This study was supported by health science and technology projects in Yunnan Province (NO.2018NS0256) and training objects of medical subject leaders in Yunnan Province (NO. D-2018039)

We performed retrospective analysis of the clinical data of male patients, initially diagnosed with epididymal cysts, admitted to the urology inpatient department of the Affiliated Hospital of Kunming University of Technology (the First People&#39;s Hospital of Yunnan Province). Written, informed consent must be obtained from patients before surgery.
1. Clinical inclusion and exclusion criteria
<ol>
	<li>Include patients who are below 45 years of age and have a need to preserve fertility. 
	&#8203;NOTE: The patient in this study was younger than 45 years old.</li>
	<li>Include patients with a clinician&#39;s preliminary diagnosis of epididymal cystic occupancy following examination with type-B ultrasound or computer tomography (CT) imaging.</li>
	<li>Exclude any patients with severe cardiopulmonary dysfunction, obvious sexual dysfunction, or anaspermia. Exclude patients with a testicular mass, epididymal tuberculosis, and patients who have difficulty to determine the relationship between the testis and the neoplasm.</li>
</ol>
2. Patient preparation
<ol>
	<li>After performing the relevant examination and active preoperative preparation, fully explain the relevant conditions, surgical plans, and related risks.</li>
	<li>Discuss with the patient and his family members the patient&#39;s condition, surgical plan, selection, and possible risks and complications. Obtain consent from the patient and his family members for testicular and epididymal exploration and microscopic cyst resection.</li>
	<li>Instruments for operation
	<ol>
		<li>Make sure that a surgical microscope and microsurgical instruments are available.</li>
	</ol>
	</li>
	<li>Preparation for operation
	<ol>
		<li>Clean and shave the inguinal/subinguinal skin and scrotum before surgery.</li>
		<li>The surgical site need not be sterilized before surgery. As a routine procedure, clean the scrotum with soap and shave the surgical area using a razor.</li>
		<li>Place the patient on the operating table in a supine position after general anesthesia. 
		&#8203;NOTE: Anesthesia is provided by the anesthetist. The anesthetist chooses the anesthetic agent and the dosage to be used.</li>
	</ol>
	</li>
</ol>
3. Procedure
<ol>
	<li>Expose and explore the testis and epididymis in the incision.
	<ol>
		<li>Perform a 2.5-3 cm scrotal skin incision with a surgical knife. Cut the scrotal flesh membrane and testicular sheath membrane layer by layer with an electric knife.</li>
		<li>Carefully explore the testis and epididymis to find and confirm the epididymal cyst. Change/stop the surgical plan if solid epididymal tumors or masses derived from the testis are found.</li>
		<li>Lift the epididymis out of the incision. Find the epididymal cyst.</li>
	</ol>
	</li>
	<li>Microscopic cyst resection
	<ol>
		<li>Bring an operating microscope into the operating field and examine the cord under a 6x-10x power magnification.</li>
		<li>Use an electric knife to cut the epididymal capsule at the base of the epididymal cyst and normal epididymal tissue. Open up the epididymal capsule carefully and avoid opening the epididymal cyst cavity (see Figure 1).</li>
		<li>Carefully explore the space between the epididymal cyst wall and the epididymal tissue (epididymal tubule). Based on this anatomical level, gradually microseparate the epididymal cyst along the cyst wall with microscissors and microscopic forceps. Carefully isolate the epididymal tissue (epididymal tubule) surrounding the epididymal cyst to the base of the epididymal cyst (see Figure 2).</li>
		<li>Microseparate the epididymal cyst from its base and the gap between the cyst and normal epididymal tissue. Excise the epididymal cyst from the base with microscissors or an electric knife after occlusion of the epididymal tissue with a microvascular clamp or ligation by a microsuture (7-0 or 6-0) (see Figure 3).</li>
		<li>Carefully dissect the separation and avoid epididymal cyst wall breakage, especially on blood epididymal cysts (see Figure 4) or large epididymal cysts with clear cystic fluid inside (see Figure 5). If the cyst wall is damaged, carefully clamp the breach with microvascular forceps to avoid fluid overflow in the cyst. Remove the epididymal cyst completely and preserve the noninvasive epididymal tubular patency as much as possible.</li>
	</ol>
	</li>
</ol>
4. Finish the operation
<ol>
	<li>Carefully perform micro hemostasis. Stitch the incisions on the epididymal capsule and periorchium in layers. Then suture the scrotal wound.</li>
	<li>Send the mass (cyst) to the pathology department for pathological examination.</li>
	<li>Leave the patients in bed for 1 day after surgery and discharge them 1-3 days after the surgery.</li>
</ol>
5. Postoperative follow-up
NOTE: The postoperative follow-up lasts for 3-50 months. Conduct the below tests/examinations in the follow-up.
<ol>
	<li>Check the patient for scrotal swelling, pain, and other clinical symptoms after surgery.</li>
	<li>Perform a detailed physical examination, Including checking the scrotal wound, testis, and epididymis.</li>
	<li>Perform type-B ultrasound examination on the testis and epididymis.</li>
</ol>

