This document provides an overview of male reproductive surgery procedures including diagnostic procedures like testicular biopsy, procedures to improve sperm production like varicocelectomy, and procedures to improve sperm delivery like vasovasostomy and vasoepididymostomy. It discusses the techniques, outcomes, and considerations for various male factor infertility surgical interventions.

1. Reproductive surgery
&
Computer Assisted Laparoscopy
In Male
Dr. Shashwat Jani.
M. S. ( Obs – Gyn )
Diploma in Advance Laparoscopy.
Consultant Assistant Professor,
Smt. N.H.L. Municipal Medical College.
Sheth V. S. General Hospital , Ahmedabad.
Mobile : 99099 44160.
E-mail : drshashwatjani@gmail.com

2. Introduction
 Male reproductive health has become an
important issue in current assisted reproduction.
 During recent years the perception of the
‘‘male factor’’ contributing to infertility has
undergone a number of revisions, realizing that
>50% of infertility is entirely or in part due to a
male factor.
 Outcomes of assisted reproduction are
primarily dependent on the availability of viable
sperm and age of the female member of the
couple being treated.
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3.  Nevertheless, the treatment of
obstructive and non obstructive azoospermia
(NOA) will often include a surgical
intervention or men with NOA, surgical sperm
retrieval is required to allow successful
treatment with ICSI.
 Additionally, surgical treatment is more
cost effective than alternative forms of
treatment such as assisted reproduction
procedures alone.
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4. Overview
Surgical Treatment can be divided into 3 main
categories :
–Diagnostic procedures
• Testis biopsy
• Seminal vesicle aspiration
• vasography
– Procedures to improve sperm production
• Varicocelectomy
– Procedures to improve sperm delivery
• Vasovasostomy
• Vasoepididymostomy
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5. Diagnostic Procedures
• Testicular Biopsy
– Azoospermia with normal FSH and normal sized
testicles :
• Can be due to obstruction, defect in
spermatogenesis, or incomplete defect.
• Obstruction vs. spermatogenic failure?
• Can also be therapeutic - consider sperm retrieval
for IVF/ICSI.
– Should be perform on both testes for nonobstructive
azoospermia.
– In obstructive azoospermia, should biopsy the larger
testis first.
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6. Diagnostic Procedures
Testicular Biopsy
– Open
– Percutaneous
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7. Open Testicular Biopsy
1. Cord block with 1% lidocaine and 0.25%
bupivicaine with 30-ga needle
2. The scrotal skin and tunica vaginalis are
then infiltrated with 2 mL of 1% lidocaine
with a 30-ga needle.
3. A 1- to 2-cm transverse incision is made to
the parietal tunica vaginalis through the
anesthetized region.
4. The tunica vaginalis is then opened with
scissors, and the edges are grasped and held
apart with two small hemostats or a small
self-retaining eyelid retractor. Lidocaine (2 to
3 mL) is dripped onto the exposed tunica
albuginea to anesthetize the testicular
surface where the biopsy specimen will be
taken. 7
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8. Open Testicular Biopsy
5. The tunica albuginea is carefully inspected
for the least vascular area for the incision. A
5-0 Prolene suture is passed at one end of the
proposed site of incision in the testis.
6. A 4- to 5-mm incision is made in the tunica
albuginea by use of a No. 11 scalpel or a
microknife, allowing extrusion of the
seminiferous tubules.
7. With the "no-touch" technique, fine, sharp
iris scissors are used to carefully excise the
extruded tubules.
8. The specimen is then placed in Zenker's,
Bouin's, or buffered glutaraldehyde solution.
The testicular specimen should not be placed
in formalin.
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9. Per cutaneous Testicular Biopsy
1. Percutaneous testicular biopsy can be
performed with local anesthesia in an office-
based setting, and it is generally associated
with less pain and morbidity than an open
testicular biopsy.
2. A 95% correlation was described between
percutaneous needle and open biopsy
techniques as long as sufficient materials are
present for diagnosis.
3. Before the biopsy is performed, the skin is
punctured with a scalpel to prevent inclusion
of scrotal skin with the specimen.
4. To avoid injury to the epididymis and the
surgeon's hand, the point of the needle
insertion should be from the lower pole
toward the upper pole.
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10. Testicular Biopsy Complications
o Hematoma
o Testicular atrophy – rare
o Inadvertent epididymal biopsy
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11. Varicoceles
 15% of the normal male population and in up to 40% of
patients with male infertility
 WHO reported that varicoceles were found in 25.4% of men with
abnormal semen parameters compared with 11.7% of men with
normal semen.
 Varicoceles have been associated with impaired semen quality and
decreased Leydig cell function.
 However, varicocele repairs have been shown to improve not only
spermatogenesis but also Leydig cell function
Most commonly performed surgical procedure in
treatment of male infertility.
