Microsurgical vasovasostomy is a common treatment for vas deferens obstruction following childhood herniorrhaphy. It's difficult to predict the location of the obstructive site before surgical exploration and it's not clear whether there are sperms in vas deferens or not, this may cause the incision selection difficulty and the vas deferens injury by semi-open exploration which reduced the success rate of anastomosis, extend the time of surgery, and increasing the risk of abdominal exploration. In previous cases, the ruptured end of the vas deferens was usually not found during the inguinal exploration resulting in discontinuation of operation and increasing the patient's surgical trauma.
Therefore, how to use the simple method to determine the site of the obstruction in order to clarify the following surgical procedures is very important. After the practice and the summary of clinical operation our specific operation measures are introduced as follows. Procedure of the surgery.
After anesthesia, we performed standard disinfection with the patient in supine position. We made a three centimeter incision along the middle fold of the scrotum. Then we pierced one testicle and incised the flesh membrane to expose the testicular sheath and spermatic cord.
We separated along the space between the vasculature of the vas deferens and vasculature of spermatic cord. Then we secured the vas deferens with the tissue forcep and prepared for our vesicocentesis. We inserted a 24G cannula needle diagonally down 15 degree along the longitudinal axis of the vas deferens, pulled out the needle core after obvious tactile breakthrough and pushed the softer trocar to the lumen.
After identification of the vas deferens, two ml of normal saline was used to push in the 24G cannula needle, it confirmed the obstruction of the proximal vas deferens with the saline could not be pushed in. The liquid in the vas deferens smear test could confirm the presence of sperm to confirm whether or not there is a simultaneous obstruction at the junction of the vas deferens and epididymis. After that, 3-0 Prolene suture was passed through the cannula needle to probe the position of obstructed site.
Our study grouped the site of obstruction into three groups. Number one, the vas deferens obstruction is located at the incision of original hernia repair. Number two, the vas deferens obstruction positions two centimeter higher than the original incision.
Number three, the vas deferens obstruction is over five centimeter from the upper edge original incision. This technology could make the exploration of the vas deferens more purposefully and accurately. Representative results.
A total of 67 patients were enrolled in the study. As shown in table one, patients age ranged from 23 to 45 years. The time since herniorrhaphy was ranging from 21 to 43 years.
The mean age of the female partners was ranging from 23 to 42 years. 11 patients had scrotal pain. Four patients were underweight, 53 were normal, eight were overweight, and two were obese.
The site of the vas deferens obstruction and results in the different subgroup based on operative styles is shown in table two. The smear test showed that no sperm are present in the cannula needle liquid in 25 cases, of these, three underwent bilateral VV in which the obstruction site is located in the original incision and the patency rates were 33.3%22 underwent ART, in which the vas deferens obstruction positions two centimeter higher than the upper edge of original incision. The smear test establishes that sperm exists in the cannula needle liquid in 42 cases, of these, 29 underwent bilateral VV in which the obstruction site is located in the original incision and the patency rates were 79.3%Then underwent Lapa-VV in which the obstruction site positions two centimeter higher than the original incision and the patency rates were 40%Three underwent SV in which the obstruction site position five centimeter higher than the original incision and the patency rates were 33.3%Conclusion and discussion.
In our study, there are several possibilities during the exploration. Number one, if a smear test establishes that no sperm is present in the cannula needle liquid, there may be a simultaneous obstruction at the junction of the vas deferens and the epididymis. If the vas deferens obstruction positions two centimeter higher than the upper edge of original incision, which is probed by the Prolene suture, it can be considered to undergo the assisted reproductive technology directly.
If the obstruction site is located in the original incision, it can be considered to undergo MVE MVV. Number two, if a smear test establishes that sperm exists in the cannula needle liquid, while 3-0 Prolene suture detection of obstruction is located at the incision of original hernia repair, the original inguinal incision can be explored directly. Number three, if a smear test establishes that sperm exists in the cannula needle liquid while 3-0 Prolene suture detection of obstruction is within two centimeter from the upper edge original incision, laparoscopy-assisted vas deferens exploration can be considered and the proximal vas deferens can be pulled out from the external inguinal annulus for anastomosis.
Number four, if a smear test establishes that sperm exists in the cannula needle liquid while 3-0 Prolene suture detection of obstruction is over five centimeter from the upper edge original incision, there may be a seminal vesicle dysplasia or ejaculatory duct obstruction. Combined with the preoperative semen volume and seminal vesicle MRI, seminal vesicle endoscopy exploration could be considered. The simple operation of 24G cannula needle and 3-0 Prolene suture has little injury of the vas deferens, optimizes the surgical procedure, increase the intensity of surgical-decision making, and provides a simple and effective method for maximizing the interest of patient.
