Archives of Urology ISSN: 2638-5228 Volume 2, Issue 2, 2019, PP: 9-23 An Updates on Techniques of Microsurgical Vasectomy Reversal- A Mini Review Dr. Kulvinder Kochar Kaur, MD1*, Dr. Gautam Allahbadia, MD (Obstt & Gynae), D. N. B2 Dr. Mandeep Singh, MD, DM. (Std) (Neurology) 1

2

Scientific3 Director, Dr Kulvinder Kaur Centre for Human Reproduction, Punjab, India. Scientific Director, Ex-Rotunda-A*kulvinder. Centre dr@gmail. for Human com reproduction, Mumbai, India. Consultant Neurologist, Swami Satyanand Hospital, Punjab, India. *Corresponding Author: Dr. Kulvinder Kochar Kaur, MD, Scientific Director, Dr Kulvinder Kaur Centre for Human Reproduction, Punjab, India.

Abstract Following sterilization by vasectomy, men my need future fertility, either due to the loss of a child or a new marriage. Following vasectomy reversal there have been a lot of advances in the field to improve the patency and pregnancy rates, although in the modern era of assisted reproductive technology they are usually not counseled with the ease of sperm retrieval and IVF/ICSI. Here we carried out a systematic analysis using the MeSH terms on the search engine Pubmed, like ‘’vasectomy reversal’’, ’’vasovasostomy’(VV)’, ’’vasoepididymostomy’’(VE), ’’optimizing success’’, ’’different sutures’’ to be used, ’’most modern techniques’’ like robotic assisted VV or VE, Video microscopy, analysis of vasal fluid‘’. We found a total of 1200 articles, out of which we selected 75 articles for this review. No meta-analysis was carried out. Further emphasis has been laid on the training of new urologists to learn this complicated technique so that natural conception can be sought for. Further techniques of some complicated cases are described. Keywords: VV; VE; Vasectomy reversal; IVF/ICSI/Vasal fluid

Introduction reversal in length, based on the recent evidence. The advances made recently in surgical technique and Vasectomy reversal is the recommended method how they contribute to this surgery are to be critically of reversing sterilization in men desiring fertility analyzed. Since they are technically problematic subsequently. With marked improvements in stress is put on role of microsurgical training, that techniques in the last 4 decades, high patency rates includes the current knowledge which are improving and favourable pregnancy outcomes following reconstruction can be expected. Though there are other treatment options that are available for these theEvaluation education in to this be field. done Preoperatively patients with post vasectomy obstructive azoospermia Preoperative examination of men with suspected OA starts with a proper history taking and thorough techniques, vasectomy reversal is the only method (OA) meaning different kinds of sperm retrieval which allows natural conception. Further Vasectomy the cause of azoospermia whether obstructive (OA) orexamination non obstructive physically. azoospermia Main idea (NOA). of this Specially is to find on in contrast to sperm retrieval to be used for IVF (in examination of the spermatic cord, a heating blanket reversal has also been found to be more cost effective vitro fertilization)/ICSI (Intracytoplasmic injection). or hot pack is placed with the idea of warming the Still the success of Vasectomy reversal is based on scrotum, thus relaxing the scrotal dartos muscle. Still and proper selection of subjects. The aim of this review this early examination can be further increased in case isgood to highlightclinical judgement, the treatment efficient approach microsurgical for vasectomy skills ofno borderline sign or symptom cases. is 100% sensitive or specific and Archives of Urology V2 . I2 . 2019 9 An Updates on Techniques of Microsurgical Vasectomy Reversal- A Mini Review I laboratory examination is usually not needed, like an best chances of success get obtained when the interval earlyIn case history of aof vasectomy. clear causative But in absence factor identification, of vasectomy, n the work done by the Vaso-vasostomy Study Group,

vasalof obstruction encounters was the under outcomes 3 years kept(patency on worsening, rate 97%, timeor if patient testosterone had difficulty (T) level. in Thisgetting discrimination a pregnancy, ofprior OA withpregnancy 15 plus rate years 76% of [7]. obstruction With increasing leading durationto patency of vsto sterilization,NOA was carried it is betterout by to Schoor get an et FSH al. and[1]. morningA length of testis of a minimum 4. 6cm, in combination with Once obstructive interval rises chances of secondary epididymaland pregnancy increase rates occursof 71%and and 30% thus respectively. the patient OA in 96% of the patients. With this the preoperative testicularan FSH level<7.6mIU/ml, biopsy has got identifies practically subjects removed having for diagnosing. Though useful, the Schoor criteria will laterequires failures, both besides vasoepididymostomy reduced pregnancy (VE). rates, Technically inspite wrongly diagnose obstruction in roughly 1in 20 men. ofVE patencyis more difficult, getting with demonstrated greater likelihood [8, 9]. Fuch’sof early etal.and Subjects with NOA, having an appropriate testicular showed a 50% increase in the probability of needing

