Weill Medical College
Cornell Institute for Reproductive Medicine
Center for Male Reproductive Medicine and Microsurgery
"State-of-the-Art Compassionate Care for the Infertile Couple"
IntroductionIn the past 5 to 10 years, very few fields in modern medicine have changed as dramatically as reproductive medicine, especially, for the treatment of male infertility. These advances include in-vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) (injection of a single sperm into an egg), refined microsurgical reconstructive techniques (vasovasostomy and vasoepididymostomy), and microsurgical techniques of surgical sperm retrieval from the epididymis and testis. All men with epididymal obstruction now have the opportunity to father their own biological children.
What is the epididymis?The epididymis is a tightly coiled (15 foot long if uncoiled) tube behind the testis where sperm go after leaving the testicle. It is basically a swimming school for sperm. Testicular sperm are unable to swim or fertilize an egg naturally, and acquire these abilities as they pass through the epididymis.
The diameter of the epididymal tubules is only 200 microns (twice the diameter of a human hair) which is how 15 feet of length can fit into a structure about half the size of the pinky. After leaving the epididymis, sperm empty into the vas deferens, which transports the sperm to the ejaculation ducts, which empty into the urethra in the penis.
What is the vasoepididymostomy?Vasoepididymostomy is the microsurgical procedure for treatment of epididymal obstruction. It is the most difficult and technically challenging microsurgical procedure for the treatment of male infertility. Surgeons must have excellent microsurgical skills and extensive experience to be able to perform this anastomosic procedure between the vas deferens and epididymis.
What is the etiology of epididymal obstruction?
What are the advantages of vasoepididymostomy (VE) versus IVF-ICSI?The advantages of the vasoepididymostomy for treatment for the epididymal obstruction are:
Physical Examination and Laboratory Tests:Physical examination of men with epididymal obstruction may reveal a somewhat enlarged, indurated epididymis. Men with epididymal obstructions are typically azoospermic (zero sperm count) and have normal semen volume. Normal serum follicle-stimulating hormone (FSH) levels and normally sized testis with epididymal fullness suggest normal sperm production. A highly positive blood antisperm antibody test confirms sperm production and eliminates the need for a testis biopsy to confirm obstruction.
Surgical Indications:The indication for recommending and performing a vasoepididymostomy is the presence of active spermatogenesis (sperm production) in the testis, evidence of an epididymal obstruction and a patent (open) vas deferens. A general anesthesia or regional (continuous epidural block) is preferred when performing a vasoepididymostomy.
Testis Biopsy:A testis biopsy is only necessary to confirm normal sperm production when blood FSH is normal, testis size is normal and a blood antisperm antibody test is negative. . Testicular biopsy performed using an operating microscope allows identification of subtunical blood vessels and reduces operative morbidity. Bouin's solution, the most widely used fixative, minimizes distortion of the testicular architecture. Other options include Zenker's solution or buffered glutaraldehyde, which are used when electron microscopy is desired.
The surgeon must be comfortable in assessing biopsy slides to make a clear plan of action based on the results. The patient with normal spermatogenesis should have in the range of 20 mature spermatids per round tubule, whereas the patient with epididymal obstruction typically should have at least 30 mature spermatids per round tubule. Alternatively, a squash preparation can be performed at the time of reconstruction to assess for the presence of sperm. This procedure involves placing a small piece of testis on a slide, with a drop of Ringer's lactate; the specimen is then compressed under a glass coverslip. This wet preparation is examined for the presence of sperm using a high, dry (40 X) objective lens. After it has been established that active spermatogenesis is present, a reconstruction can be undertaken at the time of biopsy or at a later date. Sperm can also be aspirated at the time of biopsy for use for IVF/ICSI.
Vasography:It is also important and necessary to ensure that no other sites of obstruction are present within the genitourinary tract.
