Sexual Medicine Update - Archive

Surgery Skill Courses April 2007

VASECTOMY REVERSAL TECHNIQUES

Vasectomy reversal is nowadays a common procedure for practising urologists. It is estimated that about 2-6% of men who had been vasectomized will choose vasectomy reversal to restore their fertility.

Dr. Luis Fiter Gómez
Staff Urologist
Dpt of Urology Hospital Severo Ochoa, Leganés (Madrid) SPAIN
Medical Director
Androfiv (Fertility and Andrology Clinic)
Alcorcón (Madrid) SPAIN

Vasectomy reversal can be performed with loupe magnification (macroscopic vasectomy) or with surgical microscope. Microscopic vasectomy can be done either in one or two layers. Finally we have microscopic epididymovasostomy for those patients with a suspected obstruction on the epididymis.

With the development of in vitro fecundation techniques and sperm microinjection (IVF-ICSI) many couples choose sperm harvesting from epididymis or testis instead of vasectomy reversal, although these techniques can be significantly more expensive.

Macroscopic vasovasostomy
For current urologists who do not perform many procedures in a single year a macroscopic vasovasostomy (MaVV) is more feasible. It’s simpler, quicker to do and doesn’t require extensive training in microsurgery. Technique: It can be performed either with local or general anaesthesia in an outpatient basis. Because in no case the surgeon performing MaVV is going to switch to an epididymovasostomy, there is no need to deliver the testis out of the scrotum. Just dissect the vas with its granuloma and cut it until fluid spills from the testicular end of the vas. Loupe magnification usually is 2X to 5X. Three to four sutures are placed including muscular and mucosa, with care not to perforate the opposite mucosal wall. A 25 g. abocath can help placing sutures on the abdominal vas. Once these sutures are tied, four or five additional sutures should be placed on sero-muscular layer.

Results
Patency rates for this technique are about 85-89% (1,2) and pregnancy rates between 35 and 41 %. While these results seem to be similar to microscopic vasectomy ones all of them are based on historical series with short number of patients.

Microscopic vasovasostomy
Microscope allows us to use fine (9 or 10/0) sutures which lessen inflammatory response; accurately place the sutures in the mucosa and be able to perform a two layer no-leak anastomosis.

Disadvantages are that technique is more demanding and needs experience in microsurgery; operating time is longer and it is usually performed with general or regional anaesthesia, although some surgeons can perform it with local anaesthesia too.

Technique: It can be performed in or two layers. In the one layer technique after isolating the vas from surrounding tissue and cutting the granuloma, fluid from testicular end of the vas is inspected for the presence of sperm or sperm parts with a microscope. If no sperm is seen and there is no fluid or it is thick and creamy we should decide either if we continue with vasovasostomy (Mi-VV) or move to epididymis for epididymovasostomy (EV). Even in cases where no fluid is seen from testicular end of the vas, sperm can return to the ejaculate after a well done anastomosis. A microscopic clamp helps to hold both vassal ends. Then six 9/0 sutures are placed from outside-inside and inside-outside including muscular and mucosa. We first place lateral and medial sutures ant then two additional sutures closing one hemi circle. We then rotate the vas and place another two sutures on the opposite site. We complete the operation placing seromuscular stitches between the first ones. 

In the two layers technique double armed sutures are used. Three or four sutures are placed including only vassal mucosa and after rotating 180º the vas, sutures are placed in the opposite site. Once the mucosa is sutured, ten or twelve stitches are placed on the seromuscular layer to stabilize and seal the anastomosis.

Results
The Vasovasostomy Study Group reported the longest follow-up results of vasovasostomy currently available. The patency and pregnancy rates three years after vasectomy were 97% and 76% respectively. Fifteen years after vasectomy the patency and pregnancy rates drop to 71% and 30% respectively. The conclusion was that both patency and pregnancy rates were better when the interval from the vasectomy was shorter. No differences were found between the one or two layer anastomosis techniques (3).

Fibrin glue assisted three-suture vasovasostomy
Technique: Only 3 microsurgical whole-layer sutures are placed and fibrin glue is applied to seal the anastomosis.

It has the advantage that is a simple technique and less time consuming. Series reported to date show a patency and pregnancy rates of 85% and 22% but follow-up is still too short (4).

Epididymovasostomy
EV is a more demanding technique than vasovasostomy. The surgeon should have large experience in microsurgery. Although in the original technique described by Silber (5) the anastomosis was performed from the epididymis to the vas in an end to end fashion, (EE-EV) the end to side one (ES-EV) has become the most popular.

End to sideEV: described by Thomas (6). A small window is performed in the epididymal tunic and a single loop of the tubule is identified. With micro scissors the tubule is opened and fluid examined for the presence or absence of sperm. We should look for the lowest level of the epididymis in which sperm is identified, as pregnancy rates are better. After securing seromuscular wall of the vas to adventitia of the epididymis, four or five 10/0 sutures are placed from vassal lumen to tubular mucosa. The anastomosis is completed by suturing seromuscular of the vas to adventitia of the epididymal opening.

Although end to side technique is widely used it has some disadvantages because the sutures are placed in an open, collapsed epididymal tubule and is difficult to obtain a water tight leak-proof anastomosis.

