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.

Vas deferens to rete testis anastomosis for obstructive azoospermia.

PURPOSE: This video aims to present an in-depth, step-by-step tutorial on microsurgical reconstruction for obstructive azoospermia, featuring a distinctive case involving anastomosis from vas deferens to rete testis. The primary aim of this endeavor is to offer thorough and practical insights for healthcare professionals and researchers within the realm of reproductive medicine. The video endeavors to disseminate expertise, methodologies, and perspectives that can be advantageous to individuals grappling with obstructive azoospermia, providing a significant contribution to the progress of reproductive medicine and the augmentation of existing treatment alternatives. MATERIALS AND METHODS: Surgical footage was recorded using the ORBEYE 4K 3D Orbital Camera System by Olympus America, with patient consent acquired for research purposes. Additionally, a retrospective examination of patient records was undertaken to compile relevant medical histories. RESULTS: This video furnishes an exhaustive guide to microsurgical reconstruction for obstructive azoospermia, encompassing a distinctive instance of anastomosis from vas deferens to rete testis. State-of-the-art technology, such as the ORBEYE 4K 3D Orbital Camera, heightens procedural transparency, accentuating the significance of advanced instrumentation. The ethical underpinning is emphasized by obtaining patient consent for footage utilization, and a retrospective chart review augments the repository of valuable patient data. This comprehensive approach serves as an invaluable reservoir of knowledge for medical professionals and underscores excellence in clinical and ethical healthcare research. CONCLUSIONS: Anastomosis from vas deferens to rete testis emerges as a viable surgical reconstruction alternative for obstructive azoospermia, particularly when confronted with non-dilated tubules within the epididymis.

Performance of Multiparametric MRI of the Prostate in Biopsy Naïve Men: A Meta-analysis of Prospective Studies.

OBJECTIVE: To assess the outcomes through systematic review and meta-analysis of multi-parametric magnetic resonance imaging (mpMRI) of the prostate in biopsy naïve men. METHODS: Systemic review and meta-analysis was performed to assess the performance of mpMRI on prostate cancer (PCa) detection at the time of biopsy. We used standard methods for performing a meta-analysis evaluating a diagnostic test and reported the pooled sensitivity and specificity, and the positive and negative likelihood ratios (LR) for mpMRI in the detection of any and clinically significant prostate cancer (csPCa). RESULTS: A total of 10 studies comprising 2486 patients were analyzed. Overall, if biopsies would have been performed only in men with an mpMRI suspicious for malignancy between 7.4% and 58.5% of the biopsies could have been avoided, but 2.3%-36% of any PCa and 0%-30.8% of csPCa would have been missed. The sensitivity, specificity, positive LR, and negative LR of mpMRI for any PCa detection were 0.86 (95% confidence interval [CI], 0.78-0.91), 0.67 (95% CI, 0.40-0.86), 2.6 (95% CI, 1.2-5.5), and 0.2 (95% CI, 0.12-0.32), respectively. The AUC for any PCa detection was 0.84 (95% CI, 0.75-0.90). The pooled sensitivity, specificity, positive LR, and negative LR of mpMRI for csPCa detection was 0.94 (95% CI, 0.83-0.98), 0.54 (95% CI, 0.42-0.65), 2 (95% CI, 1.5-2.7), and 0.1 (95% CI, 0.02-0.35), respectively. The AUC for csPCa detection was 0.94 (95% CI, 0.65-1). CONCLUSION: This study provides summary estimates indicating that mpMRI can accurately detect prostate cancer and help avoid unnecessary biopsies in this population.

Trends in Utilization of Robotic and Open Partial Nephrectomy for Management of cT1 Renal Masses.

BACKGROUND: Partial nephrectomy is widely used for surgical management of small renal masses. Use of robotic (RPN) versus open partial nephrectomy (OPN) among various populations is not well characterized. OBJECTIVE: To analyze trends in utilization of RPN and disparities that may be associated with this procedure for management of cT1 renal masses in the USA. DESIGN, SETTING, AND PARTICIPANTS: Patients who underwent RPN or OPN for clinical stage T1N0M0 renal masses in the USA from 2010 to 2013 were identified in the National Cancer Data Base. A total of 23 154 patients fulfilled the inclusion criteria. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Univariable and multivariable logistic regression analyses were performed to evaluate differences in receiving RPN or OPN across various patient groups. RESULTS AND LIMITATIONS: Utilization of RPN increased from 41% in 2010 to 63% in 2013. Black patients (adjusted odds ratio [aOR] 0.91, 95% confidence interval [CI] 0.84-0.98) and Hispanic patients (aOR 0.85, 95% CI 0.77-0.95) were less likely to undergo RPN. RPN was less likely to be performed in rural counties (aOR 0.80, 95% CI 0.66-0.98) and in patients with no insurance (aOR 0.52, 95% CI 0.44-0.61) or patients covered by Medicaid (aOR 0.81, 95% CI 0.73-0.90). There was no significant difference in RPN utilization between academic and non-academic facilities. Patients with higher clinical stage (aOR 0.58, 95% CI 0.55-0.62) and comorbidities (aOR 0.79, 95% CI 0.71-0.88) were also less likely to undergo RPN. CONCLUSIONS: Utilization of RPN has continued to increase over time; however, there are significant disparities in its utilization according to race and socioeconomic status. Black and Hispanic patients and patients in rural communities and with limited insurance were more likely to be treated with OPN instead of RPN. PATIENT SUMMARY: The use of robotic surgery in partial nephrectomy for management of small renal masses has increased over time. We found a significant disparity across different racial and socioeconomic groups in use of robotic partial nephrectomy compared to open surgery. Patients living in rural areas, with limited insurance, and multiple medical comorbidities were more likely to undergo open than robotic partial nephrectomy.

