Hydrocelectomy, along with inguinal herniorrhaphy, spermatocelectomy, renal transplantation, and appendectomy, is a recognized cause of iatrogenic injury to the vas deferens. Adherence of the epididymis or spermatic cord to the tunica vaginalis places these structures at risk of unintentional resection or injury by suture ligation, at the time of resection or posterior deflection of the tunica vaginalis during a bottleneck repair [21]. Zahalsky et al. reported a 5.62% rate of injury to the epididymis alone during hydrocelectomy [22].

Prior to surgery, a scrotal ultrasound should be performed to confirm absence of testis tumor. Following transverse scrotal skin-fold incision, the testicle is delivered, and the spermatic cord and vas are identified and surrounded with a Penrose drain. An opening is made in the tunica vaginalis under the microscope, the hydrocele fluid drained, and the testis and epididymis delivered. Use of the operating microscope at the time of hydrocelectomy provides a detailed view of the vas deferens, vasal vessels, and the epididymis, minimizing the possibility of iatrogenic injury. Transillumination of the opened hydrocele sac using the operating room lights can help identify the vas and epididymis, which may be splayed out within the walls of a thick and long-standing hydrocele sac, and be difficult to otherwise identify. The vas should be traced from the cord to the vasoepididymal junction. In cases where the margins of the epididymis are indistinct, the operating microscope is indispensable to assure that epididymal tubules are not transected during hydrocele sac excision. Redundant tunica vaginalis is resected, leaving a fingerbreadth margin of tunic around the epididymis. The edges of the tunic are then oversewn for control of hemostasis. A bipolar cautery is used to control small bleeding vessels. Although there is no published data available comparing the outcomes of microsurgical or nonmicrosurgical hydrocelectomy, in our experience, the microsurgical technique minimizes iatrogenic complications without significantly extending the operative time.

Spermatoceles are extratesticular, sperm-containing cystic structures emanating from the caput epididymis. They are caused by aneurysmal dilatation of an efferent duct, usually due to distal obstruction of the involved efferent duct. As such, spermatoceles are distinct from epididymal cysts, which do not contain sperm. Surgical indications for spermatocelectomy are pain or discomfort secondary to large size; sperm aspirated from spermatoceles are often of poor quality and cannot be used for intrauterine insemination, but in men with vasoepididymal obstructive azoospermia, they can serve as an easily accessible reservoir for sperm adequate for in vitro fertilization and intracytoplasmic sperm injection.

Following transverse scrotal skin-fold incision and delivery of the testis, the tunica vaginalis is opened and the testis, epididymis, and spermatocele are inspected. The spermatocele is microsurgically dissected off the epididymis down to its origin from a single efferent duct, as shown in Fig. 8.2. Care is taken to avoid puncturing the spermatocele. The isolated efferent duct is then ligated with 5-0 absorbable suture and the spermatocele is removed intact. In the only reported series of microsurgical spermatocelectomy, 23 men underwent a total of 36 microsurgical spermatocelectomy procedures, with no postoperative complications or recurrences at a mean follow-up of 17.3 months [23]. In contrast, the reported incidence of complications after nonmicrosurgical spermatocelectomy is 10–30%, with injuries to the epididymis occurring in 17.12% of cases [22].

The optical magnification provided by an operating microscope facilitates dissection of the spermatocele of the epididymis and allows clear identification of the spermatocele neck for ligation, and prevents injury to adjacent epididymal tubules. Outcomes and recurrence rates are significantly improved after microsurgical compared to nonmicrosurgical intervention. The described technique can also be applied for management of epididymal cysts, albeit the lack of communication with an efferent ductule obviates the need to ligate an efferent duct.

Inguinal herniorrhaphy is the most common cause of iatrogenic injury to the vas deferens, causing obstructive azoospermia, as well as injury to the testicular arterial supply, resulting in ischemic orchitis and testis atrophy [24]. The repair of indirect inguinal hernias, which requires the hernia sac to be dissected off the contents of the spermatic cord and ligated, can be particularly challenging, as indirect hernia sacs are often adherent to the vas deferens. Additionally, placement of surgical mesh at the time of herniorrhaphy can be associated with entrapment of the ilioinguinal or genitofemoral nerves, leading to postoperative neuropathic pain.

A skin incision is made in the inguinal crease between the internal and external rings. The superficial epigastric artery and vein are identified, ligated, and divided. The external oblique aponeurosis is opened in the direction of its fibers, and held open using a Scott retractor. Under 10× magnification, the ilioinguinal nerve is identified and retracted out of the operative field. The hernia sac is identified on the anteromedial aspect of the spermatic cord, and dissected off the surrounding cord structures to the level of the internal ring, where is twisted, suture ligated, and divided. The vas deferens, vasal vessels, and internal spermatic artery are preserved. Surgical mesh with a preformed opening for the spermatic cord is then placed around the cord, and seated in a flat position along the floor of the inguinal canal. The ilioinguinal nerve is revisualized to ensure it is not entrapped by the mesh. The mesh is then sewn to itself around the spermatic cord, and secured to the pubic tubercle using interrupted 2-0 monofilament absorbable suture. The external oblique fascia is closed over the mesh using absorbable suture. Use of long-lasting but absorbable sutures minimizes the risk of nerve entrapment syndrome, even if a nerve is inadvertently included under the suture.

