Operative note 36 Advanced
Fertility surgery
What it does: operations to find and fix blocked pipes, or to fetch sperm.
Varicocele (open routes; coils via radiology)
- Palomo (high, back of tummy): whole pedicle tied. Artery may go with it. Collaterals save the testis. Fewer veins. More hydroceles. ~15% back if the artery is spared.
- Ivanissevich (groin canal): cord lifted. Separate artery (papaverine, Doppler) and lymphatics from the ~3 veins. Artery NOT tied here. Cut the cremaster vein too, or it recurs.
- Marmar (below the canal, at the ring): no fascia opened. Many veins, branched artery. The confident microsurgeon's route.
Vasography (blocked vas, before repair)
- Transverse nick in the vas. Do not divide it.
- Fluid to a slide. No sperm = block is on the testis side.
- Saline flush runs free = open beyond. Or blue dye + catheter in bladder: blue urine.
- 0.5 mL X-ray contrast down the vas maps the level.
Vasovasostomy (rejoin the vas)
- Trim to healthy ends. Both bleed.
- 2-layer micro join: 3 x 10/0 stitches in the lining, turn 180, 3 more. 9/0 in the muscle. Then sheath layers.
Vaso-epididymostomy (join vas to epididymis)
- Fat-to-thin tube change marks the block.
- Open 1 tube. Sperm confirmed on a slide.
- Vas fixed to the sheath, 6/0. Lining joined 10/0.
- Sperm back in ~70%. Later narrowing common.
TURED (ejaculatory duct)
- Scan rectally first. Dye + contrast into ducts.
- Resect the veru. Spare neck and sphincter.
- Dye in the bed = in the duct.
- Sperm back ~50%. Risks: reflux, dry ejaculation.
MESA / PESA (sperm retrieval)
- MESA: open an epididymal tube. Pipette the fluid. Blocked system: best sperm sit HIGH (unusual).
- PESA: 27G butterfly into the head of the epididymis, held between fingers. Gentle pull. Press firmly 5 min after.
- 2026 update: micro-TESE is the standard for non-blocked azoospermia. Name it in vivas.
From the UroRef Operative Quick Guide.