Using microscope for onco-testicular sperm extraction for bilateral testis tumors.

OBJECTIVE: To demonstrate a step-by-step approach to the use of the operating microscope for onco-testicular sperm extraction. DESIGN: Video presentation. SETTING: University hospital. PATIENT(S): A 34-year-old man (status post right orchiectomy at another institution for pT3 pure seminoma with negative preoperative tumor markers) was referred for contralateral orchiectomy for multifocal left testis mass and fertility preservation. A postoperative semen analysis for attempted cryopreservation of ejaculated semen identified azoospermia. INTERVENTION(S): Left radical orchiectomy, left microsurgical onco-testicular sperm extraction (TESE). MAIN OUTCOME MEASURE(S): Intraoperative technique with commentary highlighting tips for successful fertility preservation via microsurgical onco-TESE. Discussion of alternatives. RESULT(S): This video provides a step-by-step guide to microsurgical onco-TESE coordinated with radical orchiectomy for testis cancer as a means of fertility preservation in an azoospermic patient. Preoperative imaging with scrotal ultrasound can serve as a useful guide for targeting microdissection to areas of normal testicular parenchyma for extraction of seminiferous tubules likely to host normal spermatogenesis. This patient had successful recovery and cryopreservation of abundant testicular sperm following targeted ex-vivo testicular microdissection. CONCLUSION(S): Microsurgical onco-TESE may be offered to azoospermic patients when undergoing orchiectomy for testis cancer. Use of preoperative imaging and the surgical microscope guide surgical dissection and optimize sperm recovery.

Robot-assisted single port radical nephrectomy and cholecystectomy: description and technical aspects.

INTRODUCTION: Robot-Assisted Single Site Radical Nephrectomy (RASS-RN) has been reported by surgeons in Europe and United States (1-3). To our best knowledge this video presents the first RASS-RN with concomitant cholecystectomy performed in Latin America. CASE: A 66 year-old renal transplant male due to chronic renal failure presented with an incidental 1.3cm nodule in the upper pole of the right kidney. In addition, symptomatic gallbladder stones were detected. RESULTS: Patient was placed in modified flank position. Multichannel single port device was placed using Hassan's technique through a 3cm supra-umbilical incision. Standard radical nephrectomy and cholecystectomy were made using na 8.5mm camera, two 5mm robotic arms and an assistant 5mm access. Surgery time and estimated blood loss were 208 minutes and 100mL, respectively. Patient did well and was discharged within less than 48 hours, without complications. Pathology report showed benign renomedullary tumor of interstitial cells and chronic cholecystitis. DISCUSSION: Robotic technology improves ergonomics, gives better precision and enhances ability to approach complex surgeries. Robot-assisted Single Port aims to reduce the morbidity of multiple trocar placements while maintaining the advantages of robotic surgery (2). Limitations include the use of semi-rigid instruments providing less degree of motion and limited space leading to crash between instruments. On the other hand, it is possible to perform complex and concomitant surgeries with just one incision. CONCLUSION: RASS-RN seems to be safe and feasible option for selected cases. Studies should be performed to better understand the results using single port technique in Urology.

Combined Partial Penectomy With Bilateral Robotic Inguinal Lymphadenectomy Using Near-infrared Fluorescence Guidance.

OBJECTIVE: To describe our novel technique for performing a combined partial penectomy and bilateral robotic inguinal lymphadenectomy using intraoperative near-infrared (NIR) fluorescence guidance with indocyanine green (ICG) and the DaVinci Firefly camera system. METHODS: A 58-year-old man presented status post recent excisional biopsy of a 2-cm lesion on the left coronal aspect of the glans penis. Pathology revealed "invasive squamous cell carcinoma of the penis with multifocal positive margins." His examination was suspicious for cT2 primary and his inguinal nodes were cN0. He was counseled to undergo partial penectomy with possible combined vs staged bilateral robotic inguinal lymphadenectomy. Preoperative computed tomography scan was negative for pathologic lymphadenopathy. Before incision, 5 mL of ICG was injected subcutaneously beneath the tumor. Bilateral thigh pockets were then developed simultaneously and a right, then left robotic modified inguinal lymphadenectomy was performed using NIR fluorescence guidance via the DaVinci Firefly camera. A partial penectomy was then performed in the standard fashion. RESULTS: The combined procedure was performed successfully without complication. Total operative time was 379 minutes and total robotic console time was 95 minutes for the right and 58 minutes to the left. Estimated blood loss on the right and left were 15 and 25 mL, respectively. A total of 24 lymph nodes were retrieved. CONCLUSION: This video demonstrates a safe and feasible approach for combined partial penectomy and bilateral inguinal lymphadenectomy with NIR guidance using ICG and the DaVinci Firefly camera system. The combined robotic approach has minimal morbidity and avoids the need for a staged procedure. Furthermore, use of NIR guidance with ICG during robotic inguinal lymphadenectomy is feasible and may help identify sentinel lymph nodes and improve the quality of dissection. Further studies are needed to confirm the utility of NIR guidance for robotic sentinel lymph node dissection.

