What Factors Affect Vasectomy Reversal Success?

Vasectomy anastomosis is mostly performed after vas deferens ligation for special reasons. But because the vas deferens are thin, they often fail due to narrow anastomosis.

Vasectomy

In the clinical treatment of male infertility, 10% -15% of male infertility patients are caused by obstructive azoospermia. Vasectomy and vasectomy are the most common and effective treatment for obstructive azoospermia. method. However, the clinical treatment of obstructive azoospermia is rarely carried out in hospitals in China at present, because the clinical technique of vasectomy and vasectomy is very difficult.

On the official cavity with a diameter of about 0.3-0.4mm, whether it is possible to establish a relatively good, unobstructed and leak-proof anastomosis is the key issue for resolving the rate of reopening and pregnancy. The technical difficulty can be imagined. However, with the continuous maturation of microsurgery technology, the successful application of vasectomy and angiospermia anastomosis, has made up for the shortcomings of the traditional non-microsurgery, which has unsatisfactory results, and has finally opened up obstruction. The "death knot" of azoospermia.

Branch

The ductus deferens is a direct continuation of the epididymal duct. It is a passage for sperm to be transported from the epididymis to the prostate urethra. It is 40-60 cm in length and has a small diameter (about 0.3 cm). It is the longest section in the ejaculation duct. It usually starts from the epididymis tail at the lower end of the testis and turns upwards. It then passes through the inguinal canal to the pelvic cavity with the spermatic cord, and finally merges with the seminal vesicle gland drainage tube to form an ejaculation duct opening in the urethral prostate. Its morphological characteristics are: the vas deferens tissue is milky white, tough in nature, the wall thickness, uniform thickness, easy to slide, and feel a solid palpation. According to the anatomy of the vas deferens, it can be divided into 4 parts:

testicular (parstesticularis)-refers to the shorter part of the testicular tortuous upward ascending, is the beginning of the vas deferens, close to the posterior margin of the testis.

scrotum (parsscrotum)-located between the epididymis head and the inguinal subcutaneous ring, this section is the shallowest position, mostly located in the posterior medial of the seminiferous cord, is easily accessible through the scrotal wall, is the ideal anatomical site for vas deferens.

the inguinal canal (parsinguinalis) from the shallow (subcutaneous) ring to the deep inguinal section. The scrotum and groin areas are collectively called the parsfunicularis.

pelvic (parspelvina)-is the longest segment of the vas deferens. From the deep ring of the inguinal canal to the pelvic cavity, bypass the inferior abdominal wall from the outside and start down the pelvic wall from the outside, then turn inward, across the inner end of the ureter, between the bladder and rectum to the bottom of the bladder. The pelvic segment of the vas deferens is fusiformly enlarged after crossing the ureter and is called the ampullaductus deferentis. The length of the ampulla segment is 2.0-4. Oem, the widest part of the ampulla can reach 0.7-1.0cm. Then gradually tapered, the ends of the vas deferens on both sides are also close to each other, which is equivalent to the upper edge of the prostate and the excretory tube of the seminal vesicle merge to form the (ejacatory duct), which passes through the prostate opening in the urethral prostate. The mucosal folds of the ampulla are large and branched, and the branches kiss each other to form a net; the mucosal epithelium is thick and has local depression, forming some glandular diverticula, and some glandular diverticula have active secretory functions. The ampulla of the vas deferens is the second storage anatomy for storing mature sperm. Therefore, within a period of time after the vasectomy, sperm is still contained in the discharged semen. After surgery, contraception needs to be continued for 2 months or about 10 times. If there is a condition, routine semen inspection is best.

