12.1 Background and History
Vasectomy is the safest and least expensive option for permanent sterilization and up to 354,000 men will undergo vasectomy reversal yearly in the United States [1,2]. Although vasectomy is considered permanent, up to 6% of men will ultimately seek a reversal [3]. Change in marital status is cited as the most common reason for seeking a reversal and younger age at time of vasectomy also is predictive of reversal [1]. A case–control study demonstrated that age < 30 years and spousal employment status are significant predictors of those seeking reversal [4]. There was no association with patient’s occupation, religion, or number of children [4]. Another indication for vasectomy reversal is postvasectomy pain syndrome, which is a chronic condition of scrotal pain that is estimated to occur after 1 in 1,000 vasectomies [5]. Regardless of the reasons, vasectomy can be reversed with good success rates.
Vasectomy reversal represents a technically challenging and resource-intensive undertaking [1,6]. Vasovasostomy (VV) is the surgical anastomosis of segments of the vas deferens. Vasoepididymostomy (VE), in contrast, is the surgical anastomosis of the vas deferens to a portion of the epididymis. In 1903, Martin et al. reported the first technique for VE by creating a fistulous tract between the cut end of the vas and multiple incised epididymis tubules [6]. In 1919 Quinby reported the first successful VV for vasectomy reversal [7]. A 1948 urological survey revealed that 18% of urologists were performing vasectomy reversals with success rates of about 40% of patients [8]. Minimal advancement in the technique occurred until 1977 when Silber and Owen separately reported the first microsurgical single-tubule vasoepididymal anastomosis with significantly improved success rates [9,10].
12.2 Relevant Anatomy
Vasectomy represents an iatrogenic cause of obstructive azoospermia where a portion of the vas deferens is divided to prevent passage of sperm from the testes to the ejaculatory duct. An understanding of the relevant surgical anatomy is required to understand the surgical bypass procedure needed to restore continuity. Sperm begins its transit from the seminiferous tubules through the rete testis, efferent ductules, epididymis, vas deferens, ejaculatory duct, and then urethra (Figure 12.1). After reconstruction, patency is defined as any sperm in the ejaculate.
Figure 12.1 Sperm production begins in the seminiferous tubules and progresses through the rete testis, efferent tubules, epididymal head, body, tail, and then into the vas deferens. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2007–2015. All Rights Reserved.
12.2.1 Epididymis
The epididymis is composed of a single, continuous, highly convoluted tubule contained within the tunica vaginalis. The lumen of the epididymis has a diameter that varies from 150 to 250 µm. The epididymis is divided into three anatomical segments: (1) the head (caput), (2) the body (corpora), and (3) the tail (cauda). The proximal epididymis is concerned with sperm maturation whereas the distal epididymis is concerned with sperm storage. Vasal anastomosis to the proximal epididymis has a decreased pregnancy rate when compared with those performed to the distal epididymis as it bypasses an area of critical importance for sperm maturation.
12.2.2 Vas Deferens
At the terminal end of the epididymis, a thick muscular wall surrounds the tubule and marks the proximal portion of the vas deferens. The vas deferens travels as a continuous tubule from the tail of the epididymis, through the spermatic cord, into the inguinal canal and into the pelvis where it joins with the seminal vesicles to form an ejaculatory duct. The ejaculatory duct enters the prostate posteriorly where sperms enter the urethra. The lumen of the vas deferens has a diameter of 400 µm, which is nearly twice that of the epididymis.
12.2.3 Blood Supply
The testicular artery emerges directly from the aorta and supplies the majority of the blood flow to the testis. Additional flow derives from the deferential and cremasteric arteries. In patients with history of vasectomy the deferential artery is likely compromised due to the procedure and special care should be exercised to preserve the testicular artery during dissection to avoid testicular ischemia.
The vas deferens receives its blood supply from two sources. The abdominal vas deferens receives its supply from the deferential artery. The testicular side of the vas deferens receives additional blood flow from free anastomosis between the supply to the epididymis, testicle, and vas deferens. After a vasectomy in which the deferential artery is ligated, the distal end of the vas deferens receives its supply from the supply to the testicle and epididymis in a retrograde fashion. If the vas deferens is sectioned in two locations the intervening portion is at risk of fibrosis due to ischemia.
