Factors affecting patency time and semen quality in a single-armed microsurgical vasoepididymostomy.

ABSTRACT: Although microsurgical vasoepididymostomy (MVE) is an effective treatment for epididymal obstructive azoospermia, some patients may experience delayed patency or suboptimal semen parameters after patency. However, research into patency time, semen quality postpatency, and associated influencing factors remains limited. This study aimed to address these issues by evaluating 181 patients who underwent at least one-sided MVE employing asingle-armed longitudinal intussusception vasoepididymostomy technique, with a follow-up period of over 12 months for 150 patients. The overall patency rate was 75.3%, with 86.0% of patients achieving patency within 6 months following MVE. Unexpectedly, factors such as age, history of epididymitis, duration of surgery, side of anastomosis, sperm motility in epididymal fluid, and the site of anastomosis showed no correlation with patency time. Nonetheless, our univariate and multivariate linear regression analysis indicated that only the site of anastomosis was positively correlated with and could independently predict postoperative total motile sperm count. Therefore, the site of anastomosis might serve as a predictor for optimal postoperative semen quality following the MVE procedure.

Can we improve time to patency with vasoepididymostomy with an innovative epididymal occlusion stitch?

INTRODUCTION: 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. MATERIALS AND 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. DISCUSSION: 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. CONCLUSION: 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.

High variability in self-pay pricing for vasectomy and vasectomy reversal in the United States.

CONTEXT: In the United States (US) men who undergo vasectomy and/or vasectomy reversal (vasovasotomy) are likely to pay out-of-pocket for these procedures. We characterized the publicly disclosed pricing of both procedures with a focus on variability in self-pay prices. METHODS: We queried all US hospitals for publicly disclosed prices of vasectomy and vasovasotomy. We assessed interhospital variability in self-pay pricing and compared hospitals charging high (≥75th percentile) and low (≤25th percentile) self-pay prices for either procedure. We also examined trends in pricing after the 2022 US Supreme Court decision that allowed individual states to ban abortion. RESULTS: Of 6692 hospitals, 1375 (20.5%) and 281 (4.2%) disclosed self-pay prices for vasectomy and vasovasotomy, respectively. There was a 17-fold difference between the 10th and 90th percentile self-pay prices for vasectomy ($421-$7147) and a 39-fold difference for vasovasotomy ($446-$17,249). Compared with hospitals charging low (≤25th percentile) self-pay prices for vasectomy or vasovasotomy, hospitals charging high (≥75th percentile) prices were larger (median 150 vs. 59 beds, p < 0.001) and more likely to be for-profit (31.2% vs. 7.8%, p < 0.001), academic-affiliated (52.7% vs. 23.1%, p < 0.001), and located in an urban zip code (70.1% vs. 41.3%, p < 0.001). From October 2022 to April 2023, the median self-pay price of vasectomy increased by 10% (from $1667 to $1832) while the median self-pay price of vasovasotomy decreased by 16% (from $3309 to $2786). CONCLUSION: We found large variability in self-pay pricing for vasectomy and vasectomy reversal, which may serve as a barrier to the accessibility of male reproductive care.

Effects of antisperm antibodies post vasectomy reversal on pregnancy rates.

OBJECTIVE: To investigate the correlation between antisperm antibodies (ASAs), pregnancy rates, and the method of conception following vasectomy reversal. This is particularly relevant as patients undergoing vasectomy reversal often express concerns about the potential inhibitory effects of ASAs on achieving pregnancy. Additionally, the American Urological Association guidelines for vasectomy emphasize the need for further research to address this question. PATIENT AND METHODS: We conducted a retrospective analysis involving chart reviews and phone interviews with individuals who underwent vasectomy reversal at our institution between May 2015 and April 2023. Patients who underwent vasectomy reversal for reasons other than fertility, as well as those lacking postoperative semen analysis with ASA data, were excluded. We classified patients based on low (below 50%) or high (50% or above) ASA levels determined by their initial postoperative semen analysis. The primary outcome measured was the pregnancy rate, including details on the method of conception. RESULTS: A total of 145 patients were subjected to chart review. The median age at the time of surgery was 43 years, with a median obstruction interval of 7.7 years. The median age of their partners was 29 years. The majority (80%) of patients underwent bilateral vasovasostomy. Among them, 60 patients (41.4%) exhibited low (< 50%) ASA levels, while 85 (58.6%) had high (≥ 50%) ASA levels. Follow-up phone interviews were completed by 48 patients. Among them, the 19 men with low ASA levels, 13 (68.4%) achieved pregnancy, with 6 (31.6%) experiencing spontaneous conception. For the 29 men with high ASA levels, 21 (72.4%) achieved pregnancy, including 11 (38%) through spontaneous conception. The p-value from Fisher's exact test was 0.2. CONCLUSIONS: Our findings suggest that ASA levels do not show a significant association with either the pregnancy rate or the method of conception following vasectomy reversal.

