MICROSURGICAL VASECTOMY 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 Vasectomy reversal 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 Urology, Baylor College of Medicine, Houston, Tex. structive interval, the presence both macrosurgical and micro- or absence of a sperm granulo- INVENTORY CONTEMPORARY UROLOGY 1 VASECTOMY REVERSAL FIGURE 1 FIGURE 2 FIGURE 3 Delivering testis Isolating the vas deferens Transecting the vas deferens The testicular end of the vas is The testicle 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- 2 CONTEMPORARY UROLOGY INVENTORY 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.