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.

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.

Systematic review based on a Pubmed search of surgeries to improve male fertility.

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.

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.

Obstructive azoospermia (OA) is an important cause of male infertility, and epididymal OA (EOA) is a common disease. Microsurgical reconstruction is a common technique used in the treatment of EOA. In the present study, we analyzed the effectiveness of microsurgical vasoepididymostomy (MVE) at different levels and compared the differences among several MVE techniques.

A literature search was conducted in the PubMed, Web of Science, and Embase databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The included studies were published in English until May 14, 2021. The R 4.1.2 software was utilized to evaluate the event rate, risk ratio (RR), and 95% confidence interval (CI).

A total of 51 studies involving 2853 patients with OA were included in our meta-analysis. The overall mean patency rate of patients who underwent MVE was 67.20% (95% [CI]:63.30%-71.10%), and the overall mean natural pregnancy rate of their partners was 40.05% (95% [CI]: 35.30%-45.60%). The pooled results showed that the patency rate of bilateral MVE was higher than that of unilateral MVE (RR = 1.42; 95% [CI]:1.25-1.61; p < 0.00). A comparison of the anastomotic site of MVE showed that the caudal/corpus area was favorable for the patency rate (RR = 1.17; 95% [CI]:1.04 - 1.32; p < 0.00). The caudal area was also advantageous for the patency rate (RR = 1.20; 95% CI:1.03 - 1.41; p < 0.04). Compared with typical MVE (65.20%, 95% [CI]:61.40%-69.10%), deferential vessel-sparing MVE with a higher overall mean patency rate (83.60%, 95% [CI]:75.40%-91.70%).

The meta-analyses indicated that MVE is a high- and cost-effective therapeutic method for patients with EOA, and deferential vessel-sparing MVE could be mainstream in the near future.

The basic principles of vasal reconstruction have endured since their initial description over a century ago, yet the nuances and technical approaches have evolved. Prior to performing vasectomy reversal, the clinician should perform a focused history, physical and laboratory assessment, all of which are critical for patient counseling and preoperative planning. Operative success is contingent on appropriate intraoperative decision making and technical precision in completing a tension-free, watertight, and patent anastomosis. Outcomes of vasectomy reversal differ on the basis of the type of reconstruction required, reconstructive technique, and patient-specific factors. Here we review the indications, surgical techniques, and outcomes of vasectomy reversal.

Double-armed suture longitudinal intussusception vasoepididymostomy (DA-LIVE) has been widely adopted owing to its simplicity and high success rate; however, specialized double-armed microsutures are required.

To provide a novel single-armed suture longitudinal intussusception vasoepididymostomy (SA-LIVE) technique using only two single-armed sutures, named Guo's SA-LIVE.

Four weeks after vasectomy in male adult Wistar rats, vasoepididymostomies were performed using DA-LIVE, SA-LIVE, or Guo's SA-LIVE. After 12 weeks, functional patency was functionally assessed by evaluating for motile spermatozoa distal to the anastomosis. If no motile spermatozoa were visible, the mechanical patency of the anastomosis was tested by the ability of methylene blue to pass through the surgical anastomosis. The key procedure in Guo's SA-LIVE was cutting each needle with over 1cm attaching suture and making a flat overhand bend knot to tie the needle to the other end of the suture, after the needles were passed through the epididymal tubule and then the vasal lumen in an inside-out fashion, and then, the needles were passed through the vasal lumen in an inside-out fashion.

The proportions of functional patency were 50.0% (3/6), 33.3% (2/6), and 50% (3/6) for the DA-LIVE, SA-LIVE, and Guo's SA-LIVE groups, respectively (P = .799). The proportions of mechanical plus functional patency for the three methods were 83.3% (5/6), 66.7% (4/6), and 83.3% (5/6), respectively (P = .725). The mean anastomosis times for the three LIVE techniques and the proportions of complications were similar (P = .150 and .758, respectively).