basic structure

A vas deferens is a muscular tube with a thick wall and a narrow lumen. The tube wall consists of three layers: the mucosa, the muscular layer, and the adventitia. The mucosal epithelium is a pseudo-stratified columnar epithelium with cilia on the surface of the epithelium and a thicker muscle layer (1.0-1.5mm). It consists of three layers of smooth muscles, the inner longitudinal, middle ring, and outer longitudinal, so the vas deferens feel like the thickness of a matchstick. Has a certain hardness. The inner layer is thinner and the outer layer is thicker. The middle layer is the circular muscle layer, which is the thickest of the three layers. The outer membrane is a layer of loose connective tissue rich in blood vessels and nerves. The vas deferens can perform autonomous rhythmic contraction, and its contraction frequency It gradually strengthens from the proximal end (epididymis) to the distal end and is considered to be regulated by noradrenaline. Strong rhythmic contractions during ejaculation are caused by the simultaneous large-scale release of norepinephrine from the sympathetic nerves.

Blood supply

The arteries of the vas deferens segment are the vas deferens arteries directly from the internal iliac artery, and the vas deferens from the superior bladder artery, inferior bladder artery, superior rectum, inferior artery, and internal seminiferous artery; Internal iliac vein.

Applied Anatomy of Ligation and Anastomosis

Vasigation is to ligate and excise a small segment of vas deferens, thereby blocking the inability of sperm to exit the body, thereby achieving the goal of sterilization. There are four points worth noting in terms of vasectomy anatomy:

a. From the anatomical characteristics of vas deferens easily, how to effectively fix the vas deferens is the key to vas deferens ligation. If the vas deferens slips during the operation, it should be carefully touched again to find, do not clamp blindly, so as not to cause bleeding in the scrotum.

b. The vas deferens is a muscular tube, so the vas deferens must be confirmed during the operation to be ligated. Under normal circumstances, it is not difficult to identify. If you have difficulty, you can inject a small amount of isotonic saline into the lumen puncture and observe whether there is urinary invasion, or use the needle to cut through the lumen after the resection of the vas deferens, and if there is any doubt during the operation, perform a biopsy.

c. Because the surface of the vas deferens is rich in blood vessels, nerves and connective loose tissues, these tissues are essential for the nutrition of the vas deferens. Therefore, the vas deferens must be close to the wall and separated uniformly. Be careful not to damage the surrounding blood vessels. The vas deferens artery is next to the vas deferens. The separation, separation length 1.5-2. Oem, it should not be too long so as not to affect the blood supply. If there is bleeding, the blood must be tightly stopped. Many postoperative scrotal hematomas are caused by rough operation and incomplete hemostasis due to non-anatomical structure during the operation. Because of its strong ability to reconnect the vas deferens, it may be one of the reasons for fertility after vas deferens ligation. Therefore, at least about 1. Oem, the two ends of the vas deferens are ligated and the vas deferens are embedded to prevent the vas deferens from being reconnected.

Anastomotic anastomosis (anas-tomosls. {Vasdeferens) are mostly those who require recanalization due to special reasons after vasectomy. But because the vas deferens are thin, they often fail due to narrow anastomosis. In the past 20 years, the application of microsurgical technology has greatly increased its success rate. How to ensure that the vas deferens lumen remains unobstructed and not narrowed after re-anastomosis is the key to successful anastomosis.

The vas deferens are approximately 40-50 cm in total length, approximately 3 mm in diameter, and the lumen inner diameter is approximately 0.5-0.8 mm. The vas deferens starts from the epididymal tail and begins to be semi-curled at the beginning of 2 cm. It then straightens out, and passes along the scrotum upward through the inguinal canal, retroperitoneum, and pelvis to the back of the bladder. tube. The whole process is divided into three parts: testis, spermatic cord and pelvic. The segment of the vas deferens before the subcutaneous ring of the spermatic cord was easily accessible.