12.3 Patient Evaluation
Men seeking vasectomy reversal self-refer for surgical evaluation often with the direction of a primary care physician. Men with previous paternity and normal genitourinary exams do not require additional fertility evaluation before proceeding to surgery. Patients should be questioned about previous inguinal, scrotal, or pelvic surgery as these may complicate vasal reconstruction. A number of factors should be explored including the obstructive interval, age, and reproductive status of the female partner and history of previous reconstruction as these have been shown to impact the success rates. More recently, a significant number of men are presenting on testosterone replacement therapy. This can suppress spermatogenesis and should be assessed for alternative forms of medical therapy or cessation of replacement prior to reversal.
12.3.1 Obstructive Interval
The obstructive interval is defined as the length of time from the original vasectomy. Historically, an obstructive interval of greater than 10 years was thought to portend a poorer prognosis for vasectomy reversal. More recent publications, however, demonstrate that the classic dogma may not be true. The vasectomy study group examined their experience with nearly 1,500 reversals and found that the patency and pregnancy rates did decrease with time and that the pregnancy rate was proportional to the obstructive interval [11]. When grouped by obstructive interval, patency and pregnancy rates were 97% and 76%, respectively, for less than 3 years, 88% and 53% for 3–8 years, 79% and 44% for 9–14 years, and 71% and 30% for intervals greater than 15 years [11]. In contrast, in another series of 334 patients Magheli reported that obstructive interval did not influence patency or pregnancy rates even in the group with intervals longer than 15 years [12]. Kolettis et al. retrospectively examined a group of 70 patients with extended obstructive intervals and found a patency and pregnancy rate of 74% and 40%, respectively, for obstructive intervals of 10–15 years, 87% and 36% for 16–19 years, and 75% and 27% for those with obstructive intervals longer than or equal to 20 years [13]. With good microsurgical techniques reasonable patency can be achieved after extended obstructive intervals, but the effect on pregnancy rate is less clear and likely contains many confounding factors.
12.3.2 Partner History
The age of the female partner significantly impacts post vasectomy reversal pregnancy rates as potential female fertility potential drops in women older than 40 years [13,14]. Gerrard and colleagues examined patency and pregnancy rates in a series of 249 couples in which the male underwent vasectomy reversal. Postoperative pregnancy and patency rates were 90% and 67%, respectively, for female partner age of 20–24, 89% and 52% for age 25–29, 90% and 57% for age 30–34, 86% and 54% for age 35–39, and 83% and 14% for female age 40 and older [14]. Similarly, Kolettis reviewed the records of men following vasectomy reversal with partners 35 years and older and noted a marked decrease in pregnancy rates in female partners 40 years or older [15].
By contrast the age of the male does not appear to independently influence patency or pregnancy after vasectomy reversal. In some series older male age is associated with longer obstructive intervals, which in turn may be associated with increased need to performed VE [13]. In couples where the partner’s age may compromise natural pregnancy following reversal, additional evaluation and a discussion of assisted reproductive techniques should be considered.
12.3.3 Previous Reconstruction
Patients who have failed a previous vasectomy reversal should be considered for a repeat attempt at reconstruction. Paick reviewed a series of 62 repeat vasectomy reversals and demonstrated a patency and pregnancy rate of 92% and 52%, respectively [16]. Of note the authors performed a bilateral VV in all (97%) patients unless technically not feasible regardless of the quality of the intravasal fluid [16]. In a series by Hernandez and Sabanegh 41 patients underwent repeat vasectomy reversals, of which 20 required at least a unilateral VE with an overall patency and pregnancy rate of 79% and 31%, respectively [17]. Repeat surgical intervention should be considered even after failed prior VE. Pasqualottto reported a patency and pregnancy rate of 67% and 25%, respectively; in a series of 18 patients who underwent a repeat VE after a failed prior VE [18]. In patients who have failed a prior vasectomy reversal the literature supports a repeat attempt, but the surgeon should be prepared to perform a VE if required.
12.4 Post-Vasectomy Pain Syndrome
Vasectomy is considered a safe and efficacious procedure to prevent pregnancy; however, a small subset of patients are at risk for developing a chronic type of scrotal pain termed post-vasectomy pain syndrome (PVPS). The incidence of PVPS is estimated at 1 in 1,000 patients, but the true incidence has not been fully validated [19]. Initial options for treatment are conservative and include oral pain control, anti-inflammatory medications, scrotal support, and local anesthesia. Should these fail, one can consider surgical intervention including vasectomy reversal [19]. Horowitz reviewed their series of vasectomy reversals and noted 23 patients (15% of vasectomy reversals) who underwent reversal for PVPS in which pain improved in 93% of them and resolved in 50% [19]. Similarly, Nangia’s series of 13 men with PVPS found 69% of had complete resolution of pain after VV [20]. Vasectomy reversal represents an established treatment with good success in patients who experience PVPS after conservative measures have failed.
