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.

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.

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.

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 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.

[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.

Robotic Surgery for Male Infertility and Chronic Scrotal Content Pain.

Robot-assisted microsurgery is a trending approach for the treatment of male infertility and chronic scrotal pain. The advantages seem to include increased optical magnification, improved surgical efficiency, absent tremor, and similar outcomes with standard methods. This chapter covers robotic microsurgical application and techniques for: robot-assisted vasectomy reversal with vasovasostomy and vasoepididymostomy, varicocelectomy, microsurgical testicular sperm extraction, and targeted denervation of the spermatic cord.

Combined robotic and subinguinal microsurgical vasovasostomy for vasal obstruction after inguinal hernia repair.

Obstruction of the vas deferens may occur after inguinal hernia repair with mesh and lead to infertility. In cases where natural conception is desired and after obtaining test results that suggest the presence of spermatogenesis, surgical reconstruction can be attempted but may be difficult. Several approaches have been reported, including the laparoscopic mobilisation of the pelvic vas deferens, as well as mobilisation and passage of the scrotal vas deferens intra-abdominally for robot-assisted vasovasostomy. We describe a novel approach that used the surgical robot and a no-touch technique to mobilise the pelvic vas deferens and deliver it to the subinguinal region for subinguinal microsurgical vasovasostomy. This approach appeared to be feasible and safe, allows for simultaneous bilateral repair if needed, and was associated with rapid postoperative convalescence.

Sperm granulomas: Predictive factors and impacts on patency post vasectomy reversal.

The objective of this study was to identify factors that predict for sperm granuloma formation and the impact of sperm granuloma presence and quantity on vasectomy reversal (VR) outcomes. A cross sectional retrospective review of prospectively collected data, on the impact of granuloma on VR outcomes from a single academic center was performed. The impact of age, obstructive interval, intraoperative vasal fluid findings, anastomosis type, body mass index, tobacco use and total motile count (TMC) was determined. A total of 1550 men underwent VR between January 2000 and August 2019. Granulomas were present unilaterally in 23.3% (n = 361) and bilaterally in 14.2% (n = 220). On univariate analysis, increasing patient age negatively correlated with a larger number of granulomas (p = .011). Granuloma presence was associated with finding intact and motile sperm from the vasal stump intraoperatively (p = .001), and vasoepididymostomy anastomosis (p < .001). However, granuloma presence (and quantity) did not correlate with obstructive interval or maximum TMC. Tobacco use and body mass index (BMI) were not associated with granuloma presence. On multivariate analysis, granuloma quantity was not associated with TMC. Obstructive interval and vasovasostomy anastomosis were associated with higher TMC, while BMI was negatively associated with TMC. In conclusion, increasing age was negatively correlated with granuloma formation. Granuloma presence was associated with more favourable intraoperative fluid findings and anastomosis type, but not post-VR TMC, suggesting men with and without granulomas undergoing skilled microsurgery will have similar patency rates. Heavier men should be encouraged for weight loss prior to vasectomy reversal as increasing BMI was associated with lower TMC.

European countries have different rates of sperm cryopreservation before vasectomy and at the time of reversal.

INTRODUCTION: Effective male contraceptive options are condoms and vasectomy. Vasectomy should not be considered a reversible method of contraception even if vasovasostomy can be offered to men to restore fertility after vasectomy. Therefore, there is a real questioning among urologists concerning cryopreservation before vasectomy. We carried out an international survey concerning the practice of cryopreservation before vasectomy and during vasovasostomy. MATERIAL AND METHODS: An online anonymous survey was submitted from January to June 2021 to six European urological societies. The 31-items questionnaire included questions about demography, habits of cryopreservation before vasectomy or during vasectomy reversal, and in case of urogenital cancers. RESULTS: 228 urologists from six urological societies in five different countries (Belgium, Netherlands, Luxembourg, France, Finland) answered the questionnaire. French urologists were more in favor of cryopreservation before vasectomy than other European urologists (p < 0.0001). They also significantly found that not talking about cryopreservation before vasectomy is a medical fault unlike other urologists (p < 0.0001). The specialization in andrology did not influence the choice of cryopreservation before vasectomy (p = 0.9452). The majority of urologists did not perform intraoperative sperm extraction during vasovasostomy (81%; n = 127) with a significant difference between urologists with or without andrology training (p = 0.0146). Success rates after vasovasostomy are significantly better for robot-assisted surgery (p = 0.0159) or with a microscope (p = 0.0456) versus without a microscope. CONCLUSION: Cryopreservation before definitive sterilization significantly varies among European urologists and seems to be mostly dictated by habits than by knowledge. An international consensus is needed to standardize practices and guide patients' choices.