Guo's single-armed suture technique is a potentially effective alternative to perform vasoepididymostomy when specialized double-armed microsutures are not available based on the current animal experiment.

Vasoepididymostomy is an ideal surgical approach for epididymal obstructive azoospermia. The aim of the present study was to compare reproductive outcomes of vasoepididymostomy with several anastomotic techniques, including end-to-side and longitudinal intussusception vasoepididymostomy, and partial intussusception and endo-to-side vasoepididymostomy.

A case-control study including 110 infertile men with epididymal obstructive azoospermia with mean age of 35 years was carried out. Univariate and multivariate analyses using clinical factors were carried out to predict patency and non-assisted reproductive technology pregnancy. Johnsen score count and proliferating cell nuclear antigen expression were used as surrogates for spermatogenic function. Operative time, number of 10-0 sutures and late failure rates were also compared.

The overall patency and non-assisted reproductive technology pregnancy rates were 70% and 32%, respectively. Multivariate analyses showed that the presence of motile sperm in the epididymis and a higher spermatogenic function (P < 0.05) were independent predictors for patency, and that a higher spermatogenic function and anastomosis at the caput/corpus (P < 0.001) were predictors for non-assisted reproductive technology pregnancy. The operative time was significantly shorter with partial intussusception and endo-to-side than with the other techniques (P < 0.001), and the number of 10-0 sutures was significantly less with partial intussusception and endo-to-side than with longitudinal intussusception vasoepididymostomy (P < 0.01).

Partial intussusception and endo-to-side as well as end-to-side and longitudinal intussusception vasoepididymostomy are feasible vasoepididymostomy techniques for epididymal obstruction. Spermatogenic function plays important roles in patency and non-assisted reproductive technology pregnancy after vasoepididymostomy. Depending on the surgeon's expertise, partial intussusception and endo-to-side provides similar functional outcomes to those of more established vasoepididymostomy techniques, such as end-to-side and longitudinal intussusception vasoepididymostomy, and it could therefore be considered an effective technique for seminal reconstruction in patients with epididymal obstructive azoospermia.

Infertility due to obstructive azoospermia may be treated effectively by surgical reconstruction or by retrieval of sperm from the epididymis or testis, followed by in vitro fertilization with intracytoplasmic sperm injection. This replaces the ASRM documents titled "Sperm retrieval for obstructive azoospermia" and "The management of infertility due to obstructive azoospermia," last published in 2008.

To describe and evaluate the outcomes of a new epididymovasostomy technique.

Nine patients with obstructive azoospermia were treated at the Minia University Hospital using a new microsurgical bilateral epididymovasostomy technique. The technique involved the opening of a small window in the tunica of the epididymis, making an opening in the underneath epididymal tubule and keeping it open by fixing the edges of the epididymal opening to the edge of the epididymal tunica with four 10/0 nylon sutures. The abdominal cut end of the vas deferens was then anastomosed to the epididymal opening by suturing the epididymal tubule, fixed to its tunica in one layer, to the full thickness vas deferens. The main outcome measure was finding sperm in the ejaculate.

Sperm was found in the ejaculate in six out of nine patients after our new, one-layer, epididymovasostomy technique. Mean ± sd operating time was 176 ± 23 min.

This new, one-layer, epididymovasostomy technique provides a simple alternative method of epididymovasostomy, with reasonable outcomes. More cases and follow-up are needed to make meaningful comparisons with conventional epididymovasostomy.

Obstructive azoospermia secondary to epididymal obstruction can be corrected by microsurgical reconstruction with vasoepididymostomy (VE). Although alternative management such as epididymal or testicular sperm aspiration in conjunction with intracytoplasmic sperm injection is feasible, various studies have established the superior cost-effectiveness of VE as a treatment of choice. Microsurgical VE is considered one of the most technically challenging microsurgeries. Its success rate is highly dependent on the skills and experience of the surgeons. Various techniques have been described in the literature for VE. We have pioneered a technique known as longitudinal intussusception VE (LIVE) in which the epididymal tubule is opened longitudinally to obtain a larger opening to allow its tubular content to pass through the anastomosis. Our preliminary data demonstrated a patency rate of over 90%. This technique has been widely referenced in the recent literature including robotic-assisted microsurgery. The history of the development of different VE approaches, the preoperative evaluation along with the techniques of various VE will be described in this article.