This is accomplished by performing a vasogram at the time of the vasoepididymostomy. The vas is isolated at the junction of the straight and convoluted portions. Under an operating microscope, the vasal sheath is vertically incised and the vasal vessels carefully preserved. Clean segment of bare vas is delivered, and a straight clamp is placed beneath the vas to act as a platform. The vas is hemi-transected with a 15° microknife until the lumen is revealed; the vasal fluid is examined for presence of sperm. The absence of sperm in the vasal fluid confirms epididymal obstruction. The seminal vesicle end of the vas is then cannulated with a 24-gauge angiocatheter sheath and injected with Ringer's lactate to confirm patency. If the Ringer's lactate passes easily, formal vasography is not necessary. If any doubt of the patency exists, 50% diluted indigo carmine dye may be injected and the bladder catheterized. The presence of blue dye in the urine confirms patency of the vas. If obstruction is suspected based on the Ringer's lactate and indigo carmine findings, then the site of obstruction is determined with formal vasography (use water-soluble radiographic contrast medium).
Surgical Preparation & Examination of Vas Deferens and Epididymis:The vas is exposed at the junction of the straight and convoluted portions and the vas deferens is opened. Vasal fluid is sampled. The presence of sperm in the vasal fluid signifies proximal vasal or ejaculatory duct obstruction and a vasogram is performed. If no sperm is found in the vasal fluid it means epididymal obstruction. Occasionally copious amounts of clear fluid without sperm are encountered. If no clear site of epididymal obstruction exists, a vasovasostomy should be performed. The tunica vaginalis is incised and the testes delivered. The epididymis is carefully visualized and palpated. Often a granuloma or area of relative induration above which dilated tubules are seen is present.
The incision and exposure for the vasoepididymostomy proceeds as with a vasovasostomy. It is performed to bypass the site of epididymal obstruction.
History of vasoepididymostomyDr. Edward Martin described the first successful vasoepididymostomy with subsequent pregnancy in 1902. He constructed a side-to-side vasoepididymal fistula using silver wire sutures in a man with epididymal obstruction secondary to a previous gonococcal infection. His reconstruction involved aligning the vas deferens adjacent to a slash made in multiple epididymal tubules. In general, vasoepididymostomy techniques can be broadly categorized as ‘‘fistula formation’’ based on Martin’s original technique or ‘‘tubule-to-tubule’’ as described by Dr. Silber. As Dr. AJ Thomas pointed out in 1987, although Silber generally is credited for the single tubule-to-tubule anastomosis, VD Lespinasse had a similar idea 60 years earlier, wherein a 5-0 silk suture was passed through a single epididymal loop and the mucosal surface of the vassal lumen.
Martin’s surgical standard was used for over 70 years until Dr. Sherman Silber reported a new microsurgical end-to-end technique for vasoepididymostomy in 1978. The success of Martin's technique depended on formation of a fistula between the epididymal tubule and the vas deferens. The average patency rates in the best cases were reported in literature between 1902 to 1980's less than 50%, with only 10% to 20% having normal semen analysis. Scarring with either partial or complete closure of the fistula is the major cause of failure of this procedure.
Many variations of this end-to-end anastomosis have been developed, but the end-to-end approach gradually fell out favor with the advancement of end-to-side techniques, in which a single epididymal loop is isolated and the anterior wall of the loop is unroofed for the anastomosis to the vas deferens. Resection of the epididymis for end-to-end anastomosis can result in bleeding and difficulty identifying a patent tubule. Dr. LV Wagenknecht in 1980 was one of the early advocates of the end-to-side technique and Dr. AJ Thomas in 1987 popularized the end-to-side concept of anastomosis.
In 1998, Berger published his triangulation end-to-side technique, which involves placement of three double-armed 10-0 nylon sutures into the epididymis so that each suture forms one side of a triangle. An opening is made in the epididymal tubule and the sutures are brought inside-out, invaginating the tubule into the vasal lumen. Ninety-two percent patency was achieved in 12 men with this technique. At Cornell, we have achieved and reported similar results at the 1999 American Urologic Association Annual Meeting in Dallas, TX, by using this technique. Dr. Joel Marmar in 2000 reported 2-sutue transverse technique. However, this technique has not been adapted by many microsurgeons. In 2003, Chan, Li and Goldstein from Weill Cornell introduced a widely accepted innovative two-suture longitudinal intussusception vasoepididymostomy technique, in which two double-armed or single-armed 10-0 nylon sutures are placed longitudinally along the anterior surface of a single epididymal tubule. The needles are pulled through only after the tubular opening is made. The sutures are placed into the vas deferens from inside out at four points and, when the sutures are tied, the epididymal tubule intussuscepts into the vasal lumen. The advantage is there is a larger opening in the epididymal tubule and shorter operative time.
