The authors would like to thank the West China Second University Hospital of Sichuan University for providing cases and medical records related to this work. There is no funding support for this study.

The surgical method described in this paper has been approved by the Ethics Committee of the West China Second University Hospital of Sichuan University, and the use of patient surgical videos has been authorized. Informed consent was obtained from the patients, and their data was used for presentation. The consumables and equipment used for this study are listed in the Table of Materials.
1. Preparation for operation
<ol>
	<li>Use the following inclusion criteria to select participants for the study:
	<ol>
		<li>Adult males who have opted for sterilization.</li>
		<li>Ensure preoperative color Doppler ultrasonography11 reveals normal bilateral vas deferens development in the patients.</li>
		<li>Exclude any individuals with diseases that could affect the safety of the surgery, such as poorly controlled hypertension, hyperglycemia, or respiratory diseases.</li>
	</ol>
	</li>
	<li>Apply the following exclusion criteria to exclude participants from the study:
	<ol>
		<li>Exclude patients with severe coagulopathy or other contraindications to anesthesia.</li>
	</ol>
	</li>
	<li>Perform skin preparation before surgery.</li>
</ol>
2. Surgical procedure
<ol>
	<li>Stand on the right side of the patient and perform bilateral spermatic nerve blocks using 2% lidocaine. Apply pressure for 1 min to stop bleeding and reduce local edema.</li>
	<li>Use the three-finger technique6 to fix the right vas deferens beneath the median raphe. Firmly trap the vas deferens under the thumb and index finger of the left hand and over the middle finger for fixation.</li>
	<li>Flatten the scrotal skin over the vas deferens, and clamp the vas deferens using an extracutaneous vas deferens fixation ring clamp with the right hand.</li>
	<li>Maintain the ring clamp in a clamped state and pass it from the right hand to the left. Secure the ring clamp with the left thumb, middle, and ring fingers.</li>
	<li>Press the scrotal skin downward with the left index finger while simultaneously elevating the ring clamp to tighten the skin over the vas deferens using the left thumb, middle, and ring fingers.</li>
	<li>Use one blade of the dissecting clamp to puncture the skin and vas sheath, then withdraw the dissecting clamp.</li>
	<li>Close both blades of the dissecting clamp and reinsert it through the same puncture hole. Gently open the clamp to separate the scrotal skin by about 1 cm.</li>
	<li>Use the right blade of the dissecting clamp to pierce the most superficial and prominent part of the vas deferens wall. Rotate the dissecting clamp 180 degrees laterally.</li>
	<li>Release the extracutaneous vas deferens fixation ring clamp with the left hand. Elevate the dissecting clamp and extract the right vas deferens from the body.</li>
	<li>Grasp the delivered vas deferens with the ring clamp using the left hand. Gently isolate the right vas deferens artery with the dissecting clamp, exposing a clean segment of about 2.5 cm.</li>
	<li>Pull the ring clamp toward the abdominal side and straighten the vas deferens. Use a 3-0 silk suture to complete the first ligation at the testicular end of the vas deferens.</li>
	<li>Pull the ring clamp toward the testicular side and perform a second ligation on the abdominal side, 1.5 cm from the first ligation.</li>
	<li>Tighten the suture tails of the first ligation toward the testicular side and pull the ring clamp toward the abdominal side. 
	NOTE: The bare vas deferens should now be clearly visible.</li>
	<li>Use the dissecting clamp to clamp the right vas deferens 1 cm from the first ligation on the abdominal side. Release the extracutaneous vas deferens fixation ring clamp.</li>
	<li>Complete a third ligation between the dissecting clamp and the first ligation. Transect the right vas deferens tightly against the abdominal side of the dissecting clamp.</li>
	<li>Rotate the dissecting clamp 180 degrees and pull the tails of the second ligation toward the testicular side over the dissecting clamp and the first ligation.</li>
	<li>Perform a fourth ligation on the abdominal side of the right vas deferens, 1 cm from the second ligation, using the suture tails from the third ligature.</li>
	<li>Pull the suture tails of the second ligation toward the testicular side and those of the fourth ligation toward the abdominal side. Perform a fifth ligation between the second and fourth ligations using the suture tails from the first ligation (Figure 1).</li>
	<li>Ensure there is no bleeding in the surgical area. Cut off the ends of the three sutures.</li>
	<li>Pull the right testis toward the testicular side through the scrotum, and reposition the right vas deferens with the anatomical reduction in the scrotum.</li>
	<li>Repeat the procedure on the left vas deferens and suture the scrotal incision with 5-0 absorbable sutures.</li>
</ol>
3. Postoperative care and follow-up
<ol>
	<li>Change the dressing every 3 days after surgery, and remove the sutures 1 week later.</li>
	<li>Instruct patients to refrain from ejaculation for approximately 2 weeks after the vasectomy.</li>
	<li>After 2 weeks, advise them to ejaculate regularly, twice a week. Perform post-vasectomy semen analysis (PVSA) after 20 ejaculations12.</li>
</ol>
4. Statistical analysis
<ol>
	<li>Analyze all data statistically using statistical data analysis software.</li>
	<li>Use a t-test for data conforming to a normal distribution and a non-parametric test for data not conforming to a normal distribution. Consider statistical differences significant when P &#60; 0.05.</li>
	<li>Present results as mean &#177; SD for data conforming to a normal distribution and as medians with interquartile ranges for data not conforming to a normal distribution.</li>
</ol>