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12. • Grading of Varicocele
– I - Palpable only with the Valsalva maneuver
– II - Palpable without the Valsalva maneuver
– III - Visible through the scrotal skin
Repair of larger varicoceles results in significantly greater
improvement in semen quality than does repair of smaller
varicoceles.
– On scrotal US – dilated veins > 3.5 mm
• Subclinical Varicoceles
– Diagnosed only on US
– Studies have demonstrated that subclinical varicoceles
have no impact on fertility and that repair of subclinical
varicoceles does not improve fertility rates.
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13. Varicoceles
• Four indications for treatment in adult men
– The couple has known infertility
– The female partner has normal fertility or a potentially
treatable cause of infertility
– The varicocele is palpable on physical examination, or if it
is suspected, the varicocele is corroborated by ultrasound
examination
– The male partner has an abnormal semen analysis
• In adolescent men
– Reduction in ipsilateral testicular size, otherwise
observation and /or semen analysis.
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14. Varicoceles
• Surgical Approaches
– Scrotal
• No longer used. High failure rate and testicular artery injury risk.
– Retroperitoneal
• Palomo
– High retroperitoneal ligation of the internal spermatic vein above the internal
inguinal ring.
– The recurrence can be significantly reduced by intentional ligation of the
testicular artery.
– This is thought to ensure ligation of the periarterial/cremasteric veins and thus
to prevent recurrence.
– Laparoscopic
• Excessively invasive for what should be a minor outpatient procedure
• laparoscopic varicocele repairs have been associated with a recurrence rate of less
than 2% and formation of hydroceles in 5% to 8% of patients
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15. Varicoceles
• Inguinal and sub inguinal approach
– Preferred approaches
– Less morbidity associated with the sub inguinal
(infrainguinal) approach than with the laparoscopic and
inguinal approach because of the preservation of the
muscle layers and the inguinal canal
– However, a greater number of internal spermatic veins
and arteries lie below the external ring, making this
procedure technically more challenging
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16. Lap Varicolectomy
1. Essentially the same as the Palomo
technique.
2. Establish pneumoperitoneum using
Veress or Hassan technique.
3. Parietal peritoneum is incised just lateral
to the spermatic cord. The testicular
artery and veins are dissected and
isolated. Pulling on the testis can help
identify the vessels.
4. Once the veins are isolated, they are
clipped both proximally and distally with
titanium endoclips, and these vessels are
then transected.
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17. Inguinal Approach
1. 3- to 4-cm oblique incision, two
fingerbreadths above the symphysis pubis
and just above the external ring, is carried
laterally along Langer's lines
2. The spermatic cord is mobilized near the
pubic tubercle, and a Penrose drain is
passed beneath the cord. The Penrose
drain is used to elevate the cord and bring
it through the incision.
3. Varicoceles generally appear with a typical
vascular pattern in which the artery is next
to or adherent to several veins, and there
is a separate isolated vein nearby.
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18. Inguinal Approach6. Once the dilated veins are isolated,
they are doubly ligated with either
2-0 silk sutures or small titanium
surgical clips.
7 . The cord is placed back into the
canal, and the external oblique fascia
is closed with a 3-0 Vicryl suture.
The subcutaneous layer is
reapproximated with a 3-0 plain
catgut suture, and the subcuticular
layer is closed with a 4-0 Monocryl
suture.
The incision is infiltrated with 1%
lidocaine mixed with an equal
amount of 0.5% bupivacaine.
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19. Varicocelectomy
Microsugical vs. Non-microsurgical Approach
• Significant reduction in postoperative
complications, such as testicular artery injury,
hydrocele formation, and varicocele recurrence.
• Complication rates for hydrocele formation with
the non-microsurgical technique range from 3%
to 39%, whereas hydrocele formation is rarely
reported in association with a microsurgical
technique
• The recurrence rate for microscopic inguinal
varicocelectomy has been reported between 1%
and 2%, compared with 9% and 16% for non-
microscopic inguinal varicocele repair
• The recurrence rate for non-microscopic
subinguinal varicocele repair is reported to be
5% to 20%
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20. Varicocelectomy
• Percutaneous Embolization :
– Cut-down to femoral or internal jugular vein
– embolization of the spermatic veins can be accomplished
with coils, balloons, or sclerotherapy
– Overall success rate – 68%
– Percutaneous varicocele embolization is especially useful
in a recurrent or persistent varicocele, when the anatomy
causing the varicocele needs to be radiographically
clarified.