This study is to evaluate the effectiveness of a modified single-armed suture technique for microsurgical vasoepididymostomy (VE) in patients with epididymal obstructive azoospermia. From September 2011 to December 2011, microsurgical two-suture longitudinal intussusception VEs were performed using our modified single-armed suture technique in 17 men with epididymal obstructive azoospermia at our hospital. Two of these patients underwent repeated VEs after previous failed VEs, and one patient underwent unilateral VE because of an occlusion of the left abdominal vas deferens. The presence of sperm in the semen sample at 3 months postoperation was used as the preliminary endpoint of this study. Each patient provided at least one semen sample at the 3-month time point, and the patency was assessed by the reappearance of sperm (>10(4) ml(-1)) in the semen. The mean operative time for the modified technique was 219 min. Patency was noted in 10 men (58.8%), including one patient who underwent repeated VE. The patient who underwent unilateral anastomosis manifested no sperm postoperatively in his semen. Sperm granulomas were not detected in this cohort. The results of this study demonstrate that our modified technique for microsurgical longitudinal intussusception VE is effective. We believe that it is a practical alternative that may reduce operation time and obviate the suture crossing.

Since its inception in early 2000, robotic assistance with urologic procedures continues to expand. The magnification, three-dimensional visualization, and surgical control offered by the latest daVinci Si-HD system has led to its integration into microsurgical procedures for male infertility. The addition of robotic assistance may allow an improvement in outcomes similar to when the operating microscope was introduced in microsurgery. Though the use of robotics in microsurgery is still in its early phases, initial findings are encouraging.

This review covers robotic microsurgical procedures and tools for infertility and chronic orchialgia/testicular pain such as vasovasostomy, vasoepididymostomy, varicocelectomy, testicular sperm extraction and targeted denervation of the spermatic cord. Preliminary human clinical studies appear to show improved operative efficiency and comparable outcomes. The use of robotic assistance during robotic microsurgical vasovasostomy appears to decrease operative duration and improve the rate of return of postoperative sperm counts compared to the pure microsurgical technique.

Long-term prospective controlled trials are necessary to assess the true benefit for robotic-assisted microsurgery. The preliminary findings are promising, but further evaluation is warranted.

Evaluation and surgical treatment of male infertility has evolved and expanded, now leading to more precise diagnoses and tailored treatments with diminished morbidity and greater success. Surgeries for male infertility are divided into four major categories: (i) diagnostic surgery; (ii) surgery to improve sperm production; (iii) surgery to improve sperm delivery; and (iv) surgery to retrieve sperm for use with in vitro fertilization and intracytoplasmic sperm injection (IVF-ICSI). While today we are more successful than ever in treating male infertility, pregnancy is still not always achieved likely due to factors that remain poorly understood. Clinicians treating infertility should advocate for couple-based therapy, and require that both partners have a thorough evaluation and an informed discussion before undergoing specific surgical therapies.

The use of robotic assistance during microsurgical procedures has evolved from its early beginnings in the early 2000s. Currently, its use is expanding in the treatment of male infertility and patients with chronic testicular or groin pain. The addition of this technology may allow an improvement in outcomes as when the operating microscope was introduced in microsurgery. However, this is yet to be proven.

This review covers new robotic microsurgical tools and applications of the robotic platform in microsurgical procedures such as vasectomy reversal, varicocelectomy, microsurgical denervation of the spermatic cord for chronic testicular or groin pain, post-vasectomy pain, sports hernia pain, postnephrectomy, donor nephrectomy and phantom groin pain. Preliminary animal studies show an advantage in terms of improved operative efficiency and improved surgical outcomes. Preliminary human clinical studies appear to support these findings. The use of robotic assistance during robotic microsurgical vasovasostomy appears to decrease operative duration and improve early postoperative sperm counts compared to the pure microsurgical technique.