Antisperm Antibody Levels After Vasectomy Reversal Are Not Associated With Pregnancy Rates or Method of Conception.

OBJECTIVE: To examine the relationship between antisperm antibody (ASA), pregnancy rates, and method of conception following vasectomy reversal, given that before and after vasectomy reversal, patients wonder if ASAs will prevent them from achieving pregnancy and American Urological Association vasectomy guidelines call for additional research to answer this question. METHODS: We performed retrospective chart review and phone interview of patients who underwent vasectomy reversal at our institution from 1/1/2000 to 12/31/2018. We excluded patients who underwent vasectomy reversal for pain, or without postoperative semen analysis with ASA. We categorized patients as having low (<50%) or high (≥50%) ASA levels using the first postoperative semen analysis. Our primary outcome was pregnancy rate, including method of conception. Differences in pregnancy rates were tested using Fisher exact test. RESULTS: Two hundred and four patients were chart reviewed. Median age at time of surgery was 40years and median obstruction interval was 7.3years. Median partner age was 32years. One hundred sixty-four (80%) patients underwent bilateral vasovasostomy. Eighty-five patients (42%) had low (<50%) ASA levels and 119 (58%) had high (≥50%) ASA levels. Sixty-seven patients completed phone interviews. Of 27 men with low ASA levels, 19 (70%) achieved a pregnancy with 16 (59%) spontaneous pregnancy. Of 40 men with high ASA levels, 30 (75%) achieved a pregnancy with 16 (40%) spontaneous pregnancy. The Fisher exact test P-value was .2. CONCLUSION: ASA levels are not associated with pregnancy rate or method of conception after vasectomy reversal. These findings can improve patient counseling before and after vasectomy reversal.

Comparative evaluation of double- and single-armed two-suture longitudinal intussusception techniques in microsurgical vasoepididymostomy: An updated systematic review and meta-analysis.

BACKGROUND: This study aimed to compare the outcomes of double-armed two-suture longitudinal intussusception microsurgical vasoepididymostomy (LIVE) and single-armed two-suture LIVE techniques in patients with epididymal obstructive azoospermia (EOA). The main outcomes assessed were patency rates, patency time, semen quality and natural pregnancy rates. METHODS: Data from patients with EOA who underwent two-suture LIVE were obtained from databases including PubMed, EMBASE, and Web of Science. Weighted data were analyzed using a random-effects model, and weighted mean differences were reported. RESULTS: A total of 1574 patients with EOA from 24 studies were included. The overall patency rate was approximately 68% (95% confidence interval [CI]: 63-72%), with a patency time of approximately 4.63 months (95% CI: 4.15-5.12). The sperm concentration reached 26.90 million/ml and the sperm motility was 23.74%. The natural pregnancy rate was 38% (95% CI: 31-46%). The different definitions of patency do not seem to have any meaningful impact when comparing patency rates. There was no significant difference in patency rates, patency time, semen quality and natural pregnancy rates between the double-armed and single-armed LIVE techniques. CONCLUSION: The single-armed LIVE is a potential alternative surgical option when high quality double-needle sutures are not easily accessible.

Low-dose prednisone is an effective rescue for deteriorating semen parameters following vasovasostomy.

OBJECTIVE: This retrospective study aimed to evaluate the effectiveness of low-dose prednisone as a rescue therapy for patients with deteriorating semen parameters following vasovasostomy. MATERIALS AND METHODS: Electronic medical records were queried at the University of Miami with documented CPT code 55400 (Bilateral Vasovasostomy) between January 2016 and April 2023. Records were then reviewed to identify patients who demonstrated ≥50% decrease in semen parameters, specifically sperm concentration, motility and total motile sperm count. Patients who were treated with 6 weeks of low-dose prednisone were identified, and baseline semen parameters and subsequent changes after prednisone therapy were assessed. A Mann-Whitney U Test was used to compare semen parameter changes before and after prednisone. Adverse effects associated with prednisone were monitored. RESULTS: A total of 8 patients were identified with deteriorating semen parameters who were treated with 6 weeks of low-dose prednisone. Following prednisone therapy, all patients demonstrated improvements in total motile sperm count (TMSC), with a median improvement of 6 million. The median relative improvement in TMSC was 433%. Sperm concentration and motility also improved compared to post-operative baseline. No adverse effects were reported during the treatment period. CONCLUSIONS: Low-dose prednisone therapy appears to be a safe and effective intervention for managing deteriorating semen parameters following VV. The observed improvements in TMSC suggest the potential of prednisone to rescue patients with delayed failure after VV. Further research with larger sample sizes is warranted to confirm the safety and efficacy of low-dose prednisone as a rescue therapy in this specific patient population. Optimizing VV outcomes is crucial in male infertility, and further exploration of steroid therapy and innovative biotechnologies is warranted.

