Henry Ford Hospital Medical Journal

Volume 17 | Number 1 Article 12

3-1969 Vasovasostomy — A Simplified echniqueT Edward E. Steinhardt

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Recommended Citation Steinhardt, Edward E. (1969) "Vasovasostomy — A Simplified Technique," Henry Ford Hospital Medical Journal : Vol. 17 : No. 1 , 67-70. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol17/iss1/12

This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. Henry Ford Hosp. Med. Journal Vol. 17, No. 1, 1969

NOTES AND COMMENTS: II

Vasovasostomy — A Simplified Teclinique Edward E. Steinhardt M.D.*

No reports of significance regarding reunion of the after an inten­ tional ligation appeared in the literature until 1948. O'Conor then reported on 14 patients who underwent bilateral reunion with successful results in 9.' His criteria for success were repeated counts of spermatozoa above 20 million per cc with normal morphology and motility.^ He had a 2 to 15 year followup. A questionnaire sent to 1,240 urologists at the time showed 420 operations performed with a success rate of 35 to 40%. Success was shown by the appearance of spermatozoa in the .

O'Conor later reported 24 more vasovasostomies with a success rate of 43%.^ His technique was excision of the scarred vas, and end to end anastomosis using silkworm gut as a splint. This splint was removed in 6 to 10 days.

Experimental work by Schmidt" showed that successful results were best obtained by end to end anastomosis, gentle handling of tissues, prophylactic antibiotics, internal splinting for 10 days and fine sutures. His results were 50% successful in dogs, using an internal splint of 3-0 nylon. Failures were due mostly to spermatic granulomata, although improper alignment, separation, fibrosis, and infection were contributing factors.' He later improved his technique with a No. 2 F polyethylene tubing as a splint which was brought through the wall of the vas at a location 1 cm distal to the anastomosis.' The tubing was then fixed to the skin where it drained for 10 days and then was removed. In all 10 dogs, the anastomosis remained patent.

Various urologists using an internal splint and fine sutures have reported successful human vasovasostomies in from 77 to 88% of patients'"'" Goodwin" felt that the rate of success with skillful technique could be 90%. Moon and Bunge" reported that in their experience nonsplinted anastomoses had a 12% superiority over the splinted technique in their 11 dogs, and the splints went through the proximal and distal walls of the vas. Phadke and Phadke" reported on 76 patients with 83% successful appearance of spermatozoa. For 55% pregnancy resulted in their mates. The Phadkes used meticulous technique, an internal splint for eight days, prophylactic antibiotics, and bed rest for one week. Fernandes et al" recently described a microsurgical technique for vasavasostomy in dogs, in which splinted and nonsplinted anastomoses were used. In their hands the nonsplinted technique was far superior.

* Division of .

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Figure 1

Figure 2A Injection of Icc 50% Hypaque in proximal vas.

6S Vasovasostomy — A Simplified Technique

Figure 2B

Appearance of radioopaque medium in bladder showing patency.

Personal Technique The technique we employ was developed for its simplicity and adaptability, and attempts to incorporate the best of the preceding experiences. Fine instruments are used with either general or spinal anesthesia. A high scrotal incision is made and the scarred ends of the vas are excised (Fig. lA). The proximal vas will show a milky secretion. A dilute indigo carmine solution can be injected easily into the distal vas, and will appear in the bladder. Having established patency, a readily available polyethylene catheter'* is then threaded over a No. 28 wire. Using the projecting end of the wire for an obturator, the tubing is passed several cms into the distal vas. The wire is passed up the proximal vas for 1 cm and pushed through the wall, and fixed to the skin with suture and aeroplast spray (Fig. IB & C). An end to end anastomosis is done using three sutures of 6-0 dermalon through the wall of the vas avoiding the lumen (Fig. IC). The tissues around the vas are approxi­ mated with 6-0 dermalon to prevent stress on the anastomsis. (Fig. ID and E). The patient is given tetracycline for 10 days postoperatively, is out of bed the first postoperative day, and goes home on the second postoperative day, wearing a scrotal support. When he returns on the tenth postoperative day, the splint is removed, after which he is advised to resume intercourse. Periodic semen analyses are done.

*B.D. tubing (VX020).

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Representative Patient R.L.B., #1340193-0, was a 28-year-old white factory worker who had had a bilateral partial at age 21 for socio-economic reasons (he had three children in this first marriage). He then remarried and desired further children. His examination showed bilateral upper scrotal scars and his semen showed the absence of sperm. In August, 1968, he underwent a bilateral vasovasostomy using an internal poly­ ethylene splint. His postoperative course was uneventful and he went home on his second postoperative day. Splints were removed on the tenth postoperative day. A seminal vesiculogram (Figures 2A and 2B) showed patency of the anastomosis. He resumed intercourse, and a sperm count three weeks later was 20 million, with normal appearance and motility. On a subsequent visit, he stated that his wife was pregnant.

One final word — Vasovasostomy is much easier to accomplish if the previous procedure had been done with consideration given to the possibility that the patient may have a future change of plans. A high scrotal incision over the straight portion of the vas should be used. The vas should be lightly fulgurated, and one end should be covered with a sheath of tissue."

REFERENCES

1. O'Conor, V.J.: Anastomosis of vas deferens after purposeful division for sterility, JAMA 136:162-3, Jan 17, 1948. 2. O'Conor, V.J.: Mechanical aspects and surgical management of sterility in men, JAMA 153:532-4, Oct 10, 1953. 3. O'Conor, V.J.: Mechanical aspects of surgical correction of male sterility, Fertil Steril 4:439-55, Nov-Dec 1953. 4. Schmidt, S.S.: Anastomosis of the vas deferens: an experimental study, J Urol 75:300-3, Feb 1956. 5. Schmidt, S.S.: Anastomosis of the vas deferens; an experimental study. II and III, J Urol 81:203-8, Jan 1959. 6. Schmidt, S.S.: Anastomosis of the vas deferens: an experimental study. IV. The use of fine polyethylene tubing as a splint, / Urol 85:838-41, May 1961. 7. Phadke, G.M.: Re-anastomosis of the vas deferens, J Indian Med Ass 36:386-90, May 1, 1961. 8. Roland, S.I.: Splinted and non-splinted vasovasostomy, Fertil Steril 12:191-5, Mar-Apr 1961. 9. Dorsey, J.W.: Surgical correction of postvasectomy sterility, J Int Coll Surg 27:453-6, Apr 1957. 10. Jhaver, P.S.: / Family Welfare 9;57, 1962. 11. Brewer, H.: Reversibility following sterilization by vasectomy, Eugen Rev 56:147-50, Oct 1964. 12. Moon, K.H., and Bunge, R.G.: Splinted and nonsplinted vasovasostomy: experimental study, Invest Urol 5:155-60, Sept 1967. 13. Phadke, G.M., and Phadke, A.G.: Experiences in the re-anastomosis of the vas deferens, J Urol 97:888-90, May 1967. 14. Fernandes, M.; Shah, K.N.; and Draper, J.H.: Vasovasostomy: improved micro-surgical tech­ nique, / Urol 100:763-6, Dec 1968. 15. Schmidt, S.S.: Vasectomy: indications, technic and reversibility, Fertil Steril 19:192-6, Mar-Apr 1968.

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