MICROSURGICAL REVERSAL TECHNIQUES TO IMPROVE OUTCOME

By Edward Karpman, MD, Daniel H. Williams IV, MD, and Larry I. Lipshultz, MD

In the United States today, men are playing a greater role in couples’ decisions regarding permanent contraception than they did in past generations. The latest avail- able data from the Centers for Disease Control show that 13.6% of married men chose vasectomy as a form of contraception, with approxi- surgical vasovasostomy.6 He found that although initial pa- mately 500,000 procedures performed annually.1,2 Of these tency rates appeared similar for the 2 groups (85% and 91%, men, 2% to 6% will desire reversal of their vasectomy at a respectively), pregnancy rates were better for the microsurgi- later time.3 Reasons include re-marriage, desire for further cal group (52% vs. 35%). Additionally, decreasing postoper- fertility, loss of a child, and chronic testicular pain. ative sperm counts and ultimate azoospermia were more can be performed in a variety of commonly associated with the macrosurgical approach, like- ways. Both macro- and microsurgical techniques have been ly due to secondary fibrosis at the anastomosis. described and are currently being used by practicing urolo- The Vasovasostomy Study Group evaluated predictors of gists and male infertility specialists. Owen is credited with success in 1,469 microsurgical vasectomy reversals and the first microsurgical method for reconstructing the vas found that the length of the obstructive interval was in- deferens, and his technique is the predecessor of the mod- versely related to the pregnancy rate.7 The absence of sperm ern day 2-layer microscopic vasovasostomy.4,5 in the testicular end of the vas at the time of surgery was Variability exists in the size also inversely correlated with and number of sutures used as pregnancy. Additional intra- well as in the number of layers Microsurgical vasovasostomy and operative findings that corre- anastomosed. Recently, at- lated with sperm quality at the tempts have been made to min- epididymovasostomy are effective time of vasectomy reversal in- imize the number of sutures means of vasectomy reversal for cluded the presence or absence used by placing surgical fibrin of a sperm granuloma at the glue on the outer layer. While couples desiring fertility. The key vasectomy site and the gross innovative, experience with appearance of the fluid from to success—and the hard part—is this new technique is minimal. the testicular end of the vas.8,9 Adverse consequences include meticulous reapproximation of the In our experience, an in- glue leakage into the vasal lu- creased length of the testicular men and associated risks and vasal or epididymal segments. vasal remnant was predictive the inability to adequately re- of the presence of sperm at the approximate disproportion- time of surgery.10 Testicular ately sized lumens. vasal remnants longer than 2.7 cm had a 94% chance of hav- PREDICTORS OF SUCCESS ing whole sperm at the time of Outcomes and predictors of surgery, whereas smaller vasal success for vasectomy reversal remnants had an 85% proba- have been published in the lit- bility of no sperm in the in- Dr. Karpman is a Clinical Fellow, Dr. Williams is a erature. Lee reported one of the Clinical Fellow, and Dr. Lipshultz is Lester and Sue spected fluid. largest and most detailed sin- Smith Professor and Chair, Scott Department of The duration of the ob- gle-surgeon experiences with , Baylor College of Medicine, Houston, Tex. structive interval, the presence both macrosurgical and micro- or absence of a sperm granulo-

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VASECTOMY REVERSAL

FIGURE 1 FIGURE 2 FIGURE 3 Delivering testis Isolating the Transecting the vas deferens