one of the biggest published series. Performance rate examinedsize, and a aFSH cohort value of <7.6mIU/ml, 600 men who usually presented have some with a VE for every 3 year period following vasectomy in NOAform whereof maturation services arrest were on provided histology. by Hung a single et al. unit. [2] 4.3% of the subjects had a testicular length >4.6cm exposureof VE falls following once the spermatogenesis level of obstruction [11, reaches 12]. Since the efferent ducts, secondary to inadequate epididymal be needed, many groups have chalked out extra and a normal FSH level, with maturation arrest on presenting with maturation arrest, observed both preoperativethe prognosis predictors is based largely for this on setting. if bilateral McCammack VE will biopsy. Even Tsai et al. [3] on examination of men et al. [13] tried to use magnetic resonance imaging for in 38% of the cohort they studied. Because of this laying down the prognosis of requirement of IVF in OA. testis volume and a FSH level below the threshold any reproductive urologist who asks the patient for They had a small cohort of 10 subjects with known OA, reconstructive surgery needs to know the limitations a 19. 4% increase in epididymal T1intensity predicted of the basic laboratory tests, since operative plan may change dramatically in the possible misdiagnosis. Serum antisperm antibodies assessment is useful for the need for VE in 90% of subjects. Follow up studies are required to confirm these findings which are mightconsisting prove of alarge useful cohorts. tool for Once prediction McCammack’s of epididymal finding confirming spermatogenesis; A high positive assay get confirmed, magnetic resonance imaging (MRI) confirmsMostly imaging the diagnosis studies in don’t case giveof OA much [4]. information, but for suspected ejaculatory duct obstruction, where instead of vasovasostomy (VV). Patients need to obstruction and the subsequent requirement of VE a transrectal ultrasound shows dilated seminal vesicles and/or ejaculatory ducts or midline cysts might be needed as patency and pregnancy rates are typically understand prior to the surgery that bilateral VE is additional data over physical examination in case of In terms of importance this impact of interval since diagnostic. Ultrasonography (USG) doesn’t provide any reduced in such circumstances [7]. vasal gaps, presence or absence of a sperm granuloma, obstruction has not been clear in contemporary or testicular size (if an orchid meter is utilized). Only series [14, 15]. Still most of literature implicates that the interval of obstruction remains one of the most important factor regarding preoperative counseling way USG might be helpful is in getting the diameter [16]. Other important factor in preoperative of caput epidymis, which will differentiate OA/NOA, –all these are the most important points regarding counseling is whether sperm granuloma is present. It is but not for a specific patient having maturation arrest preoperative examination [5]. Further fullness of the considered that a sperm granuloma provides a passage epidydimis might not be present in men having OA, to relieve vasal pressure, thus decreasing the risk of where obstruction is at the level of rete testis, which may be present in 15% of men with OA [6]. In contrast to obstruction interval, sperm granuloma wassecondary considered epidymal favourable obstruction in older by ‘’blowout’’ series, having [17]. should include anticipated reconstructive outcomes. more studies recently showing little or no predictive On confirming obstruction, further patient counseling 10 Archives of Urology V2 . I2 . 2019 An Updates on Techniques of Microsurgical Vasectomy Reversal- A Mini Review

