If the decision is made to proceed with VV, the new cut ends of the vas are approximated. Surgeon preference dictates the technique used (adventitial holding stitch or vas approximating clamp). A 5-0 PDS suture placed through the loose adventia on each vasal end is effective at laying the foundation for a tension-free anastomosis. Symmetry of the vasal ends should also be one of the surgeon’s priorities because this will help ensure patency.

The tradition method of anastomosing the vasal ends is a two-layer technique. The vasovasostomy anastomotic site is prepared by transection of each end of the vas deferens at the vasectomy site (Fig. 4.1). The outer layer of the anastomosis is started by placing three, 9-0 nylon interrupted sutures at the 5, 6, and 7 o’clock positions through the vasal muscularis and adventitia (Fig. 4.2). The inner layer of the anastomosis is then performed by placing three, 10-0 nylon interrupted sutures at the 5, 6, and 7 o’clock positions through the mucosal layer (Fig. 4.3). Each of these is cut immediately after it is placed and tied. The remaining inner layer sutures are placed but not tied for a total of six to eight 10-0 nylon sutures (Fig. 4.4). These are sequentially tied and cut (Fig. 4.5). A small portion of muscularis should be incorporated into the inner layer sutures to help prevent tearing of the vas. If the mucosa is difficult to visualize, a drop of indigo carmine can assist in highlighting this tissue. Methylene blue has been associated with reduced sperm motility and should be avoided [49]. The outer layer is then completed with several more interrupted, circumferential 9-0 nylon sutures (Fig. 4.6). The end result should be a watertight, tension-free inner layer anastomosis.

A single-layer anastomotic vasovasostomy technique has been described in the literature [50]. The purported advantages of this technique include its relative simplicity and reduced operative time [51]. Retrospective analysis comparing microsurgical modified one-layer versus two-layer microsurgical vasovasostomy reported similar patency and pregnancy results [32, 52]. To date, though, there have been no prospective, randomized, controlled trials comparing single-layer versus two-layer microsurgical repair, and the decision regarding which approach to use is thus based largely on surgeon preference.

The microdot technique, first described by Goldstein and colleagues [52], is a microsurgical technique developed to aid in accurate suture placement. Microdots are placed at the 3, 6, 9, and 12 o’clock positions midway between the mucosa and serosal margin of both the abdominal and testicular vas. Four more dots are then placed evenly between the initial four dots. The anastomosis is then completed using eight inner layer 10-0 sutures and eight outer layer 9-0 sutures. Care is taken to ensure that the inner layer sutures exit from the center of the microdots. The vasal sheath is also re-approximated using 6-8 interrupted 6-0 sutures. The purported advantage of this technique is the separation of suture planning and placement. Goldstein et al. report that this approach may be particularly helpful when dealing with markedly discrepant luminal diameters. No studies to date have investigated this assertion; however, patency and pregnancy rates with the microdot technique have been comparable to those found with traditional microsurgical vasovasostomy [52].

Several intraoperative findings may necessitate small alterations in surgical technique. A large vasal gap will require extra distal and proximal mobilization to ensure a tension-free anastomosis. Blunt dissection can be used to separate the vas from cord structures up to the level of the superficial inguinal ring. Testicular vasal length is added by dissection of the vas away from the epididymis, taking care to avoid the nearby vasal, epididymal, and testicular blood vessels. In rare patients, no vas is located in the inguinal canal, and retroperitoneal mobilization may be required. Isolation of the deep inferior epigastric artery and vein is performed to locate the vas curving beneath these vessels toward the seminal vesicles. This portion of the vas is mobilized and placed over the pubic symphysis. Utilizing this technique, Buch et al. demonstrated an increase in vasal segment length of 5.83  ±  0.65 cm [53].

