Vasovasostomy (Vasectomy Reversal)

About the Authors

Cara B. Cimmino MD and Raymond Costabile MD

Raymond Costabile, MD COL U.S.A (ret) assumed the position as the Jay Y. Gillenwater Professor of Urology and Vice Chairman at the University of Virginia in July 2004 following his retirement from the U.S. Army after 28 years of service. His principle clinical and research interests are in the areas of male infertility, male and female sexual health and urologic oncology. He also serves as Senior Associate Dean for Clinical Strategy in the School of Medicine.

Dr. Costabile was previously assigned as Chief of the Urology Service and Urology Residency Program Director at Madigan Army Medical Center in Tacoma Washington.  He assumed the position in May 1999 after 10 years at Walter Reed Army Medical Center. During his tenure he was also an Associate Professor of Surgery at the Uniformed Services University in Bethesda, MD. From December 2001 until September 2003, Dr. Costabile commanded the 47th Combat Support Hospital to include its deployment to Iraq/Kuwait where it was the largest coalition military hospital deployed during OPERATION IRAQI FREEDOM. Under Dr. Costabile’s command, the 47th CSH was the principle combat hospital, responsible for caring for over 92% of all battle casualties during the initial nine months of the conflict.

Dr. Costabile attended Georgetown University, Washington, DC, where he received a Bachelor of Science degree in Biology/Theology.  After receiving his medical degree from Georgetown University School of Medicine, Dr. Costabile completed his surgical internship and urology residency at Walter Reed Army Medical center, Washington, DC.  He was then afforded a fellowship in impotence and infertility from 1991-1993 at the University of Virginia Health Sciences Center, Charlottesville, Virginia.

Cara B. Cimmino, MD is currently a Male Infertility and Andrology Fellow at the University of Virginia.  She attended the University of Michigan, Ann Arbor, where she received her Bachelor of Arts degree in Psychology in 2001.  She remained in Ann Arbor to attend the University of Michigan Medical School from 2002-2006.  After medical school Dr. Cimmino completed a six year urology residency at Lahey Clinic Medical Center, Burlington, MA in 2012.  Once her fellowship is completed in June 2013, she will join the Urology department at Piedmont Hospital in Atlanta, Georgia.  Special Interests include: Male infertility, vasectomy, vasectomy reversal, male and female sexual medicine, and andrology.

SURGICAL VIDEO: Bilateral Vasovasostomy (Vasectomy Reversal)

In this video, Dr. Raymond Costabile performs the vasovasostomy procedure in a male desiring vasectomy reversal with the assistance of Dr. Cara Cimmino.

The steps of the procedure as described below follow the steps noted in the video.

Introduction

Though vasectomy should be considered a permanent form of sterilization, approximately 2-6% of men seek vasectomy reversal (1).  The most common reason is to reestablish reproductive potential in men seeking to achieve pregnancy after their initial vasectomy.  Less common is vasectomy reversal for the treatment of post-vasectomy pain syndrome (PVPS).

Indications: Patient desiring reversal of prior vasectomy for restoration of sperm to ejaculate to reestablish reproductive potential or relief of post-vasectomy pain syndrome.

Surgical Technique

Special equipment and Instruments:

Operating microscope with variable magnification from 6-32 power (diploscope allowing identical optical field for surgeon and assistant preferred), straight microforceps with tying platform, curved non-locking microneedle holders, toothed tissue forceps, vas deferens clamp or holding apparatus, curved tip microforceps, bipolar cautery forceps, glad microscope slides and capillary tubes, microirrigator made from a 10-mL syringe and 24-gauge angiocatheter, microknife, and surgical background (authors use a metal ruler within a 1-inch penrose drain).

Patient Positioning

Vasosostomy can be performed under local, regional, or general anesthesia.  These authors prefer general anesthesia in order to limit patient movement under the operating microscope.  Patient is positioned in supine position as far towards the end of the operating table as possible utilizing a table extension if necessary.  Correct patient positioning is essential to allow the surgeon to sit or stand comfortably while supporting the ulnar portion of hands, wrists, and forearms to minimize tremor.  The operating microscope should be positioned at the head or foot of the operating table with an overhanging suspensory bar.  Microscope foot pedals and bipolar pedal for operative cautery should be placed in a comfortably accessible position for the surgeon.