Bilateral Spermatic Nerve Blocks and Vasectomy Procedures in Males

<ol>
	<li>Rayala, B. Z., Viera, A. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Common+questions+about+vasectomy.">Common questions about vasectomy.</a> Am Fam Physician. 88 (11), 757-761 (2013).</li><li>Dassow, P., Bennett, J. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Vasectomy:+An+update.">Vasectomy: An update.</a> Am Fam Physician. 74 (12), 2069-2074 (2006).</li><li>Fainberg, J., Kashanian, J. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+vasectomy+is+a+surgical+sterilization+procedure+for+men+to+prevent+future+fertility.">A vasectomy is a surgical sterilization procedure for men to prevent future fertility.</a> JAMA. 319 (23), 2450 (2018).</li><li>Velez, D., Pagani, R., Mima, M., Ohlander, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Vasectomy:+A+guidelines-based+approach+to+male+surgical+contraception.">Vasectomy: A guidelines-based approach to male surgical contraception.</a> Fertil Steril. 115 (6), 1365-1368 (2021).</li><li>Ostrowski, K. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evaluation+of+vasectomy+trends+in+the+United+States.">Evaluation of vasectomy trends in the United States.</a> Urology. 118, 76-79 (2018).</li><li>Li, S., Goldstein, M., Zhu, J., Huber, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+no-scalpel+vasectomy.">The no-scalpel vasectomy.</a> J Urol. 145 (2), 341-344 (1991).</li><li>Sharlip, I. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Vasectomy:+Aua+guideline.">Vasectomy: Aua guideline.</a> J Urol. 188 (6S), 2482-2491 (2012).</li><li>Barone, M. A., Irsula, B., Chen-Mok, M., Sokal, D. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effectiveness+of+vasectomy+using+cautery.">Effectiveness of vasectomy using cautery.</a> BMC Urol. 4 (1), (2004).</li><li>Black, T., Francome, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+evolution+of+the+Marie+Stopes+electrocautery+no-scalpel+vasectomy+procedure.">The evolution of the Marie Stopes electrocautery no-scalpel vasectomy procedure.</a> J Fam Plann Reprod Health Care. 28 (3), 137-138 (2002).</li><li>Dohle, G. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=European+association+of+urology+guidelines+on+vasectomy.">European association of urology guidelines on vasectomy.</a> Eur Urol. 61 (1), 159-163 (2012).</li><li>Osama, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Duplication+of+the+vas+deferens:+A+rare+anomaly.">Duplication of the vas deferens: A rare anomaly.</a> Ochsner J. 21 (1), 108-110 (2021).</li><li>Griffin, T., Tooher, R., Nowakowski, K., Lloyd, M., Maddern, G. U. Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=How+little+is+enough?+The+evidence+for+post-vasectomy+testing.">How little is enough? The evidence for post-vasectomy testing.</a> J Urol. 174 (1), 29-36 (2005).</li><li>Art, K. S., Nangia, A. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Techniques+of+vasectomy.">Techniques of vasectomy.</a> Urol Clin North Am. 36 (3), 307-316 (2009).</li><li>Rogers, M. D., Kolettis, P. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Vasectomy.">Vasectomy.</a> Urol Clin North Am. 40 (4), 559-568 (2013).</li><li>Weiske, W. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Vasectomy.">Vasectomy.</a> Andrologia. 33 (3), 125-134 (2001).</li><li>Seth, I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Vasovasostomy:+A+systematic+review+and+meta-analysis+comparing+macroscopic,+microsurgical,+and+robot-assisted+microsurgical+techniques.">Vasovasostomy: A systematic review and meta-analysis comparing macroscopic, microsurgical, and robot-assisted microsurgical techniques.</a> Andrology. 12 (4), 740-767 (2024).</li></ol>

The authors declare that they have no competing interests.