The proximity of the vasal defect to the epididymis may require the surgeon perform a convoluted vasovasostomy (CVV). CVV is considered more technically demanding given the thin muscular wall and discrepant luminal diameters often found in the convoluted vas deferens. De-tethering should be avoided to prevent iatrogenic injury and to preserve the native blood supply. Transection site selection is paramount to avoid creating an oblique lumen. If an oblique lumen is observed, the convoluted vas can be transected at 1 mm intervals to help ensure a more optimal transverse cut [54].

The need for crossed vasovasostomy is exceedingly rare, but should be considered in men with unilateral inguinal obstruction of the vas deferens and a contralateral atrophic testicle. It may also be performed when ipsilateral obstruction of the inguinal vas or ejaculatory duct is present with obstruction of the contralateral epididymis. The vas ipsilateral to the atrophic testis is transected at the junction of the straight and convoluted portions. The contralateral vas is freed superiorly toward the site of obstruction. An incision is made in the scrotal septum and the vas is pulled to the side of the atrophic testis. The anastomosis is performed as previously described.

Following completion of the anastomosis, the wound is copiously irrigated with normal saline, and hemostasis is achieved using bipolar and monopolar cautery. All holding stitches are removed, and the testicle is returned to its appropriate location within the hemiscrotum. The dartos layer is closed with 4-0 chromic suture in a locked, running fashion. The scrotal skin can be closed with a 4-0 monocryl suture using a running horizontal mattress suture. Bacitracin ointment, sterile fluff dressings, and a scrotal support are then used to dress the wound.

A wide range of reported patency and pregnancy rates for microsurgical vasectomy reversal have been reported. These numbers can be challenging to interpret because they are often derived from small single surgeon series (Table 4.2). However, in 1991 a large (1,469 patients) multicenter study of microsurgical vasectomy reversal outcomes was published by The VVSG, with patency and pregnancy rates of 86 and 52% respectively [32]. Though these rates are lower than those reported in many of the single surgeon series, it is remains the largest multi-surgeon study to date.

The VVSG also confirmed the interval of obstruction as the most important preoperative predictor of success [32]. A progressive decline in patency and pregnancy rates were observed with increased obstructive interval: <3 years (97, 76%), 3–8 years (88, 53%), 9–14 (79, 44%), to >15 years (71, 31%) [32]. Sperm grade, vasal length, and type of microsurgical reconstruction (VV or VE) also have a significant impact on the return of sperm to the ejaculate following the procedure [32, 40, 55, 56]. Interestingly, men with the same female partner have also been shown to have superior outcomes following microsurgical vasal repair [57, 58].

The sperm grading scale established by the VVSG is based on the presence or absence of sperm and sperm parts (Table 4.1) [32]. A score of 1–5 is assigned to the sample after microscopic observation. The authors summarized the sperm grade descriptions and their corresponding patency and pregnancy rates following vasovasostomy [32]. The semen appearance and sperm grade guide the surgeon’s decision to proceed with vasovasostomy or perform a more technically challenging epididymovasostomy. Compared to vasovasostomy, epididymovasostomy is associated with significantly lower patency and pregnancy rates [59]. A separate chapter in this text thoroughly addressed the issue of epididymovasostomy, including operative techniques and outcomes.

A fairly recent study also reported an association between the length of the testicular vasal remnant and the presence of whole sperm intraoperatively [60]. Whole sperm were found in the vasal fluid of 94% of units with a testicular vasal remnant length of greater than 2.7 cm, but only 85% of units with a testicular vasal remnant length less than 2.7 cm [60]. Proximity of the vasal defect to the epididymis appears to increase the chance of intravasal azoospermia. Based on these findings, one might expect poorer outcomes associated with CVV. However, patency and pregnancy rates following CVV are comparable to vasovasostomy performed in the straight portion of the vas [54, 61]. Crossed vasovasostomy patency rates are similar; however, pregnancy rates are significantly lower [62, 63]. Factors which have been linked to vasectomy reversal outcomes are presented in Table 4.3.

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