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Overview -
Vasovasostomy
(VV)
The vas deferens is the tube that carries sperm from the
testicles to the ejaculatory duct. Vasectomy is the leading
cause of obstruction of the vas deferens, but some men are born
with or acquire obstruction later in life from trauma or
infection.
The ultimate success of a reconstructive procedure is an
unassisted pregnancy. This is dependent on several factors: the
age and fertility of the female partner, surgeon's experience,
the technique of vasectomy reversal and the length of time since
the vasectomy was performed, so-called obstructive interval. In
large study with 1,469 patients from multiple institutions, the
success rate was inversely proportional to the obstructive
interval. The shorter the interval, the higher the success. In
men with obstructed intervals of less than 3 years, the
likelihood of sperm in the semen after reversal (patency rate)
was 96% and the pregnancy rate was 75%. On the other hand, when
the obstructed interval was greater than 15 years, the patency
rater was 70% with a pregnancy rate of 30%. Most men seeking
reversal had obstructed intervals between 3 and 14 years, the
patency rate was 87% and the pregnancy rate was 44% to 53%. In
interpreting this data, one must keep in mind that the age of
the female partner plays a very important role in pregnancy and
delivery rate.
It is important to point out that, with a longer obstructed
interval, the higher the chance that a more complex
reconstruction may be required. The operation is called an
epididymovasostomy (EV). At the time of the surgery, it will be
determined if an EV will be necessary. The success for
epididymovasostomy is lower than standard vasectomy reversal.
Vasectomy reversal is done as an outpatient. Anesthesia will be
general. Oral pain medication will be prescribed and is
generally required for 24 to 48 hours. Tylenol may also be
used. No heavy lifting, sports or sexual activity may be
undertaken for 4 to 6 weeks. You may return to work in 7 days
unless your have a physically demanding job, then a 10 to 14 day
wait is recommended. Semen analysis will be obtained at 3
months postop. Sperm may not return for 6 months or more with
VV and for up to 12 months following EV. You should not drive
for 7 to 14 days. It is preferable in the first 4 weeks that
you be the rider rather than the driver in a car.
The average length of time to achieve pregnancy is about one
year. 3% to 5% of initially successful VV may develop recurrent
obstruction after sperm were initially present recommended that
you consider sperm banking once sperm count has peaked to
safeguard against this problem. Bleeding and infection are
uncommon. Scarring and persistent pain at the operative site
occur rarely.
The epididymis is the structure behind the testicle. It is made
of coils of tubules through which the sperm migrate and mature.
The procedure to correct epididymal obstruction is
epididymovasostomy during which the vas deferens is attached to
an epididymal tubule in order to bypass the obstruction in
between.
The patency rate for epididymovasostomy is about 50% to 60 %
with a pregnancy rate of 30% to 40%. Some men may not have sperm
present for up to 12 months afterwards. Pregnancy may take one
to two years to achieve. Up to 10% of initially successful EV
patients may develop recurrent obstruction after sperm were
initially present. I recommend sperm banking as a safeguard
against this problem.
About the Surgical Procedure
Q: Exactly what happens during vasectomy
reversal?
A:
Simply stated, we undo the vasectomy in vasovasostomy and bypass
the blockage. In VV, a small incision is made on either side of
the scrotum and the vas deferens is examined. The vasectomy
site and the vas deferens are identified and excised back to
healthy tissue. The side of the vas is now unblocked and
typically oozes fluid of various consistencies, depending on the
obstructive interval. For VV, the ends are then brought
together and reconnected, using surgical sutures with the aid of
an operative micro-scope. A modified one-layer technique may be
used, depending on the surgeon's preference and the degree of
vas lumen disparity. In EV, a larger incision will be needed to
gain access to the epididymis. The vasectomy site is similarly
approached and excised. The thick fluid consistency and the
lack of sperm will mandate the performance of EV. The
epididymis is examined and a single tubule is selected for the
bypass. Various techniques have been used to connect the vas to
the epididymis. The current approach relies on invaginating the
epididymal tubule to the lumen of the vas. The approach or its
variations has the distinct advantage of being easier to perform
and has a higher success rate when compared with the traditional
"end-to-side" technique.
Q: Will local anesthesia with sedation
suffice?
A:
In my experience, local anesthesia is inadequate and is not used
in my vasectomy reversal. The problem with local anesthesia is
that the patient will have to remain still for an extended
period of time despite sedation. The delicate nature of the
procedure and the greatly magnified operative field do not allow
for any patient movement. Despite being touted by some as a
money-saving alternative, local anesthesia has not gained
popularity among the majority of surgeons for vasectomy
reversal.
Q: What about two-layer vs. modified
one-layer vasectomy reversal?
A:
Depending on the surgeon's preference and the size difference
between the ends of the vas, one may choose either one of
above. In two-layer reversal, the lining of the vas lumen and
the inner thickness are incorporated in the first layer of
suture closure. The outer aspect is then approximated with the
second layer of suture.
In modified
one-layer reversal, the initial layer incorporates the full
thickness of the vas, including the lining. This is the
approach I prefer.
With either technique, one may then choose to further reinforce
using the surrounding soft tissue coating. Success rate with
either approach is the same (VVSG, 1991).
Q: What is
micro-dot vasectomy reversal?
A:
Micro-dot is the dotting the vas with a miniature marking pen to
pre-select suture entry and exit points. In theory, it adds
another degree of precision in suture placement and vas
alignment. I personally have not found this extra step helpful
in suture placement, and I do not utilize this technique. |
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