for these cases where IVF is unavoidable, utilization value [7, 14, 15, 18]. Boorjian et al. presented a large ofsperm vasectomy retrieval reversal is the has best decreased option. Howevermarkedly exceptin the inexperience patency ratesof a single following surgeon, a vasectomy finding more reversal chance (95% of post –ICSI era. Although many cases of increased use statistical significance (p=0.07) regarding difference family building [23]. It is clear that with increasing granuloma,vis a vis 78% since for subjects a granuloma without might a palpable be pointing sperm maternalof ART, exist, age onethere major is an cause inverse is thatrelation women to chances delay the of granuloma). Despite that some examine for sperm reconstruction and hence imply a greater chance that wanting fertility following vasectomy tend to be older oneto acan greater perform –quality a VV procedure intravasal that fluid is lesser during tough the andnatural might conception have partners and ART who outcomes.are of high Further, age as well. men Following vasectomy reversal main factor which [7,Other 18]. aspects on history/general physical examination patency, is the age of the female partner. According predicts pregnancy, besides re-establishment of big vas al gaps, if any iatrogenic vasal injury is to Megheli et al. [14], who described a cohort of 334 (GPE), include history of previous vasectomy reversal, subjects who underwent reconstruction and found herniorrhaphy. A lot of small series presented success that female age was the only independent predictor of followingreflected by previous another failed procedure reversal, carried found out moderately earlier like pregnancy, that outperformed obstructive interval and decreased success rates. The Vasovasostomy Study sperm granuloma status. Just like that on examination repeat procedure was done, and found a patency rate obstructive intervals of at least 15years Fuchs et Group presented a series of 199 subjects in which a al.of [8] 173 found men that undergoing pregnancy vasectomy rates of 64% reversal and 32% for cohort done following that consisted of 41 patient who hadin 75% at least of subjects, 1previous with attempt a pregnancy at vasal rate reconstruction of 43% [7]. A 40 years respectively. Thus the overall pregnancy rate wasaccording 43%, tothat partners, was similar having to <30 the yearcontemporary age vis a vis IVF/ 36- ICSI results. Since it can sometimes take >6mths for showedreported thatby Hernandez 39% of their etal. subjects[19] Found needed a patency bilateral rate sperms to return to the ejaculate, and hence successful and pregnancy rate of 79% and 31% respectively. They pregnancy might even take longer, some consider that Once large vasal gaps or iatrogenic injury to vas is vasectomy reversal is not the choice of treatment for present,VE that gives it points importance to the inability of preoperative of vas to get knowledge. a tension couples that have partner of advanced maternal age –free anastamosis. Which should be discussed with the patient prior to the intervention [20]. Although such [9, 24, 25]. Stratification was attempted in a better settings are rare, surgical approach varies markedly analyzed 136 men who chose to undergo vasectomy reversalway by Kapadia even if their et al. partners [26] as perwere womans 35 years age. or olderThey specialized equipment [21]. No long term outcomes results that had been documented. They found that arefrom available the traditional regarding VV these and VE reconstructions and may even which need liveand birthcompared rates the were result comparable they obtained between with per the cycleART are full of complexity. Patient attempting these need IVF data and vasectomy reversal. For subjects with to be aware of lack of information as regards patency partners over 40 years, the vasectomy reversal group and pregnancy rate anticipated.

