Microsurgical Repair of the Male Genital Tract: Refinements and Predictors of Success

Microsurgical repair of obstructive male infertility is a challenge for the physician, but successful treatment depends on the experience and skills of the surgeon. Fertility can often be restored, thus avoiding the need for artificial reproductive techniques. The surgical procedures can be combined with sperm aspiration and cryopreservation, to be used for intracytoplasmic sperm injection in cases of surgical failure. In this review we will discuss the results of microsurgical procedures for obstructive male infertility, with special emphasis on technical refinements and prognostic indicators. Recently, surgical refinements, such as the invagination technique, have been introduced for the vasoepididymostomy procedure, showing promising first results. This simplified technique enables less experienced microsurgeons to perform this difficult operation successfully. The procedure is indicated for men with primary infertility and epididymal obstruction and for vasectomized men with secondary epididymal obstruction due to leakage of semen from the dilated epididymal tubule with subsequent fibrosis. This can be found in men with a long obstructive interval between vasectomy and reversal. In men with obstruction of the seminal tract, patency is found in 70–90% after microsurgical repair. In primary infertility and epididymal obstruction, other anatomical abnormalities of the reproductive tract can be found in nearly half of them, like obstructions of the ejaculatory ducts. In men with extreme oligozoospermia, by normal physical examination and normal hormonal evaluation partial obstructions of the seminal Curriculum in Urology D ow nl oa de d by : 54 .7 0. 40 .1 1 11 /1 7/ 20 17 7 :0 9: 48 P M ‘blow-out’ with subsequent leakage of semen in the connective tissue of the organ, resulting in fibrosis and scarring. Also, a long interval of obstruction will eventually cause loss of epididymal function, poor fertilizing capacity of the spermatozoa, and the formation of antisperm antibodies. In about 20% of the men with obstructive azoospermia, fibrosis and other irreparable conditions of the epididymis are found during scrotal exploration, and microsurgery cannot be performed. Furthermore, epididymal obstruction is frequently accompanied by congenital abnormalities of the genital tract and ejaculatory duct obstruction [2]. Epididymal obstruction can be congenital (idiopathic) or acquired, due to epididymal infection or previous inguinal and scrotal surgery. About 10% of the men with obstructive azoospermia present with a primary structural abnormality of the genital tract, like congenital bilateral absence of the vas deferens, a mild form of cystic fibrosis [3]. In these men part of the epididymis and the scrotal vas deferens are absent, due to an early regression of the wolffian duct. Also, the seminal vesicles are either hypoplastic or absent, resulting in low seminal volume (<1.0 ml) and pH (<7.0). Obstructions of the ejaculatory ducts are found in men with recurrent prostatitis and with prostatic cysts. On transrectal ultrasound, effects of distal obstructions of the genital tract can be found such as dilation of the ejaculatory ducts and the seminal vesicles as well as calcifications in the region [4]. In Western Europe, about 10–15% of the male population rely on the vasectomy procedure as a contraceptive method. Since the divorce rates are increasing, the demand for vasectomy reversal is high: 2–6.5% of the vasectomized men undergo a vasovasostomy (VVS) [5]. In this review, we will discuss the different aspects of microsurgical treatment of obstructive male infertility and focus on recent modifications and refinements of the techniques of vasoepididymostomy (VES) and VVS procedures and on the value of the different prognostic factors involved in refertilization surgery for obstructive azoospermia. Dohle/Weber Eur Urol 2001;40/4 (Curric Urol 1–10) tract can be found in 50–60% of them. Vasectomy reversal is still the treatment of choice for secondary infertility after previous vasectomy. Although patency remains high, even after a long obstructive interval, the number of spontaneous pregnancies progressively decreases after a period of 10 years, due to loss of epididymal function and sperm motility. The main predictive factors for a successful outcome are the obstructive interval and the age of the female partner. Late stenosis after initial successful operation occurs in 12–18%. Repeat reversal procedures show a patency rate of 64–79%, and pregnancies are reported in 27–31%. Microsurgical reconstruction of obstructive male infertility can be a very rewarding procedure for both the infertile couple and the physician. Practical teaching courses are very helpful, and a learning curve should be taken into account. Urologists with an interest in male infertility should be encouraged to learn microsurgery as a part of their surgical training. The operations are best performed in centres for reproductive medicine, allowing different options to be available.