The gold standard for vasectomy is ligation with mucosal cautery13, but not all operating rooms have electrocautery equipment. Therefore, this modification technique achieved ideal surgical results by ligating the vas deferens five times with non-absorbable silk sutures, without the need for electrocautery equipment. It has been documented that applying excessive pressure to the vas with sutures can create ischemia and sloughing of the ligated stump, leading to recanalization. This may explain some of the higher failure rates associated with these methods14. The most significant modification compared to NSV is the repeated ligation-two times at the testicular end and three times at the abdominal end. Additionally, the third and fourth ligations use the same suture, as do the first and fifth ligations, to minimize the sloughing of the knots.
In addition, histological studies of vasectomy sites after failure have reported that one or more channels (canaliculi) can form through the connective and scar tissue between the vas stumps, allowing the passage of sperm, especially in cases of chronic inflammation15. The critical step of the modification technique is interlacing and binding the two ends of the vas together, which results in the separation of the two transected sections. Consequently, an ischemic region of at least 1 cm is formed, making natural recanalization more difficult in the future.
Moreover, some patients may reconsider natural paternity after vasectomy due to events like the death of a child, divorce, or remarriage16. This modification technique, which binds the two vas stumps together, creates better surgical conditions and makes it easier to locate the vas ends when performing vasovasostomy in the future.
The limitation of this modification technique is that the operation time is longer than that of NSV due to repeated ligations. The modified vasectomy lasted approximately 30 min; however, no additional anesthetics were needed during the surgery. The longer operation time may lead patients to pay more attention to the procedure and improve adherence.
In summary, this modification technique could result in better outcomes for vasectomy, particularly in operating rooms without electrocautery equipment.

Vasectomy is a surgical sterilization procedure for men to prevent future fertility1,2,3. It is equally effective as tubal ligation for preventing pregnancy but is simpler, safer, faster, and less expensive4. This type of surgery has lower implementation requirements, and more than 80% of vasectomies are performed in the office5. Since 1971, when Li Shunqiang et al. performed the first modified vasectomy (the no-scalpel vasectomy or NSV)6, the procedure has advanced significantly. The invention of the extracutaneous vas deferens fixation ring clamp has reduced the number of surgical steps, while simultaneously minimizing surgical damage and the difficulty of the procedure1. As a result, NSV has become the mainstream surgical method for vasectomy.
However, NSV still uses a single ligation and transection to seal the bilateral vas deferens ends, and the postoperative recanalization rate remains high. It has been reported that the occlusive failure rate after simple vasectomy is around 13.79%, and the postoperative recanalization rate is still 5.85% after vasectomy and fascial interposition7. As such, andrologists continue to explore improvements to vasectomy. Literature reports indicate that the postoperative recanalization rate can be reduced to 1% by using mucosal cautery on the ligated stumps8. Additionally, non-divisional vasectomy with extended electrocautery can further reduce the postoperative recanalization rate to 0.64%9.
However, for medical institutions lacking electrocautery equipment, reducing the postoperative recanalization rate remains a challenge. Therefore, the new technique proposes performing five ligations of the vas deferens without electrocautery conditions, building on the NSV method to reduce the postoperative recanalization rate. After five ligations, the formation of a vas deferens ischemic zone greater than 1 cm in length can increase the difficulty of vas deferens recanalization. This modified technique is also advantageous for exploring the ends of the vas deferens during future vasovasostomy. Compared to previous reports10, this modification does not require electrocautery equipment during surgery, thereby reducing equipment requirements. This approach can help operating rooms without electrocautery equipment to perform a vasectomy.

<table><tbody><tr><td>3-0 silk braided non-absorbable suture</td><td>Johnson &amp;amp; Johnson Medical (China) Ltd.</td><td>SA84G</td><td>15 &amp;times; 60cm</td></tr><tr><td>5-0 Coated VICRYL Plus (Polyglactin 910) Synthetic Absorbable Suture</td><td>Ethicon.Inc.</td><td>VCP433H</td><td>13 mm 1/2c (70cm)</td></tr><tr><td>Dissecting clamp</td><td>Xinhua Surgical Instruments Co., Ltd.</td><td>ZJ197R</td><td>125 mm</td></tr><tr><td>Extracutaneous vas deferens fixation ring clamp</td><td>Xinhua Surgical Instruments Co., Ltd.</td><td>ZJ196R</td><td>140 mm</td></tr><tr><td>Scissors</td><td>Xinhua Surgical Instruments Co., Ltd.</td><td>ZC344R</td><td>140 mm</td></tr><tr><td>SPSS 23.0</td><td>IBM</td><td></td><td></td></tr></tbody></table>