The testicular end of the vas is The is delivered with the isolated with a penetrating towel A nerve holder is used to stabilize the tunica vaginalis intact. clamp and is dissected free. vas as it is transected. ma, the gross appearance of the fluid, movasostomy based on the intraoper- (range, 37%-40%) rates have been re- and the length of the testicular vas are ative findings. ported for all of these approaches. all predictive of whether or not sperm Therefore, technique selection should will be found at the time of vasectomy CHOOSING A TECHNIQUE be based on the individual surgeon’s reversal. The presence of sperm at the Microscopic epididymovasostomy was experience and preference.14-18 time of vasectomy reversal is predic- first performed in an end-to-end fash- In the literature, significant empha- tive of a successful vasovasostomy ion.14 This technique was succeeded sis is placed on the number of mucosal procedure. by a microscopic end-to-side ap- sutures used and the manner in which proach. A newer technique of trian- they are placed. In our experience, REASONS FOR FAILURE gulation end-to-side intussusception other factors are equally important. Unsuccessful vasovasostomy for vasec- epididymovasostomy has been report- Making the appropriate decision to tomy reversal has been attributed pri- ed.15 Variations on the intussusception perform a vasovasostomy or an epi- marily to surgical technique and fail- technique have included transverse didymovasostomy, adequate mobiliza- ure to recognize a secondary epididy- and vertical suture placement of only tion of the abdominal vas with preserva- mal obstruction (SEO), which can 2 needles.16,17 Comparable patency tion of the perivasal blood supply, and develop after vasectomy. Silber char- (range, 81%-92%) and pregnancy tension-free advancement of the vas acterized the phenomenon of are instrumental for a suc- SEO as a result of epididymal TABLE 1 cessful vasectomy reversal. extravasation following va- Vasal fluid appearance and indications Bridging the defect created by sectomy and recommended for vasovasostomy or epididymovasostomy vasectomy in a tension-free epididymovasostomy to by- manner often represents the pass the obstruction.11 The Reversal most difficult part of the op- need to perform epididy- Sperm quality Comments technique eration. movasostomy has been re- Whole sperm +/- motile V V The following descriptions ported to be as high as 62% of microsurgical vasovasos- in patients undergoing rever- None Clear fluid, < 5 y V V tomy and epididymovasos- sal 15 or more years after va- since vasectomy tomy are based on the experi- 12 sectomy. Unrecognized Heads < 10 y since V V ence at our institution. As SEO was the cause of failure and tails vasectomy described above, variations in almost half of patients pre- on both techniques exist, and senting for a repeat vasova- Heads Thick fluid V V or EV surgeons should use the 13 sostomy. For these reasons, None Thick, creamy/ EV approach that offers their surgeons performing vasecto- pasty fluid patients the best chances of my reversal should be experi- pregnancy, in the shortest enced at microsurgery and VV = vasovasostomy; EV = epididymovasostomy. time, and in the most cost- prepared to perform epididy- effective manner. Our tech-

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VASECTOMY REVERSAL

FIGURE 4 FIGURE 5 FIGURE 6 Dilating the vas deferens Intubation and irrigation Approximating the vas deferens

Using a 25-gauge angiocatheter syringe, A 5-0 suture is placed in the adventitial The cut end of the abdominal vas is the abdominal end of the vas is intubated tissue and is used to approximate the dilated with a fine jeweler’s forceps. and irrigated with normal saline. cut ends of the vas. nique of vasovasostomy has been de- with a penetrating towel clamp and transect it at a right angle (Figure 3). scribed previously.19 See “CPT codes dissected free from the surrounding Fluid from the testicular end of the for vasectomy reversal and sperm aspi- tissue (Figure 2). Care is taken not to vas is grossly inspected for quality. The ration” on this page for coding infor- devascularize the perivasal tissue. A 5-0 fluid is collected and plated on a slide mation. chromic stay suture is placed in the and then inspected using light mi- muscular layer of the testicular vas to croscopy. The decision to proceed PREOPERATIVE PROTOCOL prevent retraction. A nerve holder with vasovasostomy or epididymova- The preoperative evaluation and set- (#3.0 or #4.0) is used to stabilize the sostomy is based on the absence or up are similar for both vasovasostomy vas, and a Dennis blade is used to presence of sperm or sperm parts un- and epididymovasostomy. All patients der the microscope as well as the gross are offered sperm aspiration and cryo- FIGURE 7 quality of the fluid (Table 1). If motile preservation prior to vasectomy rever- Suture placement sperm are identified, they are collected sal. The preservation of sperm allows and cryopreserved based on patient the patient to pursue assisted repro- preference. ductive techniques without undergo- When a decision to proceed with a ing additional surgical procedures in vasovasostomy has been made, a site case the reversal is not successful. on the vas above the previous vasecto- Patients are admitted to the ambu- my site is identified. This site is isolat- latory surgery center, and general anes- ed, dissected out, and transected in a thesia is administered. The patient is fashion similar to that performed for placed in the supine position and is the testicular end of the vas. Care must prepared by shaving the scrotum and be taken not to mobilize an excessive scrubbing with sterile Betadine. An amount of abdominal vas as this may operative microscope providing vari- A web-like appearance is created after jeopardize the perivasal blood supply. able magnification from 3ϫ to 25ϫ is placement of 10-0 nylon sutures. The isolated segment of vas is tied at positioned at the beginning of the case each end using a 3-0 chromic suture. and is used for the entire procedure. The abdominal and testicular ends CPT codes for vasectomy of the vas are dilated using a fine jew- TWO-LAYER VASOVASOSTOMY reversal and sperm eler’s forceps (Figure 4), and the lumi- A vertical incision is made in the aspiration nal diameter and the discrepancy be- hemiscrotum, and the testicle is deliv- tween the 2 ends are evaluated. The ered with the tunica vaginalis intact Vasovasostomy 55400 abdominal end of the vas is intubated (Figure 1). The site of the previous va- Epididymovasostomy 54900 with a 25-gauge angiocatheter syringe sectomy is palpated to identify sperm and is irrigated with normal saline to granuloma, and the testicular end of Sperm aspiration 55899 confirm distal patency of the lumen the vas is measured. The vas is isolated (Figure 5). A 5-0 polydioxanone su-

