MICROSURGICAL VASECTOMY REVERSAL

1 Chose VASECTOMY as a form of contraception, with approxi-mately 500,000 procedures performed ,2Of thesemen, 2% to 6% will desire REVERSAL of their VASECTOMY at alater include re-marriage, desire for furtherfertility, loss of a child, and chronic testicular pain. VASECTOMY REVERSAL can be performed in a variety ofways. Both macro- and MICROSURGICAL techniques have beendescribed and are currently being used by practicing urolo-gists and male infertility specialists. Owen is credited withthe first MICROSURGICAL method for reconstructing the vasdeferens, and his technique is the predecessor of the mod-ern day 2-layer microscopic ,5 Variability exists in the sizeand number of sutures used aswell as in the number of layersanastomosed.

2 Recently, at-tempts have been made to min-imize the number of suturesused by placing surgical fibringlue on the outer layer. Whileinnovative, experience withthis new technique is consequences includeglue leakage into the vasal lu-men and associated risks andthe inability to adequately re-approximate disproportion-ately sized lumens. PREDICTORS OF SUCCESSO utcomes and predictors ofsuccess for VASECTOMY reversalhave been published in the lit-erature. Lee reported one of thelargest and most detailed sin-gle-surgeon experiences withboth macrosurgical and micro-surgical found that although initial pa-tency rates appeared similar for the 2 groups (85% and 91%,respectively), pregnancy rates were better for the microsurgi-cal group (52% vs.)

3 35%). Additionally, decreasing postoper-ative sperm counts and ultimate azoospermia were morecommonly associated with the macrosurgical approach, like-ly due to secondary fibrosis at the anastomosis. The Vasovasostomy Study Group evaluated predictors ofsuccess in 1,469 MICROSURGICAL VASECTOMY reversals andfound that the length of the obstructive interval was in-versely related to the pregnancy absence of spermin the testicular end of the vas at the time of surgery wasalso inversely correlated withpregnancy. Additional intra-operative findings that corre-lated with sperm quality at thetime of VASECTOMY REVERSAL in-cluded the presence or absenceof a sperm granuloma at thevasectomy site and the grossappearance of the fluid fromthe testicular end of the ,9In our experience, an in-creased length of the testicularvasal remnant was predictiveof the presence of sperm at thetime of remnants longer than had a 94% chance of hav-ing whole sperm at the time ofsurgery.

4 Whereas smaller vasalremnants had an 85% proba-bility of no sperm in the in-spected fluid. The duration of the ob-structive interval, the presenceor absence of a sperm granulo-INVENTORY CONTEMPORARY UROLOGY1 MICROSURGICAL VASECTOMY REVERSALTECHNIQUES TO IMPROVE OUTCOME By Edward Karpman, MD, Daniel H. Williams IV, MD, and Larry I. Lipshultz, MDMicrosurgical vasovasostomy andepididymovasostomy are effectivemeans of VASECTOMY REVERSAL forcouples desiring fertility. The key to success and the hard part ismeticulous reapproximation of thevasal or epididymal segments.

5 Dr. Karpmanis a Clinical Fellow, Dr. Williamsis aClinical Fellow, and Dr. Lipshultzis Lester and SueSmith Professor and Chair, Scott Department ofUrology, Baylor College of Medicine, Houston, the United States today, men are playing a greater role in couples decisions regarding permanent contraceptionthan they did in past generations. The latest avail-able data from the Centers for Disease Control show that of married men ma, the gross appearance of the fluid,and the length of the testicular vas areall predictive of whether or not spermwill be found at the time of vasectomyreversal.

6 The presence of sperm at thetime of VASECTOMY REVERSAL is predic-tive of a successful vasovasostomyprocedure. REASONS FOR FAILUREU nsuccessful vasovasostomy for vasec-tomy REVERSAL has been attributed pri-marily to surgical technique and fail-ure to recognize a secondary epididy-mal obstruction (SEO), which candevelop after VASECTOMY . Silber char-acterized the phenomenon ofSEO as a result of epididymalextravasation following va-sectomy and recommendedepididymovasostomy to by-pass the to perform epididy-movasostomy has been re-ported to be as high as 62%in patients undergoing rever-sal 15 or more years after was the cause of failurein almost half of patients pre-senting for a repeat these reasons.

7 Surgeons performing vasecto-my REVERSAL should be experi-enced at microsurgery andprepared to perform epididy-movasostomy based on the intraoper-ative A TECHNIQUEM icroscopic epididymovasostomy wasfirst performed in an end-to-end technique was succeededby a microscopic end-to-side ap-proach. A newer technique of trian-gulation end-to-side intussusceptionepididymovasostomy has been on the intussusceptiontechnique have included transverseand vertical suture placement of only2 ,17 Comparable patency(range, 81%-92%) and pregnancy(range, 37%-40%) rates have been re-ported for all of these , technique selection shouldbe based on the individual surgeon sexperience and the literature, significant empha-sis is placed on the number of mucosalsutures used and the manner in whichthey are placed.

8 In our experience,other factors are equally the appropriate decision toperform a vasovasostomy or an epi-didymovasostomy, adequate mobiliza-tion of the abdominal vas with preserva-tion of the perivasal blood supply, andtension-free advancement of the vasare instrumental for a suc-cessful VASECTOMY the defect created byvasectomy in a tension-freemanner often represents themost difficult part of the op-eration. The following descriptionsof MICROSURGICAL vasovasos-tomy and epididymovasos-tomy are based on the experi-ence at our institution.

9 As described above, variationson both techniques exist, andsurgeons should use the approach that offers their patients the best chances ofpregnancy, in the shortesttime, and in the most cost-effective manner. Our tech- VASECTOMY REVERSAL2 CONTEMPORARY UROLOGYINVENTORYR eversalSperm qualityCommentstechniqueWhole sperm+/- motileV VNoneClear fluid, < 5 yV V since vasectomyHeads < 10 y sinceV Vand tailsvasectomyHeadsThick fluidV V or E VNoneThick, creamy/EVpasty fluidVV= vasovasostomy; EV= 1 Vasal fluid appearance and indications for vasovasostomy or epididymovasostomyFIGURE 3 Transecting the vas deferensA nerve holder is used to stabilize thevas as it is 2 Isolating the vas deferensThe testicular end of the vas isisolated with a penetrating towelclamp and is dissected 1 Delivering testisThe testicle is delivered with thetunica vaginalis intact.

10 Nique of vasovasostomy has been de-scribed CPT codesfor VASECTOMY REVERSAL and sperm aspi-ration on this page for coding PROTOCOLThe preoperative evaluation and set-up are similar for both vasovasostomyand epididymovasostomy. All patientsare offered sperm aspiration and cryo-preservation prior to VASECTOMY rever-sal. The preservation of sperm allowsthe patient to pursue assisted repro-ductive techniques without undergo-ing additional surgical procedures incase the REVERSAL is not successful. Patients are admitted to the ambu-latory surgery center, and general anes-thesia is administered.