Vasovasostomy and Vasoepididymostomy

Vasovasostomy and Vasoepididymostomy




Approximately 500,000 vasectomies are performed annually in the United States (1). Up to 6% of men undergoing vasectomy will ultimately request vasectomy reversal for multiple reasons (2). Vasectomy reversal has evolved since its introduction in the early 1900s (3). Modern microsurgical reconstruction has been demonstrated as a safe and efficacious treatment for most cases of vasal or epididymal obstruction using vasovasostomy or vasoepididymostomy, respectively. The majority of patients with obstructive azoospermia postvasectomy maintain normal or near normal exocrine and endocrine function including sperm production in the testis (4). A precise, watertight, mucosa-to-mucosa, tension-free anastomosis of healthy tissue with excellent blood supply is critical to reestablish patency. Microsurgical reconstruction with vasovasostomy was initially described by Sherman Silber (5) and Earl Owen (6) in the 1970s and has been refined over the ensuing decades. Owen (6) reported a patency rate of 98% in his series of 50 patients, and patency rates have more recently approached 99.5% in some series with experienced microsurgeons (7). Cost-benefit analyses have characterized reversal procedures as the most effective and economic management of postvasectomy infertility (8), even in men with previous failed vasectomy reversal (9), demonstrating that microsurgical reconstruction is an important treatment option for appropriately selected patients (10).

Return of adequate numbers of motile sperm with good fertilizing capacity can take 3 to 18 months after a technically successful reversal. This is especially important for men with partners of advanced maternal age. For optimal outcomes, access to a microsurgeon trained in the vasovasostomy and vasoepididymostomy procedures is requisite. With widespread accessibility of in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) using aspirated sperm, the role for complex reconstructive procedures for postvasectomy infertility has been debated. For patients who either prefer to avoid surgical reconstruction or who, for a variety of reasons, may be poor candidates for reconstruction, motile sperm may consistently be retrieved preferably by microsurgical epididymal sperm aspiration (MESA) for IVF with ICSI (11).

Indications of Surgery

Microsurgical reconstruction is performed for patients desiring additional children and for treatment of postvasectomy pain, iatrogenic (hernia or hydrocele repair, orchiopexy), infectious, or traumatic causes of vasal obstruction. In a series of 472 patients undergoing surgical exploration for obstructive azoospermia, approximately 7% had an iatrogenic injury secondary to inguinal hernia repair (frequently pediatric hernia surgery), renal transplantation, appendectomy, or spermatocelectomy (17). Such patients typically exhibit long vasal defects, impaired blood supply, longer obstructive duration, increased technical complexity of surgery, and poorer outcomes compared to vasectomy reversal patients.

Prognostic Factors

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.

Alternative Therapy

The alternative to reversal surgery is IVF with ICSI using retrieved sperm. Sperm retrieval is optimally performed by MESA with high yields of good quality sperm and excellent outcomes. Testicular aspiration typically yields motile sperm but far fewer in number and poorer in quality (4,11). Following sperm retrieval, there is no need to synchronize sperm and egg retrieval because outcomes with sperm cryopreservation are equivalent to fresh samples (21,22,23). Sperm retrieval rates for men with obstructive azoospermia using ICSI are high (96% to 100%) regardless of the etiology for obstruction or the use of testicular versus epididymal sperm (24,25).

FIGURE 52.1 The operating microscope has two heads for the surgeon and the assistant. Microscope settings are checked before starting the procedure. (All photos courtesy of Marc Goldstein, MD, and Philip S. Li, MD.)

Vasovasostomy Surgical Technique

Operating Room Setup

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.

FIGURE 52.2 The specially designed microsurgical chair adjusts for optimal support of the chest and arms.

FIGURE 52.3 The right surgical incision is marked over the scrotal skin. The external inguinal ring is marked with an X. The incision is at least 1 cm away from the penis.


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.

FIGURE 52.4 The skin incision is made with a no. 15 blade.

FIGURE 52.5 Electrocautery is used for the underlying dartos layer.

Exposure of the Vasa Deferentia

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.

FIGURE 52.6 The testis is delivered into the field, with the tunica vaginalis intact.