The wall of the vas deferens is composed of three layers: the mucosa, the muscle layer, and the adventitia. The mucosal layer is composed of epithelium and lamina propria, which together protrude into the cavity, forming several longitudinal folds, causing irregularity of the vas deferens; the muscular layer has three layers: the medial longitudinal muscle, the median circular muscle, and the lateral longitudinal muscle. The muscular layer is developed. The thick muscular layer makes the vas deferens have strong peristalsis. The outer membrane is a layer of loose connective tissue, which is rich in blood vessels, lymph and nerves. Therefore, when doing vasectomy, you should also avoid causing damage to the adventitia. The vas deferens are covered with epithelium. The mucosa near the epididymis is similar to the epithelium of the epididymis. It is characterized by large columnar cells, neat pairs of cilia, and is a kind of static or microcilia. Epithelial cells in the distal lumen of the vas deferens are small and ciliated.

The most meaningful anatomical location for vasectomy in clinical practice is often the mid-scrotum. The blood supply of the vas deferens comes from the vas deferens artery, which is a branch of the inferior bladder artery and is also an important collateral circulation supplying the testes. If vasectomy is accidentally injured during vasectomy, postoperative bleeding may occur. The vas deferens sheath contains painful sensory nerve fibers and sympathetic nerve fibers that release norepinephrine. These fibers cause the vas deferens to move spontaneously. The rhythmic movement inside the vas deferens depends on the local noradrenaline concentration. Therefore, the release of norepinephrine from the end of the sympathetic nerves controls the ejaculation period from the beginning, which causes a strong and coordinated series of contractions of the vas deferens, pushing the sperm from the epididymis to the urethra.

Due to the small and irregular lumen of the vas deferens, for the repair and reconstruction of the vas deferens, if a full-layer suture is used, a fine non-invasive suture must be selected to reduce the damage of the mucosa; if the mucosa and the muscular layer are sutured in two layers, It is the most critical for good mucosa and sutured muscle layer.

Pathological changes after ligation

Three months after vasectomy, there are fewer mature spermatids in the seminiferous tubules, which means that the spermatogenic process is impaired. After 10 months, the seminiferous tubules generally atrophied, leaving only supporter cells and a few spermatogonia, and the spermatogenic process completely stopped. From 12 months, the spermatogenic process gradually recovered. After 16-28 months, except for the atrophy of the thin tubules scattered in the scar, most of the spermatogenic epithelium thickened and the spermatids at all levels became active. The structural and functional changes of the testis after vasectomy are dynamic processes of injury, repair, scarring, and healing. This process changes with the length of postoperative time and is not related to changes in serum antisperm antibody titers. Early postoperative spermatogenesis disorders may be related to changes in the testicular environment (stress, physicochemical and biological factors) due to sperm storage. Some people think that the destruction of the blood testis barrier early after operation is the main reason for environmental changes. By 16-28 months after surgery, the blood-testis barrier is normal, indicating that the internal environment adapted to spermatogenesis in the seminiferous seminiferous tubules has been re-established, becoming an important condition for the restoration of the normal spermatogenic process. The pathological changes of the epididymis were also serious at 10 months after operation, and they subsided significantly at 16-28 months after operation, which is the material basis for successful anastomosis.

1. Separate the vas deferens from the seminiferous cord, fix them under the scrotum, cut the scrotal skin 2 to 3 cm at the corresponding site, and separate the nodules with separation forceps.

2. The nodule was lifted out of the incision, the tissue around the nodule was separated with a small blade, and the upper and lower end of the nodule were carefully freed from each tube 1 cm away from the nodule. The vas deferens were cut at 3 cm and the nodules were removed.

3 The two ends of the vas deferens must be normal, and semen overflow was seen near the testis. The distal testis was perfused with saline without any resistance.

4 Cut the vas deferens evenly. Use a No. 4 injection needle to enter the vas deferens from the distal testicular stump, penetrate the tube wall at a distance of 1 to 1.50 m, and pass through the skin of the scrotum. Place the support such as pony tail, nylon thread or plastic tube into the needle cavity . Withdraw from the needle, the support is introduced into the lumen of the vas deferens, one end is left outside the scrotal skin, and the other end is led out by the broken end. The stump end of the vas deferens was exposed, and then inserted into the lumen of the proximal testicular vas deferens 2 to 3 cm.