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21. Varicocelectomy
• Outcomes
– studies have shown that repair of varicoceles can retard further damage to
testicular function
– overall rate of improvement in semen parameters after varicocelectomy ranged
from 51% to 78%
– improve not only semen motility, density, and morphologic features but also
serum FSH and testosterone levels
• Predictors of successful repair
– Sperm concentration > 5million/ml or density > 50 million per ejaculate
– lack of testicular atrophy
– sperm motility of 60% or more
– serum FSH values less than 300 ng/mL (normal, 50 to 300 ng/mL)
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25. Vasectomy Reversal
 Epididymal obstruction appears, in most instances, to be
a time-related phenomenon . . .
62% of patients who underwent reversal 15 years or
more after their vasectomy required either a
unilateral or a bilateral vasoepididymostomy.
VE depends on quality of fluid from proximal vas
when the material coming from the proximal vas
lumen is thick, pasty, and devoid of sperm; if the
fluid is creamy, containing only debris.
 Microsurgical vasectomy reversal are superior to results
of non microsurgical techniques.
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26. Vasovasostomy
Anesthetic Considerations
1. General vs. local ?
2. Preparing the vas for anastomosis
1. Vas grasped through skin above the
vasectomy site.
2. Once the vas is exposed, injection of a
mixture of 0.5% bupivacaine and 1%
lidocaine into the distal perivasal sheath
will provide sufficient anesthetic
coverage for the vasal anastomosis to be
performed.
3. Placement of 6-0 Prolene sutures just
into the muscularis holds the vas above
the incision and make it easily accessible
for anastomosis.
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27. Vasovasostomy
4. The vas above and below the vasectomy
site should be transected with use of the operating
microscope Once the point of the vas that is to be
cut is chosen, the vasal vessels are secured with 7-0
Prolene sutures just proximal to the point of
transection. Some experienced microsurgeons
prefer to cut the vas deferens through the groove of
a nerve-holding forceps to ensure a straight cut.
5. A few drops of fluid from the testicular end
of the vas lumen are placed on a sterile glass slide
and examined by light microscopy.
6. If there are sperm or sperm parts (sperm
heads, sperm with partial tails) in large numbers or
the fluid is clear and copious with no visible sperm,
vasovasostomy is generally indicated. If the fluid is
thick, pasty, and devoid of sperm or contains only a
few sperm heads, vaso epididymostomy should be
considered.
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28. Vasovasostomy - Multilayer Anastomosis
1. The anastomosis is begun by passing a
9-0 suture through the muscularis and the
adventitia at the 5- and 7-o'clock positions .
2. A double-armed 10-0 suture is passed
through the lumen at the posterior 6-o'clock
position and tied.
3. The next sutures are placed in the wall
of the lumen on either side of the first. These
sutures are tied after both are in place.
4. Three to five more sutures are placed
equidistant from one another to close the
remainder of the lumen but are left untied
until all the sutures have been placed.
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29. Vasovasostomy – Single Layer Anastomosis
1. A double-armed 10-0 suture is
passed full thickness through the edge of
the proximal and distal lumen at the 6-
o'clock position.
2. Two more sutures are placed, full
thickness, at the 4- and 8-o'clock positions
and tied.
3. Three more full-thickness sutures are
passed at the 10-, 12-, and 2-o'clock
positions and then tied.
4. The anastomosis is completed by closing
the muscularis and adventitia to the
opposite side, placing two 9-0 sutures
between each of the 10-0 full-thickness
sutures.
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30. Vasovasostomy
• Post-op Care
o Moderate activity for the first week after surgery
and to refrain from heavy exercise and sexual activity for 3
weeks.
o Examination of the semen occurs at 1 month and
every 3 months in the year after surgery. Most patients will
have sperm in their semen within 4 weeks after
vasovasostomy.
o If sperm are not present by 6 months, the operation is
considered a failure.
oRepeated surgery or sperm retrieval and IVF-ICSI may
be offered.
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33. Vaso epididymostomy
• Epididymal Obstruction
– Can be idipathic, inflammatory, iatrogenic, congenital.
– Time-dependent with vasectomy.
– Decision to perform a vaso epididymostomy is based primarily on the
quality of fluid found at the proximal (testicular) vas.
• 3 microsurgical techniques
– Direct end-to-end
– End-to-side
– End-to-side intussusception
• Pre-op Consideration
– General/epidural anesthetic
– Cryopreserve sperm?
– Patient positioning/comfort/safety
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34. Vasoepididymostomy
1. Testis biopsy to confirm
spematogenesis.
2. Incision is enlarged and the
testis delivered out of the
scrotum and examined. In
most instances, the
epididymis will be visibly
dilated, even without optical
magnification .
3. Mobilize the distal vas.
4. Confirm vasal patency with
vasography.
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35. Vasoepididymostomy : End to End
1. The epididymal tail can be dissected free from the
inferior aspect of the testis and the epididymis
transected at its distal end.
2. When the epididymis is cut proximal to the
obstructed area, there will be a continuous flow of
sperm-laden fluid from one opened epididymal tubule.