Long-term prospective controlled trials are necessary to assess the true cost-benefit ratio for robotic assisted microsurgery. The preliminary findings are promising and evidence is mounting, but further evaluation is warranted.

Assisted reproductive technology is an evolving area, and several adjuvant procedures have been created to increase a couple's chance of conceiving. For male infertility, the current challenges are to properly accommodate old and new techniques that are both cost-effective and evidence-based. In this context, urologists are expected to diagnose, counsel, provide medical or surgical treatment whenever possible and/or correctly refer male patients for assisted conception. Urologists are sometimes part of a multiprofessional team in an assisted reproduction unit and are responsible for the above-cited tasks as well as the surgical retrieval of sperm from either the epididymides or testicles. We present a comprehensive review of the surgical treatment options for infertile males, including the perioperative planning and prognostic aspects, with an emphasis on the role of microsurgery in the optimization of treatment results. This review also discusses current techniques for sperm retrieval that are used in association with assisted reproductive technology and includes sperm retrieval success rates according to the technique and the type of azoospermia. New insights are provided with regard to each surgical treatment option in view of the availability of assisted conception to overcome male infertility.

To evaluate the clinical outcomes of loupe-assisted intussusception vasoepididymostomy (VE) in the treatment of epididymal obstructive azoospermia (EOA), we retrospectively analyzed data from 49 patients with EOA who underwent two-suture longitudinal intussusception vasoepididymostomy (LIVE) between 2000 and 2007. The data included the surgical method, postoperative motile sperm count per ejaculation, percentage of progressive motile sperm and patency and pregnancy outcomes. There were a total of 49 men undergoing scrotal exploration, and epididymal obstruction was found in all cases. Bilateral or unilateral anastomoses were performed in 40 and 6 men, respectively. The postoperative courses of 42 patients were followed up for more than 6 months, and the courses of 38 patients were followed up for more than 1 year. The overall patency and pregnancy rates were 71.4% and 26.3%, respectively. Moreover, progressive motile sperm was more frequently present in those patients who had undergone anastomosis at cauda than at corpus or caput. Pregnancy was achieved only in those patients who had undergone anastomosis at least on one side of the cauda epididymis. We think that the loupe-assisted method, with a lower overall cost and a simplified surgical procedure, can achieve satisfactory patency outcomes and pregnancy results. Data from this paper also suggest that paternity outcomes occur more frequently after anastomoses at cauda than at corpus or caput.

Microsurgical reconstruction to correct male infertility, although usually performed for vasectomy reversal, also is performed to correct other types of iatrogenic, congenital, and postinflammatory obstruction. In an effort to improve success rates and facilitate performance of these complex microsurgical procedures, modifications are continually suggested. This article reviews some of these proposed modifications. The modifications can be divided into five general categories: (1) use of biomaterials/sealants, (2) laser soldering, (3) use of absorbable and nonabsorbable stents, (4) new intussusception vasoepididymostomy (VE) anastomotic techniques, and (5) use of robotics.

A less-invasive approach for vasoepididymostomy is described. The technique might decrease postoperative discomfort and swelling by obviating the need to make a large scrotal incision for complete exteriorization of the testis to perform an accurate and successful anastomosis.

Vasoepididymostomy outcomes are heavily dependent on the surgeon's microsurgical experience and skill. To avoid back-walling the tubular lumen, the needles are generally placed inside-out through the vasal lumen using double-armed microsutures. These double-armed sutures for infertility microsurgery are very expensive and may be difficult to obtain. We describe a randomized trial that used a novel single-armed suture placement pattern for vasoepididymostomy.