optimizing the modified no-scalpel vasectomy technique

No-scalpel vasectomy (NSV) is a commonly used contraceptive method for males. In previous applications of this surgical method, issues such as knot detachment and postoperative recanalization resulted in a reduced contraceptive success rate after vasectomy. This new technique innovatively modifies the ligation procedure during NSV to address knot detachment and postoperative recanalization. Two ligations of the testicular end of the vas deferens and one ligation of the abdominal end are completed before transection of the vas deferens. A fourth ligation of the abdominal end is performed using the suture tails of the third ligature of the testicular end after transection of the vas deferens. The fifth ligation of the abdominal end is performed using the suture tails of the first ligature of the testicular end. These modifications strengthen the ligations and reduce the postoperative recanalization rate. Additionally, the two stumps are gathered together, creating better conditions for a possible vasovasostomy in the future, thereby achieving overall better outcomes with vasectomy.

From January 2021 to August 2023, 58 vasectomies were performed at this hospital. All 58 patients had at least one child with their spouses before undergoing vasectomy. Although the modification involved more surgical steps compared to NSV, it did not significantly increase the difficulty of the operations. As a result, all 58 vasectomies were successfully completed without any unsuccessful operations. Patients were followed up regularly by telephone. Follow-up ended when the PVSA demonstrated less than 2,00,000 sperm/mL. If more than six months after the vasectomy, a patient impregnated his wife or the last PVSA showed more than 2,00,000 sperm/mL, it was designated as recanalization.
In the NSV group, all 24 vasectomies were successfully performed. Three patients experienced recanalization after vasectomy. Four patients had incomplete data: three declined the PVSA, and one refused phone calls. The remaining 17 patients had complete data, with ages ranging from 23-47 years (median 35 years), and a follow-up period ranging from 1-25 months (median 9 months). None of the patients reported any discomfort after surgery.
In the modified group, all 34 vasectomies were successfully performed after the NSV group. However, it is regrettable that 10 patients declined the PVSA. A total of 24 patients had complete data, with ages ranging from 28 to 46 years (median 33.5 years), and a follow-up period ranging from 1-17 months (median 2.5 months). Only one patient reported chronic left scrotal pain. None of the 57 patients who answered the phone had undergone vasovasostomy.
No significant difference in age was found between the two groups (p &#62; 0.05), indicating that both groups were within the same age range. However, there was a significant difference in follow-up duration (p &#60; 0.05), suggesting superior adherence in the modified group. It is possible that a longer surgical time encourages patients to be more attentive to postoperative follow-up. The last PVSA was performed more than 11 months after the vasectomy, and the sperm concentrations were over 25,000,000 sperm/mL in the three patients who experienced recanalization in the NSV group. Two of the 24 patients in the NSV group (one of whom refused phone calls) impregnated their wives, while the patients in the modified group were deemed sterile. The follow-up results of the modified group were significantly better than those of the NSV group. The demographic information of the patients is displayed in Table 1.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/67148/67148fig01.jpg" /> 
Figure 1: Location and relationship of the 5 ligations. The figure illustrates the location and relationship of the five ligations used in the procedure. The modification technique interlaces the two ends of the vas and binds them together. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/67148/67148fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td colspan="2">Items</td>
			<td>NSV</td>
			<td>The modification</td>
			<td>&#160;P&#160; value</td>
		</tr>
		<tr>
			<td colspan="2">Patients</td>
			<td>24</td>
			<td>34</td>
			<td></td>
		</tr>
		<tr>
			<td colspan="2">Patients were recanalized after surgery</td>
			<td>3</td>
			<td>0</td>
			<td></td>
		</tr>
		<tr>
			<td colspan="2">Patients rejected the PVSA</td>
			<td>3</td>
			<td>10</td>
			<td></td>
		</tr>
		<tr>
			<td colspan="2">Patients impregnated their spouses after surgery</td>
			<td>2</td>
			<td>0</td>
			<td></td>
		</tr>
		<tr>
			<td colspan="2">Patients refused phone calls</td>
			<td>1</td>
			<td>0</td>
			<td></td>
		</tr>
		<tr>
			<td colspan="2">Patients whose spouses have completed childbirth before surgery</td>
			<td>24</td>
			<td>34</td>
			<td></td>
		</tr>
		<tr>
			<td colspan="2">Patients had complete data</td>
			<td>17</td>
			<td>24</td>
			<td></td>
		</tr>
		<tr>
			<td colspan="2">The Age of patients had complete data, year</td>
			<td>35 (32,36)</td>
			<td>33.5 (30.5,35)</td>
			<td>0.408</td>
		</tr>
		<tr>
			<td colspan="2">The end of the follow-up,months</td>
			<td>9 (3,13.5)</td>
			<td>2.5 (1,4)</td>
			<td>0.001</td>
		</tr>
		<tr>
			<td colspan="2">Postoperative complications</td>
			<td>0</td>
			<td>1</td>
			<td></td>
		</tr>
	</tbody>
</table>
Table 1: Demographic data. Statistical differences were considered significant when P &#60; 0.05. Abbreviations: PVSA = post-vasectomy semen analysis.