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VASECTOMY REVERSAL

FIGURE 8 FIGURE 9 ture is placed in the adventitial tissue Completed inner layer Completed outer layer at the base of each cut end of the vas and tied. This maneuver approximates the cut ends of the vas (Figure 6). Prior to creating the anastomosis, a fine-tip marking pen is used to mark the 6-o’clock position. A 9-0 nylon su- ture is used to reappose the serosal lay- er at the 5-, 6-, and 7-o’clock posi- tions. Next, double-armed 10-0 nylon sutures are placed in the vasal mucosa at similar positions and tied. Five ad- ditional double-armed 10-0 nylon su- Appearance of completed vasal Appearance of completed vasal serosa tures are then placed at the 1-, 3-, 9-, mucosa layer, demonstrating layer, demonstrating a tension-free 11-, and 12-o’clock positions of the watertight mucosal apposition. anastomosis. vasal mucosa prior to tying, creating a web-like appearance (Figure 7). The ered. The is inspected, and the sperm are harvested for cryo- mucosal sutures are then tied to pro- an area proximal to the presumed site preservation. After the tubule is pre- vide a watertight mucosal apposition of obstruction is identified. The tunic of pared and sperm are confirmed on (Figure 8). An adequate number of the epididymis is opened with a pair light microscopy, double-armed 10-0 9-0 nylon sutures are placed in the of dissecting microscissors. Using a nylon sutures are carefully placed at serosa to create a tension-free anasto- pair of fine jeweler’s forceps, a single the 3-, 6-, 9-, and 12-o’clock positions mosis (Figure 9). epididymal tubule is carefully dissected in the lumen of the epididymal tubule (Figure 10). Methylene blue is used to (Figure 11). END-TO-SIDE EPIDIDYMOVASOSTOMY better outline the single tubule. Next, Next, the previously mobilized ab- When a decision to perform an epi- using the dissecting microscissors a cir- dominal end of the vas is brought didymovasostomy has been made, a cular opening is cut tangentially at the through an opening created in the tu- segment of the abdominal vas is mobi- apex of the epididymal tubule. nica vaginalis. The adventitia of the vas lized in a manner similar to that used Fluid is collected from the tubule is secured to the tunic of the epididymis when performing a vasovasostomy. with a 25-gauge angiocatheter syringe using a 5-0 polydioxanone suture at a This segment must be longer than that and is plated on a slide. When motile point approximately 1 cm below the used in the vasovasostomy procedure sperm are not identified, a similar ex- cut edge (Figure 12). An additional 7-0 to bridge the gap created by the vasec- ploration is performed on the epi- Prolene suture can be placed in a simi- tomy. didymis more proximal to this loca- lar manner, but more distally, on the The tunica vaginalis is opened, and tion. When motile sperm are identi- vas to advance it closer to the anasto- the testicle and epididymis are deliv- fied and if the patient has requested it, motic site. This step-wise progression

FIGURE 10 FIGURE 11 FIGURE 12 Isolated epididymal tubule Creating the mucosal Securing the vas deferens anastomosis

A single epididymal tubule is isolated Four 10-0 nylon sutures are used to The abdominal vas is secured to the from the epididymis. create the mucosal anastomosis. epididymal tunic using a 5-0 suture.

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VASECTOMY REVERSAL

FIGURE 13 FIGURE 14 FIGURE 15 Securing the serosal edge Completed inner layer Completed outer layer

