Microsurgical vasovasostomy after failed vasovasostomy

PURPOSE: We analyzed our experience with repeat microsurgical vasovasostomy after failed vasovasostomy and elucidate the possible predictors of surgical outcome. MATERIALS AND METHODS: We evaluated 62 repeat vasectomy reversal cases with followup data available. Regardless of the intraoperative observation of sperm in the vasal fluid bilateral microsurgical 2-layer vasovasostomy was performed when surgically possible. Of these 62 patients 60 (97%) underwent bilateral (58) or unilateral (2) vasovasostomy and 2 (3%) underwent unilateral vasovasostomy with contralateral epididymovasostomy. RESULTS: Patency and pregnancy followup data were available on 62 and 42 patients, respectively. The overall patency and pregnancy rates achieved were 92% and 57%, respectively, and the natural birth rate was 52%. Increased age of the wife proved a negative prognostic factor for pregnancy (p = 0.018). The intraoperative detection of sperm and other factors, including obstructive interval, reconstruction type, anastomotic site, patient age and postoperative semen parameters, did not influence the surgical outcome. CONCLUSIONS: Regardless of the detection of sperm in the intravasal fluid during the operation repeat microsurgical vasovasostomy resulted in a better outcome than in other studies, in which adopted epididymovasostomy was done when sperm was absent from the vas fluid. Our study suggests that compromised anastomosis after previous surgery is the most common cause of failed vasovasostomy. We recommend that microsurgical vasovasostomy should be performed preferentially in failed vasovasostomy cases.     

Microsurgical vasovasostomy

Up to 6% of men who have undergone vasectomy will ultimately elect for reversal in the form of vasovasostomy or vasoepididymostomy for various reasons. Vasovasostomy performed to regain fertility is a technique that has undergone numerous advances during the last century, including the use of microsurgical equipment and principles to construct a meticulous anastomosis. It is important during vasovasostomy to ensure good blood supply to the anastomosis as well as to build as a tension-free anastomosis. Visual inspection to ensure healthy mucosa and inner muscularis as well as atraumatic handling of tissues is helpful. With vasovasostomy, it is essential to create a watertight anastomosis to prevent secondary scar formation. The microdot technique of vasovasostomy allows for markedly discrepant lumens to be brought together more precisely. Thereby, the planning is separated from suture placement, which prevents dog-ears and avoids subsequent leaks. In the age of in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI), it becomes even more important to clarify outcomes after vasectomy reversals, as patients now have a choice between surgical sperm retrieval coupled with IVF/ICSI versus vasectomy reversal. Little data on long-term outcomes for vasectomy reversals exist. Therefore, further research in this field needs to evaluate the rate of late failures and the predictors of late failures.     

Laser-assisted vasovasostomy

To find a less time-consuming alternative to conventional microsurgical vasovasostomy, we performed vasal anastomosis in four sterilized men by means of a Nd:YAG laser (wavelength 1,060 nm) under macroscopic conditions. After dissection of the vasal ends, the ends were approximated using 6-0 prolene sutures as intervasal stents. The apposed tissue edges were welded by laser pulses of 0.5 sec in duration and 10 W in power. Postoperative sperm counts proved normal in two patients; one of them reported a successful pregnancy in his wife 12 months after vasovasostomy. One patient had cryptospermia and one patient oligoasthenospermia. Laser-assisted vasovasostomy is a simple procedure and shortens the operative time. More patients still need to be studied to allow a favorable comparison with conventional suture techniques.     

Robot-assisted vasovasostomy

Robot-assisted vasovasostomy is an attractive alternative to traditional microscopic techniques for several reasons. The normal physiologic tremor is removed and greater ease and precision of suture placement is possible. The training period or learning curve for robot-assisted vasovasostomy is shorter than traditional microscopic techniques. This will allow more surgeons to provide quality technical surgical care for their patients. Additional costs are only a few hundred dollars. As surgical robots become increasingly available and used for a wider variety of procedures, the feasibility of robotic vasovasostomy becomes more realistic and vasoepididymostomy is likely. Although robotic surgery has improved prostate surgery, its contribution to microsurgical technique has the potential for a more profound impact.     

