Multiple patient and partner factors affect the outcome of vasectomy reversal and should be assessed during preoperative evaluation. Factors include prior fertility, medical and surgical history subsequent to vasectomy (inguinal hernia repair, previous failed vasectomy reversal, presence of sperm granuloma), obstructive interval, and female partner’s age/fertility status. The likelihood of successful pregnancy following vasectomy reversal decreases from 56% in patients whose partners are 20 to 39 years of age to 14% in those whose partners are age 40 years and older (18). Men with the same partners prior to and following vasectomy procedure also have better outcomes, perhaps from proven previous fecundity together and shorter time interval since vasectomy (19). Regarding time interval from initial vasectomy to subsequent vasectomy reversal, patency and pregnancy rates of 91% and 89%, respectively, were identified for obstruction interval of <5 years, whereas patency and pregnancy rates of 89% and 44% for obstruction interval of >15 years were identified (12). The Vasovasostomy Study Group demonstrated similar results with patency and pregnancy rates of 97% and 76%, respectively, for obstruction interval of <3 years, which declined to 71% and 30% for obstruction interval of ≥15 years (20). Determining when vasovasostomy or vasoepididymostomy is performed primarily depends on intraoperative vasal fluid findings.

Dual-headed operating microscope with 6× to 32× power magnification is used with foot pedal controls allowing the surgeon to customize zoom and focus the field of view without interrupting surgery (Fig. 52.1). The patient is placed in supine position with all pressure points padded. Following incision and initial dissection, the microscope is used for the entire procedure until closure. Although the operation can be performed in the standing position if preferred, custom-designed microsurgical chairs increase stability of the surgeon’s chest and arms (Fig. 52.2). By positioning the
surgeon on the patient’s right side, the right-handed surgeon is in the optimal location to place the more challenging abdominal end vasal sutures with the forehand.

Although local or regional anesthesia has been used for uncomplicated vasovasostomy, general anesthesia is preferred. The patient’s ability to remain still and the surgeon’s experience and comfort level should be considered in selecting the type of anesthesia.

Following intravenous cefazolin administration and standard surgical preparation of the groin and genitalia in the supine position, the external inguinal ring is marked on both sides (Fig. 52.3). Careful palpation of the vasectomy site assists in determining the required level of the incisions. Following demarcation of the external inguinal ring, high vertical scrotal incisions (at least 1 cm lateral to the base of the penis) provide optimal exposure and cosmetic results. The incision should be adequate to permit delivery of the testis; the tunica vaginalis should be maintained intact for optimal exposure of the vas deferens (Figs. 52.4, 52.5 and 52.6). The incision may be extended as needed toward the external ring to compensate for high vasectomy site or large vasal gap. If the site of vasal disruption, however, is even higher (such as following inguinal obstruction from herniorrhaphy), an inguinal incision is preferred so that inguinal anastomosis may be completed without tension. Incision through the scar from the previous hernia surgery usually leads directly to the site of obstruction. With this incision, the epididymis may be exposed as needed by delivering the testis through the inguinal incision or via a separate scrotal incision.

Adequate exposure and meticulous mobilization of the vas deferens is essential for an eventual tension-free anastomosis (Fig. 52.7). To maintain the vasal blood supply, the optimal dissection plane must be established along the vasal sheath; venturing too close to the sheath risks injury to the periadventitial vasal blood supply, whereas too much distance from the sheath may threaten the testicular artery. Injury to the testicular artery may lead to testicular atrophy because the deferential artery likely was disrupted during vasectomy. Mobilization can be performed in part bluntly with a Kittner or
gauze-encased fingertip. The operating microscope should be used for this dissection with at least 10× power magnification for sufficient visualization to minimize risk of stripping the vasal vessels. The deferential artery provides the blood supply to the vas deferens (along with the inferior epididymal artery derived from the deferential artery), which originates from the superior or inferior vesicle branches of the internal iliac (hypogastric) artery. Iatrogenic injury to the testicular blood supply (testicular, deferential, and cremasteric arteries) could lead to testicular atrophy.

Following careful blunt dissection of the vas deferens, two Babcock clamps are placed above and below the obstructed segment (Fig. 52.8). With the clamps held with light tension, the proper dissection plane can be entered by transilluminating the sheath with the operating light (Fig. 52.9). Using a curved mosquito clamp, the spaces at two points on either side of the vasectomy site are punctured (Fig. 52.10), and two quarter-inch Penrose drains replace the clamp to serve as handles to manipulate the vas deferens on mild tension while gently separating the vas from surrounding tissue with both blunt and sharp dissection using small fine Metzenbaum scissors (Fig. 52.11).

Multiple techniques can achieve additional length when a long vasal gap would preclude tension-free anastomosis. Blunt dissection using the index finger through the external inguinal ring can free the abdominal vas deferens nearly to the internal inguinal ring level without opening the external oblique aponeurosis. Further, the convoluted vas deferens can be dissected from the epididymal tunica (Figs. 52.12, 52.13, and 52.14A). Up to 6 cm of additional length can be obtained by these techniques. An additional 4 to 6 cm can be released by dissecting the epididymis from the testis, up to two-thirds of the length of the epididymis to the level of the caput epididymis (Fig. 52.14B). During epididymal dissection, the epididymal blood supply (composed of the superior epididymal artery [originating from the testicular artery] and inferior epididymal artery [derived from the deferential artery]) should be recognized and preserved. Additionally, orchidopexy can be performed to reposition the testis higher in the scrotum. Lastly, laparoscopic or robotic mobilization of the intra-abdominal vas may be performed (26,27). The Prentiss maneuver, with placement of the vas medially to the inferior epigastric vessels, may deliver up to 10 cm of vasal length when used in combination with the other methodologies to facilitate subsequent inguinal vasovasostomy.

