Treatment Efficacy of Microsurgical Vasoepididymostomy for Obstructive Azoospermia: An Updated Systematic Review and Meta‐Analysis

Background Microsurgical vasoepididymostomy (MVE) is the standard treatment for epididymal obstructive azoospermia (EOA). However, existing studies report inconsistent pregnancy and patency rates. Objectives To comprehensively review the therapeutic effects of various MVE techniques on EOA, address prior research controversies, and identify factors influencing MVE efficacy. Materials and Methods Eligible studies focused on MVE outcomes, such as patency, pregnancy, or natural pregnancy rates. Relative pregnancy rate refers to natural pregnancies occurring in partners of patients with post‐operative patency. Meta‐analyses were performed using the “meta” R package. Heterogeneity was assessed with Q and I 2 tests. Results A total of 56 studies involving 3204 patients were included. End‐to‐end/end‐to‐side (EE/ES) techniques were associated with patency, pregnancy, and relative pregnancy rates of 65.0%, 23.0%, and 38.0%, respectively, whereas longitudinal intussusception vasoepididymostomy (LIVE) technique demonstrated slightly higher rates (68.0%, 27.0%, 40.0%). However these differences were not statistically significant (all p > 0.05). Compared with the 2‐suture TIVE (72.0%) and LIVE (58.0%; p < 0.01) techniques, the 3‐suture transverse intussusception vasoepididymostomy (TIVE) technique demonstrated significantly higher patency rates (89.0%). Pregnancy rates (33.0% vs. 26.0% vs. 28.0%) and relative pregnancy rates (38.0% vs. 33.0% vs. 42.0%) did not significantly differ among the three techniques ( p > 0.05). Single‐armed LIVE (SA‐LIVE) demonstrated numerically higher patency (69.0% vs. 64.0%), pregnancy (31.0% vs. 26.0%), and relative pregnancy rates (46.0% vs. 39.0%) compared with double‐armed LIVE (DA‐LIVE). However, these differences were not statistically significant (all p > 0.05). Vessel‐sparing SA‐LIVE demonstrated superior patency (83.0%) compared with classical SA‐LIVE (67.0%; p < 0.01), whereas pregnancy (38.0% vs. 31.0%) and relative pregnancy rates (both 47.0%) were not significantly different ( p > 0.05). Bilateral MVE, genital infections, and the presence of motile spermatozoa were associated with increased patency rates. The overall late failure rate was 23.0%, with significantly higher rates for the EE/ES techniques (32.0%) than the IVE technique (15.0%; p = 0.03). Conclusion This meta‐analysis confirms the efficacy of MVE for EOA. IVE has supplanted ES/EE, likely owing to its technical superiority and reduced rate of late failures, with LIVE emerging as the dominant approach. SA‐LIVE and DA‐LIVE yield comparable outcomes, and both should be recommended. Bilateral cases, infectious etiology, and motile epididymal spermatozoa predict increased patency rate. The relative pregnancy rate may better reflect effectiveness.