Transseptal crossed vasovasostomy

We examined 11 patients with acquired obstructive azoospermia resulting from irreparable obstruction of 1 vas deferens and severe damage to the contralateral testis. All of the patients underwent transseptal crossed vasovasostomy with no morbidity. Of 8 patients evaluated with postoperative semen analyses 4 (50 per cent) demonstrated total sperm counts of 29 to 205 million and 2 pregnancies (25 per cent) have been reported, with followup ranging from 5 months to 2 years. The etiologies of the vasal obstruction included previous inguinal surgery in 7 patients, vasectomy in 1, ejaculatory duct obstruction in 1, ectopic ureter in 1 and vasal agenesis in 1. Factors leading to loss of the contralateral testis were torsion in 5 patients, mumps orchitis in 2, varicocele in 1, pediatric inguinal herniorrhaphy in 1, epididymal blow out in 1 and unknown in 1. A representative case involving a unilateral ectopic ureter emptying into the seminal vesicle and subsequent contralateral testicular torsion is presented. The results indicate that a transseptal crossed vasovasostomy should be done in patients satisfying the criteria presented.     

Macroscopic vasovasostomy re-examined

Results of 273 consecutive macroscopic vasovasostomy procedures performed at a single institution over a nine-year period between 1978 and 1987 were reviewed. When patients operated on less than five years after vasectomy were compared with those in whom more than five years had elapsed since vasectomy, significant declines in technical success rates as measured by return of sperm to the ejaculate (93% vs. 74%, p less than 0.004), biologic recovery as measured by mean sperm counts (55 million vs. 35 million) and mean progressive sperm motility (30% vs. 13%), and clinical success as measured by pregnancy rates (52% vs. 30%, p less than 0.02), were observed. Examination of complications of vasovasostomy showed a 7.7 percent overall complication rate and a 1.5 percent incidence of major complications.     

Laparoscopy-assisted pelvi-scrotal vasovasostomy

Iatrogenic obstruction of the vas deferens within the inguinal canal can be managed by direct on-site vasovasostomy. However, in cases with large defect of the vas, the anastomosis may be under tension. Dissecting through the site of a previous hernia repair is tedious, and may lead to recurrence of the hernia. The present work reports an, first of a kind, alternative technique that avoids the latter drawbacks. Fifteen cases were operated upon. Under laparoscopic vision, the pelvic vas was dissected and the lateral-most end was clipped, cut and extruded from the abdomen through a port in the external inguinal ring. End-to-end vasovasostomy and microsurgical anastomosis for the vasal vessels were performed, bridging the retrieved stump of the pelvic vas with the scrotal vas. There were positive results in the form of sperm count ranging from 1.5 to 15 million ml(-1), an average of 7.25 (SD 5.44) in nine of 15 cases (60%), within the first 6 months following surgery. "Pelvi-scrotal vasovasostomy" can be offered as a cost-effective and successful alternative or supplement to intracytoplasmic sperm injection, for cases with iatrogenic large defects of the vas deferens within the inguinal canal.     

Argon laser-assisted vasovasostomy.

Laser-assisted vasovasostomy recently has become a popular procedure in the United States. Only the microsurgical carbon dioxide laser is approved by the Food and Drug Administration for vasovasostomies. Using the HGM argon laser, the procedure was performed on 3 laboratory dogs with a patency rate of 100 percent (6/6) and anastomotic leak 17 percent (1/6). This procedure requires little microsurgical expertise, can be performed without the use of a microscope, and does not require a perfectly dry field. The argon laser is a superior technique to previously described laser-assisted vasovasostomies and further clinical correlation is recommended.     

