Surgical approaches

The testis was accessed through a 3–4 cm vertical scrotal incision, and the vas was exposed at the junction of the straight and convoluted portions. Under the operating microscope, the deferential vessels were visible and easy to identify along the vas deferens. A vascular sling was passed through the gap between the vas deferens and deferential vessels. The vas was lifted, and the small vertical branches of the deferential vessels supplying the vas were bluntly separated and cauterized by low-power microsurgical cautery. Then, the deferential vessels were carefully separated from the vas deferens for 1–3 cm (Figure 2). A microvascular Doppler ultrasound (VTI 20 MHz, Vascular Technology, Inc., Nashua, NH, USA) was used to identify the deferential artery and ensure that no inadvertent injuries to the deferential artery occurred during microsurgical dissection and anastomosis. After vasal hemisection, epididymal obstruction was confirmed by the absence of sperm in the fluid collected from the testicular end, while distal patency was confirmed by infusing diluted methylene blue through the abdominal vas and detecting dye in the urine. A suitable site for anastomosis on the epididymis was chosen by examining the dilated epididymal tubules under the operating microscope. The vas deferens was fully transected, and the isolated segment of the vas deferens was passed through a small window in the parietal tunica vaginalis to reach the anastomotic site. If the length of the vas deferens was insufficient to achieve a tension-free anastomosis, the distal vas with its vessels was further mobilized toward the external ring.

Deferential vessel-sparing technique. (a) The deferential vessels were dissected from the vas deferens. (b) The 1–3 cm isolated segment of the vas deferens.

Our modified single-armed suture technique for LIVE was performed using two single-armed nonabsorbable monofilament polypropylene blue 10-0 sutures (W2790, 13 cm length, 3.8 mm 3/8 circle taper point, BV 75-3; Ethicon, New Brunswick, NJ, USA). Each suture was trimmed to a length of 4–5 cm prior to LIVE. Two sutures were then passed in an outside-in fashion through the mucosal layer of the vas deferens at points “a1” and “b1” (Figure 3a). Then, the two needles (a1 and b1) were placed in parallel with each other longitudinally on a single exposed epididymal tubule (Figure 3b). After carefully opening the epididymal tubule between the two needles, the exuded epididymal fluid was examined under the microscope for the presence of motile sperm. When motile sperm were found, the epididymal fluid was aspirated for cryopreservation. The needles were then pulled out and placed inside-out through the mucosal layer of the vas at positions “a2” and “b2” (Figure 3c). The opening of the epididymal tubule was intussuscepted into the vasal lumen when the sutures were carefully tied together (Figure 3d). Then, the epididymal tunic was secured to the muscularis edge of the vas deferens with 8 to 10 interrupted monofilament polypropylene 9-0 sutures (Ethicon, W2783, 13 cm length, 5 mm 3/8 circle taper point, BV 100-4) to ensure a tension-free anastomosis.

Modified single-armed suture LIVE technique. (a) The needles were sequentially placed outside-in (a1 and b1) through the mucosal layer of the vas deferens. (b) Two needles were placed longitudinally (a1 and b1) in parallel with each other on a single exposed epididymal tubule. (c) The needles were sequentially placed inside-out (a2 and b2) through the mucosal layer of the vas deferens. (d) The opening of the epididymal tubule was intussuscepted into the vasal lumen. LIVE: longitudinal intussusception vasoepididymostomy.