Preparation

Scrotum is clipped free of hair.  Standard alcohol-based or povidone-iodine solutions should be utilized to sterilize the operative site.  If the patient has had prior inguinal surgery, both groins should be shaved and prepared for the possibility of performing an inguinal vasectomy reversal.

Incision and Dissection

Several options for initial incisions are available.  For primary vasectomy reversal, where the vasectomy site is in the straight portion of the vas deferens, a small 1.5cm midline raphe incision can be utilized and bilateral vas accessed through this singular incision.  This is the method utilized by the authors.  Alternatively, bilateral vertical 1.5 cm incisions can be made on each hemiscrotum to allow access to each vas separately.  Incision should be made after grasping the vasectomy site or sperm granuloma with a penetrating towel clamp.  It is preferable not to deliver the spermatic cord and testis for a simple vasectomy reversal.  This approach can be reserved for more difficult dissections or vasoepididymostomy, and incision can be extended if required.

Once the vasectomy site has been delivered through the incision, the operating microscope can be positioned with care to ensure that both surgeon and assistant can comfortably visualize the operative field.  The scrotal and abdominal ends of the vasectomy defect are identified and vessel loop placed around the vas deferens on each respective side.  A healthy portion of vas deferens is then identified approximately 1 cm away from the vasectomy site.  Care should be taken to avoid stripping of the adventitia and further disturbance of the blood supply to the anastomosis.  A metal ruler or flat clamp is placed under the vas deferens and a #10, #11 scalpel blade or microknife is used to transect the vas with a 90-degree perpendicular cut angle on both the abdominal and testicular end of the vas deferens.  Some surgeons utilize a #4 nerve holder to stabilize the vas deferens and incise through its slotted groove with a Denis blade to ensure a perpendicular cut.

Once the testicular end is prepared, fluid is coaxed from the testicular portion of the vas deferens, collected with glass capillary tube, and placed on a microscope slide for microscopic examination for spermatozoa off the field.  The presence of motile, nonmotile whole, or sperm fragments should be identified before proceeding with anastomosis.  If no sperm components are identified from the collected fluid, the testicular portion of the vas deferens should be cut back further, or vasoepididymostomy should be considered.  The abdominal portion of the vas is cannulated with a 24-gauge microirrigator and 1-3cc of saline is gently injected to confirm patency.  Once both ends have been prepared, a microclamp is used to approximate the two ends together in a tension free manner for repair.  Alternatively, a 5-0 or 6-0 nylon suture can be placed in the adventitial layer of the vas deferens to prevent migration and oppose the tissue.

Repair

Two approaches are frequently described for the anastomosis of the vas deferens.  The modified one-layer closure is the technique utilized by the authors, and depicted in the video.

Modified One-Layer Closure:

Six 9-0 nylon sutures (Ethicon vas 100-4 needle) are used for each layer of the anastomosis.  Three initial sutures are placed through all three layers (mucosa, muscularis, and adventitia) of the vas deferens on the back wall, and tied as they are placed.  The lumen should be incorporated in the 3 sutures.  Three additional partial-thickness 9-0 nylon sutures are then interposed between each of the full-thickness sutures, incorporating only the seromuscular layers.

The vas clamp is then rotated 180 degrees to allow visualization of the front wall of the vas deferens.  Three additional full-thickness 9-0 nylon sutures are preplaced without immediate tying.  Once all three are evenly placed, they are sequentially tied.  The additional three seromuscular 9-0 nylon sutures are interposed between the full-thickness sutures on the front side of the vas deferens to complete the anastomosis.

Some surgeons describe utilizing the assistance of placement of six microdots with a microtip marking pen on the lumen of each end of the vas deferens in order to assist with appropriate alignment.  Using this method, microdots are placed at the 1 o‘clock, 3 o’clock, 5 o’clock, 7 o’clock, 9 o’clock, and 11 o’clock positions.

Two-Layer Anastamosis:

A two-layer anastomosis can be utilized when performing a vasovasostomy as well.  This approach is particularly helpful when there is a considerable size discrepancy between the lumens of the two cut ends of the vas deferens.  In this approach, the luminal sutures used are typically 10-0 nylon double armed sutures with 70 um diameter taper-point needles bent into a fish hook configuration (Sharpoint and Ethicon), while the outer layer utilizes 9-0 double-armed nylon sutures.  Three luminal sutures are placed in the back wall incorporating the mucosa and a small portion of the muscularis of the vas deferens, excluding the adventitia.  Three outer seromuscular sutures are then placed in between the luminal sutures, as in the modified one-layer anastomosis.  The vas clamp is then rotated 180 degrees and the front wall is completed as was previously described.