Transient fertility after vasovasostomy

Sperm generally appear in the ejaculate within three weeks after vasovasostomy, but may soon disappear because of scarring of the anastomotic site. For this reason attempt at conception early after the operation should be encouraged.     

Loupe-assisted modified one-layer vasovasostomy

Several studies indicate that microsurgical modified one-layer vasovasostomy is comparable to the two-layer anastomosis with respect to patency and pregnancy rates. The objective of this study was to determine the feasibility and result of modified one-layer vasovasostomy under loupe magnification only. Thirty-two patients aged 28 to 64 years (mean 41.3 +/- 6 years) underwent vasovasostomy at CGMH from July 1997 to June 2002, with all operations being a modified on-layer anastomosis created with the aid of a 3 x loupe. The estimated duration of vasectomy ranged from 4 months to 27 years, with a mean of 9.2 +/- 4.8 years. Postoperative semen analysis and pregnancy were examined. Each patient was followed up at 1,4, and 12 weeks postoperatively. The total operation time ranged from 118 to 228 minutes (average 150 +/- 35 minutes). There was no operation-related complication such as hematoma or wound infection. The patency rate was 89% (25/28), and the pregnancy rate at 2 years or more of follow-up was 39% (11/28). The patency and pregnancy rates were similar to those obtained in most studies of microsurgical vasovasostomy. For uncomplicated vasectomy reversal, this simple loupe-assisted modified one-lyer vasovasostomy seems to provide an adequate anastomosis.     

Restoration of fertility by vasovasostomy

Vasovasostomy was performed on 41 patients. The surgical technique is described and the results are presented. The success rate was 83 per cent for pregnancy. Reasons for failure and suggestions for improvement in results are discussed.     

Use of exteriorized stents in vasovasostomy

Ten patients, three to fifteen years postvasectomy, underwent vasovasostomy. Using 2-0 nylon, stents were brought to the scrotal surface. Vas anastomosis was accomplished with a single transmural layer of 6-0 or 7-0 proline or chromic sutures under loupe magnification. Stents were removed in seven to ten days. After two years, a pregnancy rate of 70 per cent was achieved, comparing favorably with other more difficult operative techniques.     

Sperm function tests after vasovasostomy

Aim: To evaluate the sperm function after vasovasostomy. Methods: Semen samples from 42 subjects after vasovasostomy (Group A: 1 -6 months, Group B: 6 - 12 months; Group C: 12 - 18 months after vasectomy reversal) were investigated. Semen from 34 normal fertile men was used as controls. Sperm function tests, including hyposmotic swelling test (HOST), acridine orange (AO) fluorescence, acrosome reaction (triple-stain), cervical mucus penetration test (CMPT), etc were done. Results: After vasectomy reversal, the percentage of HOST was significantly lower than that of the normal fertile men. In regard to AO, there were no significant differences between the three vasovasostomy groups and between these 3 groups and the controls. With triple-stain, the percentage of normal acrosome reaction was significantly lower in Group A as compared with the controls, but not in Groups B and C. There were no significant differences in the results of CMPT between the vasovasostomy groups and the controls. However, the number of “poor“ type was significantly higher in Groups A and C than in the controls; the percentage of “negafive“ type were higher in Groups A and B than in the controls. Conclusion: After vasovasostomy a lower level of HOST remained for one year and gradually recovered after one year. Six months after vasectomy reversal, the percentage of acrosome reaction could be changed from lower level to normal range. The data of AO indicated that the genetic material (double-stranded DNA) in spermatozoa was not affected by vasovasostomy. To evaluate the result of CMPT after vasectomy reversal, not only the normal results but also the abnormal results (“poor“ and “negative“ types) should also be considered.     

Carbon dioxide laser microsurgical vasovasostomy

Microsurgical carbon dioxide (CO2) laser vasovasostomy was successfully achieved by fusion coagulation of protein under similar laboratory conditions as those seen in the operating room. Speed of performance, patent lumen, and lack of granuloma formation support the CO2 laser's ability to simplify this technique.