Optimizing the Modified No-Scalpel Vasectomy Technique

A modified no-scalpel vasectomy technique reduces the postoperative recanalization rate. This protocol describes a modified no-scalpel vasectomy technique that can reduce the postoperative recanalization rate.

No-scalpel vasectomy (NSV) is a commonly used contraceptive method for males. In previous applications of this surgical method, issues such as knot ...

optimizing-the-modified-no-scalpel-vasectomy-technique

Nanyang Technological University

Research

JoVE Journal

Medicine

240 Views.  Sichuan University. De reikwijdte van ons onderzoek is andrologie, waarbij we graag antwoord willen geven op deze vragen over de belangrijkste punten van deze operatie. De uitdaging van deze operatie is om de zaadleider te laten struikelen en vast te klemmen met behulp van de fixatieringklem. Deze aanpak kan helpen bij het uitvoeren van zones zonder elektrische cauterisatieapparatuur om vasectomie uit te voeren.Om vasectomie uit te voeren, selecteert u een patiënt met ee...

Video: Optimalisatie van de gemodificeerde vasectomietechniek zonder scalpel

Modified Technique for Coronary Artery Ligation in Mice

Myocardial infarction (MI) is one of the most important causes of mortality in humans1-3. In order to improve morbidity and mortality in patients with MI we need better knowledge about pathophysiology of myocardial ischemia. This knowledge may be valuable to define new therapeutic targets for innovative cardiovascular therapies4. Experimental MI model in mice is an increasingly popular small-animal model in preclinical research in which MI is induced by means of permanent or temporary ligation of left coronary artery (LCA)5. In this video, we describe the step-by-step method of how to induce experimental MI in mice.
The animal is first anesthetized with 2% isoflurane. The unconscious mouse is then intubated and connected to a ventilator for artificial ventilation. The left chest is shaved and 1.5 cm incision along mid-axillary line is made in the skin. The left pectoralis major muscle is bluntly dissociated until the ribs are exposed. The muscle layers are pulled aside and fixed with an eyelid-retractor. After these preparations, left thoracotomy is performed between the third and fourth ribs in order to visualize the anterior surface of the heart and left lung. The proximal segment of LCA artery is then ligated with a 7-0 ethilon suture which typically induces an infarct size ~40% of left ventricle. At the end, the chest is closed and the animals receive postoperative analgesia (Temgesic, 0.3 mg/50 ml, ip). The animals are kept in a warm cage until spontaneous recovery.

The surgical procedure used to induce experimental myocardial infarction in mice begins with left thoracotomy between the third and the fourth ribs in order to visualize the anterior surface of the heart and left lung. The left coronary artery is ligated, the chest is closed and the mouse is allowed to recover spontaneously.

Myocardial infarction (MI) is one of the most important causes of mortality in humans1-3. In order to improve morbidity and mortality in patients with MI ...

Murine Cervical Heart Transplantation Model Using a Modified Cuff Technique

Mouse models are of special interest in research since a wide variety of monoclonal antibodies and commercially defined inbred and knockout strains are available to perform mechanistic in vivo studies. While heart transplantation models using a suture technique were first successfully developed in rats, the translation into an equally widespread used murine equivalent was never achieved due the technical complexity of the microsurgical procedure. In contrast, non-suture cuff techniques, also developed initially in rats, were successfully adapted for use in mice1-3. This technique for revascularization involves two major steps I) everting the recipient vessel over a polyethylene cuff; II) pulling the donor vessel over the formerly everted recipient vessel and holding it in place with a circumferential tie. This ensures a continuity of the endothelial layer, short operating time and very high patency rates4.
Using this technique for vascular anastomosis we performed more than 1,000 cervical heart transplants with an overall success rate of 95%. For arterial inflow the common carotid artery and the proximal aortic arch were anastomosed resulting in a retrograde perfusion of the transplanted heart. For venous drainage the pulmonary artery of the graft was anastomosed with the external jugular vein of the recipient5.
Herein, we provide additional details of this technique to supplement the video.

The murine cervical heart transplantation model is well suited for immunological as well as ischemia reperfusion injury studies. We modified the procedure using a non-suture cuff technique and performed more than 1,000 successful transplants with this approach.
Herein, we provide additional details of this technique to supplement the video.

Mouse models are of special interest in research since a wide variety of monoclonal antibodies and commercially defined inbred and knockout strains are ...

