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  • Vasoepididymostomy: The Complex “Bypass” Vasectomy Reversal

    ABOUT THE SURGEON

    Wayne Kuang MD

    Dr. Wayne Kuang

    Wayne Kuang MD is the only fellowship-trained male fertility specialist in New Mexico specializing in office microsurgical vasectomy reversals. After completing his undergraduate studies at the Massachusetts Institute of Technology, he received his medical degree from Stanford University. Dr. Kuang then pursued his residency at the Cleveland Clinic to become a board-certified urologist. Passionate about helping infertile couples build a healthy family, he dedicated a year to the academic investigation of the clinical efficacy of complex “bypass” vasectomy reversals and the effects of cancer drugs on sperm function. Additionally, Dr. Kuang published articles about the novel use of the da Vinci robot for microsurgeries and a computer model to predict vasectomy reversal outcomes. Since then, Dr. Kuang has authored more than 20 publications as well as two book chapters focusing on maximizing a man’s reproductive health. To be able to perform state-of-the-art vasectomy reversals, he devoted an additional year at the Cleveland Clinic to complete a Male Infertility Clinical Fellowship to learn the microsurgical skills for reversing vasectomies under the mentorship of Dr. Anthony Thomas, one of the forefathers of the complex “bypass” technique. Dr. Kuang is now the Director of the Southwest Fertility Center for Men in Albuquerque, a private clinic devoted to optimizing a man’s reproductive health in order to help infertile couples welcome their “little bundle of joy.”

    For further information please visit his website (Link)

    VIDEO

    PROCEDURE

    In the context of unfavorable findings during vasal fluid microscopy (creamy or pasty fluid with no sperm or only sperm heads), the decision may be to perform a complex “bypass” vasoepididymostomy (VE) using a longitudinal intussusception technique (End to side).

    The testicle is delivered into the operative field. The abdominal vas has already been mobilized all the way to the external ring (not shown in this video). Careful attention is paid to preserving the vasal blood supply. Ideally enough length is necessary to avoid tension at the anastomosis. However, excessive dissection of the vas should be avoided to prevent unnecessary devascularization. The testis has already been placed in its normal anatomical position in the video, in order to account for tension free anastomosis.

    The tunica vaginalis over the testicle is opened longitudinally. Epididymal exploration identifies the site of epididymal blockage. This is typically done by palpation/visual inspection of dilated prominent epididymal tubules. Surgeon experience aids in identification of the level of obstruction. The vas is brought through the tunica vaginalis to lay next to the epididymis above the level of epididymal blockage. This step also allows for the vas to follow a relatively straight course.

    The peri-vasal vessels are sealed with 6-0 prolene suture. The end of the vas is cut at a 90 degree angle back to healthy tissue. Small vessels on the adventitial edge of the vas may be controlled with a small cautery. A 8-0 nylon stay stitch is placed in the seromuscular layer two inches from the vasal cut end.

    Under magnification (in this video 15-25x power), the epididymal tunic is incised with a Beaver blade at a length of ~3mm. A single epididymal tubule is mobilized with gentle blunt and fine sharp dissection. In this video one can appreciate the single loop of dilated epididymal tubule that is isolated. Two double-armed 10-0 nylons are placed longitudinally into a single tubule that is then incised with a micro-knife. A glass slide is placed over the fluid to obtain a sample. The sample is inspected with a tabletop microscope at 400x magnification. Sufficient amounts of opaque fluid with complete sperm were seen (not shown in video). If desired, sperm may be collected and processed for cryopreservation.

    The seromuscular layer of the vas and the epididymal tunic are brought together with interrupted 9-0 nylons at the 5 and 7 o’clock positions. The needles of the double-armed 10-0 nylons are place in their respective positions into the mucosal layer of the vas. To remove tension from the anastomosis, a single interrupted 9-0 nylon is placed between the epididymal tunic and the seromuscular layer of the vas at the 12 o’clock position. By then tying down the 10-0 nylons, the epididymal tubule is intussuscepted into the lumen of the vas. The VE is completed by placing interrupted 9-0 stitches between the seromuscular layer of the vas to the epididymal tunic for the remaining circumference of the outer layer.

    The tunica vaginalis is closed longitudinally with a running 4-0 vicryl. The testicle is placed back into the scrotum. Dartos is closed with a running 3-0 vicryl. The skin is closed with a running horizontal mattress 3-0 chromic and dressed in a sterile fashion.

    OUTCOMES

    Vasoepididymostomy outcomes

    Vasoepididymostomy outcomes.

    References:

    1.           Chan PT, Goldstein M. Superior outcomes of microsurgical vasectomy reversal in men with the same female partners. Fertility and sterility. 2004 May;81(5):1371-4. PubMed PMID: 15136104.

    2.           Marmar JL, Sharlip I, Goldstein M. Results of vasovasostomy or vasoepididymostomy after failed percutaneous epididymal sperm aspirations. The Journal of urology. 2008 Apr;179(4):1506-9. PubMed PMID: 18295271.

    3.           Peng J, Yuan Y, Zhang Z, Gao B, Song W, Xin Z, et al. Patency rates of microsurgical vasoepididymostomy for patients with idiopathic obstructive azoospermia: a prospective analysis of factors associated with patency–single-center experience. Urology. 2012 Jan;79(1):119-22. PubMed PMID: 22202547.

    4.           Berger RE. Triangulation end-to-side vasoepididymostomy. The Journal of urology. 1998 Jun;159(6):1951-3. PubMed PMID: 9598495.

    5.           Kumar R, Mukherjee S, Gupta NP. Intussusception vasoepididymostomy with longitudinal suture placement for idiopathic obstructive azoospermia. The Journal of urology. 2010 Apr;183(4):1489-92. PubMed PMID: 20171699.