Female Factor a birth rate of 14.2%, when selecting for couples who got a birth rate of 15.4%, while one cycle of ART gave Clinical characteristics of the female partner must be did not have any separate female infertility factors. considered while making the decision on treatment Still whether vasectomy reversal is proper when the woman is >35years remains unanswered since plan for OA, Since these factors will affect prognosis while many vasectomy reversal couples in the long as significantly as the males preoperative evaluation. runKapadia will et undergo al. [26] multiplejust compared cycles. per Still cycle all outcome subjects Current reproductive urologist has different procedures spermto offer retrieval men techniques.following Invasectomy some cases that like tubalrange from factor,definitive the reconstructioncouples are forced to theto have different IVF and kinds hence of seeking vasectomy reversal it is worth offering that vasectomy reversal is more cost effective than ART. Archives of Urology V2 . I2 . 2019 Lee et al. [27] utilized a constructive and analytical11 An Updates on Techniques of Microsurgical Vasectomy Reversal- A Mini Review model for comparison of vasectomy reversal with patency. In view of crossover recombination, sperm will sperm retrieval along with IVF/ICSI, which included outside of the immune privileged space of the testis cost in 2005 for vasectomy reversal, microsurgical [34].produce If leakage an inflammatory of sperm occurs response from whena reconstruction presented epididymalindirect costs sperm [27]. with In terms IVF/ICSI, of dollars and testicular the calculated sperm side will result in a granuloma development, that aspiration with IVF/ICSI were, 25321$, 58528$ and might distract the anastamosis, causing failure [35, 36]. Further to achieve a high quality anastamosis in the male reproductive tract, where the vasal lumen is adds61, 977%respectively. to much less morbidity This was with similar complications to the cost if as small as 0.3mm and epididymal tubules as small vasectomyfactor analysis reversal by Heidenreich was opted for. etal. [28], that further as 0.15mm, proper visualization with an operating Finally history of proven fertility in the partner in the can be obtained using loupes and prolene stent, couples who present is another important preoperative microsope is pivotal[37, ]. Though reasonable patency factor. In the earlier studies that contained small expected results are still lesser than the traditional cohorts found high pregnancy rates when the male microsurgical reconstruction that maintains the partner was seeking pregnancy with the same female partner prior to vasectomy. The study carried out option of doing V E if required [37]. done using a high bilateral scrotal incision. Some underwent reconstruction secondary to death of a Both types of vasectomy reversal, VV o r VE, can be by the Vasovasostomy Study Group, subjects that a small midline incision via no scalpel vasectomy subjects having a new partner got a pregnancy rate of maneuversworkers have [38]. retried Although a modified patency techniqueand pain outcomes utilizing child, got a pregnancy rate of 76%(n=21), while in and can be rather hindering for large vasal gaps or Obta50%(n=612)[7].ined pregnancy On ratesthe same of 60% lines and subjects 86% respectivel with they. were favourable, the limited surgical exposure VE same partner, Kolettis etal. [29] and Chan etal. [30] Ostrowsky et al. [31], conducted a comparison of 258 the traditional high scrotal exposure since it is couples where partner was same with the rest of significant granulomas. The group of Hayden prefers vasectomy reversal cohort. A pregnancy rate of 83% were obtained when vasectomy reversal was done in highgenerally bilateral well scrotal tolerated incisions and gives can marked be used flexibility even in a couple with proven fertility in contrast to 60% in the awakefor an unexpected procedures, different although reconstruction. most surgeons Further prefer reasons not very clear prognosis when partner is same isother markedly cohort greater, giving an which odds should ratio of be 2.0(P<0.01). emphasized For in anaesthesia should VE gets indicated [36, 39]. preoperative counseling. DecisionIrrespective making of the following incision an opted intraoperative for, the vasectomy approach Thus the criteria combining both male and his wife will update regarding the prognosis for any attempt carried vssal gap and resection of nonviable vas deferens with reversal begins with the idea of notification of the out at vasectomy reversal. Thus the reproductive the help of a slotted nerve clamps provide comparable urologist has to make a decision along with the male partner weighing al pros and cons. Though vasectomy obtainedoutcomes through [40]. Distal a saline patency or water must soluble be ensured contrast to confirm practicality of reconstruction, that might be for all patient reporting, sperm retrieval might prove vasogram [35]. If obstruction of the abdominal vas reversal is the gold standard and is most cost effective remnant might occur due to inadequate resection of the vasectomy site, or due to unrecognized theVasectomy most effective Reversal: choice Techniques in certain situations [32] iatrogenic injuries from procedures that occurred The techniques of vasectomy reversal got optimized after sterilization (e.g herniorrhaphy) [41]. In the in 1980s and further in 1990s with marked work of rare scenario of inguinal and abdominal obstruction (usually from previous hernia repair) crossed VV might be of use in case the contralateral testis has a whichthe Vasovasostomy is a tension free, Study mucosa Group to [7, mucosa 33]. The connection basics of thateither maintains VV or VE adequate depend on blood a good supply, quality The anastamosis has to be water tight for maximizing the chances of epidydimispatent epidydimis is blocked (as [42]. confirmed by the presence of sperm in testicular and vasal fluid, while the ipsilateral 12 Archives of Urology V2 . I2 . 2019 An Updates on Techniques of Microsurgical Vasectomy Reversal- A Mini Review For particular cases, assessing the vasal end might ends should be patent, having proper blood supply as planVE; yetthat the is going surgeon to be. must interpret the macroscopic be the first decision point for the surgeon. The vasal findings of the vasal efflux to make sure the operative What is of importance is that mucosal vessels will assessed by bleeding from the final mucosal vessels. basis of its colour, consistency and volume. If there usually bleed following a short delay, while adventitial Overall, the vasal efflux can be differentiated on the vessels will bleed briskly following transection. is “toothpaste” like fluid, that is a part of the vassal perfusion. The surgeon should be able to see 4 epithelium, and in the absence of sperm, it warrants VE Usually the testicular remnant will determine better of vas deferens generally indicates a patent epididymis, layers: mucosa, two layers of muscle (subtle), and [47, 48]. But plenty of clear fluid following transaction the adventitia. If 2 muscular layers are not seen, it might indicate residual scar from the vasectomy. even in the absenceof sperm [7, 48]. Problem exists More resection for optimizing the vasal ends must be if there is intravasal azoospermia, with a low efflux weighed against the criterion of a larger vasal gap, a openingvolume, orthe if tunicathe colour/consistency vaginalis [49]. A istransition different point from choice that can be helped by experience via adequate ofclear dilated and ofthin. dilated In this to contextnondilated Hayden epididymal et al. advocate tubules microsurgical training. is a clear sign of secondary obstruction. Though a On obtaining homeostasis for the testicular vasal its absence does not rule out epididymal blockade [50]. Othertransition strategies point isare specific, barbotage it is notof the very testicular sensitive, vassal and remnant with the use of a low-power bipolar cautery, obscuring contamination with red blood cells. Macro remnant in hopes of discovering sperm or waiting intravasal fluid can be examined following that without a short period of time, (i.e. while the contralateral surgeon whether secondary epididymal obstruction side is examined), that sometimes might result in and microscopic appearance of the vasal efflux tells the return of very few sperms. Because of this it is always has occurred, thus obliterating VE. One can anticipate, the possibility of epididymal obstruction, with post which technique is to be used. VVfinding patency of motile rates spermnearing within 100% vas for deferens some series rules [43]. out important to evaluate both sides prior to finalizing The presence of non motile but intact sperms also An important factor that can complicate the predicts high patency rates. For this latter case, the T replacement therapy (or less common, anabolic assessment of intravasal fluid is the commonly used Vasovasostomy Study Group showed a patency rate of gonadotropins centrally. Although systemic T levels of 91% to 96% [7]. On visualizing only sperm parts mightsteroids). reach Exogenous therapeutic androgens levels, suppress spermatogenesis the release studies(i. e sperm found heads), similar the results, Vasovasostomy on the basis Study of Groupwhich needs intratesticular concentrations to be higher showed a patency rate of 75%. Subsequent smaller in quantity [51] In the absence of intratesticular analysismany providers that included carried 1239 out a subjects VE in such across a setting 6 studies, [44]. impaired sperm production because of inadequacy of Scovell et al. [45] Carried out a contemporary meta- exogenousT synthesis hormone that is stimulatedreplacement by therapy. LH, there So much will beso that azoospermia was induced in 95%of subjects in a reversal.re-examined Observation the role of of sperm intravasal parts fluid or sperms assessment with study with the use of high dose T undecanoate [52]. shortthat neared tails statistical positively significance correlated during with pregnancy,vasectomy Thus the subjects presenting for vasectomy reversal rendering the recommendations for VV in such a case. with recent use of androgens might present with Subsequently a retrospective review was carried out intravasal azoospermia because of poor synthesis