Vasovasostomy: A systematic review and meta-analysis comparing macroscopic, microsurgical, and robot-assisted microsurgical techniques.

BACKGROUND AND OBJECTIVES: 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. CONCLUSION: 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.

[Surgery to improve male fertility]. / Chirurgies visant à améliorer la fertilité masculine.

BACKGROUND: At a time when increasing attention is being paid to the limitations and risks of in vitro fertilisation techniques, surgeries to improve male fertility are attracting growing interest. METHODS: Systematic review based on a Pubmed search of surgeries to improve male fertility. RESULTS: Vasovasostomy (VV) gives patency rates of 70-97% and pregnancy rates of 30-76%. Vasoepididymostomy (VE) gives patency rates of 80-84%, with pregnancy rates of 40-44%. The duration of obstruction and the age of the partner are 2 predictive parameters for the occurrence of a natural pregnancy. In cases of obstructive azoospermia due to pelvic obstruction (prostatic cyst, obstruction of the ejaculatory ducts), several surgical procedures may be proposed. Transurethral resection of the ejaculatory ducts leads to an improvement in sperm parameters in 63-83% of patients, with spontaneous pregnancy occurring in 12-31% of cases. Microsurgical cure of varicocele by the subinguinal route is a benchmark technique with recurrence rates of less than 4%. It improves live birth and pregnancy rates, both naturally and by in vitro fertilization, as well as sperm count, motility and DNA fragmentation rates. CONCLUSION: Whenever possible, the urologist should present the surgical options for improving male fertility to the ART team and to the couple, discussing the benefit/risk balance of the operation as part of a personalized approach.

The effects of different vasovasostomy techniques on motility of vas deferens (vas motility following vasovasostomy).

PURPOSE: Vasovasostomy is used to correct vas deferens (VD) transections encountered during surgery or to reverse sterilization vasectomies. Achieving vasal patency is the primary goal and the success is assessed on various factors including VD patency, flow rates, and pregnancy rates. While preserving vas motility is not a major concern in surgical practice, it is worth noting that VD has peristaltic activity which plays crucial role during ejaculation. Any disruption in its motility could potentially lead to negative outcomes in the future. We conducted an experimental study to assess vas motility changes following vasovasostomy. METHODS: The study was approved by Gazi University, Animals Ethic Committee. Twenty-four rats were allocated to four groups. Left-sided VD was harvested in control group (Gr1). The rest of the animals were subjected to transection of VD. Gr2 and 3 underwent microscopic and macroscopic anastomosis, respectively, while Gr4 underwent vasal approximation. After 12 weeks, all left-sided VD were resected, electrical field stimulation (EFS) and exogenous drugs were applied to induce contractions. Statistical analyses were performed and p value < 0.05 was regarded as statistically significant. RESULTS: The first and second phases of EFS-induced contractile responses(CR) increased for Gr3 and decreased for Gr4 at submaximal and maximal frequencies. An increase only at maximal frequency for second phase EFS-induced CR was encountered for Gr2. α-ß-methylene-ATP-induced CR decreased for Gr3 and 4. Noradrenaline-induced CR increased for Gr2, and 3 and decreased for Gr4. CONCLUSION: The results suggest that vasovasostomy performed using a surgical technique that minimizes disruption or damage to VD may have a favorable impact on motility.

A realistic model for vasectomy reversal training using swine testicles.