Male adult Wistar rats underwent vasectomy. Two weeks later, vasoepididymostomies were performed using either a single-armed longitudinal intussusception vasoepididymostomy (n = 6) or a standard double-armed longitudinal intussusception vasoepididymostomy (n = 6) technique. After 9 weeks, patency was assessed functionally by evaluating for motile sperm distal to the anastomosis. If no motile sperm were visible, the mechanical patency of the anastomoses was tested by the ability of methylene blue to pass through the surgical anastomosis.

The patency rate for the double-armed vasoepididymostomy group was 100% (6 of 6) compared with 83.3% (5 of 6) for the single-armed vasoepididymostomy group. This difference was not significant (P = 0.50). Sperm granulomas were found in three (50%) of six anastomoses in the double-armed group and five (83%) of six anastomoses in the single-armed vasoepididymostomy group (P = 0.27). The mean operative times for the double and single-armed longitudinal intussusception vasoepididymostomy techniques were similar (35 minutes versus 43 minutes; P = 0.39).

The results of our study have shown that the single-armed suture technique to perform vasoepididymostomy is almost as effective as the double-armed technique. Although we still prefer to use double-armed sutures, we believe that this is a practical and effective alternative when specialized double-armed microsurgical sutures are not available.

Although the objective of the urologist is to correct the factors of male infertility and to favour natural procreation, the strategy must consider also the couple and the female aspects of infertility. Some types of male infertility require specific treatment. In severe cases, recent advances in medical assistance to procreation have changed the prognosis of male infertility. Pregnancy can be obtained by the means of gamet manipulation and spermatozoid selection. Nevertheless, such techniques expose to genetic disorders transmission. Subsequently, genetic assessment is required during male infertility management, especially for difficult cases.

We retrospectively reviewed our experiences with repeat vasectomy reversal and report the patency and natural pregnancy rates. Our data demonstrate that repeat vasectomy reversal is a valid option in patients with a failed initial reversal, although the suitability of repeat reversal should be based on the obstructive interval, the original reversal, the experience of the reversal surgeon, and any female factors, as well as the couple's wishes.

We determined the feasibility and outcome of microsurgical reconstruction of the excurrent ductal tract in men with obstruction secondary to iatrogenic injury to the epididymis from hydrocelectomy.

A retrospective chart review was done to identify men with iatrogenic injury to the epididymis or scrotal vas deferens and a history of hydrocelectomy. The outcome of microsurgical reconstruction was assessed by postoperative semen analysis. Pregnancy data were noted in patients actively attempting to conceive at a followup of 6 months or greater.

Eight men were found to have iatrogenic injury to the epididymides (6) or scrotal vas deferens (2) due to previous hydrocelectomy. Injury was bilateral in 4 men and unilateral in 4 with contralateral testicular absence, dysfunction or obstruction resulting from different etiologies, rendering all patients azoospermic. The mean obstructive interval was 16 years (range 6 to 32). Bilateral and unilateral vasoepididymostomy was performed in 4 and 2 men each, and crossed vasovasostomy was performed in 2. Postoperative semen analysis data were available on 6 men. A patent microsurgical anastomosis was observed in 5 of 6 cases (83%). Four of the 5 men with patency had a followup of greater than 6 months, of whom 3 actively pursued conception. One pregnancy was achieved naturally and 1 was achieved by in vitro fertilization with intracytoplasmic sperm injection.

Hydrocelectomy may result in inadvertent injury to the excurrent ductal tract, causing obstruction and infertility. Microsurgical reconstruction results in the restoration of spermatozoa to the ejaculate in 83% of cases. The return of spermatozoa to the ejaculate may provide the couple with an opportunity to conceive naturally or through assisted reproduction.

The introduction of microsurgical techniques has revolutionized the treatment of male infertility. As a result of technical advances and innovation over the past 10-15 years, previously infertile couples are now able to conceive naturally or to parent their own biological children with the aid of assisted reproductive technologies. This article reviews the indications, techniques, and outcomes of the various microsurgical procedures currently used to optimize male fertility. The most up-to-date methods of microsurgical vasal and epididymal reconstruction, sperm retrieval, and varicocele repair are discussed.