Coward et al. [53] treated 6 patient with clomiphene in 902 subjects, where finding of only sperm parts rather than due to epidydimal blockade. Recently in intravasal fluid assessment neared statistical expected rates of intravasal sperm during surgery. onsignificance with VV when for worseonly sperm post parts reversal are found, pregnancy since and /or HCG prior to vasectomy reversal. They showed outcomes (p=0. 05) [46]. Still most providers now go results especially with the testis recovery is complex Presence of intravasal azoospermia might indicate followingBigger studies exogenous are required androgen for exposureconfirming [54]. these early the expected patency rates are greater than for VE. Archives of Urology V2 . I2 . 2019 13 An Updates on Techniques of Microsurgical Vasectomy Reversal- A Mini Review Vasovasostomy large vassal gaps, more advanced procedures might be required like inverting the test is to add to the supplied F if length [42]. On bringing both ends of the vas together VV is needed one must assess the resulting vasal gap ollowing assessment of vasogram and intravasal fluid without tension, microspike approximator use helps by freeing both vasal remnants to make sure that there is a tension free anastamosis. One must take care that to be given to see that vas deferens does not twist vasal vasculature is preserved, for preventing failure in exposure along with fixation [42]. Importance has because of ischemia. Better mobility and length can utilize the microdot technique as well for preplanning be obtained usually from the testicular remnant, placementwhile setting of every up the suture, reconstruction. which is very Hayden helpful et al. if especially when the convoluted vas is freed. In case of

luminal discrepancy exists [43] (fig 1).

Fig 1. Courtesy ref no 49. (A) Setup and placement of the mucosal sutures for VV. (B) Note that the initial three sutures must form a “three-string guitar” before tying, a heuristic that helps ensure no sutures inadvertently crossed each other. (C) Flipping of the microspike approximator facilitates the remaining mucosal sutures. With this exposure the initial three ties should be visible and checked for inadvertent back-walling during initial suture placement.

14 Archives of Urology V2 . I2 . 2019 An Updates on Techniques of Microsurgical Vasectomy Reversal- A Mini Review the muscularis. Adventitia is further brought together

The Vasovasostomy Study Group did not find any statistical difference in patency or pregnancy thatwith at give least additional six 9-0 sutures. tensile Ultimately strength tothe the adventitia repair. whereoutcomes 6,633 for patients two layer were and involved single [16]. layer Possibly, VVs [7]. a Animalis brought studies together have withindicated 7-0 polydioxanone noninferiority ofsutures, nylon highFollowing quality that single a meta-analysis layer anastamosis confirmed might these prevent results extravasation and thus reduce the accompanying risk allsutures sutures for are the put 10-0 inside and out 9-0 [49]. layers In some[55]. challengingTo prevent two layer technique, since that it has been associated casesback wallingcross microsurgical double-armed atypical sutures vasovas are a must ostomy since in withof granuloma. greater patency But Hayden rate et that al. has continue been to published use the [43, 49]. For highlighting the mucosa indigo carmine crossover transseptal vasovas ostomy has been can be used prior to placing the sutures. A total of six consideredscrotum of atypical as an OAalternative [56]. (FIG for 2, 3,very 4). selectedSimilarly

10-0 sutures get used for approximating the mucosa, cases of iatrogenic injury to vas deferens. [57] with additional six 9-0 sutures placed to approximate (fig 5, 6).