PURPOSE: To evaluate the viability of the porcine vas deferens as a realistic microsurgical training model for vasectomy reversal. METHODS: The model uses swine testicles (vas deferent), which are usually discarded in large street markets since they are not part of Brazilian cuisine. The spermatic cord was carefully dissected, and the vas deferens were isolated, measuring 10 cm in length. A paper quadrilateral with 5 cm2 was built to delimit the surgical training field. The objective of the model is to simulate only the microsurgical step when the vas deferens are already isolated. The parameters analyzed were: feasibility for reproducing the technique, patency before and after performing the vasovasostomy, cost of the model, ease of acquisition, ease of handling, execution time, and model reproducibility. RESULTS: The simulator presented low cost. All models made were viable with a texture similar to human, with positive patency obtained in 100% of the procedures. The internal and external diameters of the vas deferens varied between 0.2-0.4 mm and 2-3 mm, respectively, with a mean length of 9 ± 1.2 cm. The total procedure time was 43.28 ± 3.22 minutes. CONCLUSIONS: The realistic model presented proved to be viable for carrying out vasectomy reversal training, due to its low cost, easy acquisition, and easy handling, and providing similar tissue characteristics to humans.

The Diversity of Vasectomy Reversal Providers and Their Web-based Advertising Habits in the United States.

OBJECTIVE: To better understand the internet advertising material published on clinician websites for the 30,000 men who undergo evaluation for vasectomy reversal (VR), which is a technically demanding procedure requiring microsurgical expertise. METHODS: Internet search trends for "vasectomy" and "vasectomy reversal" from 2004 to 2022 were assessed using Google Trends. Search engines were then queried on a state-by-state basis for physicians performing VR and the available information aggregated and analyzed using standard statistical approaches. RESULTS: VR search volume consistently represented roughly one-tenth of the search volume for vasectomy. One hundred and ninety reversal clinics were identified in 44 of 50 states with the highest number identified in the southeast region and an overall median price of $6500. Ninety percent of physicians were male and completed residencies in urology. Other specialties included obstetrics and gynecology, general surgery, family medicine and orthopedic surgery. Forty-two percent of urologists had completed infertility fellowships. Sixty percent of physicians utilized a microscope, and 4.7% of physicians explicitly stated they did not perform vasoepididymostomy even when indicated. Fifty two percent of clinics reported VR success rates as high as 100%, and 34% of clinics reported pregnancy outcomes. Twenty-five percent of clinics reported out-of-pocket VR pricing and 26% discussed possible complications. CONCLUSION: VR is a technically demanding cash-pay procedure being performed by physicians with a wide array of backgrounds and outcomes. Urologists should strive to lead by example and report their training, personal experiences, and expected outcomes to enable optimal medical decision making for each patient.

[Recommendations of the Committee of Andrology and Sexual Medicine of the AFU concerning the management of Vasectomy]. / Recommandations du Comité d'Andrologie et de Médecine Sexuelle de l'AFU concernant la prise en charge de la vasectomie.

OBJECTIVES: To answer the main clinical questions asked by practitioners and men consulting for a vasectomy request. METHOD: The CPR method was used. The clinical questions were formulated according to the PICO methodology. A Pubmed literature search for the period 1984-2021 identified 508 references, of which 79 were selected and analyzed with the GRADE grid. RECOMMENDATIONS: Vasectomy is a permanent, potentially reversible contraception. It is a safe procedure. A second vasectomy is necessary in only 1 % of cases. Surgical complications (hematoma, infection, pain, etc.) are rare. The frequency of prolonged scrotal pain after vasectomy is about 5 %, and less than 2 % describe a negative impact of this pain on their quality of life. Vasectomy does not have negative consequences on sexuality. The only contraindication to vasectomy is the minor patient. Patients at increased risk of remorse are single, divorced or separated men under the age of 30. Sperm storage may be particularly appropriate for them. Whatever the reason, the law allows the surgeon to refuse to perform the vasectomy. He must inform the patient of this at the first consultation. The choice of the type of anesthesia is left to the discretion of the surgeon and the patient. It must be decided during the preoperative consultation. Local anesthesia should be considered first. General anesthesia should be particularly considered in cases of anxiety or intense sensitivity of the patient to palpation of the vas deferens, difficulty palpating the vas deferens, or a history of scrotal surgery that would make the procedure more complex. Concerning the vasectomy technique, 2 points seem to improve the efficiency of the vasectomy: coagulation of the deferential mucosa and interposition of fascia. Leaving the proximal end of the vas deferens free seems to reduce the risk of post-vasectomy syndrome without increasing the risk of failure or complications. No-scalpel vasectomy is associated with a lower risk of postoperative complications than conventional vasectomy. Regarding follow-up, it is recommended to perform a spermogram at 3 months post-vasectomy and after 30 ejaculations. If there are still a few non-motile spermatozoa at 3 months, it is recommended that a check-up be performed at 6 months post-vasectomy. In case of motile spermatozoa or more than 100,000 immobile spermatozoa/mL at 6 months (defining failure), a new vasectomy should be considered. Contraception must be maintained until the effectiveness of the vasectomy is confirmed.