The obstructed segment is excised including any associated vasectomy clips or sperm granuloma. Initial excision is performed on the testicular side with an ultrasharp knife and a slotted 2-mm, 2.5-mm, or 3-mm-diameter nerve-holding clamp (Accurate Surgical & Scientific Instruments Corp, Westbury, New York). The slotted nerve-holding clamp permits a perfect 90-degree transection (Figs. 52.14, 52.15 and 52.16). Under 15× to 25× magnification, three distinct layers are visualized including the mucosa, muscularis, and adventitia. Healthy mucosa should be white and elastic and muscularis should be smooth and supple. Bleeding at each layer represents healthy blood supply. If the blood supply is in question, or if the muscularis is gritty and fibrotic, additional cuts in the same manner should be made until consistently healthy tissue is identified (see Fig. 52.16). The deferential artery and vein are ligated using 6-0 Vicryl. The micro-bipolar coagulation forceps, set at 2.5 to 3.5 watts, controls small bleeders, but caution should be exercised to avoid mucosal thermal injury.

The testicular end of the vas deferens is milked until fluid is expressed and a touch prep is completed using a glass slide (Fig. 52.17). The fluid is mixed with a single drop of lactated Ringer solution and a cover slip is mounted. The slide is immediately examined under 40× power magnification with a separate bench microscope setup in the OR (Fig. 52.18). The Practice Committee of the American Society for Reproductive Medicine (28) (ASRM Guidelines) grades the sperm quality of vasal fluid as follows: grade 1, mainly normal motile sperm; grade 2, mainly normal nonmotile sperm; grade 3, mainly sperm heads; grade 4, only sperm heads; and grade 5, no sperm. Vasovasostomy is the ideal approach for grades 1 through 4. If no sperm are identified in the vasal fluid (grade 5), the gross appearance of the vasal fluid is used to select between vasovasostomy and vasoepididymostomy (Table 52.1). Copious, crystal clear waterlike fluid squirting from the testicular end of the vas even when no sperm are found in this fluid initially is usually associated with return of sperm to the ejaculate after vasovasostomy. In fact, resampling of the fluid again just prior to tying the last mucosal suture often reveals rare long-tailed, even motile, sperm. Thick, white, water-insoluble toothpaste-like material indicates epididymal obstruction necessitating vasoepididymostomy (Fig. 52.19). Although a standard algorithm has not been established, vasovasostomy is completed when complete sperm or copious sperm heads, especially with occasional short tails, are identified in the vasal fluid or when fluid is copious and watery. Vasoepididymostomy should be elected if the vasal sperm is absent after barbitage or if the fluid is thick, white, and creamy and devoid of sperm or sperm parts. If no fluid can be expressed for evaluation, the testicular end of the vas deferens is barbitaged with 0.1 mL of saline using a 24-gauge angiocatheter sheath, and the expressed fluid is examined (Fig. 52.20). With large sperm granulomas, the testicular end of the vas is minimally dilated with very little or no luminal fluid; barbitage with milking often expresses a small amount of fluid containing long-tailed, even motile, sperm.

The abdominal end of the vas deferens is similarly transected and inspected. The lumen is gently dilated with a microvessel dilator and approximately 1 mL of saline is gently injected with a tuberculin (TB) syringe attached to a 24-gauge angiocatheter sheath to confirm patency without resistance. If there is any question, a Foley catheter with 5-mL balloon (inflated with air) is placed gently against the bladder neck. One milliliter of
indigo carmine (1:1 ratio with lactated Ringer) is injected into the abdominal vas, with blue urine confirming patency. Additional tests to identify obstruction location include passage of a 2-0 prolene suture (non-needle end) into the lumen of the abdominal vas (with a clamp placed on the suture when it meets obstruction) to calculate distance to the location of an inguinal obstruction. Finally, formal vasogram may be completed with 0.5 mL of injected water-soluble radiographic contrast injected using a no. 3 whistle-tip ureteral catheter to identify obstruction while a Foley catheter with 5 mL balloon is placed gently against the bladder neck. Vasography must be performed with microsurgical technique because poor vasotomy closure can result in stricture formation, sperm granuloma, or obstruction at the vasography site. In assessing patency of the testicular and abdominal ends of the vasa deferentia, the surgeon must assess both the left and right sides before proceeding with reconstruction. Often, a crossed vasovasostomy or vasoepididymostomy is the best solution for complex problems such as a patent abdominal vas on one side where there is also epididymal obstruction, or a nonfunctioning testis and an obstructed inguinal vas or ejaculatory duct on the contralateral side where sperm are found in the testicular vas.

In preparation for the anastomosis, the two ends of the vas deferens are stabilized without tension with a microspike approximating clamp (Fig. 52.21) (29). A tongue blade encased in a 1-inch Penrose drain provides a suturing platform (Fig. 52.22). The entire setup is brought up through a slit in a rubber dam (Fig. 52.23). The rubber dam provides a contrasting field for the black suture visualization and prevents sutures from adhering to surrounding tissue.