infertility and androgen deficiency^{51, 52} in aging men, and this underscores the importance of using a varicocelectomy technique that minimizes the risk of complications and varicocele recurrence.

Preferred approaches: microsurgical inguinal and subinguinal operations

The advantages of microsurgical techniques over other approaches to varicocele repair (e.g. open surgical, laparoscopic, and percutaneous techniques) are the reliable identification and preservation of the testicular artery or arteries, cremasteric artery or arteries, and lymphatic channels, as well as the reliable identification of all internal spermatic veins and gubernacular veins. Delivery of the testis through the subinguinal incision allows inspection of the gubernacular veins, assuring direct visual access to all possible routes of venous return, including external spermatic, cremasteric, and gubernacular veins.⁵³ Postoperatively, venous return is via the deferential (vasal) veins, which drain into the internal pudendal veins and usually have competent valves.

The application of microsurgical techniques^{53, 54} to varicocelectomy has resulted in a substantial reduction in the incidence of hydrocele formation. This is because the lymphatic vessels can be more easily identified and preserved (Figure 5A). Furthermore, the use of magnification enhances the surgeon's ability to identify and preserve the 0.5–1.5 mm testicular artery⁵⁵ (Figure 5B), thus avoiding the complications of atrophy or azoospermia.

Figure 5 Microsurgical varicocelectomy (25)

(A) Lymphatic vessel. (B) Testicular artery. Reproduced with permission from reference 23 © (2002) Elsevier Inc.

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Varicocelectomy outcomes

The goals of varicocele repair are to relieve pain in symptomatic cases and to improve semen parameters, testicular function, and pregnancy rates in couples with male-factor infertility associated with varicocele. Studies have shown that varicocele repair can improve all three of these in infertile men,^{46, 56} with a significant improvement in semen analysis seen in 60–80% of men.⁵⁷ Varicocele repair in young men might be able to prevent infertility and androgen deficiency later in life.⁵⁰

The clinical outcomes of varicocelectomy are also related to the size of the varicocele. Repair of large varicoceles results in a significantly greater improvement in semen quality than repair of small varicoceles.^{58, 59} In addition, large varicoceles are associated with greater preoperative impairment in semen quality than small varicoceles; consequently, overall pregnancy rates are similar regardless of varicocele size. In the presence of small (grade I) varicoceles along with larger (grade II and III), contralateral varicoceles, greater improvement in semen parameters can be expected if repair is performed bilaterally, rather than only the larger side being repaired.⁶⁰ Some evidence suggests that the younger the patient is at the time of varicocele repair, the greater the improvement after repair and the more likely the testis is to recover from varicocele-induced injury.^{61, 62, 63} Testicular artery ligation and postvaricocelectomy hydrocele formation may be associated with poor postoperative results.

In a controlled trial of varicocele repair in infertile men that compared surgery with no surgery, the surgery group had a pregnancy rate of 44% at 1 year, compared with 10% in the no-surgery group. Using the microsurgical technique in 1,500 men who underwent varicocelectomy, the pregnancy rate in couples was 43% after 1 year and 69% after 2 years, compared to 16% in couples with men who declined surgery and instead had hormone treatment or used ART. There have been only 14 recurrences (1%), no reports of hydrocele or testicular atrophy,⁵³ and only a 1% incidence of inadvertent unilateral testicular artery ligation.⁶⁴

The most common complications of varicocelectomy are hydrocele formation, varicocele recurrence, and testicular artery injury (Table 3). Use of the operating microscope allows for reliable identification of spermatic cord lymphatics, internal spermatic veins and venous collaterals, and the testicular artery or arteries; the incidence of such complications can, therefore, be significantly reduced. Delivery of the testis through a small subinguinal incision provides direct visual access to all possible avenues of testicular drainage to ensure complete ligation. Failure to deliver the testis might result in varicocele recurrence in 7% of patients because of scrotal collaterals.⁶⁵ Additional benefits of delivery of the testis include the identification of otherwise-undetected small testicular tumors and previously undiagnosed epididymal or vasal obstructions (M Goldstein, unpublished data).

Table 3 Techniques of varicocelectomy and potential complications.

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Advocates of nonmicrosurgical techniques contend that the deferential (vasal) artery and, if preserved, the cremasteric artery, will ensure blood supply to the testes that is adequate to prevent atrophy.^{66, 67} Anatomic studies, however, have shown that the diameter of the testicular artery is greater than the diameter of the deferential artery and cremasteric artery combined.⁵⁵ The testicular artery is the main blood supply to the testes. At the very least, it is inarguable that ligation of the testicular artery is unlikely to enhance testicular function. Microsurgical varicocelectomy is a safe and effective approach to varicocele repair, and preserves testicular function, improves semen quality and pregnancy rates in a significant number of couples. Ultimately, the ideal intervention for varicoceles can only be determined by a large, prospective, randomized and controlled study using a microsurgical, artery and lymphatic-sparing technique.