<ol>
	<li>Jelloul, L., Billerey, C., Ait Ali Slimane, M., Mboyo, A., Aubert, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Epididymal+cysts+in+adolescents.">Epididymal cysts in adolescents.</a> Annales d'Urologie. 33 (2), 104-108 (1999).</li><li>Boscarelli, A., Bellini, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Epididymal+cyst+in+children.">Epididymal cyst in children.</a> European Journal of Pediatrics. 180 (9), 2723-2729 (2021).</li><li>Yong-Bao, W., 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=The+efficacy+and+safety+of+scrotoscope+in+the+treatment+of+masses+in+caput+epididymidis.">The efficacy and safety of scrotoscope in the treatment of masses in caput epididymidis.</a> Journal of Trauma and Emergency Surgery. 6 (4), 208-211 (2018).</li><li>Erikci, V., 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=Management+of+epididymal+cysts+in+childhood.">Management of epididymal cysts in childhood.</a> Journal of Pediatric Surgery. 48 (10), 2153-2156 (2013).</li><li>Zhen-Chao, L., Xing-You, Q., Rong-De, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnosis+value+of+high+frequency+color+doppler+ultrasound+for+epididymis+cyst.">Diagnosis value of high frequency color doppler ultrasound for epididymis cyst.</a> China Modern Medicine. 20 (3), 102-103 (2013).</li><li>Sinha, V., Shankar, M., Sardana, N., Aggarwal, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+rare+case+of+epididymal+cyst+due+to+schistosomiasis.">A rare case of epididymal cyst due to schistosomiasis.</a> Cureus. 11 (9), e5755 (2019).</li><li>Mukendi, A. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bilateral+spontaneous+resolution.">Bilateral spontaneous resolution.</a> Clinical Case Reports. 8 (12), 2689-2691 (2020).</li><li>Patoulias, D., Kalogirou, M., Patoulias, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intraparenchymal+4+cm+in+diameter+in+a+15-year+old+male+patient;+a+case+report+and+review+of+the+literature.">Intraparenchymal 4 cm in diameter in a 15-year old male patient; a case report and review of the literature.</a> Acta Medica. 59 (4), 137-139 (2016).</li><li>Sun-Biao, L., Meng, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+analysis+of+43+epididymal+mass+patients.">Clinical analysis of 43 epididymal mass patients.</a> Fujian Medical Journal. 31 (3), 32-33 (2009).</li><li>Wang, J., 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=Treatment+for+childhood+herniorrhaphy.">Treatment for childhood herniorrhaphy.</a> Urology. 112, 80-84 (2018).</li><li>Ory, J., 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=Predictors+of+success+after+bilateral+during+vasectomy+reversal:+A+multi-institutional+analysis.">Predictors of success after bilateral during vasectomy reversal: A multi-institutional analysis.</a> Canadian Urological Association Journal. 16 (3), E132-E136 (2022).</li></ol>

The authors have nothing to disclose.