Fig 2. Courtesy ref no 49.-Steps for successful LIVE. See text (“Vasoepididymostomy” section) for a written description.

Fig 3. Courtesy ref no. 56Intraoperative deferentography demonstrating obstructed right vas deferens and normal left vas and seminal vesicle. Archives of Urology V2 . I2 . 2019 15 An Updates on Techniques of Microsurgical Vasectomy Reversal- A Mini Review

Fig 4. Courtesy ref no 56.A) Schematic view of iatrogenic injury to right vas deferens with hypotrophic left testis. B) Schematic view of surgical procedure for microsurgical crossover transseptal vasovasostom

Fig 5. Courtesy ref no 56. Final aspect of the microsurgical crossover transseptal vasovasostomy.

16 Archives of Urology V2 . I2 . 2019 An Updates on Techniques of Microsurgical Vasectomy Reversal- A Mini Review

Fig 6. Courtesy ref no 57-Cross vasovasostomy in the scrotum The arrow refers to the anastomosis site

Fig 7. Courtesy ref no-Cross vasovasostomy in the scrotum The arrow refers to the anastomosis site Archives of Urology V2 . I2 . 2019 17 An Updates on Techniques of Microsurgical Vasectomy Reversal- A Mini Review Vasoepididymostomy absence of sperms. Once no sperms are found, this site needs to be given up and look for a new tubule upstream. If sperms are present, the already placed of the size and fragility of epidymal tubules. Still double armed sutures are then placed through the theVE istechnique much more needs difficult to be as mastered compared by to any VV surgeon in view attempting vasectomy reversal as the presence or et al. mark the vas with microdots for simplifying the absence of epididymal obstruction can be judged mucosa of the vassal end (fig 7D). Just as in VV, Hayden bringing the vas lumen down into the tubulotomy by length of the abdominal vasal remnant is essential to securingsututure the passage. vasal Followingadventititia that to the 9-0 tunical stay suture window, for beonly obtained intraoperatively. so that tension [58]Just freeanastamosis like VV, a sufficient can be performed. Since the abdominal vas gives less ability to free more length, occasionally testis might have to shoulddirectly be opposite applied totill the all snack initial has anchoring been removed(as stitch (fig be pexed superiorly for avoiding undue stress on the indicated7E). Prior by to subsequenttying the 10-0 movement sutures, of careful the opposite tension resulting reconconstruction [42]. Following that a side of the stitch ). This step also makes sure that small window is made in the tunica vaginalis, and the abdominal remnant is drawn through to facilitate the which need to be tied together at that time. Finally step reversal. proper identification of both legs of the same suture, the tunical window window with multiple interrupted tubule size, its orientation, and the natural lay of the of VE is to secure the rest of the vas circumference to vasHow deferens. to select Sincthe epididymal e patency outcomestubule is guided tend to by drop the watertight seal. as more epididymal length is excluded, the initial 9-0 Nylons (fig 7F). Spacing of sutures will ensure a tubule which is selected should be as distal as is possible, but above any transition points which might Little modifications of this LIVE technique have been be present [12]. Small window of epididymal tunic is [60].described The patency in the different which results publications. following Varioususe of single trials then excised by gently raising the tissue with jeweler have examined, the use of single armed 10-0 sutures forceps and transected with the help of microscissors. of traditional double –arm ed sutures. To reduce back Inadvertent entry into an epididymal tubule means to armed 10-0sutures tend to be lesser than with the use repeat attempt upstream within the epididymis. Then the vas is anchored to the edge of the tunical window walling Hayden et al. use only double –armed sutures. ofZhang varicocoele et al 61]. repair. Made Larger another series modification, that corroborat a vessel this with the use of approximator clamp, since any tension havesparing not VE, been that published. was meant Still for the pts improved with a long success history of mightwith 9-0 tear nylon these sutures delicate (fig7A). tissues. This might be helped of errors. Longitudinal Intusussecption vasoepididymostomy LIVE technique and its simplicity decrease the chances There are multiple techniques for VE, although the New Tools animal studies and now is the one considered as the Advances in surgical tools have given more chances for standard(LIVE) procedure of care [59]. has The been selected found epididymal to be better tubule in improving microsurgical reconstruction. The biggest e. is 1st linked with indigo carmine for helping watch the armed nylon sutures are then put longitudinally along g is robotic surgery, since it offers high resolution, three thelumen tubule once in a atubulotomy parallel fashion. is made. It isTwo crucial 10-0 that double the dimensional magnification, with tremor –reduced fine roboticmanipulation –assisted by different VV on fresh surgical human graspers. vas deferens Earliest epidermal tubule, that will make the tubulotomy overly publications regarding possibility and effectivity of needles are left in situ for preventing deflation of the animal studies were subsequently carried out for the needles in the beginning, would allow enough assessingspecimens patency was given outcomes. by Kuang The et al.only [62]. randomized Different spacetraumatic for making otherwise a tubulotomy. (fig 7B and Then 7C). withFurther the placinghelp of ophthalmic knife the tubules between the needle then incises the tubules between the needles. Then the operatingcontrolled microscope trial was conducteddone in a rat by model. Schiff Following et al. 9 [63] weekswhere of they recovery compared these roboticrats were VV killed and and VE examined with the effluxed18 fluid needs to be examined for the presence/ Archives of Urology V2 . I2 . 2019 An Updates on Techniques of Microsurgical Vasectomy Reversal- A Mini Review for patency and granuloma formation. The time taken for surgery for VV were considerably lower in the azoospermia, that occurred in upto 12% and 50% for VE. Late failures, by definition is a return of seminal anastamosis getting shut down it is better to counsel ratesrobotic were group, observed while no betweendifference the2 in operating instruments. time theVV andpatient VE, forrespectively. sperm cryofreezing In view of oncehigh patencyrates of hasthe was noted in VE. No statistical difference in patency

