Surgical Procedures for Male Infertility: An Update

William R. Visser; L.I. Smith-Harrison; Sarah C. Krzastek

Disclosures

Curr Opin Urol. 2021;31(1):43-48. 

In This Article

Procedures to Optimize Sperm in the Ejaculate

Treatment of Ejaculatory Duct Obstruction

Ejaculatory duct obstruction (EDO) is a well defined cause of infertility in men, representing up to 5% of cases of obstructive azoospermia. EDO may be partial or complete, and patients may present with a range of symptoms from oligoasthenospermia to azoospermia, low to low-normal semen pH, low to low-normal ejaculate volume, hematospermia or pain with ejaculation.[15] EDO may be caused by a congenital or iatrogenic anatomical obstruction, or by function obstruction because of failure of seminal vesicle peristalsis or absent emission.[15,16]

Transurethral resection (TURED) has been a mainstay of treatment for EDO since the 1970s,[17] and the technique for performing this procedure has changed very little over the past few decades, with the exception of advancements in endoscopic equipment. A transrectal ultrasound (TRUS) may be performed at the beginning of the procedure to evaluate for seminal vesicle dilation, cystic structures, and to aspirate sperm from the seminal vesicles for cryopreservation for future assisted reproductive techniques (ART). At the time of TRUS, the seminal vesicles may be injected with indigo carmine to facilitate transurethral resection to confirm patency of the ejaculatory ducts. A resectoscope is then inserted into the urethra and the ejaculatory ducts are resected at the level of the verumontanum using pure cutting current electrocautery. Coagulation is avoided to minimize risk of iatrogenic EDO. Resection is performed until efflux of indigo carmine is noted. Complications following TURED are frequent, occurring in up to 26% of cases, and most commonly include reflux of urine into the ejaculatory ducts with subsequent epididymoorchitis, dribbling of urine, or secondary obstruction. A recent review of 57 publications found that TURED results in a 12.5--31% spontaneous pregnancy rate, with a 59--94% improvement in semen parameters. Ejaculate volume was found to be increased in 90.5% of cases, with 50% of patients experiencing improvement in sperm count, 60.5% of azoospermic patients experiencing return of sperm to the ejaculate, and 38% of patients experiencing return to normal semen parameters.[15]

Alternative methods to manage EDO have also been described. Ejaculatory ducts may be dilated with angiocatheter balloons, by advancing a wire antegrade into the seminal vesicles under TRUS guidance until the wire is visualized emanating from the ejaculatory ducts by cystourethroscopy, followed by passing the balloon dilator over the wire and across the stenosis.[18,19] Alternatively, retrograde seminal vesiculoscopy may be employed. This has historically been used to evaluate hematospermia and involves passing a flexible ureteroscope into the ejaculatory ducts both for passive dilation and to evaluate for stones or other anatomic causes of obstruction. Complications from vesiculoscopy are rare but restenosis is common. Despite high recurrence rates, ejaculatory duct dilation may be a good option to allow for temporary adequate return of sperm to the ejaculate to allow for natural conception. A retrospective review of seminal vesiculoscopy for ejaculatory duct dilation showed that 90% of patients had return of sperm into the ejaculate within 12 months.[20] Initial results from the study of vesiculoscopy for dilation of EDO have been promising, though further research is needed to evaluate long-term outcomes following this procedure. If EDO is because of prostatic, utricular, Mullerian duct or wolffian duct cysts, the cyst can be aspirated or resected to relieve the obstruction. TRUS-guided aspiration of cysts has been reported to allow for return of sperm to the ejaculate in some series.[21]

Reconstruction

Vasectomy reversals have been performed for over 100 years, with significant improvements in patency rates with the advent of microsurgical techniques in the 1970s.[22] Patency rates following vasovasostomy are reported to be approximately 72–98%, depending on how patency is defined.[23] Since the 1970s, however, few modifications in surgical technique have been developed, with little impact on pregnancy and patency rates. Historically, vasovasostomy was first described using a double-layer closure technique, reapproximating the mucosa in the first layer using 10–0 nylon sutures and closing the muscularis in the second layer with 9–0 nylon sutures. Although the two-layer closure is still used in many practices, a modified one-layer approach was described in the late 1970s to early 1980s, in which the vasal ends are reapproximated using full-thickness 9–0 nylon sutures circumferentially, with further seromuscular sutures placed as needed to create a water-tight anastomosis.[24] Studies have shown that a modified one-layer closure has similar patency and pregnancy rates with shorter operative times and lower associated costs as compared with the standard two-layer technique, and as such, the modified one-layer closure is widely used today.[24–26]