Robotic-assisted microsurgery in andrology: a systematic review.

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.

One-layer macroscopic verus two-layer microscopic vasovasostomy: Our experience in two referral hospitals.

OBJECTIVE: Vasovasostomy is the most common surgery to restore the fertility of vasectomized men. This study aimed to compare the outcomes of one-layer macroscopic VV (MOLVV) or two-layer microscopic VV (TLMVV). METHODS: This study was performed on the medical records of 100 patients who underwent VV surgery in two tertiary hospitals from 2014 to 2017. All patient information, including demographic and sperm analysis, was collected. The chi-square test, independent t-test, and survival analysis using Kaplan-Meyer test and Cox regression were performed to analyze the data using SPSS software version 25, and the significance level was considered 0.05. RESULTS: The fertility rate in patients of both groups was 15%. The findings showed a statistically significant difference between the mean percentage of normal sperm morphology according to the type of surgery (p = 0.045). There was no statistically significant difference between the mean sperm count, sperm motility percentage, and mean hospital costs according to the type of surgical procedure (p > 0.05). The incidence of spouse pregnancy in the TLMVV method after 15 and 24 months was 87.5% and 58.3%, respectively. In patients with unilateral anastomosis, the incidence of pregnancy at 13 and 15 months after surgery was 98.7% and 95.8%, respectively. The mean and median time of pregnancy in the spouses of patients with each surgical shower were 24 and 25 months. Other variables had no significant effect on spouse pregnancy. CONCLUSION: Vasovasostomy with the one and two-layer methods had equal results. The number, movement, and normal morphology of sperm after surgery were low. Therefore, these people will need assisted reproductive techniques.

Vasectomy Regret Among Childless Men.

OBJECTIVE: To address historical concerns surrounding vasectomy in childless men, we sought to evaluate for the level of regret in this unique cohort. METHODS: The records of patients who underwent vasectomy via single surgeon between 2006 and 2021 were retrospectively reviewed and those who had not fathered children in any capacity at time of vasectomy were selected. We devised a 6-question survey inquiring about regret and thoughts on vasectomy reversal and assisted reproductive technology (ART). The questions are listed in Table 1. Patients were queried via a telephone call to rate their level of regret, both immediately after vasectomy and present day. The cohort was analyzed via age at time of vasectomy, time since vasectomy and marital status. RESULTS: There were 4812 overall patients who underwent vasectomy in this interval, with 205 (4.3%) who were childless. The response rate was 33.2% (68/205). Average age was 36.6 years with average time since vasectomy at time of phone call was 5.51 years. Regret rate was 4.4% immediately following vasectomy and 7.4% at time of telephone interview. A confirmatory, second consultation before vasectomy was present in 6.8% (14/205). The majority of patients 150/205 (73.1%) were married. When patients were stratified by marital status, there was no significant difference in any of the questions. The majority of patients were satisfied with their decision, with few contemplating or pursuing reversal or ART (Table 1). CONCLUSION: Regret in childless patients who undergo vasectomy is very rare, with the majority of patients feeling that their life was improved.

Vasectomy reversal in China during the recent decade: insights from a multicenter retrospective investigation.

To date, there is little information about the demography of vasectomy reversal (VR) patients or the factors currently influencing VR effectiveness in China, especially after the universal two-child policy was released in 2015. In this research, demographic data and perioperative medical records of VR patients were extracted from seven major hospitals in different provinces or municipalities of China. Meanwhile, a telephone survey of the patients was conducted to collect follow-up information. Eventually, 448 VR cases from the past 13 years were included. The results were analyzed by stratified comparison to investigate factors that can influence postoperative vas deferens patency and pregnancy rate. Appropriately statistical methods were used, and all of the protocols were approved by the Ethics Committees of the institutes in this research. The results showed that the annual operation volume of VR quadrupled after the two-child policy was implemented. Nonmicrosurgery and a long duration of vasectomy were significantly associated with a lower patency rate. A follow-up survey showed that the general postoperative pregnancy rate was 27.2%. For female partners over the age of 35 years, the postoperative pregnancy rate showed a more severe decline, but only 35.5% of them had been given a fertility examination before their husbands' VR surgery. Our work revealed that more patients in China have been demanding VR in recent years. High-quality microsurgery and a short duration of vasectomy are crucial for restoring patency by VR. Clinical andrologists should perform a preoperative fertility evaluation of the patients' female partners.

