This article details the contemporary preoperative preparation, microsurgical techniques, and postoperative care recommended for vasectomy reversal. The two-layer vasovasostomy and intussuscepted epididymovasostomy techniques are presented in detail.
Urologists perform approximately 500,000 vasectomies in the United States each year. Because of changing social circumstances, however, up to 6% of men request reversal after vasectomy. Microsurgical reconstruction also may be requested for other, less common sources of vasal occlusion such as iatrogenic injury (hernia repair), secondary obstruction caused by infections, and postvasectomy pain syndrome (PVPS). Vasovasostomy (VV) and epididymovasostomy (EV) are thus commonly requested procedures for the urologist. The regularity with which this operation is requested and performed, however, belies its degree of difficulty and the nuances associated with treating couples desiring fertility. This article details the contemporary preoperative preparation, microsurgical techniques, and postoperative care recommended for vasectomy reversal. The two-layer VV and intussuscepted EV techniques are presented in detail.
Preparation for vasectomy reversal
Specialized Training
It generally is accepted that microsurgical vasectomy reversal yields better results than macrosurgical anastomoses. Therefore, requisite training in microsurgical techniques is recommended. The importance of the surgeon’s microsurgical expertise is particularly relevant when an EV is indicated. Although preoperative nomograms have been advocated by some to aid in predicting the need for an EV versus a VV, certain men who have favorable preoperative parameters nonetheless will require the more technically demanding EV. Consequently, a vasectomy reversal ideally is performed by a surgeon prepared to perform both VVs and EVs as dictated by intraoperative findings. The surgeon should discuss the differences between these techniques and the expected outcomes and the surgeon’s own experience.
Patient Evaluation
A thorough preoperative history of the male and female partner is taken, and a focused physical examination of the male is performed. By far, the most important prognostic factor for reversal success is the duration of occlusion. A detailed history of the patient’s vasectomy, including a postvasectomy hematoma or infection can prepare the surgeon for peri-testicular inflammatory changes and a more difficult dissection and reanastomosis. The surgeon should attempt to identify other historical factors that may impact on the surgical procedures such as previous inguinal surgery (especially hernia repairs using mesh after vasectomy), prior proven male fertility, and his general medical conditions. On physical examination, prognostic factors include the presence of a sperm granuloma and the testicular vasal segment length, both of which may act to decompress the epididymis and may prevent concurrent epididymal obstruction. Large missing vasal segments, testicular abnormalities, and marked induration of the vas deferens or epididymis should be noted. Serum follicle-stimulating hormone (FSH) testing is unnecessary before most reconstructions, unless small testes are noted on examination, and testicular damage is suspected.
Patients or couples interested in pursuing vasectomy reversal to restore fertility should be apprised of the risks, benefits and alternatives to surgical reconstruction. Realistic, patient-specific operative outcomes using preoperative nomograms and the surgeon’s own outcome data can be useful in this setting. In addition, the reproductive potential of the female partner should be assessed and discussed objectively with the couple. This is particularly important if the woman is nulliparous or over 35 years of age. Including the woman’s gynecologist in this workup helps establish an unbiased assessment of the female partner’s fertility potential.
The surgeon should be prepared to present alternatives to vasectomy reversal, including the extraction of sperm for in vitro fertilization (IVF) with ICSI, donor sperm insemination, and adoption. Additionally, the potential and desirability of a multiple-gestation pregnancy with assisted reproduction should be taken into account. The cost of multiple pregnancies using IVF with ICSI is significantly greater than that of vasectomy reversal.
If vasectomy reversal is to be performed, the option of intraoperative sperm cryopreservation, if available, should be considered. Sperm may be harvested from the testicular vasal segment, from an incised epididymal tubule, or from the testicle (TESE) at the time of reconstruction. There is debate among practitioners as to the cost-effectiveness and utility of sperm cryopreservation, with some advocating and others discouraging its practice. The authors’ practice is to encourage cryopreservation if preoperative parameters predict EV and if the patient would be unwilling to undergo further procedures for IVF with ICSI in the event of a failed reconstruction. This also may allow couples to pursue IVF concurrently with reconstruction.
Instrumentation and Equipment
The microsurgical instrumentation required for vasectomy reversal should be customized for each individual surgeon’s hands and technique. Various microsurgical instruments are available from numerous companies. The microsurgical instrument set that the authors find essential to performing vasectomy reversal are outlined in Table 1 . It is important to have duplicates of these instruments if contamination or malfunction occurs during the case.
| 3.3 Bishop Harmon Forceps | #5 Jeweler’s Forceps | Vannasd Pattern Suture Scissors |
| McPherson tying forceps | Curved Castroviejo needle holder, nonlocking | Nerve holder (#4) |
| 0.12 Castroviejo suturing forceps | 12 cm Halsey needle holder | Towel clamps |
| Jacobson mosquito forceps | Straight Iris scissors | #3 knife handle |
| #3 Jeweler’s forceps (2) | Vannas pattern dissecting scissors | Dennis blade holder |
Various sutures are available for microsurgical cases. The suture preference of the authors is 10-0 nylon 2XBRM5 double-armed for luminal VV stitches and the open epididymal tubule-to-vas lumen during an EV. A 9-0 nylon HSV6 suture is used for the seromuscular layer of the VV, and for the epididymal tunical edge to the seromuscular vas (EV).
The patient is positioned supine, on a surgical bed with a central support and leg extension (Skytron). Comfortable positioning is important for the surgeon and patient during a potentially lengthy procedure. The operative microscope used by the authors is a Zeiss model ZMS-414. A microscope, preferably with phase contrast, is needed in the operating room for the intraoperative examination of the vasal or epididymal fluid.