A crossed transseptal approach was described shortly thereafter as an option for reconstruction in select patients, such as those with irreparable distal obstruction of one vas deferens and nonfunctional contralateral testis.[27] For these cases, a vasogram is performed to confirm a distal vasal obstruction ipsilateral to the normal functional testis, and a normal vas on the contralateral side. The contralateral vas is transected as proximally to the testis as possible. The ipsilateral vas is transected as distally as possible and tunneled through the scrotal septum and anastomosed to the contralateral segment. Patency and pregnancy rates have been reported to be 50 and 25%, respectively, and this approach continues to be described.[27,28] An end-to-side crossed transseptal vasovasostomy has also been reported, in cases of a normal contralateral testis where the patent vas is not transected. Liang et al.[29] have reported patency rates of 75% in small numbers of patients using this technique, and have also reported improvements in semen parameters when performing crossed transseptal vasovasostomy concurrently with vasovasostomy or vasoepididymostomy. However, their sample size was small and follow-up was 12 months, so it is difficult to determine long-term outcomes following these complex reconstructive procedures and rates of any long-term complications, such as re-stenosis. Though it is interesting that patency and spontaneous pregnancies are possible with these approaches, work needs to be done to establish long-term outcomes and an understanding of the costs versus benefits of the increased operative time and technical skill required for such complex reconstructions.

Since the introduction of the operating robot to the field of urology, interest has been placed on expanding the use of the robot to nonlaparoscopic indications, because of its ability to improve visualization with a three-dimensional magnified field of view and stable ergonomic platform. Given the technical challenges and learning curve associated with microsurgical reconstructive techniques, Urologists have investigated the utility of the robotic operating platform for male reproductive surgeries, and debate is ongoing regarding the pros and cons of utilizing the robotic platform in this setting.[30] There may be certain situations in which the robot is indicated for male reconstructive procedures, as in patients with vasal obstruction at the level of the internal inguinal ring or intra-abdominally. Additionally, some studies suggest that a robotic vasectomy reversal has higher patency and pregnancy rates with shorter operative time in some hands.[31] However, because of the high costs associated with the robotic platform and the equivocal improvements in outcomes, routine use of the operating robot as a substitute for the operating microscope in the hands of a fellowship trained microsurgeon is not currently recommended.

Aside from minor changes to technique, such as the introduction of the two-suture longitudinal intussusception vasoepididymostomy technique, which has shown lower failure rates and trends towards higher patency rates for vasoepididymostomy,[32] there have been few device or technical advancements over the years to further improve outcomes associated with vasectomy reversal. To this point, Savage and colleagues recently described a novel suturing technique to address a common complication of vasovasostomy observed at their tertiary referral center. This group noted that a majority of vasovasostomy failures referred for repeat surgery were because of vas separation. In attempt to reduce failure rates, once the standard two-layer vasovasostomy was completed, additional reinforcing sutures were placed in the peri-vasal tissue to bring the vasal ends in parallel to each other, to take further tension off of the anastomosis. This group compared 30 men who underwent the reinforced suture technique to 39 men who underwent traditional two-layer vasovasostomy over a 5-year period. Patients who received reinforcing sutures had significantly higher rates of return of sperm to the ejaculate defined as more than 0 sperm at any point on semen analysis (92.9 vs. 64.9%, P < 0.01), with significantly higher percentages of patient achieving more than 15 million sperm/ml (82.1 vs. 44.4%, P < 0.01).[22] Though the authors acknowledge the limitations of their findings including short follow-up time and limited data on pregnancy outcomes, their findings suggest that vasectomy reversal outcomes may be optimized with placement of additional reinforcing sutures to take the anastomosis further off of tension.

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