The effect of BMI and age on the outcomes of microsurgical vasoepididymostomy: a retrospective analysis of 181 patients operated by a single surgeon.

To design a treatment plan for patients with epididymal obstruction, we explored the potential impact of factors such as body mass index (BMI) and age on the surgical outcomes of vasoepididymostomy (VE). In this retrospective study, 181 patients diagnosed with obstructive azoospermia (OA) due to epididymal obstruction between September 2014 and September 2017 were reviewed. All patients underwent single-armed microsurgical intussusception VEs with longitudinal two-suture placement performed by a single surgeon (KH) in a single hospital (Peking University Third Hospital, Beijing, China). Six factors that could possibly influence the patency rates were analyzed, including BMI, age, mode of anastomosis, site of anastomosis, and sperm motility and quantity in the intraoperative epididymal fluid. Single-factor outcome analysis was performed via Chi-square test and multivariable analysis was performed using logistic regression. A total of 159 (87.8%, 159/181) patients were followed up. The follow-up time (mean ± standard deviation [s.d.]) was 27.7 ± 9.3 months, ranging from 12 months to 48 months. The overall patency rate was 73.0% (116/159). The multivariable analysis revealed that BMI and age significantly influenced the patency rate (P = 0.008 and 0.028, respectively). Younger age (≤28 years; odds ratio [OR] = 3.531, 95% confidence interval [95% CI]: 1.397-8.924) and lower BMI score (<26.0 kg m-2; OR = 2.352, 95% CI: 1.095-5.054) appeared to be associated with a higher patency rate. BMI and age were independent factors affecting the outcomes of microsurgical VEs depending on surgical expertise and the use of advanced technology.

[Application analysis of laparoscopic assisted microsurgical vasovasostomy in the treatment of vas deferens obstruction caused by inguinal herniorrhaphy].

OBJECTIVE: To investigate the effiicacy of laparoscopic assisted microsurgical vasovasostomy in the treatment of vas deferens obstruction caused by inguinal herniorrhaphy. METHODS: Clinical data of patients undergoing surgical treatment for deferential obstruction after inguinal hernia repair in the andrology department of the First Affiliated Hospital of Zhengzhou University from 2018 to 2022 were retrospectively analyzed, and they were divided into two groups according to different surgical methods: double mirror combined group and microscope group. The basic clinical data, intraoperative conditions, postoperative effects and complications of the two groups were compared. RESULTS: There were 14 cases in the double mirror group and 34 cases in the microscope group. There was no significant difference in age and history of groin operation between the two groups (P>0.05). The average length of hospital stay in the two-lens group was less than that in the microscope group (5.07±0.26 days vs 7.09±1.86 days, P< 0.01), and the average operation time in the two-lens group was more than that in the microscope group (211.93±58.55min vs 162.26±40.70min, P<0.01). The postoperative recurrence rate (85.7% vs 73.5%, P > 0.05) was similar between the two groups. There was no significant difference in early postoperative complications (0% vs 2.9%, P > 0.05). Only 1 patient in the microscope group experienced fat liquefaction and recovered after intensive dressing change. CONCLUSION: Laparoscope-assisted microscopy provides natural fertility opportunities for patients with vas deferens obstruction after inguinal hernia repair, reduces the difficulty of surgery and the length of hospital stay, and is a safe and effective surgical method comparable to traditional surgical methods.

Vasectomy reversal outcomes in men after testosterone therapy.

The prevalence of males on testosterone therapy (TT) seeking vasectomy reversal (VR) is rising. As medical therapy (MT) to recover spermatogenesis after TT has been previously described, our study's objective is to present our institution's management and outcomes of VR in men previously on TT. We performed a retrospective case series of vasectomy patients on TT with subsequent VR by a single microsurgeon between March, 2010 and March, 2022. 14 men undergoing VR during the study period met inclusion criteria. The median age at VR was 43 years with a median obstructive interval of 11 years. Median time from MT to VR was 5 months. Post-operative semen analysis was performed in 10 men and all demonstrated patency. 2 patients had very low sperm counts secondary to continuing TT following VR contrary to medical advice and 5 men with patency achieved pregnancy. Our study noted a high rate of vasovasostomy (VV) (96%) and sustained patency despite a 12-year median obstructive interval. Our findings support favorable outcomes with less stringent VV indications after MT in patients previously on TT that desire VR. The use of MT reduces the recommended wait times for VR after TT discontinuation by more than half.