Vasoepididymostomy remains one of the most technically challenging procedures in all of microsurgery. The technique has evolved from an end-to-end, to an end-to-side technique, then to intussusception end-to-side methods. We recently reported the superiority of 2-suture longitudinal and 3-suture triangulation intussusception techniques in rats. In the present study we report our results in humans. We evaluated all vasoepididymostomies performed by 1 surgeon from January 1992 until the present for patency, pregnancy and for disappearance of sperm after initial return of sperm to the ejaculate.

We recorded the results of 153 consecutive vasoepdidymostomies done by 1 surgeon (MG) from January 1992 until February 2004. Four techniques were used, namely end-to-end (EE), end-to-side (ES), 3-suture triangulation intussusception (TIVE) and 2-suture longitudinal intussusception (LIVE). Data collected included technique, months of followup, sperm density, motility and morphology (WHO 1992 criteria), pregnancy outcome and late failures. Late failures were defined as having return of sperm to the ejaculate after vasoepididymostomy and then becoming azoospermic on at least 2 subsequent semen analyses.

A total of 153 men underwent bilateral vasoepididymostomies. The most recent 17 were LIVE, preceeded by 38 TIVE, 32 ES and 66 EE. Mean followup for the groups were 17.2 (LIVE), 70.8 (TIVE), 116.7 (ES) and 140.2 (EE) months, respectively. Intact sperm were seen in the ejaculates of 12 men (80%) in the LIVE group, 16 in the TIVE group (84%), 20 in the ES group (74%) and 30 men in the EE group (73%). Motile sperm were found in the ejaculates of 10 of 15 (67%) in the LIVE group, 13 of 19 (68%) in the TIVE group, 10 of 27 (37%) in the ES group and 20 of 41 (49%) in the EE group (p =0.2). Mean times for return of sperm to the ejaculate were 2.9, 2.8, 2.8 and 3.5 months, respectively. Pregnancies were reported by 4 men in the LIVE group all before 12 months, 6 in the TIVE group and 3 were by 12 months, and 4 each by the ES and EE groups with 3 and 2 by 12 months (p =0.07). Thus far, there have been no late failures in the LIVE group, only 1 in the TIVE group (8%), 5 in the ES group (50%) and 6 in the EE group (30%) (p =0.04).

Although vasoepididymostomy remains a technically demanding microsurgical procedure, recent technical innovations of TIVE and LIVE offer better or comparable outcomes compared with EE and ES procedures with the use of fewer sutures, which simplifies the performance of the anastomosis. In addition, the late failure rate is lower with the use of the intussusception techniques (LIVE and TIVE) with only 1 late failure in 22 men with return of sperm to the ejaculate procedures (4%) compared with 11 of 30 (37%) in the nonintussusception groups (p =0.006).

We devised a model to predict, preoperatively, the need for a vasoepididymostomy (VE) when performing a vasectomy reversal. Urologists could use it to identify those patients who need a referral to an experienced VE surgeon.

We performed a retrospective review of 483 patients who underwent vasectomy reversal by a single surgeon (AJT) including 393 vasovasostomies and 90 vasoepididymostomies. Selection was based on chart availability. Established criteria were used in deciding the type of reversal (eg gross appearance and microscopic examination of vasal fluid). Type of reversal, patient age and time since vasectomy were recorded. Univariate analysis revealed that patient age (p <0.001) and time since vasectomy (p <0.001) were significant predictors of reversal type. On multivariate logistic regression analysis, time since vasectomy (p <0.001) was the only significant independent predictor. We designed a linear regression algorithm based on time since vasectomy and patient age to predict if a VE would be performed. The model was designed using 433 patients and then tested on a separate randomly selected 50 patient group. The model was designed to be 100% sensitive in detecting patients requiring VE.

In the test group the model was 100% sensitive in predicting VE with a specificity of 58.8%. The area under the ROC curves for the design and test groups was 0.8. Palm (PalmSource Inc., Sunnyvale, California) and Windows (Microsoft Corporation, Redmond, Washington) versions are available as free shareware from www.uroengineering.com.