12.5 Physical Exam
A physical exam should be performed on the patient seeking vasectomy reversal. Exam should focus on the scrotum and contents. The testes should be examined for normal size (>20 ml volume or 4 cm in length) and consistency. The exam may also reveal testicular abnormalities or epididymal induration. The vas deferens should be palpated with a goal to locate the vasectomy defect with annotation of the length of the defect. The presence of a sperm granuloma should be noted [21]. The epididymis should be palpated to examine for fullness and/or induration, which predicts epididymal obstruction, thus the increased possibility of VE (specificity 89%, sensitivity 33%] [22].
12.6 Epididymal Obstruction and Sperm Granuloma
Multiple techniques for division of the vas deferens exist during vasectomy, including suturing, metal clips, and electro-cautery. All of the various techniques purport to achieve the same end: complete deferential obstruction. The obstruction, however, leads to increased intra vas deferential and epididymal pressures, rupture, and subsequent luminal obliteration [23]. Thus, vasectomy not only disrupts the site of vas deferens removal, but has the potential to create a more proximal blockage which would require VE to bypass.
A sperm granuloma is a collection of extravasated sperm found at the proximal end of the divided vas deferens in men who have previously undergone vasectomy. These can range in size from millimeters to centimeters. Sperm granulomas are thought to act as a “pop-off” valve. Some have suggested that they protect the epididymis from increased pressure as a result of vasectomy and thus, if found, would lead to better success rates with reversal. However, the Vasectomy Study Group found no difference in either patency or pregnancy rates based on the presence of a sperm granuloma [11]. In another series of 213 men who underwent vasectomy reversal, 28% had at least a unilateral granuloma [21]. Of those who had a unilateral granuloma, 14% required VE compared with 31% in their overall series [21]. The patency and pregnancy did not statistically differ based on the presence of a granuloma (patency 95 vs 78%, p = 0.07; pregnancy 83 vs 78%, p > 0.05) [21]. These sources contrast with a third series in which sperm granuloma was found to increase both patency and pregnancy rates [24]. If a sperm granuloma is found at the time of initial exam or at reconstruction it may increase the post-surgical patency and pregnancy; and decrease the need for VE.
12.7 Surgical Technique
Since the initial publications in 1977, microsurgical vasectomy reversal has become the gold standard, setting the benchmark in terms of patency and pregnancy rates [9,10]. Microsurgical repair is superior when compared with pregnancy and patency due to loupe magnification and unmagnified repair [25–27]. General or spinal anesthesia may be preferred to local anesthesia due to the duration of the case and need for minimal to no patient movement. The patient should be placed in the supine position, and his pubic hair clipped and adequately removed to prevent interference with suture visualization. Prophylactic antibiotics should be provided and sequential compression devices used. The vasal defects should be palpated and brought to the skin. High vertical scrotal incisions directed toward the external inguinal ring no longer than 2 cm are made over the defect. The dartos is divided until the vas deferens is identified and brought up to the field.
Healthy appearing vasa deferentia are identified proximal to and distal to the vasectomy defects. The vasa are then carefully dissected with judicious electrocautery in order to preserve maximal perfusion. Battery-powered hand-operated electrocautery instruments can be useful during dissection as these have a very limited area of collateral tissue damage. Vessel loops or fine stay sutures are placed in the vasal adventia to assist with retraction. The vascular pedicle to the vasa is then ligated with 6-0 polypropylene suture to the level of the proposed anastomosis. When additional vas length is needed to perform a tension-free anastomosis, the distal vas can be mobilized on its vascular pedicle into the inguinal canal to gain several additional centimeters of length (Figure 12.2).
Figure 12.2 Additional vas deferens length can be obtained by extending the scrotal incision toward the external inguinal ring and mobilization of the vas. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2007–2015. All Rights Reserved.
After mobilization and vascular control the operative microscope is moved over the operative field. The microscope should be positioned such that the surgeon and assistant can work comfortably and thus minimize unnecessary movement. Success rates are similar between anastomosis to the straight and convoluted vasa; therefore, healthy tissue should be sought [28]. The proximal vasa is then divided perpendicular to its axis with a Beaver blade or a super-sharp ophthalmic blade. The division may be performed with free hand or against a surface such as a tongue blade or a cutting guide. Fluid from the proximal vasa is obtained with the possible aid of gentle milking of the vas or epididymis, and examined under a bench-top microscope. A touch prep of the effluent can be prepared by touching a sterile slide to the proximal vas. Alternatively, the effluent can be aspirated through a small angiocatheter attached to a sterile tuberculin syringe preloaded with a small amount of saline.