As we mentioned previously, epididymal cysts mostly occur in men aged 20 to 40 years, while there is also some literature on epididymal cysts in childhood1,2. To date, the cause of epididymal cysts is not clear, and there is no specific medicine for its treatment. In addition to a few reports that epididymal cysts can resolve spontaneously without surgery7, most epididymal cysts, although their progression and enlargement are relatively slow, are unable to be absorbed and eliminated by themselves. Although a benign lesion, a large epididymal cyst can cause damage to the proximal vas deferens, obstruction, and even secondary azoospermia. Due to the small diameter of the epididymal tube (about 0.5 mm), without the amplification effect of the surgical microscope, it is difficult to avoid traditional epididymal cyst resection, the destruction of the epididymal tube around the cyst, or obvious scar hyperplasia after surgery. As a result, patients who have undergone traditional (nonmicroscopic) epididymal cyst resection surgery or epididymectomy are prone to postoperative complications, including seminal tract obstruction, immune infertility, postoperative scrotal hematoma, persistent pain, and even testicular atrophy3,4,5. Therefore, some scholars believe that caution should be taken in the resection of epididymal cysts for young patients with fertility needs2,9.
We took the lead in carrying out microscopic epididymal exploration and cyst resection surgery in China. According to the follow-up data derived from the 41 patients included in this study, the visualization of the subtle tissue structure of the epididymis was greatly improved by microscopic manipulation, and the cysts could be clearly separated and completely removed. The high precision of microsurgical techniques and low damage to the surrounding tissue have achieved good results in the treatment of vas deferens and epididymal obstruction10,11. In addition, our experience suggested that microscopic epididymal exploration and cystectomy can effectively preserve epididymal patency with fine treatment, while achieving a better preservation of sperm delivery pipelines and unobstructed prognosis. At the same time, according to the follow-up data of this study, microscopic treatment significantly reduced the incidence of postoperative scrotal hematoma, edema, and long-term postoperative pain; thus, it also promises higher surgical success rates and the prevention of recurrence due to scar obstruction.
We have also noted the following limitations of this technique. Firstly, the operating surgeon needs to master microsurgical skills. Secondly, if the cyst wall of the epididymal cyst is destroyed during the operation, it will result in difficulty in the precise and complete removal of the cyst, which will increase the destruction of the surrounding epididymal tissue. Therefore, one should immediately close the rupture with a microvascular clamp and a microsuture (7-0 or 8-0 ) if finding that the cyst wall is damaged.
Based on our preliminary experience, we recommend that surgery be carried out before the epididymal cyst develops to 0.8 cm in diameter, for fear that a larger epididymal cyst (&#62;0.9 cm in diameter) could cause complete destruction of all tubules of the ipsilateral epididymis - a more severe case with damage to the testicular output network.
Finally, we hope that microscopic epididymis exploration and resection of microscopic epididymis cysts can be recognized and improved by more surgeons to treat patients diagnosed with epididymal cysts.

Epididymal cysts mostly occur in men aged 20-40 years old, although some literature also exists concerning epididymal cysts in childhood1,2. Previous reports have covered concerns about surgical destruction and postoperative scarring in patients undertaking nonmicroscopic epididymal cyst resection or epididymal resection3,4. Other postoperative complexes include seminal tract obstruction, immune infertility, and testicular atrophy. There is also a higher risk for postoperative occurrence, and even recurrence, of hematoma, edema, and a sustaining pain and cyst5,6. There are also reports that epididymal cysts can resolve spontaneously without surgery7. As a result, previous studies have concluded that epididymal cysts do not lead to testicular network expansion without intervention, and puncture or surgical treatment can be considered if epididymal cysts combine with testicular network expansion or damage of the proximal vas deferens2,4. Further, some investigators believe that patients with large epididymal cysts combined with pain are also suitable for surgical resection8. The treatment of epididymal cysts by puncture alone is prone to relapse. Traditional (nonmicroscopic) cyst resection or epididymectomy may destroy the epididymal canal, leading to epididymal obstruction, immune infertility, or even testicular atrophy; therefore, one should be cautious for young patients with fertility requirements2,9. Patients with childbirth plans are recommended to choose traditional (nonmicroscopic) epididymal cyst surgery as a cautionary measure. 
Microsurgical methods have been widely used in the treatment of vas deferens obstruction and epididymal obstruction, with excellent results10,11. The treatment of male epididymal cysts via microtechnology may be a beneficial option, however the necessity of extending microtechnology treatment to male epididymal cysts is questionable. We took the lead in carrying out microscopic epididymal exploration and cyst resection surgery in China. We carried out retrospective analysis of the clinical data of male patients, initially diagnosed with epididymal cysts, admitted to the urology inpatient department of the Affiliated Hospital of Kunming University of Technology (the First People's Hospital of Yunnan Province) between September 2017 and April 2019. The patients were younger than 45 years old and required fertility preservation. Based on microscopic manipulation, which largely improved visualization of the subtle tissue structures of the epididymis, the cyst could be clearly dissected apart and completely removed intact.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Ablation electrode</td>
			<td>Baisheng Medical Devices Co., Ltd. China</td>
			<td>OBS-Db</td>
			<td></td>
		</tr>
		<tr>
			<td>Anesthesia apparatus</td>
			<td>Datex-Ohmeda,Inc.USA</td>
			<td>Aespire View, Datex-Ohmeda</td>
			<td></td>
		</tr>
		<tr>
			<td>Compact Anesthesia Monitor</td>
			<td>GE Healthcare Finland OY.Finland</td>
			<td>S/5 Compact</td>
			<td></td>
		</tr>
		<tr>
			<td>&#160;Electric knife</td>
			<td>Valleylab.USA</td>
			<td>Valleylab Force FX-8C</td>
			<td></td>
		</tr>
		<tr>
			<td>Surgical (operation) microscope</td>
			<td>Lecia Microsysterms (Schweiz) AG. Germany</td>
			<td>Lecia M525 F20</td>
			<td></td>
		</tr>
	</tbody>
</table>