[Imaging quality of the robotic visualization 4K3D system and its application in microscopic vasectomy reversal in rats].

OBJECTIVE: To quantitatively assess the performance of the new robotic visualization system (Zeiss, KINEVO 900) in terms of visual imaging effect and evaluate its potential application in microscopic vasectomy reversal. METHODS: We made a parallel comparison between the effects of the plane and stereo visual images of KINEVO 900 and optical surgical microscopy (Zeiss, S7), and performed microscopic vasectomy reversal on the rat model using KINEVO 900. RESULTS: Compared with S7, KINEVO 900 provided an even longer working distance (200－625 mm), a 3－4 times larger effective field area and a 1.5－2 times deeper front depth of field with the same working distance of 200 mm. No statistically significant difference was observed in the average anastomosis time and immediate patency rate between the two platforms (P > 0.05). CONCLUSION: The 4K3D video image stream outputted by KINEVO 900 is not inferior to that of the optical surgical microscope represented by S7 and is sufficient for microsurgeries in urology and andrology. More prospective randomized clinical animal experiments are needed to further evaluate its application value in andrology.

Vasectomy reversal: Unilateral versus bilateral vasovasostomy.

The aim of this study was to evaluate and compare the efficiencies of unilateral and bilateral vasovasostomies as the vasectomy reversal procedures. A total of 95 patients with a history of bilateral vasectomy were evaluated. 42 of them had undergone unilateral surgery, and bilateral surgery had been done for the other 53 patients. Their information including the age, the time interval between the initial vasectomy to the reversal surgery and other underlying illnesses or medications was gathered. Patency rates in the unilateral and bilateral groups were 88.1% (38 patients) and 88.7% (48 patients), respectively, the difference of which was not statistically significant (p = .907). Successful pregnancies occurred in 22 (52.4%) and 29 (54.7%) patients, respectively, which did not show any statistically significant difference too (p = .713). Based on the multivariate logistic regression model, only the time interval between vasectomy and the reversal (duration of obstruction) was predictive of patency (OR = 1.112, p = .037). The outcomes of the unilateral and bilateral vasovasostomies in terms of patency and pregnancy rates were not significantly different. We suggest that performing unilateral, instead of bilateral, vasovasostomy can reduce the time of anaesthesia and surgery and save costs and consumables without having a significant negative impact on the surgical outcomes.

Vasectomy re-reversal: effectiveness and parameters associated with its success

ABSTRACT Introduction: When the vasectomy reversal (VR) fails, and the patient desires natural conception with his sperm, vasectomy re-reversal (VRR) is the only alternative. Purpose: To determine the VRR effectiveness and whether specific parameters can be associated with its success. Materials and Methods: We retrospectively evaluated 18 consecutive vasectomized patients, who had failed their VR through bilateral vasovasostomy, and posteriorly were submitted to VRR. The parameters of the study were: age of the patients, elapsed time between vasectomy and VRR (V-VRRt), elapsed time between VR and VRR (VR-VRRt), presence of spermatozoa in the proximal vas deferens fluid (SptzVDF) in the VRR and results of semen analysis after VRR (SA-VRR). Results: The mean of the age of the patients was 44.11±6.55 years (32.0-57.0), the mean of V-VRRt was 11.76±6.46 years (1.5-25.0) and the mean of VR-VRRt was 2.13±2.27 years (0.5-10.0). SptzVDF in the VRR were found bilaterally in 8 patients, unilaterally in 4 and absent in 6. SA-VRR demonstrated normozoospermia in 9 patients, oligozoospermia in 3 and azoospermia in 6, with patency rate of 66.67%. SA-VRR showed statistically significant dependence only with SptzVDF in the VRR (p <0.01). Conclusions: VRR was effective in restoring the obstruction in more than half of the patients. Furthermore, the presence of spermatozoa in the vas deferens fluid was the parameter associated with the VRR success.