Utero-tubal Embryo Transfer and Vasectomy in the Mouse Model

The transfer of preimplantation embryos to a surrogate female is a required step for the production of genetically modified mice or to study the effects of epigenetic alterations originated during preimplantation development on subsequent fetal development and adult health. The use of an effective and consistent embryo transfer technique is crucial to enhance the generation of genetically modified animals and to determine the effect of different treatments on implantation rates and survival to term. Embryos at the blastocyst stage are usually transferred by uterine transfer, performing a puncture in the uterine wall to introduce the embryo manipulation pipette. The orifice performed in the uterus does not close after the pipette has been withdrawn, and the embryos can outflow to the abdominal cavity due to the positive pressure of the uterus. The puncture can also produce a hemorrhage that impairs implantation, blocks the transfer pipette and may affect embryo development, especially when embryos without zona are transferred. Consequently, this technique often results in very variable and overall low embryo survival rates. Avoiding these negative effects, utero-tubal embryo transfer take advantage of the utero-tubal junction as a natural barrier that impedes embryo outflow and avoid the puncture of the uterine wall. Vasectomized males are required for obtaining pseudopregnant recipients. A technique to perform vasectomy is described as a complement to the utero-tubal embryo transfer.

Utero-tubal embryo transfer uses the utero-tubal junction as a barrier to prevent the embryo outflow that may occur when performing uterine transfer. Vasectomized males are required to obtain pseudopregnant recipients for embryo transfer. Both techniques are discussed.

The transfer of preimplantation embryos to a surrogate female is a required step for the production of genetically modified mice or to study the effects ...

Biology

Vessel-Sparing Microsurgical Longitudinal Intussusception Vasoepididymostomy to Treat Epididymal Obstructive Azoospermia

The epididymis is a common site of obstruction in obstructive azoospermia (OA). Vasoepididymostomy has become an important method for the treatment of epididymal OA since 2000. There are two challenges in classic microscopic vasoepididymostomy. First, anastomosis of the vas deferens and epididymis is performed with double-needle sutures. However, there is a lack of good-quality and cost-effective double-needle sutures in China, which leads to increased difficulty and poor success rates of anastomosis. Second, the separation of the vas deferens does not retain vasculature, although the vas deferens vasculature plays an important role in the blood supply to the vas deferens, epididymis, and testis. This affects the blood supply to the anastomotic area and epididymis.
Therefore, this team has made innovative improvements to address these problems. Good-quality, cost-effective, single-needle sutures, which are easy to purchase in China and other countries, were used in microsurgical longitudinal intussusception vasoepididymostomy. This can optimize the operation procedure and shorten the operation time while ensuring the success rate of the anastomosis. The surgical method of preserving the vas deferens vessels was innovatively proposed because the etiology of epididymal OA is mostly inflammatory in China. The protection of the blood supply to the vas deferens and epididymis is maximized using microsurgical forceps to separate and protect the vasculature. Patency reached 81.7% in the postoperative follow-up, indicating a better surgical treatment effect.

The present protocol describes a vessel-sparing, longitudinal intussusception vasoepididymostomy using readily available single-needle sutures in China, a safe and effective procedure, which may improve patients' patency and natural pregnancy rates.

The epididymis is a common site of obstruction in obstructive azoospermia (OA). Vasoepididymostomy has become an important method for the treatment of ...

A Modified Vessel-Sparing Microsurgical Vasoepididymostomy

Microsurgical vasoepididymostomy (MVE) is the main surgical treatment for epididymal obstruction. The vasal vessels are ligated during MVE. However, preserving the vasal vessels during MVE might better simulate the normal physiological structure and be meaningful for patients who have undergone varicocelectomy. Nevertheless, preserving the vasal vessels might elevate the risk of increasing the tension of anastomosis, affecting the patency rate and leading to delayed postoperative bleeding. Therefore, we developed a novel vessel-sparing MVE to make it safer. Here is a summary of the improvements to the procedure. 1) The retrograde dissociation of the vasal vessels on the proximal testicular side was adopted as the main method, and the anterograde dissociation of the vasal vessels on the distal testicular side was adopted as a supplement to dissociate the vasal vessels to be preserved. This improvement ensures the blood supply to the vas deferens that will be used for anastomosis and also provides longer vasal vessels, which reduces the tension of anastomosis. 2) By fixing the vas deferens to be anastomosed and the broken end of the vas deferens, the free vasal vessels get fixed, which resolves the problem of transmission of vas tension to the vasal vessels and reduces the risk of vasal vessel hemorrhage. 3) Dissociation of the vas deferens after opening the tunica vaginalis increases the mobilization of the vas deferens, which also makes the new procedure easier to complete. The evaluation of the outcomes of this new procedure showed that no significant postoperative complications occurred in the patients, and the patency rate was no different from that of the conventional procedure. Therefore, this new, improved procedure can be considered safe, with satisfactory postoperative results.