microscopic cyst resection for the treatment of patients diagnosed with epididymal cyst

Epididymal cysts mostly occur in men aged 20-40 years old. Previous reports have covered concerns about postoperative complexes, including postoperative asoedema, hematoma, sustaining pain, and seminal tract obstruction in patients who have undertaken nonmicroscopic epididymal cyst resection or epididymal resection. Nonmicroscopic epididymal cyst surgery is suggested for patients with childbirth plans as a precaution. The treatment of male epididymal cysts via microtechnology is obviously a beneficial option; we took the lead in carrying out microscopic epididymal exploration and cyst resection surgery in China. From September 2017 to April 2021, 41 young and middle-aged male patients diagnosed with epididymal cysts underwent microtechnology treatment in a program titled &#34;microscopic epididymal exploration and cystectomy&#34;. The postoperative follow-up lasted for 3-50 months. The results confirmed that, as microscopic manipulation largely improved visualization of the subtle tissue structures of the epididymis, the cyst could be clearly dissected apart and completely removed intact under the microscope. Bleeding during the operation was significantly reduced (2-3 mL) and wound drainage was not required. According to follow-up data, microscopic treatment significantly reduced the incidence of postoperative scrotal hematoma, edema, and long-term postoperative pain, thereby promising a higher surgical success rate as well as recurrence prevention. Besides, preliminary experience and reflection suggest that microscopic epididymal exploration and cystectomy provide efficient preservation of the epididymal patency through refined treatment, while a better prognosis can be achieved. We recommend that surgery be carried out before the epididymal cyst develops to 0.8 cm in diameter, for fear that a larger epididymal cyst (&#62;0.9 cm in diameter) could cause the complete destruction of all tubules of the ipsilateral epididymis - a more severe case with damage to the testicular output network.