The model is 100% sensitivity in detecting those patients who may require a VE during vasectomy reversal (specificity of 58.8%). It may allow urologists to preoperatively identify these patients.

Microsurgical reversal surgery for the treatment of vasal and epididymal obstruction represents one of the most challenging procedures in urology. An awareness of the latest information surrounding these procedures is essential to success. This article discusses current techniques in preparation, anastomosis, and investigational methods.

Vasoepididymostomy is a technically demanding procedure that requires excellent positioning of the abdominal vas deferens at the epididymal tubule as well as a tension-free anastomosis. We describe a novel technique of securing the vas deferens to the testicle that allows manipulation of the epididymis and ensures a tension-free anastomosis.

After the vas deferens and epididymis are isolated in the usual fashion the vas is brought to the lateral portion of the testicle. A stay stitch is placed on the abdominal vas. This stay stitch is then placed through the tunica albuginea immediately posterior to the corpus or cauda epididymis. This allows the epididymis to slide in cephalad and caudad fashion prior to vasoepididymostomy and allows a tension-free anastomosis.

We have used this technique routinely for vasoepididymostomy without any associated complications and have found it to be technically feasible in our last 50 cases.

Although it is simple, the epididymal slide technique allows minimal to no distortion of the epididymal tubule, secure and safe fixation of the vas deferens, flexibility in choosing an appropriate epididymal tubule and tailoring of tension at the conclusion of the procedure. This technique is now used routinely at our center to allow a tension-free anastomosis during vasoepididymostomy and it has been technically feasible in all of our last 50 cases.

Microsurgical vasovasostomy and vasoepididymostomy remain technically challenging procedures. Refinements in technique have continually improved patency and pregnancy rates for the 2 procedures in experienced hands. Advances in surgical robotics produced the Da Vinci robot (Intuitive Surgical, Inc., Sunnyvale, California) with motion reduction and no tremor, features that may improve outcomes in microsurgery. We report a randomized prospective study of vasoepididymostomy and vasovasostomy using the Da Vinci robot in rats.

A total of 24 adult male Wistar rats underwent vasectomy through a midline abdominal incision. Two weeks later the animals were randomized to microsurgical multilayer vasovasostomy, longitudinal vasoepididymostomy or robotic vasovasostomy and vasoepididymostomy groups. Outcomes measured included surgical time, complications, patency and sperm granuloma formation at 9 weeks.

Animals were sacrificed 9 weeks after microsurgery. There were no significant differences in complications among the groups. Robotic vasovasostomy was significantly faster than the conventional microsurgical technique (68.5 vs 102.5 minutes, p = 0.002). The robotic and microsurgical vasoepididymostomy groups did not differ significantly in time. Patency rates were 100% for the robotic vasovasostomy and vasoepididymostomy groups, and 90% in the microsurgical vasovasostomy and vasoepididymostomy groups. These differences were not significant. Sperm granulomas were found in 70% of microsurgical vasovasostomy anastomoses and 27% of robotic vasovasostomy anastomoses (p = 0.001). No significant difference in the sperm granuloma rate was found between the robotic or microsurgical vasoepididymostomy groups (42% and 50%, respectively, p = 0.37).

To our knowledge we report the first randomized prospective study using the Da Vinci robot for microsurgery. We believe that the improved stability and motion reduction during microsurgical suturing with the robot helped achieve excellent patency rates for vasovasostomy and vasoepididymostomy. The robot may also allow experienced microsurgeons to perform microsurgical procedures in patients at remote locations where no experienced microsurgeons are available.

We studied the impact of the interval from vasectomy to reversal and presence of sperm granuloma on outcomes of reversal.

A total of 213 microsurgical vasectomy reversals performed by a single surgeon were stratified according to obstructive intervals of less than 5 years, 5 to 10 years, 10 to 15 years and greater than 15 years. The effects of obstructive interval on patency and pregnancy rates were assessed using multivariate logistical regression. The impact of sperm granuloma on patency and pregnancy was assessed using the chi-square test.