This new technique of longitudinal intussusception vasoepididymostomy that developed at Cornell has become the most preferred technique for many microsurgeons worldwide.
It is very important to understand that vasoepididymostomy is the most technically demanding microsurgical procedure in urology and clinical andrology. In addition, the decision as to which to do is highly based on the surgeon's abilities and familiarity with each procedure as well as intraoperative findings. Therefore, the clinical outcome of this procedure is highly dependent on surgeon’s technical perfection. Patients should also ask or check the surgeon’s microsurgical training background. Microsurgical vasoepididymostomy should only be attempted by experienced microsurgeons who perform the procedure frequently. Male infertility microsurgical technique must be learned in a good microsurgical lab, not on the patients.
End-to-side techniques of vasoepididymostomy have the advantage of being minimally traumatic to the epididymis and relatively bloodless and also it does not disturb the epididymal blood supply. Currently, the longitudinal end-to-side intussusception vasoepididymostomy technique has become a preferred microsurgical procedure at Cornell.
When the level of epididymal obstruction is clearly demarcated by the presence of markedly dilated tubules proximally and collapsed tubules distally, the site at which the anastomosis should be performed is readily apparent. The end-to-side approach has the advantage of allowing accurate approximation of the muscularis and adventitia of the vas deferens to a precisely tailored opening in the tunica of the epididymis. This is the preferred technique when vasoepididymostomy is performed simultaneously with inguinal vasovasostomy because it is possible to preserve the vasal blood supply deriving from epididymal branches of the testicular artery. This provides blood supply to the segment of vas intervening between the two anastomoses. Maintenance of the deferential artery's contribution to the testicular blood supply is also important in situations where the integrity of the testicular artery is in doubt due to prior surgery such as orchidopexy, non-microscopic varicocelectomy or hernia repair.
The testis is delivered through a 3-4 centimeter high vertical scrotal incision. The vas deferens is identified, isolated with a Babcock clamp and then surrounded with a Penrose drain at the junction of the straight and convoluted portions of the vas deferens. Using 8-15 power magnification provided by the operating microscope, the vasal sheath is longitudinally incised with a micro-knife and a bare segment of vas stripped of its carefully preserved vessels is delivered. The vas is hemi-transected with the ultrasharp knife until the lumen is entered. The vasal fluid is sampled. If microscopic examination of this fluid reveals the absence of sperm, the diagnosis of epididymal obstruction is confirmed. Patency of the vas and ejaculatory ducts is confirmed by cannulating the abdominal end of the vas with a 24 g angiocatheter sheath and gently injecting lactated Ringer’s solution with a 1 ml tuberculin syringe. Further confirmation of patency may be obtained by injecting indigo carmine, catheterizing the bladder and observing blue tinged urine. The vas is then completely transected using a 2.5 mm slotted nerve clamp and the vas is prepared as for vasovasostomy as described earlier.
After opening the tunica vaginalis, the epididymis is inspected under the operating microscope. An anastomotic site is selected above the area of suspected obstruction, proximal to any visible sperm granulomas, where dilated epididymal tubules are clearly seen beneath the epididymal tunica. A relatively avascular area is grasped with sharp jeweler’s forceps and the epididymal tunica tented upward. A 3-4 mm bottonhole is made in the tunica with microscissors to create a round opening that matches the outer diameter of the previously prepared vas deferens. The epididymal tubules are then gently dissected with a combination of sharp and blunt dissection until dilated loops of tubule are clearly exposed, If the level of obstruction is not clearly delineated, after the buttonhole opening is made in the tunic, a 70 µm diameter tapered needle from the 10-0 nylon microsuture is used to puncture the epididymal tubule beginning as distal as possible and fluid sampled from the puncture site. When sperm are found, the puncture sites are sealed with micro-bipolar forceps, a new buttonhole made in the epididymal tunic just proximally and the tubule prepared as described previously. The vas deferens is drawn thru an opening in the tunica vaginalis and secured in proximity to the anastomotic site with 2 to 4 interrupted sutures of 6-0 polypropylene placed through the vasal adventitia and the tunica vaginalis. The vasal lumen should reach the opening in the epididymal tunica easily, with length to spare. The posterior edge of the epididymal tunica is then approximated to the posterior edge of the vas muscularis and adventitia with two to three interrupted sutures of double-armed 9-0 nylon .This is done in such a way as to bring the vasal lumen in close approximation to the epididymal tubule selected for anastomosis.