The reference values for semen analysis following VV.Sperm granuloma formation was higher significantly been confirmed. in the microscopic VV, with no difference in rates of vasectomy reversal had not been clear till now. A cohort So far various small studies have reported noninferior of 139 subjects were examined following vasectomy outcomes of robotic vasectomy reversal in humans reversal by Majzoub et al. [68]. They found that men [64]. Yet the uptake of robotic vasectomy reversal who were able to achieve a pregnancy had much lower has been infrequent, probably due to cost factor and the traditionally trained microsurgeons being more 6/ml, motility comfortable with the operating microscope. Though semen parameters in contrast to WHO referral values were[69]. 15%, A sperm 21.3%, concentration and 14% respectively of <5x10 [68]. Though the<10% studies and morphology cohort was <1%small, a pregnancythere initial rate data observed give an wherecost –efficacy intracorporeal of robotic vasal –assisted reconstruction vasectomy has reversal to be early means of interpreting the postreversal semen doneis debatable, [65]. Larger it may series be excellentare needed in to difficult corroborate cases th edition criteria and the this approach and verify the durability of patency binary outcome of patency [69]. following extended follow up. analysis beyond the WHO, 5 Training of the Surgeons Video microsurgery is another technology, which is Since vasectomy reversal is a procedure which requires coming up and might be used for vasectomy reversal. adequate attention it needs dedicated microsurgical training to make sure optimum results are achieved resolution camera which transmits to monitors that Here instead of the operating microscope, a high for the patients. Tissue handling technique, needle with accompanying eye wear gets utilized [66]. of vasal stumps, tension, and epididymal tubule Tillare capable now, the of technology producing forthree-dimensional obtaining the needed images selectioncontrol of can 10-0 only sutures, be acquired intraoperative via experience assessment rather resolution for facilitating safe visualization using this than from published literature. With male infertility

Zeiss are manufacturing products which surpass the to further superspecialize and thus there will be imagingprocedure limits was needed limited. for Recently, surgery. both Video Olympus microscopy and condensationfellowships quiet into common, centres of this excellence. field will Incontinue other has promise for a longer working focal length, wider urologic subspecialities, learning curve s for common field of view, along with minimal surgeon strain due to control of the practitioners. For this the best example the projected performance of video microscopes vis a surgeries are being defined for allowing quality visposture the traditional [67]. More operating studies are microscope. needed for confirming to carry out a robotic –assisted prostatectomy is being Post Operative Manipulation comes from oncology field, where minimal case load

