Longitudinal Intussusception Vasoepididymostomy (LIVE) for Epididymal Obstruction

Martinez, M

obstructive azoospermia, epididymal obstruction, vasoepididymostomy, intussusception

Obstructive azoospermia (OA) accounts for 40% of all cases of azoospermia.  Congenital or acquired OA is usually caused by the blockade along the reproductive tract.  Epididymal obstruction is the most prevalent among the different etiologies of OA.

Microsurgical vasoepididymostomy (VE) is the procedure of choice for infertile men with epididymal obstruction who desire to achieve natural pregnancy.  There are several techniques to perform VE. These include the end-to-end anastomosis, end-to-side anastomosis and intussusception VE.  Among these techniques, intussusception VE showed higher patency and pregnancy rates particularly if longitudinal intussusception vasoepididymostomy (LIVE) is accomplished. Two 10-0 sutures are used for the anastomosis. The first suture is placed at 4 o’clock in an out-in fashion of the vas deferens while the second suture is placed at 8 o’ clock position with same manner of suture placement.   Both 2 needles are placed on the longitudinal aspect of the indurated epididymal tubule. Using a 15 degree ophthalmic knife, a longitudinal incision is made between the 2 needles. If there is presence of sperm, the needles will be placed at 2 o’ clock and 10 o’ clock position in an in-out fashion of the vas deferens.  A tension-reducing suture is placed to approximate the epididymal tunica to the vasal sheath prior to tying the 2 10- sutures. Several interrupted sutures are placed for the outer layer closure.  Microsurgical LIVE is  a very technically challenging procedure.  Principles of a successful anastomosis include use of appropriate microsurgical instruments, mucosa-to-mucosa apposition, tension-free and watertight reconstruction and preservation of the blood supply.

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