Weill Cornell preferred Longitudinal Intussusception Vasoepididymostomy (LIVE) :
The LIVE technique was developed at Cornell in 2003, which has become our preferred microsurgical technique for vasoepididymostomy. The setup is identical to that for the single-armed suture technique described above in which the abdominal side of the vas is anchored to the epididymal tunic with a single 10-0 nylon suture. However, two 10-0 nylon double-armed sutures are used (Sharpoint AK-0101, Surgical Specialties Corp.) with a different suture placement pattern. In the initial step, one needle from each of the two sutures is placed longitudinally along both edges of the selected epididymal tubule parallel to each other in the same configuration as above, without pulling the needles through, then, the epididymal tubule is opened longitudinally between the two needles. The needles are pulled through and prepared for placement through the vas . Starting with the first suture, the needle on one end is passed inside-out through the mucosal layer of the vas at position a1 while the needle on the other end is passed inside-out through position a2 . The same maneuver is performed with the second suture. One needle is passed inside-out through the mucosal layer of the vas at position b1 and the needle on the other end of the suture is passed inside-out through position b2). The two sutures are tied down (a1 to a2 and b1 to b2), resulting in intussusception of the epididymal tubule into the vasal lumen.
The epididymal tunic is secured to the vasal muscle and adventitia with eight to ten interrupted 10-0 nylon sutures using the remaining length of the single-armed sutures.
The advantages of the longitudinal end-to-side intussusception technique are:
The keys to successful employment of the triangulation end-to-side technique are:
Cornell Youtube Video Library:
Key words: Cornellbrady 1, Marc Goldstein, Peter N. Schlegel
References:1. H.H. Kim and M. Goldstein, History of vasectomy reversal: Vasectomy and vasectomy reversal . Urol Clinics of NA, 36(3):359-373, 2009.
2. Goldstein, M., Li, P.S, Gerald, J.M.: Microsurgical Vasovasostomy: The Microdot Technique Of Precision Suture Placement. J. of Urol. 159: 188-198, 1998
3. G.J. Matthews, P.N. Schlegel, and M. Goldstein, Patency following microsurgical vasoepididymostomy and vasovasostomy: Temporal considerations. J. Urol. 154:2070-2073, 1995.
4. G.J. Matthews and M. Goldstein, A simple technique for the atraumatic recovery of sperm at the time of microsurgical vasoepididymostomy. Urology 47:123-125, 1996.
5. McCallum, S, Li, P.S, SU, LM, Sheynkin Y, Chan P, and Goldstein, M: Comparison of triangulation end-to-side and conventional end-to-side microsurgical vasoepididymostomy in rats. J. Urol, 167:2284-2288, 2002
6. R.A. Costabile, M. Goldstein, P. Schlegel, A.L. Belker, L. Lipschultz, I. Sharlip, A.J. Thomas, D.C. Park, and M. Spevak, Technique of vasovasostomy and vaso-epididymostomy:Shortening the learning curve. AUA Update Series 36:282-287, 1999.
7. Chan, P, Li, PS and Goldstein, M: Microsurgical Vasoepididymostomy: A Randomized Study of the Different intussuception techniques in rats. 169:1924-1929, J. of Urology, May 2003
8. Schiff, JD, Li, PS Goldstein, M: Robotic Microsurgical Vasovasostomy and Vasoepididymostomy: A prospective Random Study in rat model. J. of Urology, 171:1720-1725; April 2004.
9. J. Schiff, P.S. Li, M. Goldstein: Robotic microsurgical vasovasostomy and vasoepididymostomy: A prospective randomized study in a rat model. J. Urol., 171,1720-1725, 2004.
10. P.T.K. Chan, R.A. Brandell, M. Goldstein, Prospective analysis of outcomes after microsurgical intussusception vaso-epididymostomy. B. J. U. Int., 96, 598-601, 2005.
11. Monoski, M, Schiff, J, Li, PS, Chan, P, Goldstein, M: A new approach for a safe and successful use of single-armed sutures in microsurgical vasoepididymostomy. Urology, 69 (4): 800-804, April 2007