The serosal edge of the vas is secured to the epididymal tunic with 9-0 nylon Appearance of the completed mucosal Appearance of completed serosa-tunic sutures at the 5-, 6-, and 7-o’clock anastomosis, demonstrating a anastomosis, demonstrating a positions. watertight mucosal apposition. tension-free anastomosis. of the securing sutures from 5-0 to 7-0 than proceeding directly to sperm aspi- 13. Chawla A, O’Brien J, Lisi M, et al. Should all urolo- gists performing vasectomy reversals be able to per- to 9-0 allows the vas to be incremental- ration and assisted reproduction. Suc- form vasoepididymostomies if required? J Urol. ly advanced closer to the anastomosis cess rates are higher even when the 2004;172:1048-1050. for ultimate placement of the mucosal more complex epididymovasostomy 14. Silber SJ. Microscopic : spe- cific microanastomosis to the epididymal tubule. Fertil sutures. The serosal edge of the vas is procedure or a repeat vasectomy rever- Steril. 1978;30:565-571. then secured to the opened edge of the sal is performed or when the patient’s 15. Berger RE. Triangulation end-to-side vasoepididy- mostomy. J Urol. 1998;159:1951-1953. 20-23 CU epididymal tunic using 9-0 nylon su- partner is an older female. 16. Chan PT, Li PS, Goldstein M. Microsurgical vaso- tures at the 5-, 6-, and 7-o’clock posi- epididymostomy: a prospective randomized study of 3 intussusception techniques in rats. J Urol. 2003; REFERENCES tions (Figure 13). 169:1924-1929. 1. Centers for Disease Control. Contraceptive use in 17. Marmar JL. Modified vasoepididymostomy with si- The previously placed double- the United States: 1982-90. Available at http:// multaneous double needle placement, tubulotomy www.cdc.gov/nchs/pressroom/95facts/fs_ad260.htm. armed 10-0 nylon sutures are individ- and tubular invagination. J Urol. 2000;163:483-486. Accessed February 23, 2006. ually placed through the vasal mucosa. 18. Kim ED, Winkel E, Orejuela F, et al. Pathological 2. Marquette CM, Koonin LM, Antarsh L, et al. Vasec- epididymal obstruction unrelated to vasectomy: re- The sutures are tied to create a water- tomy in the United States, 1991. Am J Pub Health. sults with microsurgical reconstruction. J Urol. 1995;85:644-649. tight mucosal apposition between the 1998;160:2078-2080. 3. Derrick FC Jr, Yarbrough W, D’Agostino J. Vasova- vas and the epididymal tubule (Figure sostomy: results of questionnaire of members of the 19. Shin D, Chuang WW, Lipshultz LI. Vasovasostomy. BJU Int. 2004;93:1363-1378. 14). Additional 9-0 nylon sutures are American Urological Association. J Urol. 1973;110: 556-557. 20. Pavlovich CP, Schlegel PN. Fertility options after placed through the serosal edge of the 4. Owen ER. Microsurgical vasovasostomy: a reliable vasectomy: a cost-effectiveness analysis. Fertil Steril. vas and the epididymal tunica, releas- vasectomy reversal. 1977. J Urol. 2002;167:1205. 1997;67:133-141. 5. Owen ER. Microsurgical vasovasostomy: a reliable 21. Kolettis PN, Thomas AJ Jr. Vasoepididymostomy ing tension off of the mucosal sutures vasectomy reversal. Aust N Z J Surg. 1977;47:305- for vasectomy reversal: a critical assessment in the (Figure 15). Next, the testicle is re- 309. era of intracytoplasmic sperm injection. J Urol. 6. Lee HY. A 20-year experience with vasovasosto- 1997;158:467-470. placed inside the tunica vaginalis, my. J Urol. 1986;136:413-415. 22. Donovan JF Jr, DiBaise M, Sparks AE, et al. Com- which is then closed. 7. Belker AM, Thomas AJ Jr, Fuchs EF, et al. Results of parison of microscopic epididymal sperm aspiration 1,469 microsurgical vasectomy reversals by the Vaso- and intracytoplasmic sperm injection/in-vitro fertiliza- vasostomy Study Group. J Urol. 1991;145: 505-511. tion with repeat microscopic reconstruction following CONCLUSION 8. Sharlip ID, Belker AM, Konnak JW, et al. Relation- vasectomy: is second attempt vas reversal worth the ship of gross appearance of vas fluid during vasova- effort? Hum Reprod. 1998;13:387-393 . Vasovasostomy and epididymovasos- sostomy to sperm quality, obstructive interval and 23. Deck AJ, Berger RE. Should vasectomy reversal be tomy are effective means of reversing a sperm granuloma. J Urol. 1984;131:681-683. performed in men with older female partners? J Urol. 9. Belker AM, Konnak JW, Sharlip ID, et al. Intraopera- 2000;163:105-106. vasectomy for couples desiring fertility. tive observations during vasovasostomy in 334 pa- The microsurgical approach appears to tients. J Urol. 1983;129:524-527. 10. Witt MA, Heron S, Lipshultz LI. The post-vasecto- See Urology Times at offer the best results for these patients my length of the testicular vasal remnant: a predictor when microsurgical principles are of surgical outcome in microscopic vasectomy rever- www.urologytimes.com for additional sal. J Urol. 1994;151:892-894. coverage of topics related to this article: meticulously adhered to, permitting 11. Silber SJ. Epididymal extravasation following va- the creation of a watertight, tension- sectomy as a cause for failure of vasectomy reversal. • Vasectomy reversal: Data point to free anastomosis. Microsurgical recon- Fertil Steril. 1979;31:309-315. choice of technique (February 2006, 12. Fuchs EF, Burt RA. Vasectomy reversal performed pg 23) struction remains the most natural and 15 years or more after vasectomy: correlation of pregnancy outcome with partner age and with preg- • Advances in moving quickly cost-effective way of achieving preg- nancy results of in vitro fertilization with intracytoplas- into practice (May 15, 2005, pg 14) nancy with a better chance of success mic sperm injection. Fertil Steril. 2002;77:516-519.

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