Intussusception technique: In the triangular intussusception technique (TIVE) described by Berger (7) in 1997, before opening the epididymal tubule three 10/0 stitches are placed in a triangular or V fashion. With a micro-knife the tubule is opened and the fluid is aspirated with micropipettes for cryopreservation. Then needles from double-armed sutures are placed inside-out into the vas deferens mucosa. Once tied, this sutures intussuscepts the epididymal tubule into the vassal lumen providing a leak-proof anastomosis. The anastomosis is completed placing interrupted 9/0 sutures from vassal muscularis to epididymal tunica. Recently, Goldstein has described a variation of this technique denominated longitudinal intussusception (LIVE) in which only two holding sutures are placed before opening the tubule.

Results:
TIVE and LIVE techniques offer better or comparable outcomes compared to EE and ES epididymovasostomies with the advantage of less sutures and a simpler anastomosis. The late failure rate is lower with intussusception techniques (8).

The role of IVF-ICSI
The estimated cost of a IVF-ICSI cycle with harvesting of sperm from testis or epididymis is about 4500 €. Although the cost of a vasectomy reversal surgery could exceed this budget, two or three IVF-ICSI procedures are frequently needed to achieve the same pregnancy rate, so only for those patients whose couple gets pregnant at the first attempt assisted reproduction is worthwhile.

As we work within a reproduction unit, our current policy is to offer the option of sperm harvesting and freezing during vasectomy reversal to every patient if previous vasectomy was performed more than ten years ago and in all cases in which we perform epididymovasostomy. In our experience, fecundation oocite rates do not differ whether we use freezed-thawed sperm or fresh sperm, and patients don’t need a second surgical procedure in the case that vasectomy reversal fails.

References
1.Hsieh Ml, Huang HC, Chen y, Huang ST, Chang PL. Loupe-assisted vs. microsurgical technique for modified one-layer vasovasostomy: is the microsurgery really better? BJU Int 2005; 96(6): 864-866.
2.Dewire DM, Lawson RK. Experience with macroscopic vasectomy reversal al the Medical College of Wisconsin. Wis Med J 1994; 93 (3): 107-109.
3.Belker AM, Thomas AJ Jr, Fuchs EF, Konnak JW, Sharlip ID. Results of 1469 microsurgical vasectomy reversals by the Vasovasostomy Study Group. J Urol 1991; 145: 505-511.
4.Ho KL, Witte MN, Bird ET, Hakim S. Fibrin glue assisted 3-suture vasovasostomy. J Urol 2005 174 (4 Pt 1): 1360-1363.
5.Silber SJ. Microscopic vasoepididymostomy: specific microanastomosis to the epididymal tubule. Fertil Steril 1978; 30:565-571.
6.Thomas I. Epididymovasostomy. Urol Clin North Am 1987, 14 (3): 527-530.
7.Berger RE. Triangulation end to side Epididymovasostomy. J Urol 1998; 159: 1951-1953.
8.Schiff J, Chan P, Li PS, Finkelberg S, Goldstein M. Outcome and late failures compared in 4 techniques of microsurgical vasoepididymostomy in 153 consecutive men. J Urol 2005; 174 (2): 651-655.

Questions:
1. The pregnancy rates after vasovasostomy are better

a) After macroscopic vasovasostomy
b) After microscopic one-layer vasovasostomy
c) After microscopic two-layer vasovasostomy
d) b and c

Correct answer: D
Pregnancy rates are better for microscopic vasovasostomy but similar for both types of microscopic reversal.

2. After vasectomy reversal better results are obtained
a) If vasectomy was performed few years before
b) If there is granuloma formation after vasectomy
c) When vasectomy was performed with no-scalpel technique
d) a and b

Correct answer: A
Although granuloma seems to protect from epididymal obstruction, the only factor that affects pregnancy rates is the lapse of time from vasectomy.

3. If no fluid spills from testicular end of the vas the surgeon should
a) Cut more proximal to the testis until fluid is seen
b) Perform a Epididymovasostomy
c) Continue with vasovasostomy and collect sperm from epididymis or testis for freezing.
d) All of them

Correct answer: D
If after moving proximal to epididymis still no fluid is seen and the surgeon has experience with epididymovasostomy this should be the choice, but for surgeons without experience a good option is continue with vasovasostomy and offer the patient the opportunity to freeze sperm for the case that technique fails.

4. When performing an Epididymovasostomy we should
a) Anastomose the vas to the tail of epididymis
b) Anastomose the vas to the caput of epididymis
c) Anastomose the vas to the lowest level of the epididymis in which sperm is identified
d) No matter the level if sperm is present

Correct answer: C
Anastomosis to the caput epididymis has the lowest pregnancy rate as compared to corpus and cauda.

5. Sperm harvesting from testis or epididymis for IVF-ICSI
a) Is more cost-effective than vasectomy reversal
b) Should always be done during vasectomy reversal
c) Is a good option during epididymovasostomy and for patients whose vasectomy was performed long time ago.
d) a and c are correct.

Correct answer: C
Although vasectomy reversal could exceed the cost of a IVF-ICSI procedure, the pregnancy rate per cycle is significantly higher and frequently two or more IVF cycles are needed. Sperm harvesting and freezing is an excellent option in selected patients.