Patency did not change with increasing obstructive intervals as can be seen with 91% patency at less than 5 years, 88% at 5 to 10 years, 91% at 10 to 15 and 89% at greater than 15 years. There was no difference in pregnancy rates (89%, 82% or 86%) at obstructive intervals of 0 to 5, 5 to 10 or 10 to 15 years, respectively. Pregnancy rates were significantly lower (44%, p <0.05) with obstructive intervals greater than 15 years. Men with at least unilateral sperm granuloma had patency of 95% vs 78% without granulomas, a trend which did not quite reach statistical significance (p = 0.07). There was no difference in pregnancy rates with or without granulomas.

Vasectomy reversal patency rates are high regardless of time since vasectomy. Pregnancy rates are lower more than 15 years after vasectomy. Sperm granuloma had a favorable impact on patency. Our data indicate that for obstructive intervals less than 15 years vasectomy reversal yields much higher pregnancy rates than in vitro fertilization and intracytoplasmic sperm injection, and that even for intervals greater than 15 years reversal outcomes equal or exceed those of in vitro fertilization and intracytoplasmic sperm injection.

Background: Although the number of patients receiving vasoepididymostomies is gradually increasing, these individuals are limited in the recent advanced assisted reproductive technology (ART) era. A novel technique involving vasoepididymostomy with epididymal tubular invagination has been reported. We attempted to define the results of this method and to compare them with the conventional end-to-side technique in patients with suspected epididymal obstruction and no previous history of vasectomy. Methods and Results: Eight eligible triangulation end-to-side vasoepididymostomy procedures performed on five azoospermic patients exhibiting either unilateral or bilateral epididymal obstruction are described. The overall patency rate following operation was 100% (five of five). Two pregnancies were achieved by natural intercourse and one was accomplished via artificial insemination. A single pregnancy was obtained with an intracytoplasmic sperm injection using frozen-thawed sperm collected during the operation. Conclusion: Vasoepididymostomy, using the triangulation technique for epididymal obstruction, resulted in an earlier patency in all patients. This method may afford advantages when compared with the conventional end-to-side approach; however, larger subject populations are required in order to assess further the efficacy of this procedure. In addition, long-term follow up is necessary. (Reprod Med Biol 2003; 2: 101-104).

We review the outcomes after vasectomy reversal for couples with female partners 35 years old or older.

A retrospective review of experience at 2 institutions was performed. Patency was defined as the presence of motile sperm. Patients with less than 6 months of followup were excluded from the patency rate analysis unless they had sperm in the semen. Similarly, patients with less than 12 months of followup or no ongoing interest in establishing conception were excluded from the pregnancy rate analysis unless they had established a pregnancy or they were azoospermic with sufficient followup.

A total of 46 men with partners 35 years old or older underwent vasectomy reversal at 2 institutions. Mean partner age was 37 +/- 2 years, and median obstructive interval was 10 years. Bilateral vasovasostomy was performed in 43 men, unilateral vasovasostomy in 2 and vasovasostomy/vasoepididymostomy in 1. Of the 46 men 27 had followup semen analyses with a patency rate of 81% (22). Transient patency occurred in 2 cases (7%). Pregnancy occurred in 35% of the couples (14 of 40 patients) with sufficient followup. The ongoing/live delivery rate was 33% (13 of 40 cases). The pregnancy and ongoing/delivery rates were 46% (12 of 26 patients) and 46% (12 of 26) for female partners 35 to 39 years old, and 14% (2 of 14) and 7% (1 of 14) for female partners older than 40, respectively.

Vasectomy reversal offers reasonable chance for success when the female partner is 35 years old or older. The chance for success is similar to that of a single cycle of in vitro fertilization with intracytoplasmic sperm injection. These couples should not be eliminated from consideration for reversal simply because the female partner is 35 years old or older.