Anesthetic Considerations
The anesthetic used for vasectomy reversal is surgeon- and patient-dependant. Surgeons comfortable with the combination of local anesthetic and sedation use a one-to-one mixture of 1% lidocaine HCl and 0.25% bupivacaine HCl with intravenous sedation. General anesthesia or epidural have significant advantages, including:
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For a highly anxious patient
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Surgeon preference
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If the expected procedure length is longer than 3 hours
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If extensive mobilization of the vas or epididymis is anticipated.
Microscopic vasovasostomy
Preparation and Exposure
After induction of general anesthesia, the patient is shaved and prepared for standard surgery. The authors have found a layer of waterproof drapes useful to avoid soaking the patient with irrigation. The groin is included in the operative field for an extended incision, if necessary, and the penis draped cephalad to avoid interference. The operating microscope is positioned at head of the bed, on the patient’s left, and the surgeon is seated with his dominant hand toward the foot. The operating table is slid to the foot (certain tables will require a leg extension or support), permitting comfortable seating for the surgeon and assistant. The authors deliver the testes and spermatic cords with the tunica vaginalis intact through vertical, paramedian scrotal incisions.
A ball tip towel clamp is placed around the vas deferens and adventitia on the testicular side of the vasectomy site, and downward traction is applied. Curved iris scissors are passed behind the vas, and the assistant places a Jacobson mosquito in this space. Minimal dissection of the vasal adventitia at this site is performed, with care to leave abundant peri-vasal blood supply. A 5-0 chromic stay suture is placed through the adventitia of the vas 1 to 2 cm inferior to the anticipated transection site. It is important to minimize the use of cautery, using only a microtip bipolar at low setting if necessary. A 2 to 3 mm slotted nerve holder then is placed on the vas at the selected transection site; an Adson or other toothed forceps grasps the vasectomy site to provide stability, and a Dennis blade is passed briskly through the slot. The vas should be under no tension during the transection to avoid protrusion of the mucosal edge. The abdominal vas deferens is isolated and divided in an identical manner. The intervening vasal segment is ligated at each end with a 4-0 chromic tie, or excised. Bleeding is controlled with the microtip bipolar device, taking care to minimize contact with the vas itself. At this point, instillation of saline or methylene blue using an angiocatheter into the lumen of the abdominal vas may be performed. Back pressure or an absence of blue tint in a catheterized urine sample suggests obstruction. The authors do not perform this maneuver routinely, unless the patient’s prior history suggests obstruction.
Attention next is turned to the fluid expressed from the testicular vas. Fluid may flow freely from the lumen, or may require gentle pressure on the epididymis and milking of the convoluted vas. The quality and quantity of the fluid are noted. The fluid is aspirated with a 3 mL syringe fitted with a 25 French angiocatheter, primed with 0.1 cc of either human tubular fluid (HTF) or normal saline. The former fluid is preferred if cryopreservation is a consideration. The lumen may be dilated gently with a fine jeweler’s forceps to facilitate the aspiration. A drop of the aspirated fluid then is examined under 400 × magnification. Whole sperm and the degree of sperm motility, sperm parts, or a blizzard effect of degenerated cells may be observed. The decision to perform a VV or EV is based in large part on the macro- and microscopic quality of the fluid. This is discussed elsewhere in this article. If motile sperm are observed and cryopreservation desired, continuous gentle pressure is applied to the epididymis/convoluted vas, and the fluid is collected by the assistant until the flow ceases. The fluid is stored in sperm-safe containers sterilized by radiation and sent to the laboratory for cryopreservation. Prior coordination with laboratory personnel is critical for proper preparation and preservation for later use with ICSI, if necessary.
If the fluid expressed from the testicular vas deferens is suitable for VV, the two vasal ends are approximated. There are several methods to approximate the two ends of the vas at this point. Some surgeons use a vas approximating clamp, while others, including the authors, prefer an adventitial holding stitch. Regardless of technique, it is important to ensure that the ends overlap easily and that the anastomosis will be under no tension. The authors place a 5-0 PDS suture through the loose adventitia of each vasal end, with attention paid to symmetry. If the approximating suture is asymmetrical, the cut ends of the vas will not be in an ideal position for anastomosis. As the assistant ties the 5-0 approximating suture, the surgeon crosses over the previously placed chromic stay sutures to approximate the vasa until the 5-0 PDS is tied securely. Scott elastic retractor hooks secured to the drapes are particularly useful at this point to expose the approximated vasal ends and to minimize encroaching scrotal or spermatic cord fat.
The authors then perform a two-layer vasovasostomy. The 6 o’clock position on each vas is identified with a micropoint marker. The anastomosis begins with interrupted 9-0 nylon stitches (Sharpoint, half-circle needle) at the 5 o’clock, 6 o’clock, and 7 o’clock positions through the vasal muscularis and adventitia ( Fig. 1 ). An interrupted 10-0 nylon suture (Sharpoint, biconcave needle) then is passed through the mucosal layer at the 6 o’clock position, being sure to include a small of bite of muscularis ( Fig. 2 ). A drop of methylene blue placed on the cut surface of the vas improves visualization of the mucosal surface. Additional mucosal sutures are placed on either side of this stitch and tied down. Three to five additional mucosal stitches then are placed equidistant from each other, and left untied until all are placed ( Fig. 3 ). The mucosal sutures then are tied down sequentially. A 9-0 nylon suture is placed though the seromuscular layer at the 12 o’clock position. Interrupted seromuscular 9-0 nylon sutures then are placed circumferentially to complete the anastomosis ( Fig. 4 ).