Here, we present a protocol to preserve the vasal vessels in microsurgical vasoepididymostomy. The surgical security is enhanced by preserving the vasal vessels using a retrograde-anterograde dissociation and fixing the vasal vessels.

Microsurgical vasoepididymostomy (MVE) is the main surgical treatment for epididymal obstruction. The vasal vessels are ligated during MVE. However, ...

Clinical Application of 24 G Cannula Needle and 3-0 Polypropylene Suture in Vas Deferens Exploration

The goal of this article is to present the application of a 24 G cannula and 3-0 polypropylene suture as a simple method for the exploration of the vas deferens. During the exploration of the vas deferens, a 24 G cannula needle was used to puncture it. The fluid in the smear confirmed the presence of sperm, to determine whether or not there was concomitant obstruction at the junction of the epididymis and the vas deferens. Then, a 3-0 polypropylene suture (this suture specification has the advantages of a smooth surface, robust quality, and can be passed through a 24 G cannula needle) was passed through the cannula needle to probe the location of the obstructed site. With this technique, exploration of the vas deferens could be more targeted and accurate.

This protocol presents the clinical application of a 24 G cannula and 3-0 polypropylene suture as a simple and effective method for the exploration of the vas deferens.

The goal of this article is to present the application of a 24 G cannula and 3-0 polypropylene suture as a simple method for the exploration of the vas ...

Seminal Vesiculoscope Laser-Assisted Surgery to Treat Ejaculatory Duct Blockage

Treatment of Ejaculatory Duct Obstruction by Seminal Vesiculoscopy Assisted Flow Modification

Transurethral resection of ejaculatory duct (TURED) is a primary surgical approach to treat ejaculatory duct obstruction (EDO) caused by the ejaculatory duct cyst. Intraoperative excision of the verumontanum is usually required to expose the ejaculatory ducts. However, preserving the verumontanum structure allows for a better simulation of normal physiological anatomy. Maintaining the verumontanum may increase the risk of postoperative distal ejaculatory duct scarring, leading to recurrent obstruction or reduced semen volume. Therefore, we attempted a novel technique that preserves the verumontanum, which is relatively easier and safer compared to TURED. The following were the procedural steps: 1. A 6F seminal vesiculoscope was introduced through the external urethral orifice to the vicinity of the verumontanum, locating the opening of the affected-side ejaculatory duct and introducing a guidewire into the cyst. This successful step preserved the verumontanum, maximizing the retention of the anti-reflux mechanism in the distal ejaculatory duct. 2. The holmium laser enlarged the affected-side ejaculatory duct opening to 5 mm, decreasing the likelihood of postoperative closure of the ejaculatory duct opening and simplifying the procedure. 3. A window was created within the cyst to access the contralateral seminal vesicle, and then a holmium laser was used to burn and dilate the opening to 5 mm, redirecting the contralateral ejaculatory duct into the cystic cavity. This modification preserved the opening of the healthy-side ejaculatory duct and provided a new outflow passage for semen, reducing the risk of decreased semen volume postoperatively. The patients experienced no complications postoperatively, had shorter hospital stays, and showed improvement in semen volume. Hence, this surgical approach is simple yet effective.

Author Spotlight: Advanced Treatment of Seminal Duct Blockage Employing Endoscopy-Mediated Semen Channel Refluviation 

This protocol introduces the clinical application of seminal vesicle endoscopy combined with holmium laser in the treatment of ejaculatory duct obstruction caused by ejaculatory duct cyst.

Transurethral resection of ejaculatory duct (TURED) is a primary surgical approach to treat ejaculatory duct obstruction (EDO) caused by the ejaculatory ...

Combination of High Ligation and Intraoperative Embolization using Polidocanol for Treatment of Varicoceles