From September 2017 to April 2021, 41 young and middle-aged male patients diagnosed with epididymal cysts underwent microtechnology treatment in a program titled &#34;microscopic epididymal exploration and cystectomy.&#34;
Here, we show the data from a single patient as a representative example. The patient was operated on for descending surgery (testicular and epididymal exploration and microscopic cyst removal) under general anesthesia. A scrotal incision was made, the testicular sheath was cut, the scrotum was explored, and the epididymis on the surgical side was isolated under a microscope. The epididymal mass (cyst) was sought, and the epididymal capsule was cut microscopically and carefully microseparated along the boundary of the normal epididymal tubular tissue. The base part of the epididymal mass (cyst) and the mass were completely removed. The noninvasive epididymal tubular patency was preserved as much as possible. After achieving micro hemostasis carefully, the incisions on the epididymal capsule and periorchium were stitched in layers. Then the scrotal wound was routinely sutured. The mass (cyst) was sent for disease examination. The patients were left in bed for 1 day after surgery and were discharged 1 to 3 days after surgery.
The following data are all derived from the 41 patients included in this study. The procedure time was 30-50 min (38.9 &#177; 8.5 min). All epididymal cysts were completely removed. Bleeding during the operation was significantly reduced (2-3 mL); wound drainage was no longer required. The postoperative follow-up lasted for 3-50 months. It must be noted that the operation time is longer than the traditional operation because of the use of the surgical microscope and fine microscopic operation.This may present as a limitation to the widespread use of the technique. No patient had a recurrence of the epididymal cyst by type-B ultrasound, and no patient developed postoperative scrotal hematoma. Only one patient had scrotal surgical site pain. The results confirmed that, as microscopic manipulation largely improved visualization of the subtle tissue structures of the epididymis, the cyst could be clearly dissected apart and completely removed intact under the microscope. According to follow-up data, microscopic treatment significantly reduced the incidence of postoperative scrotal hematoma, edema, and long-term postoperative pain, thereby promising a higher surgical success rate as well as recurrence prevention3 (see Table 1 and Table 2).
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/64083/64083fig01.jpg" /> 
Figure 1: Opening the epididymal capsule. The epididymal capsule is opened, avoiding opening the epididymal cyst cavity <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64083/64083fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/64083/64083fig02.jpg" /> 
Figure 2: Epididymal cyst isolation. The tissue surrounding the epididymal cyst was isolated carefully. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64083/64083fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/64083/64083fig03.jpg" /> 
Figure 3: Epididymal cyst excision. The epididymal cyst was excised from the base. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64083/64083fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/64083/64083fig04.jpg" /> 
Figure 4: Blood epididymal cyst. Separation of the blood epididymal cyst without cyst wall breakage. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64083/64083fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/64083/64083fig05.jpg" /> 
Figure 5: Large epididymal cyst. A large epididymal cyst with clear cystic fluid inside was carefully separated without cyst wall breakage. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64083/64083fig05large.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></td>
			<td>Clinical data</td>
			<td>Median</td>
			<td>Least value</td>
			<td>Maximum value</td>
		</tr>
		<tr>
			<td>Enrolled No.</td>
			<td>41</td>
			<td>/</td>
			<td>/</td>
			<td>/</td>
		</tr>
		<tr>
			<td>Age (years)&#160;</td>
			<td>24.89 &#177; 4.46</td>
			<td>25</td>
			<td>18</td>
			<td>40</td>
		</tr>
		<tr>
			<td>Operation time (min)</td>
			<td>38.95 &#177; 8.51</td>
			<td>40</td>
			<td>30</td>
			<td>50</td>
		</tr>
		<tr>
			<td>Bleeding during operation (mL)</td>
			<td>2.50 &#177; 0.46</td>
			<td>2.5</td>
			<td>2</td>
			<td>3</td>
		</tr>
		<tr>
			<td>Follow-up time (months)</td>
			<td>22.73 &#177; 14.56</td>
			<td>18</td>
			<td>3</td>
			<td>50</td>
		</tr>
		<tr>
			<td>Recurrence of epididymal cysts</td>
			<td>0</td>
			<td>/</td>
			<td>/</td>
			<td>/</td>
		</tr>
		<tr>
			<td>Scrotal hematoma</td>
			<td>0</td>
			<td>/</td>
			<td>/</td>
			<td>/</td>
		</tr>
		<tr>
			<td>&#160;Scrotal edema</td>
			<td>0</td>
			<td>/</td>
			<td>/</td>
			<td>/</td>
		</tr>
		<tr>
			<td>Short-term Scrotal surgical site pain</td>
			<td>1(2.44%)</td>
			<td>/</td>
			<td>/</td>
			<td>/</td>
		</tr>
		<tr>
			<td>Long-term postoperative pain</td>
			<td>0</td>
			<td>/</td>
			<td>/</td>
			<td>/</td>
		</tr>
	</tbody>
</table>
Table 1: Clinical data of epididymal cyst patients.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Surgical method</td>
			<td>Microtechnology Treatment of Male Epididymal Cysts</td>
			<td>Non-microscopic surgery(by&#160; scrotal mirror)&#160;</td>
		</tr>
		<tr>
			<td>Enrolled No.</td>
			<td>41</td>
			<td>57</td>
		</tr>
		<tr>
			<td>Recurrence of epididymal cysts</td>
			<td>0</td>
			<td>2(3.4%)</td>
		</tr>
		<tr>
			<td>Scrotal hematoma</td>
			<td>0</td>
			<td>2(3.4%)</td>
		</tr>
		<tr>
			<td>&#160;Scrotal edema</td>
			<td>0</td>
			<td>7(12.3%)</td>
		</tr>
		<tr>
			<td>Short-term Scrotal surgical site pain</td>
			<td>1(2.44%)</td>
			<td>10(17.54)</td>
		</tr>
		<tr>
			<td>Long-term postoperative pain</td>
			<td>0</td>
			<td>2(3.4%)</td>
		</tr>
	</tbody>
</table>
Table 2: Table of surgical complications.

Watch this Scientific Journal Video about Microscopic Cyst Resection for the Treatment of Patients Diagnosed with Epididymal Cyst at JoVE.com

Microscopic Cyst Resection for the Treatment of Patients Diagnosed with Epididymal Cyst

Here, we present a protocol to treat patients diagnosed with an epididymal cyst using microscopic cyst resection. Based on microscopic manipulation, a largely improved visualization of the subtle tissue structures of the epididymis was obtained, so the cyst could be clearly dissected apart and completely removed intact.