Three-piece Penile Prosthesis Implantation in Refractory Ischemic Priapism-Tips and Tricks.

INTRODUCTION AND OBJECTIVES: Implantation of a penile prosthesis in a patient with significant corporal fibrosis can pose a significant challenge to the surgeon, necessitating the knowledge of specific techniques used to dilate and close aggressively scarred corpora. The objective of our instructional video is to discuss 2 techniques used to approach corporal fibrosis: proper and safe use of cavernotomes for dilation and use of narrower prostheses. METHODS: In this video, we present a 53-year-old man with a history of priapism 3 years ago that lasted 4 days in the setting of trazodone use. He was managed with corporal irrigation and subsequently developed severe erectile dysfunction. Notably, the patient had a history of sickle cell anemia, and on physical examination was noted to have densely fibrotic corpora. After extensive counseling regarding options, he chose a penile implant. The surgical was planned using the "no touch technique." After the corporotomies were made, we began dilating the corpora. Hegar dilators and Dilamezinsert were attempted at first but met significant resistance. We switched to cutting cavernotomes and were able to dilate up to 11-Fr distally and up to 13-Fr proximally. The proper use of cavernotomes is highlighted in our video, with care being taken to aim the cutting edge of the cavernotome laterally away from the urethra. We also used the narrowest inflatable prosthesis available to us (Coloplast Titan narrow-base) and describe the narrower devices available in inflatable and malleable forms as an option for less-than-ideally dilated corpora. The pump and reservoir placement was completed uneventfully. RESULTS: The patient was admitted overnight for observation and check of a complete blood count given his history of sickle cell anemia. He was able to be discharged after 23 hours of observation. The patient presented to the clinic 4 weeks later for pump activation. He was able to achieve good rigidity and had a penile length adequate for penetration after maximal activation. CONCLUSION: This video discusses the approach to penile prosthesis placement in patients with significant corporal fibrosis. It highlights the proper use of cutting cavernotomes and the availability of narrow-diameter prostheses, both malleable and inflatable.

Transurethral resection of ejaculatory ducts: a step-by-step guide.

OBJECTIVE: To demonstrate the key components for completing a successful transurethral resection of ejaculatory ducts (TURED) for completely obstructed ejaculatory ducts (EDs). DESIGN: Video presentation. SETTING: University Hospital. PATIENT(S): A 40-year-old man presenting with primary infertility and abnormal semen analysis (pH 6.4, volume of 0.7 cc, concentration 16 million/cc, and 7% motility) in whom a transrectal ultrasonography revealed dilated seminal vesicles measuring more than 1.5 cm and seminal vesicle aspiration detected no sperm in the aspirate. INTERVENTION(S): Transurethral resection of ejaculatory ducts. MAIN OUTCOME MEASURE(S): Intraoperative technique with commentary highlighting tips for a successful TURED. RESULT(S): This video provides a step-by-step guide for TURED, including transrectal ultrasonography-guided seminal vesicle puncture for instillation of methylene blue to allow more precise identification of EDs. Vesiculography was performed near the end of the procedure to assess for patency of EDs and confirm both sides had been opened. (Institutional review board approval was obtained for this presentation.) CONCLUSION(S): The key portions for performing a successful TURED includes seminal vesicle instillation of methylene blue for easier identification of EDs. Vesiculography is performed near the end of the procedure to ensure both EDs have been opened as well as to assess for passive drainage of the seminal vesicles through the newly open EDs.

Microsurgical identification and excision of an intratesticular mass.

OBJECTIVE: To demonstrate a step-by-step approach to microsurgical partial orchiectomy (PO) in a man with a small intratesticular mass. DESIGN: Video presentation. SETTING: University hospital. PATIENT(S): A 22-year-old man with right testicular pain and swelling found to have a small, nonpalpable 8-mm hypoechoic testicular mass on ultrasound. Tumor markers were negative. INTERVENTION(S): Partial orchiectomy. MAIN OUTCOME MEASURE(S): Intraoperative technique with commentary highlighting tips for a successful resection. RESULT(S): This video provides a brief introduction to and indications for PO as an alternative to radical orchiectomy. We describe the microsurgical approach to PO through an inguinal incision for the resection of a small intratesticular mass. CONCLUSION(S): Microsurgical PO should be considered for select patients as an alternative to radical orchiectomy. The microscopic approach provides a more precise resection with limited collateral damage to surrounding parenchyma.