Microsurgically assisted hernia repair may be performed as an independent procedure, or concurrently at the time of ipsilateral or contralateral varicocelectomy. Use of the operating microscope minimizes iatrogenic injuries and urologic complications, and should certainly be considered for recurrent or otherwise challenging indirect inguinal hernia repairs.

Lymphedema of the scrotum may be idiopathic, or secondary to parasitic infection, radiation, or radical pelvic surgery. The traditional approach for treatment of lymphedema has been excision of the involved tissue, but this approach is invasive, and still carries a risk of recurrence [25]. The use of microsurgery for the treatment of genital lymphedema was first described by Huang et al. in 1981, based on the technique previously developed for treatment of lymphedema in the upper and lower extremities [26].

In their original approach, the authors used bilateral curved scrotal incisions, and outlined the scrotal lymphatics by subcutaneous, intradermal injection of methylene blue. Under the operating microscope, the stained lymphatics were then anastomosed to superficial scrotal veins [27]. The maximum number of possible anastomoses was performed, averaging about two per side. In three patients treated by this technique, scrotal size returned to nearly normal, and was maintained at 18-month ­follow-up. The authors noted that appropriate patient selection was important. ­Long-standing excess lymphatic fluid accumulated in the intercellular space leads to chronic inflammation, and compression of the lymphatic channels, making surgical reconstruction challenging [27]. Therefore, lymphovenous anastomosis is ideally performed prior to the onset of fibrosis.

Mukenge et al. described a modification of the above technique in which lymphovenous anastomoses were performed between the lymphatics of the spermatic cord and the veins of the pampiniform plexus, thereby allowing testicular lymphatic drainage [28]. In their series of five patients, progressive improvement was noted in terms of visual improvement in scrotal size, consistency and color, decrease in patient-reported discomfort, and by scrotal lymphangiography, in all cases. 90–100% resolution of edema was noted at 3 years of follow-up [28].

The advantages of microsurgical lymphovenous anastomoses over traditional scrotoplasty for treatment of scrotal lymphedema include a limited dissection, either in the superficial scrotum, or in the spermatic cord, with minimal tissue trauma and bleeding, and significantly fewer complications, such as cellulitis and scrotal hematoma. The experience with microsurgical lymphovenous anastomoses is certainly limited, given the infrequent presentation of scrotal lymphedema. One drawback of the procedure is its lengthy duration, with Mukenge et al. reporting an operative time of over 7 h in some patients with long-standing scrotal edema and fibrosis [28].

The incidence of undescended testes in full term infants is approximately 3% at birth. The majority of cryptorchid testes descend spontaneously during the first year of life, with 0.8% of male infants having undescended testes at 1 year of age. For intra-abdominal testes, a staged orchidopexy procedure consisting of division of the spermatic vessels, followed by testicular mobilization and scrotal orchidopexy, has been the mainstay of operative approaches since its description by Fowler and Stephens [29]. The facility of this procedure has been increased by the introduction of laparoscopy and minimally invasive techniques.

As an alternative to the Fowler–Stephens technique, Silber and Kelly described using a microvascular anastomosis to bring extra blood supply to the testicle after mobilization of a high intra-abdominal testicle into the scrotum [30]. Slight modifications have been made to the original technique over the years [7]. A high inguinal incision is made to avoid injury to the epigastric vessels. The retroperitoneum is entered and the testicle is identified. High ligation of the testicular arteries and veins is performed to provide maximal length for vascular anastomosis following scrotal transplantation. The testicle is mobilized, taking a wide strip of peritoneum with the vas deferens. A subdartos pouch is created in the scrotum to accommodate the testicle in a dependent position, without tension on the vas. The inferior epigastric vessels are then isolated and distally ligated, leaving an intact 8–9 cm intact length from their origin at the external iliac vessels. Small vascular branches along this length are also ligated. Under the microscope, the vessels are cleaned of excess adventitial tissue and flushed with heparinized saline. An end-to-end or end-to-side anastomosis using 10-0 nylon may be performed between the testicular and inferior epigastric arteries, based on the discrepancy in their sizes, while an end-to-end anastomosis between the testicular and inferior epigastric vein usually suffices. The testicle is then secured within the dartos pouch.

Several groups have reported excellent long-term results with microsurgical testicular autotransplantation. In the largest series by Bukowski et al., over 95% of the 30 autotransplants performed over a 17-year period were successful [7]. Combined with the results of other small series, there is an aggregate success rate of over 88–95% [31–33]. Despite these promising results, microsurgical testicular autotransplantation has not been widely adopted, due to the need of an operating microscope, microsurgical skill, and the long duration of cases. Recently, the combination of laparoscopic surgery for testicular harvesting with minimal morbidity and maximal vascular pedicle length, and microsurgery for execution of the vascular reanastomosis has been described [34, 35], with comparable success rates, even in patients who had failed previous Fowler–Stephens orchidopexy [34]. The use of microsurgery for orchidopexy of high intra-abdominal testis may, therefore, again increase.