Epididymal cysts mostly occur in men aged 20-40 years old. Previous reports have covered concerns about postoperative complexes, including postoperative ...

microscopic-cyst-resection-for-treatment-patients-diagnosed-with

Nanyang Technological University

Research

JoVE Journal

Medicine

7.3K Views.  The First People’s Hospital of Yunnan Province (Medical College of Kunming University of Science and Technology). Here, we present a protocol to treat patients diagnosed with an epididymal cyst using microscopic cyst resection. Based on microscopic manipulation, a largely improved visualization of the subtle tissue structures of the epididymis was obtained, so the cyst could be clearly dissected apart and completely removed intact.

Video: Microscopic Cyst Resection for the Treatment of Patients Diagnosed with Epididymal Cyst

Tumor Treating Field Therapy in Combination with Bevacizumab for the Treatment of Recurrent Glioblastoma

A novel device that employs TTF therapy has recently been developed and is currently in use for the treatment of recurrent glioblastoma (rGBM). It was FDA approved in April 2011 for the treatment of patients 22 years or older with rGBM. The device delivers alternating electric fields and is programmed to ensure maximal tumor cell kill1.
Glioblastoma is the most common type of glioma and has an estimated incidence of approximately 10,000 new cases per year in the United States alone2. This tumor is particularly resistant to treatment and is uniformly fatal especially in the recurrent setting3-5. Prior to the approval of the TTF System, the only FDA approved treatment for rGBM was bevacizumab6. Bevacizumab is a humanized monoclonal antibody targeted against the vascular endothelial growth factor (VEGF) protein that drives tumor angiogenesis7. By blocking the VEGF pathway, bevacizumab can result in a significant radiographic response (pseudoresponse), improve progression free survival and reduce corticosteroid requirements in rGBM patients8,9. Bevacizumab however failed to prolong overall survival in a recent phase III trial26. A pivotal phase III trial (EF-11) demonstrated comparable overall survival between physicians&#8217; choice chemotherapy and TTF Therapy but better quality of life were observed in the TTF arm10.
There is currently an unmet need to develop novel approaches designed to prolong overall survival and/or improve quality of life in this unfortunate patient population. One appealing approach would be to combine the two currently approved treatment modalities namely bevacizumab and TTF Therapy. These two treatments are currently approved as monotherapy11,12, but their combination has never been evaluated in a clinical trial. We have developed an approach for combining those two treatment modalities and treated 2 rGBM patients. Here we describe a detailed methodology outlining this novel treatment protocol and present representative data from one of the treated patients.

A novel methodology that is employed for the treatment of recurrent glioblastomas is described. This treatment approach employs the application of alternating electric tumor treating fields (TTFields), known as TTF Therapy in combination with bevacizumab, a targeted agent that is currently FDA approved as monotherapy.

A novel device that employs TTF therapy has recently been developed and is currently in use for the treatment of recurrent glioblastoma (rGBM). It was FDA ...

Murine Ileocolic Bowel Resection with Primary Anastomosis

Intestinal resections are frequently required for treatment of diseases involving the gastrointestinal tract, with Crohn&#8217;s disease and colon cancer being two common examples. Despite the frequency of these procedures, a significant knowledge gap remains in describing the inherent effects of intestinal resection on host physiology and disease pathophysiology. This article provides detailed instructions for an ileocolic resection with primary end-to-end anastomosis in mice, as well as essential aspects of peri-operative care to maximize post-operative success. When followed closely, this procedure yields a 95% long-term survival rate, no failure to thrive, and minimizes post-operative complications of bowel obstruction and anastomotic leak. The technical challenges of performing the procedure in mice are a barrier to its wide spread use in research. The skills described in this article can be acquired without previous surgical experience. Once mastered, the murine ileocolic resection procedure will provide a reproducible tool for studying the effects of intestinal resection in models of human disease.

Ileocolic resection is commonly performed in several human diseases; however, little is known regarding the impact of intestinal resection on surgical illnesses. This article provides instruction on executing the procedure in mice with high success, providing a means to study the effects of ileocolic resection in models of disease.

Intestinal resections are frequently required for treatment of diseases involving the gastrointestinal tract, with Crohn&#8217;s disease and colon cancer ...