FIGURE 52.7 Blunt dissection with a gauze-covered finger releases the vas deferens from the surrounding tissue.

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).

FIGURE 52.8 Two Babcock clamps are placed along the length of the vas deferens.

FIGURE 52.9 Transilluminating the tissue surrounding the vas deferens by bringing the operating light low helps to identify the correct dissection plane.

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.

FIGURE 52.10 The plane between the vas deferens and the surrounding tissue is pierced with a Crile clamp.

FIGURE 52.11 Quarter-inch Penrose drains are brought through the two openings made by transillumination. Using traction on the Penrose drains, the vas deferens is released using both blunt and sharp dissection.

FIGURE 52.12 The vas deferens is freed distally to the level of the convoluted vas.

FIGURE 52.13 A and B: The convoluted vas deferens is fully exposed.

FIGURE 52.14 A: The convoluted vas is dissected from testis to provide additional length when required. B: The epididymis is dissected from testis to achieve additional length in the situation of long vasal gap. An additional 4 to 6 cm can be released by this dissection up to two-thirds of the length of the epididymis to the level of the caput epididymis.

FIGURE 52.15 A: The slotted nerve-holding clamp is used to make perfect 90-degree transections of the vas deferens. B: Sperm granulomas are found in 10% to 30% of men undergoing vasovasostomy. The initial cut is made on the testicular side of the obstructed segment or sperm granuloma. C: If additional length is necessary, the convoluted segment is carefully dissected free. The vasal cut is made at the juncture of the straight and convoluted portions. D: Slotted nerve clamp with ultra-sharp knife used for vas transection. This is performed only when necessary in the convoluted vas as shown.

Preparation of the Vasa Deferentia

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.

FIGURE 52.16 An unhealthy segment of vas deferens demonstrates white, avascular vasal layers surrounded by fibrotic scar tissue.

FIGURE 52.17 A touch prep of the vasal fluid is made by blotting the freshly cut testicular portion of the vas deferens onto a glass slide.

Examination of Vasal Fluid

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.


Gross appearance

Microscopic appearance


Indicated surgery

Copious, cloudy, thin, water-soluble

Sperm with tails

1, 2


Copious, creamy yellow, water-soluble

Many sperm heads, occasional sperm with short tails

3, 4


Scant fluid, sperm granuloma present

Barbitage fluid with sperm



Copious, crystal clear, watery

No sperm



Scant, white, thin fluid

No sperm



Copious, thick, white, toothpaste-like, water-insoluble

No sperm




No sperm



Typical intraoperative findings on vasal fluid evaluation and recommended procedure for each finding.

FIGURE 52.18 A separate microscope setup should be used to examine the vasal fluid under 40× magnification.

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.

FIGURE 52.19 A thick, greasy, “toothpaste” consistency indicates a poor prognosis for sperm in the vasal fluid.

FIGURE 52.20 If the vas deferens is “dry,” a 24-gauge angiocatheter sheath is used to barbitage the lumen with saline.

FIGURE 52.21 The microspike approximating clamp stabilizes the two ends of the vas deferens for suturing.

FIGURE 52.22 A tongue blade wrapped with 1-inch Penrose drain provides a platform for suture placement.

FIGURE 52.23 A rubber dam prevents sutures from sticking and getting lost in the surrounding tissue.

FIGURE 52.24 A: Schematic illustrating suture placement for the microsurgical multilayer (four-layer) vasovasostomy. (1) Microdot placement demonstrating mucosal suture placement for six 10-0 sutures. (2 and 3) Additionally, suture placement positions are shown for the muscularis and adventitial layers, respectively. (4) The perivasal tissue is then reapproximated, completing the vasal anastomosis. B: The microdots are made on the clock face of each cut vasal end using a microtip marking pen. C: The microdots should be symmetrical and mirror the corresponding side. Note the size discrepancy of the two vasal ends, with the larger dilated testicular end resulting from occlusive pressure.

Vasovasostomy: Anastomosis of the Vasa Deferentia

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.

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Apr 24, 2020 | Posted by in UROLOGY | Comments Off on Vasovasostomy and Vasoepididymostomy
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