In many Western countries vasectomy reversal is describedNeed for [70]. standardization and quality control of conducted as a day procedure. Convalescence of reproductive urologists has been noticed for a longtime. patient is similar to that for minor scrotal surgeries, that are well tolerated. Complications are haematoma, general surgeons who were practicing vasectomy and infrequently infection. These patients are followed reversalWood et toal. assess[71] surveyed the volume both andurologists outcomes. along Those with up by most reproductive urologists with serial semen who submitted high volumes (>15/year) obtained a analyzing the kinetics and later failure rates were delineatedanalysis. Farber for the et pooledal. [9] conducted data of 24 a studies.meta-analysis, Sperm patency rate of 87% in contrast to those practitioners return to the ejaculate happened between a mean i.having e. patency lesser ratesvolume of (<6/year), 89% and 53%having respectively, a patency rate for thoseof 56%. who Nagler did and et al. did [72] not observed practice similar the skills results, in a rangeArchives of 1.7of Urology -4.3 mths V2 for . I2 VV . 2019 and upto 6.6mths for 19 An Updates on Techniques of Microsurgical Vasectomy Reversal- A Mini Review microsurgical lab. A rat model is used accurately to [3] Clinical characteristics and reproductive outcomesTsai MC, Cheng in infertile YS, Lin men TY, with Yang testicular WH, Lin early YM. gavesimulate promising both the results VV andfrom VE their techniques training curriculum in Hayden etal. Centre [73]. Just like that the Toronto group also and late maturation arrest. Urology, 2012; 80: [74]. [4] 826-32. microsurgical vasectomy reversal is a goal that has not Description of learning curve for the traditional antibodiesinLee R, Goldstein diagnosing M, Ullery obstructive BW, Ehrlich azoospermia. I, Soares the learning curve for the transition of a skilled M Razaano RA et al. Value of serum sperm been reached till now. Kavoussi et al [75]. Described [5] for a single high volume reproductive urologist. It was J Urol 2 009; 181: 264-9. foundmicrosurgeon patency torates robotic-assisted remained consistent vasectomy and reversal within caputPezella pididymisA, Barbonetti diameter A, D’Andreas is reduced S, Neconzione in non acceptable limits over time, but operative times obstructiveS, Micillo A, Di Gregorio azoospermia A, et al. comparedUltrasonographic with st 50 cases. Thus normozoospermia but is not predictor for a continuous work is required to mature reproductive urologysignificantly for standardizing reduced following and optimizingthe 1 training of future guidelines. successful sperm retrieval after TESE. Hum [6] Reprod 2014; 29: 1368-74. Conclusions sperm retrieval and sperm injection outcomes Techniques of microsurgical vasectomy reversal keep inMiyaoka obstructive R, Esteves azoospermia: SC, Predictive do etiology, factors retrieval for on evolving continuously for improving outcomes techniques and gamete source play a role? Clinics for males who want fertility following elective sterilization. Success begins with proper pinpointing of proper candidates for this surgery preoperatively. (Saulo Paulo)2013; 68 (Suppl1): 111-9. Need for assessing both partners is a must and very [7] vasectomyBelker AM, reversal Thomas by AJ the Jr, VasoFuchs Vasostomy EF, Konnak Study JW, important for postoperative OA, and proper preop Sharlip ID. Results from1469 microsurgical examination and counseling can help in choosing [8] Group. J Urol 1991; 145: 505-11. vasectomy reversal the surgeon might face various 15years or more after vasectomy: correlation of Fuchs EF, Burt RS. Vasectomy reversal performed intraoperativethe proper treatment decisions plan. making Even on after the choosing basis of pregnancy outcome with partner age and with remaining healthy anatomy along with examination of pregnancy results of invitro fertilization and intracytoplasmic sperminjection. Fertil Steril intravasal fluid. In view of the great amount of work algorithm is known, despite some occasional [9] by the Vasovasostomy Study Group, most treatment 2002; 77: 51 6-9. questions regarding if only sperm parts are found. kinetic of spermreturn and late failure following vasovasostomyFarber EF, Flannigan and R, Li vasoepididymostomy: P, Li PS, Goldstein M. The a outcomes can be ensured to the pts. For continuous deliveryHigh rates of quality of patency care, reproductive with favourable urologists pregnancy need to standardize fellowship education, and pass it on to [10] systematic review. J Urol 2019; 201: 241-50. the next generation of subspecialists. withneedFuchs ME, for Anderson vasoepididymostomy RE, Ostrowski Ka,at the Brant time WO, of References Fuchs EF, Preoperative risk factors associated [1] [11] vasectomy reversal. Andrology 2016; 4: 160-2. LS. The role of testicular biopsy in the modern Schoor RA, Elhanbly RS, Niederberger CS, Ross Moore HD, Hartman TD, Pryor JP, Development of the oocyte-penetration capacity of spermatozoa management of male infertility. J Urol 2002 ; 167: in the human epididymis. Int J Androl 1983; 6: [2] 197-200. [12] 310-8.Pasqualotto FF, Agarwal A, Srivastava M, Nelson Maturation arrest: a unique subset of men with Hung AJ, King P, Schlegel PN. Uniform testicular DR, Thomas AJ Jr. Fertility outcome after rapeat 20 obstructive azoospermia. 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Citation: Dr. Kulvinder Kochar Kaur, Dr. Gautam Allahbadia, Dr. Mandeep Singh. An Updates on Techniques of Microsurgical Vasectomy Reversal- A Mini Review. Archives of Urology. 2019; 2(2): 9-23. Copyright: © 2019 Dr. Kulvinder Kochar Kaur, Dr. Gautam Allahbadia, Dr. Mandeep Singh. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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