Network Analysis of Foramen Ovale Electrode Recordings in Drug-resistant Temporal Lobe Epilepsy Patients

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control seizures. However, a significant minority of patients continues to exhibit post-operative seizures, even in those cases in which the suspected source of seizures has been correctly localized and resected. The protocol presented here combines a clinical procedure routinely employed during the pre-operative evaluation of temporal lobe epilepsy (TLE) patients with a novel technique for network analysis. The method allows for the evaluation of the temporal evolution of mesial network parameters. The bilateral insertion of foramen ovale electrodes (FOE) into the ambient cistern simultaneously records electrocortical activity at several mesial areas in the temporal lobe. Furthermore, network methodology applied to the recorded time series tracks the temporal evolution of the mesial networks both interictally and during the seizures. In this way, the presented protocol offers a unique way to visualize and quantify measures that considers the relationships between several mesial areas instead of a single area.

This protocol describes a procedure to track the evolution of mesial network measures in temporal lobe epilepsy (TLE) patients. It is based on the combination of intracranial recordings with a novel numerical technique for data analysis. Specifically, we present a protocol for network analyses of foramen ovale recordings.

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control ...

Endoscopic Septoplasty with Limited Two-line Resection: Minimally Invasive Surgery for Septal Deviation

Endoscopic septoplasty is a surgical procedure in otolaryngology that is commonly performed to treat nasal airway obstruction caused by nasal septal deviation. It has a long history with multiple variations. In this article, a modified endoscopic septoplasty procedure using the limited two-line resection (2LoRs) technique at the posterior and inferior junction of the cartilaginous and bony septum is presented based on embryologic and anatomic knowledge of the nasal septum and the biomechanics of cartilaginous behavior. With this procedure, the quadrangular cartilage can be preserved as much as possible, which is helpful in retaining the supporting framework and rigidness of the septum. 2LoRs has been proven effective and sound for the correction of nasal septal deviation with rare complications. This modified procedure can be applied to correct the deviated nasal septum in the absence of any external nasal deformity to improve nasal patency or to improve access to the middle meatus or to the axillary region of the middle turbinate. It may also be used to expand the indications of septoplasty to children and adolescents because of its minimally invasive approach.

Endoscopic septoplasty is a time-honored surgical procedure with multiple variations. This paper focuses on a step-by-step surgical approach to perform a modified septoplasty procedure known as limited two-line resection. This surgical technique can be applied to correct a deviated nasal septum in the absence of an external nasal deformity.

Endoscopic septoplasty is a surgical procedure in otolaryngology that is commonly performed to treat nasal airway obstruction caused by nasal septal ...

Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is a common disorder that causes a significant loss of productivity. The transaxillary first rib resection (TFRR) protocol has been used for the decompression of trapped neurovascular structures in the TOS. Among the other surgical procedures, the advantage of the TFRR is that it has the smallest rate of recurrence and better cosmetic outcomes. The disadvantage of TFRR is that it provides a narrow, and deep working corridor that makes obtaining vascular control challenging.

Here, we present a protocol of the transaxillary resection of the first rib for treatment of thoracic outlet syndrome caused by compression of the brachial plexus, subclavian vein and artery.

Thoracic outlet syndrome (TOS) is a common disorder that causes a significant loss of productivity. The transaxillary first rib resection (TFRR) protocol ...

Robotic Left Hepatectomy using Indocyanine Green Fluorescence Imaging for an Intrahepatic Complex Biliary Cyst

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract and bear a significant risk of carcinogenesis. Surgery is the cornerstone treatment for patients with BC. While total BC excision and Roux-Y hepaticojejunostomy is the treatment method of the choice in patients with extrahepatic BC (i.e., Todani I-IV), patients with intrahepatic BC (i.e., Todani V) benefit the most from a surgical liver resection. In recent years, minimally invasive liver surgery (MILS) including robotic MILS has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. Robotic major MILS is still considered technically demanding and a detailed description of the technical approach during robotic major MILS has only been limitedly discussed in the literature. The current article describes the main steps for a robotic left hepatectomy in a patient with a large BC Todani Type V. The patient is in French position with 5 trocars placed (4 robotic, 1 laparoscopic assistant). After mobilizing the left hemiliver, the left and right hepatic artery are dissected carefully followed by a cholecystectomy. Intraoperative ultrasound is performed to confirm localization and margins of the BC. The Left hepatic artery and left portal vein are isolated, clipped, and divided. Indocyanine green (ICG) fluorescence imaging is used regularly during the entire procedure to visualize and confirm biliary tract anatomy and the BC. Parenchymal transection is performed with robotic cautery hook for the superficial part and robotic cautery spatula, bipolar cautery, and vessel sealer for the deeper parenchyma. The postoperative course was uncomplicated. A robotic left hepatectomy is technically demanding, yet a feasible and safe procedure. ICG-fluorescence imaging aids in delineating the BC and bile duct anatomy. Further, comparative studies are needed to confirm clinical benefits of robotic MILS for benign and malignant indications.