5. In the state where the two ends of the vas deferens are not twisted, tension-free, and naturally intact, 5-0 or 7-O nylon threads are used for the whole layer of the vas deferens to anastomize 4 to 6 needles.

6. Use silk thread to reduce the suture around the vas deferens for 2 to 3 stitches. Vasectasis reduction. Place rubber sheet to drain. Suture the scrotal skin. Fix the support at the scrotal skin exit.

Intraoperative precautions

1. When separating the vas deferens, it should not be separated too long or too short. If it is too long, it will hinder the blood flow of the vas deferens. If it is too short, it will be affected by tension and not conducive to healing.

2. When separating the vas deferens, care should be taken to avoid damage to the testicular arteries.

3. After the stent line is inserted into the vas deferens, it should be fixed on the skin with silk sutures in time to avoid being accidentally pulled out during the operation.

Postoperative considerations

1. Support the scrotum with a T-band after surgery.

2. Partially need to be protected from wet dirt.

3 Use antibiotics to prevent infection.

4 The rubber sheet was drained the next day after surgery.

5. Take 3mg of diethylstilbestrol every night for 5 days after the operation to control libido.

6. The skin sutures are removed 5 to 6 days after surgery. If the method of general surgery is used, if there is a support for the vas deferens, it will take 7 to 9 days to remove the support within the vas deferens.

7. Do semen checks regularly. Semen examination was performed at 1 month and 3 months after the operation. During anastomosis of the vas deferens, semen often overflows from the vas deferens near the epididymal end, but the sperm are often unable to move. With the recanalization of the lumen, the internal pressure decreases, and the obstructive factors that inhibit spermatogenesis are eliminated, and the number of sperm usually increases gradually within 1-2 months after surgery. Generally, the new generation of sperm reappears at 3-6 months, and the semen tends to be normal.

8 It is advisable to rest in bed for 1 week after operation to avoid premature walking. Epithelial growth of the anastomosis of the vas deferens takes 8-10 days. Walking prematurely on the platform can cripple the scrotum and affect healing. Clinical observations confirmed that within 7 days after surgery, the combined power of kisses was 67% for walkers, and for 7 days, the combined power of kisses could rise to 83%.

1. How long does a vasectomy take?

Vascular anastomosis is a slightly less difficult operation in male surgery. The surgical injury is small and the time required is not long. Generally, the time required for bilateral vasectomy is about 30-60 minutes.

2.Whether a vasectomy requires hospitalization

Patients undergoing this surgery need to be hospitalized. Generally, hospitalization should be performed one to two days before the operation, so as to facilitate the necessary examination and physiological and psychological preparation before the operation. Postoperative observation is usually required for three to five days to understand the recovery of the surgical incision and the presence of early complications.

3, how long after the vasectomy?

The incision for vas deferens is in the scrotum, which is rich in blood flow and the incision heals quickly. Generally, the suture can be removed in about five days after surgery. The stent placed during the operation is generally pulled out about ten days after the operation.

4. Is anti-inflammatory treatment needed after vasectomy?

Although vasectomy is not a difficult operation, in order to facilitate recovery after surgery and avoid incision infection, anti-inflammatory treatment is necessary, which usually lasts about one week.

There are many factors that affect the success of anastomosis, including the following points.

Interval between iliac ligation and anastomosis. In general, the anastomosis effect is better within 10 years after ligation, the longer the time, the worse the anastomosis effect.

Whether semen cysts formed after ligation.

(3) The occurrence of autoimmune reactions. It has been found that people with blocked vas deferens produce anti-sperm antibodies, which can agglutinate their own sperm or make them inactive.

Technical factors of anastomosis. There are some technical details that make sense for the success of the anastomosis.

From the above analysis, we can see that obstructive azoospermia is one of the causes of male infertility, and vasectomy is an effective treatment. Experts remind that male infertility patients should go to a professional male hospital for examination, find out the cause, and then choose a reasonable treatment.