The decision to continue with VV or perform a VE depends on the findings when examining the vasal effluent. Based on the gross and microscopic findings one should proceed with a VV or move to a VE (Table 12.1). In situations where intravasal azoospermia and an absence of fluid is encountered and VE is unable to be performed due to inadequate vasal length, a VV should be performed as a small subset will still be patent [29]. If suspicion of distal obstruction is present (childhood inguinal hernia repair, prior unsuccessful vasectomy reversal), distal vasal patency can be confirmed with a saline vasogram, radiographic vasogram, simultaneous cystoscopy and methylene blue vasal flush, or intubation with a 0-nylon suture. Often the proximal and distal ends are of discordant sizing due to the proximal vasal dilation upstream of an obstruction. Some choose to dilate the distal vasa with lacrimal duct probes or tips of microforceps. The ends of the vasa are held in proximity with gentle traction on stay stiches or in a VV clamp. If tension is present nearby tissue can be approximated such that tension-free anastomosis can be performed. A fine-tip marker can be used to place symmetric microdots on the cut edge of the vasa to mark the planned suture exit sites to help facilitate precise suture placement [30]. VV can be performed with a two-layer anastomosis or a modified one-layer. The two techniques yield similar patency and pregnancy rates [31,32]. The two-layer anastomosis may provide better approximation for anastomosis with vasa with large discrepancies in lumen size. The two-layer anastomosis is slower than the modified one-layer, however [31].
Table 12.1 Surgical Recommendation based on Gross and Microscopic Vasal Fluid Findings
| Gross Vasal Fluid | Microscopic Findings | Recommendation |
|---|---|---|
| Creamy, cloudy, or clear | Motile sperm | VV |
| Sperm, nonmotile | VV | |
| Sperm heads | VV | |
| Copious clear fluid | No sperm | VV |
| Thick “toothpaste-like” fluid | No sperm | VE |
| No fluid | No sperm (after irrigation) | VE |
12.7.1 Two-Layer Anastomosis
The two-layer anastomosis begins by securing the vasal adventia with two interrupted 9-0 nylon sutures on the posterior side of the anastomosis (Figure 12.3A). Next, interrupted 10-0 nylon sutures are placed in the mucosal layer starting on the posterior aspect (Figure 12.3B). The first two to three posterior sutures can be gently tied to approximate the delicate mucosal tissue. Additional interrupted 10-0 nylon sutures are placed working posterior to anterior until a total of six to eight evenly placed mucosal sutures are present (Figure 12.3C). The sutures should be placed such that the knots are outside of the vasal lumen. The second layer is completed by placing an additional four to five interrupted 9-0 nylon sutures through the advential and muscularis layer of the anterior vas (Figure 12.3D). Additional nylon sutures (up to 6-0) can be used to approximate the vasal sheath if desired.
Figure 12.3 The two-layer vasovasostomy anastomosis. (A) After placement of two interrupted posterior sutures the mucosa is approximated posteriorly. (B) The anterior mucosa is then further approximated with several additional interrupted sutures. (C) After mucosal approximation the second layer is completed by four to five additional interrupted sutures through the adventitia. (D) An additional nylon suture can be used to reapproximate the vasal sheath. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2007–2015. All Rights Reserved.
12.7.2 Modified One-Layer Anastomosis
The approach to a modified one-layer anastomosis remains identical to that of the traditional two-layer anastomosis in terms of exposure and dissection. The technique diverges during re-anastomosis of the isolated vasal ends. Two to three full-thickness 9-0 nylon sutures are placed through the vasal mucosa, muscularis, and adventitia and secured with a knot outside of the lumen (Figure 12.4A). The surgeon can either start on the posterior aspect of the vasa and move forward, or can start anteriorly and rotate the vasa to suture posteriorly. A total of four to six evenly placed full-thickness 9-0 nylon sutures are required to create a water-tight mucosal anastomosis (Figure 12.4B). After the lumen is reconstructed a second layer of partial thickness 9-0 nylon sutures are placed in between the full-thickness sutures through the adventia and muscularis to finalize the anastomosis (Figure 12.4C).
Figure 12.4 The modified one-layer anastomosis. (A) Three full-thickness sutures are placed on the posterior side of the vas deferens through all layers. (B) Three additional evenly spaced interrupted nylon sutures are placed through all layers of the vas deferens. (C) After the lumen is reconstructed one to two sutures are placed between each full-thickness suture through the adventitia and muscularis to finalize the anastomosis. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2007–2015. All Rights Reserved.
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