Varicoceles are dilated veins within the pampiniform plexus and are relatively common in the general male population. The spermatic vein has many branches in the scrotal segment and then gradually merges into 1-2 trunks after passing through the internal inguinal ring. The key to a successful varicocelectomy is to ligate all the spermatic veins while protecting the testicular arteries and spermatic lymphatic vessels from damage. The small veins, including the branches of spermatic veins and collateral veins, are easily missed for ligation during conventional high ligation of varicocele, which has been suggested as a major cause of postoperative recurrence. Although microsurgery effectively reduces the risk of missing ligation of the spermatic veins during surgery, it has several shortcomings, such as long operation time and a steep learning curve. More importantly, this technique is difficult to carry out in primary hospitals due to the requirement of specialized equipment. Therefore, an attempt to modify the traditional high ligation aiming to reduce the postoperative recurrence rate has been carried out here. The protocol here combines traditional high ligation with intraoperative embolization to seal off the branches of the spermatic vein and collateral veins. We rapidly injected foamed sclerosant into the internal spermatic vein under direct observation after separation of the spermatic vein and then ligated all the veins. The foamed sclerosant through the varicose vein hampers endothelial cell growth, promotes the growth of thrombus and fibrosis, and ultimately forms fibrous streaks that permanently fill the venous. The results showed a more satisfactory effect on reducing the postoperative recurrence rate compared with traditional high ligation. Since this protocol is simple to carry out and has better results in reducing the recurrence rate, this can be an alternative surgical method for the treatment of varicocele, especially in primary hospitals.

To reduce the postoperative recurrence rate of varicocelectomy, we combined high ligation of varicocele with intraoperative embolization. We injected polidocanol from the spermatic vein during surgery to embolize the branches of the spermatic vein and collateral veins. This is an alternative surgical method for the treatment of varicocele.

Varicoceles are dilated veins within the pampiniform plexus and are relatively common in the general male population. The spermatic vein has many branches ...

Electrical Stimulation Therapy: Non-Surgical Remedy for Varicocele-Induced Pain

Transcutaneous Neuromuscular Electrical Stimulation for Treating Varicocele-Induced Scrotal Pain

Varicocele is a prevalent vascular disorder affecting the male reproductive system, leading to scrotal pain and testicular dysfunction. Epidemiological studies have shown that varicocele occurs in approximately 10% to 15% of adult males, while scrotal pain affects 2% to 10% of the population. Currently, clinical treatment options for varicocele-induced scrotal pain include general therapy, medication, and surgery. Among these, surgical intervention is considered the most effective method, boasting a success rate of 80%. However, it carries risks such as postoperative bleeding, infection, and recurrence, making it less desirable for some patients. In recent years, transcutaneous neuromuscular electrical stimulation has gained wide acceptance for treating various andrological conditions, including erectile dysfunction and premature ejaculation, yielding positive outcomes. This non-invasive technique offers a promising alternative for managing varicocele-induced scrotal pain, potentially reducing the need for surgical intervention and its associated risks. Its growing popularity underscores the need for further research and clinical trials to validate its efficacy and safety in treating this condition.

Author Spotlight: Advancing Varicocele Treatment with Neuromuscular Electrical Stimulation

This protocol outlines the use of transcutaneous neuromuscular electrical stimulation for treating varicocele-induced scrotal pain. It compares visual analog scale (VAS) scores and imaging changes before and after treatment to assess effectiveness. Results indicate that patients experienced improved scrotal pain symptoms following the treatment.

Varicocele is a prevalent vascular disorder affecting the male reproductive system, leading to scrotal pain and testicular dysfunction. Epidemiological ...

Microsurgical Varicocele Removal Under Local Anesthesia

Microscopic Varicocelectomy under Local Anesthesia as the Treatment of Varicocele

Varicocele, characterized by the dilation of veins within the spermatic cord, is a prevalent disease in males, accounting for 35%-40% of infertility cases among men of reproductive age. This condition may disrupt normal neuroregulation, blood supply, and temperature regulation in the testicles, thereby impacting sperm count, quality (morphology, fragmentation rate), and functionality (motility). It may even induce symptoms such as pain and testicular atrophy. The international standard treatment method is microscopic varicocelectomy, typically performed under general anesthesia. This requires patients to fast before surgery and necessitates recovery and fasting care postoperatively. The arterial blood pressure drop caused by anesthesia may obscure the fluctuation of the spermatic artery, making the precise intraoperative isolation and protection of the spermatic artery more challenging. Therefore, this study proposes and implements microscopic varicocelectomy under local anesthesia. This method facilitates rapid and precise identification of the fluctuating spermatic artery, reducing the risk of spermatic artery damage. It also provides more humane care for patients, reduces economic burden, and offers a new perspective on the treatment of varicocele.

Author Spotlight: Advancing Varicocele Treatment Through Enhanced Surgical Techniques

Varicocele accounts for 35%-40% of infertility cases among men of reproductive age. The international standard treatment method is microscopic varicocelectomy, typically performed under general anesthesia. This study proposes and implements microscopic varicocelectomy under local anesthesia, which provides more humane care for patients and reduces the economic burden.

Varicocele, characterized by the dilation of veins within the spermatic cord, is a prevalent disease in males, accounting for 35%-40% of infertility cases ...

Optimizing the Modified No-Scalpel Vasectomy Technique

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