found in the testicular vasal lumen of at least one side which is associated with favorable outcomes. Low semen volume could indicate ejaculatory duct obstruction and should be investigated with transrectal ultrasound. Serum follicle-stimulating hormone (FSH) less than 7.6 IU per L and normal testosterone reflect intact Sertoli and Leydig cell function, respectively. Elevation of FSH suggests poor spermatogenesis in men with small, soft testes, which may require further diagnostic workup and increased requirement for assisted reproductive technologies following vasectomy reversal (15). In men with elevated serum FSH levels or in men without prior fertility, a positive serum antisperm antibody assay confirms active spermatogenesis obviating the need for testicular biopsy before reconstruction (16).
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.
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 52.7 Blunt dissection with a gauze-covered finger releases the vas deferens from the surrounding tissue.
FIGURE 52.9 Transilluminating the tissue surrounding the vas deferens by bringing the operating light low helps to identify the correct dissection plane.
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 52.16 An unhealthy segment of vas deferens demonstrates white, avascular vasal layers surrounded by fibrotic scar tissue.
TABLE 52.1 EVALUATION OF VASAL FLUID
FIGURE 52.18 A separate microscope setup should be used to examine the vasal fluid under 40× magnification.
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.