Some choose to provide an additional third layer of six 7-0 polydioxanone sutures to re-approximate the vasal sheath over the anastomosis.  This is not performed by the authors.

Closure

Once the anastomosis is complete, and hemostasis confirmed, the vas is returned through the incision into the scrotum.  The operating microscope is removed from the field.  The testicles are gently tugged to ensure return to appropriate dependent position in the scrotum.  The dartos fascia and scrotal incisions are then closed with 4-0 absorbable suture.  Sterile fluff gauze dressings are placed over the incisions and held in place with a scrotal support garment.

Postoperative Care

Vasectomy reversal is an outpatient procedure, and patients are discharged after recovery from anesthesia.  Ice packs and scrotal support are recommended for 48 hours or less after the procedure to minimize narcotic use.  Patients are advised to decrease physical activity for 2-3 weeks, and to abstain from sexual activity for 3-4 weeks in order to decrease the risk of anastomotic sperm leak, granuloma formation, and stricture.  Semen analysis is obtained 6 weeks after surgery and every 3 months thereafter until the couple has achieved pregnancy.  Delayed return of sperm to the ejaculate may occur up to 6 months after vasovasostomy and 18 months after vasoepididymostomy, after which point failure of the procedure is presumed (2).

Potential Complications

  • Bleeding:  Most common complication with occurrence rate of <1% in the literature.  Hematomas typically are small, require no surgical drainage, and resolve within 6-12 weeks.
  • Infection:  Rarely reported.
  • Postoperative reobstruction:  can occur from scar formation at the anastomotic site.  Incidence of postoperative reobstruction is reportedly between 3%-12% after vasovasostomy and approximately 21% after vasoepididymostomy (3,4)

Outcomes

Experienced urologic surgeons trained in microsurgical techniques, report success rates for anastomotic patency and return of semen to the ejaculate of 85%-99.5% (5, 6).  Pregnancy rates are more variable and depend more on the age and fertility status of the female partner.  Regarding relief of pain for those patients undergoing vasectomy reversal for post-vasectomy pain syndrome, this is a small population and outcome studies are limited by small subject numbers.  However in one recent study in the literature 93% of patients experienced significant improvement in pain, and 50% saw complete resolution (7).  Studies comparing the microsurgical modified one-layer technique and the microsurgical two-layer closure yield comparable results (5, 8).  The high complexity of the microsurgical technique utilized for vasovasostomy warrants referral to a surgeon specialty trained in such techniques.

References

  1. Sandlow JL and Nagler HM:  Vasectomy and vasectomy reversal: important issues.  Preface.  Urol Clin North Am 2009;  36(3):  xiii-xiv.
  2. Jarow JP, Sigman M, Buch JP, Oates RD:  Delayed appearance of sperm after end-to-side vasoepididymostomy.  J Urol 1995; 153(4):1156-8.
  3. Belker AM, Fuchs EF, konnak JW, Sharlip ID, Thomas AJ Jr.:  Transient fertility after vasovasostomy in 892 patients.  J Urol 1985; 134(1): 75-6.
  4. Matthews GJ, Schlegel PN, Goldstein M:  Patency following microsurgical vasoepididymostomy and vasovasostomy:  temporal considerations.  J Urol 1995; 154(6):2070-3.
  5. Belker AM, Thomas AJ, Fuchs EF, Konnak JW, Sharlip ID:  Results of 1,469 microsurgical vasectomy reversals by the Vasovasostomy Study Group.  J Urol 1991;145:505-11.
  6. Goldstein M, Li PS, et al: Microsurgical vasovasostomy: the microdot technique of precision suture placement. J Urol 1998; 159(1):188-190.
  7. Horovitz D, Tjohg V, Domes T, Lo K, Grober ED, Jarvi K:  Vasectomy reversal provides long-term pain relief for men with the post-vasectomy pain syndrome.  J Urol 2012; 187(2): 613-617.
  8. Fischer MA, Grantmyre JE:  Comparison of modified one- and two-layer microsurgical vasovasostomy.  BJU Int 2000;85:1085-8.