3. The lumen of the vas deferens is anastomosed to the
cut, open tubule exuding sperm. The first step is to
secure the cut end of the abdominal vas to the
epididymal tunic with two 9-0 nylon sutures passed
through the edge of the epididymal tunic and into the
adventitia and muscularis of the vas deferens at the 5-
and 7-o'clock positions. Four equally spaced double-
armed 10-0 sutures are placed into the edge of the
epididymal tubule, inside out, and then carried through
the vas lumen, beginning at the 6-o'clock position. The
first suture is tied, but the sutures at the 3-, 9-, and 12-
o'clock positions are not tied until all are placed.
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36. Vasoepididymostomy : End to End
4. The muscularis and
adventitia of the vas
deferens are secured to
the tunic of the
epididymis with
interrupted 9-0 sutures .
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37. Vasoepididymostomy :
End to Side
The rationale is that there
is far less dissection
required, less
troublesome bleeding
from the transected
epididymis, and
therefore a clearer field.
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38. Vasoepididymostomy :
3 Suture Intussusception
1. This technique differs from the end-
to-side technique in that the lumen
is opened after the sutures are
positioned in the epididymal loop.
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39. Vasoepididymostomy
• Post-op Care
– Similar to VasoVas
• Complications
– Infection
– Hematoma
– DVT
– Injury to testicular artery
• Results
– Very wide variation even with microsurgical techniques.
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41. Diagnosis of EJDO:
Complete obstruction - low volume azoospermia,
acidic semen lacking fructose, gonadotropins &
testosterone levels are normal
Partial obstruction may present as low semen
volume, severe oligoasthenospermia out of
proportion to what might be expected from the
testis size, and consistency combined with
hormonal data.
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42. Patients with those findings should be evaluated
by TRUS, along with vasography and seminal
vesiculography.
TRUS shows
dilated seminal vesicles (over 1.5cm).
Once visualised, seminal vesicle aspiration is
important to document sperm production,
if present, and initiate surgery.
No sperm = obstruction = vasography to confirm
obstruction
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43. Surgical management of EJDO is TURED –
Trans uretheral resection of the ejaculatory ducts
Assoc. with risk of bladder neck and ext sphincter injury
ie : retrograde ejac, urine reflux into ducts leading to
acute/chronic epididymitis and rectourethral fistula
Alternative methods are
TUBED –
Trans urethral balloon dilation of the ejaculatory duct.
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44. PROCEDURES TO IMPROVE
SPERM RETRIEVAL
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48. Other Sx…
 Hypospadias repair
 Plication for Peyronie’s disease
 Electroejaculation / Penile Vibratory stimulation
for anejaculation (caused by SC injury or
retroperitoneal lymph node dissection)
 Testicular tumor removal / orchiectomy ex
Leydig cell tumor causing azoospermia
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49. C.A.L.S.
Similar to the acceptance of robotic
assisted laparoscopic surgery for a number of
urological conditions, the use of robotic
assisted microsurgery is in its infancy and may
progress as cheaper, cost effective robotic
microsurgical platforms become more
accessible.
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50. Robotic set-up and instrumentation for
Robotic Vasectomy Reversal.

51. Surgeon’s view in the surgeon console during Robotic Vasoepididymostomy:
(I) main image from the 3D high-definition robot camera in the middle top;
(II) image on the left lower hand side from the optical phase contrast microscope assessing the
epididymal fluid for sperm; and
(III) image on the right lower hand side from the video telescope operating monitor (VITOM)
optical magnification camera

52. A Surgeon view in surgeon console during Robotic TESE :
Main image from 3D high-definition robot camera,
Image on the left hand side from optical microscope and
Image on the right hand side from video telescope operating monitor (VITOM) camera.
‘ The surgeon can simultaneously asses the extracted tissue at the same time with the
embryologist. TESE, testicular sperm extraction. ‘

53. The upper images illustrate the probes,
the lower images illustrate the use of the probes during
robotic assisted sub-inguinal Varicocelectomy.

54. Conclusions
Robotic assistance for microsurgical procedures
in male infertility and urology appears to be a
possible adjunct to standard microsurgery.
Advantages :
 Elimination of tremor,
 Multi-view magnification,
 Additional instrument arms,
 Enhanced dexterity with articulating instrument
arms.
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55.  The current literature supports that these
procedures appear to be safe and feasible.
 However, larger, prospective studies are
needed to demonstrate the clinical benefits
over standard microsurgery.
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56. Let’s Hope…
 Cost and the lack of tactile feedback are
some challenges of the current commercially
available da Vinci robotic system.
 However, as technology evolves, it is
likely that these limitations will be overcome
with newer and competing platforms.
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57. Dr Shashwat Jani
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