Robotic liver surgery has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. However, robotic left hepatectomy is still technically demanding. We describe our surgical technique of a robotic left hepatectomy using indocyanine green fluorescence imaging for a large biliary cyst.

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract and bear a significant risk of carcinogenesis. ...

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 ...

Modified Posterior Vertebral Column Resection for Patients with Thoracolumbar Kyphotic Deformity

Old compression vertebrae fracture or congenital kyphoscoliosis with abnormal vertebral body development and other diseases that invade the spine may cause severe thoracolumbar kyphotic deformity, often accompanied by intractable low back pain or compression of the spinal cord, leading to severe neurological symptoms or even paralysis. If conservative treatment cannot relieve the symptoms or correct the deformities, surgical treatment is usually needed. For severe kyphotic deformity, reconstruction of the physiological curvature and rigid fixation determine the prognosis of the patients. Osteotomy and orthopedics are the standard procedure for deformities with severe compression of the front and middle column, but the trauma to the patients is high, with a long operation time and massive blood loss. To avoid these disadvantages, we have developed a modified technique to remove the diseased vertebra unilaterally. In this technique, we use a modified trephine to resect the vertebral columns like in the pedicle screw technique by adding a locking instrument that can restrict the trephine to lower the risk of osteotomy and shorten the surgery time and blood loss.

We describe a modified technique for resecting the posterior vertebral column unilaterally based on a modified trephine for patients with thoracolumbar kyphotic deformity.

Old compression vertebrae fracture or congenital kyphoscoliosis with abnormal vertebral body development and other diseases that invade the spine may ...

Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, laparoscopic radical resection for sigmoid colon or high rectal cancer with natural orifice specimen extraction surgery (NOSES) has the advantage of a small incision, quick postoperative recovery, and short hospital stay. Yet, there are still only a few reports on NOSES. This paper describes the indications, preoperative preparations, surgical steps, and precautions for single-surgeon, three-port, laparoscopic radical resection of the sigmoid colon and high rectal cancer, and intraoperative specimen collection through the natural orifice. 
The protocol focuses on the steps of radical dissection and the main technical points of resection and reconstruction. At the same time, a procedure for fixing an anvil seat by self-traction of extracorporeal silk thread, used for purse-string suture fixation after the proximal anvil was placed in the abdominal cavity, was creatively improved. This operation could effectively avoid problems such as an insufficient proximal intestinal tube, shaking off the anvil seat, and weak purse-string suture during a single operation. The surgical care had less variability and was easy to perform, effectively avoiding postoperative anastomotic leakage and bleeding due to excessive intraoperative anastomotic tissue. This surgery could be widely promoted in primary hospitals.

Here, we present a protocol to successfully perform single-surgeon, three-port, laparoscopic resection for colorectal cancer with natural orifice specimen extraction.

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, ...

Robotic D3 Partial Duodenal Resection with Primary Side-to-Side Anastomosis

Duodenal stenosis is a condition that can be related to several diseases, being either intrinsic, such as neoplasm and inflammatory stenosis, or extrinsic, such as pancreatic pseudocyst, superior mesenteric artery syndrome, and foreign bodies. Current treatments range from endoscopic approaches, such as endoscopic resection and stent placement, to surgical approaches, including duodenal resection, pancreaticoduodenectomy, and gastrointestinal bypass. Minimally invasive robot-assisted surgery is gaining importance due to its potential to decrease surgical stress, intraoperative blood loss, and postoperative pain, while its instruments and 3D-vision facilitate fine dissection and intra-abdominal suturing, all leading to a reduced time to functional recovery and shorter hospital stay. We present a case of a 75-year-old female who underwent robotic D3 partial duodenal resection with primary side-to-side duodeno-jejunal anastomosis for a 5 cm adenoma with focal high-grade dysplasia.

This protocol presents a case of a robotic partial duodenal resection with primary side-to-side duodeno-jejunal reconstruction in a patient with a 5 cm duodenal stenosis. This is done at the third duodenal segment (D3) after an endoscopic mucosal resection (EMR) for a duodenal polyp.