Background: Reconnecting “the pipes”
Approximately 6% of the 600,000 men undergoing vasectomy annually in the United States decide to have their vasectomy reversed. The vas deferens is the plumbing or tube that carries sperm from the testicle and epididymis. The epididymis is the back part of the testis (where additional sperm maturation occurs following production in the testis). Sperm are produced in the testicle, and then travel to the epididymis for additional maturation. From the epididymis, the vas carries sperm toward the ejaculatory ducts, which empty into the urethra (urine channel) and out of the body (see diagrams below). Following vasectomy, the vas may be reconnected with excellent success depending on several factors. Certainly, fluid quality from the vas during surgery, shorter time (<15 years) after vasectomy, presence of sperm granuloma (lump of leaked sperm and immune cells that appears along the vas or epididymis following vasectomy), increased microsurgeon experience, all lead to better outcomes if reversal is desired.
Microsurgical reconstruction is performed under local, regional, or general anesthesia. Incisions on each side of the scrotum are made, approximately 1 cm lateral to the base of the penis. This incision location allows for the testicles to be delivered and for exposure of the epididymis if needed (for VE) for tension-free anastomosis. Successful vasectomy reversal requires careful dissection of the vas to increase vasal remnant length without harming the vasal vessels. The vasectomy site is identified and the vas is cut on the testicular side of the vasectomy site. Although the vas was cut during vasectomy, scar is usually present and requires both ends of the cut vas to be freed.
Vasectomy reversal is technically done in one of two ways depending on where the blockage is located. The first, and most common way is vasovasostomy (reconnecting the vas ends) after removing the vasectomy blockage site. The second, and more complex way which is only done when there is obstruction of the epididymis and this is called vasoepididymostomy, (or VE for short). VE reconnects the upper vas end to the epididymis, which is the cap on the back of the testis (where late sperm maturation occurs). See diagrams of each procedure below, followed by additional information.
Vasal fluid is checked during the operation under the microscope and findings help to select vasovasostomy (VV) or vasoepididymostomy (VE) procedure. If sperm are identified in vasal fluid, then the location of obstruction is identified and vasovasostomy (vas to vas connection) is completed. If no sperm are identified in vasal fluid, then epididymal obstruction is confirmed and VE (vas to epididymis connection) is completed. Rarely, additional obstruction can be found in the vas closer to the ejaculatory ducts which empty into the urethra (urine channel, where semen also passes out of the body). Before doing the anastomosis, confirmation that the upper vas end is patent is done by injecting fluid that does not meet resistance.
After vasectomy, the vas deferens (tube connecting testis and epididymis to the ejaculatory duct and urethra) on both left and right sides is cut. See “Anatomy 101” to help make sense of vasectomy.
Vasovasostomy: The Procedure:
If vasovasostomy is indicated, the vas deferens tube is reconnected using a microscope (microsurgery) or infrequently using the Da Vinci robot) in a very precise way. The repaired vas deferens must be tension-free and watertight for the best outcome. This anastomosis is done in multiple layers using microdots (small dots serve as a blueprint to mark where sutures should be placed and allow accurate realignment of the vas). Also a “scaffolding” (special approximating clamp) is used to align the ends of the vas for reconneciton. The inner (mucosal) layer is completed with special 10-0 monofilament sutures (smaller than a single human hair). The second layer (deep muscularis) is reapproximated using interrupted 9-0 monofilament sutures (slightly thicker suture, but still smaller than human hair). The third adventitial layer is also realigned using 9-0 monofilament sutures. Finally the vasal sheath is brought together with 8-0 monofilament sutures. Special techniques are used when the vas obstruction site is close to the testicle (in the convoluted vas) or when there are large vasal gaps (crossed vasovasostomy or testicular transposition may be needed).
Vasoepididymostomy (VE): The Procedure:
VE is the indicated treatment for epididymal obstruction and involves the re-routing of the upper portion of the vas to the epididymis (colored orange on diagram below), bypassing the obstructed lower portion of the vas. The lower portion of the vas is then no longer involved in sperm transport following surgery. VE involves delicate anastomosis between vas and epididymis compared to the vas-to-vas connection in vasovasostomy. Following the first VE in the early 1900’s with very low success, surgical technique has improved throughout the last 30 years most recently including longitudinal placement of sutures in the epididymal tubule known as longitudinal intussusception VE (LIVE) which has resulted in patency rates (successful vas reconnection) of 90% and pregnancy rates of 40%. The LIVE technique permits a larger diameter for flow from epididymal tubule to vas, with better results than other techniques.
After freeing up the abdominal vas to allow tension-free anastomosis to the epididymis, the covering of the testis and epididymis (tunica vaginalis) is opened, and the epididymis is examined. Classically, dilated tubules near the testis-side of the obstruction are noted, while collapsed non-dilated tubules are found on the other side (closer to the abdomen) of obstruction. A larger diameter, straight epididymal tubule is selected and a very small opening is made in the thin covering over it (epididymal tunic). VE anastomosis is completed using an epididymal tubule with abundant sperm regardless of motility. The quality of the epididymal fluid from the selected tubule will not be known until after sutures are placed using the LIVE technique. If sperm or abundant sperm parts are absent following incision of the epididymal tubule, then epididymal obstruction is located more proximally (closer to testicle) and the sutures must be removed and the anastomosis restarted using closer to the testis.
With the LIVE technique, four microdots are placed on the vas end (indicating the exit points of the four needles), and two 10-0 monofilament nylon sutures are placed longitudinally into the epididymal tubule under x25-x40 magnification. An ophthalmic microknife (15 degree) is used to incise between the needles which are not pulled through until after incision (since leakage will occur given larger diameter of needle than suture). If abundant sperm with motility are identified in epididymal fluid, the fluid is aspirated into multiple micropipettes and cryopreserved. The anastomosis is then completed by placing the four needles inside-to-out through vasal mucosa, exiting through each microdot on the vas. After tying the 10-0 sutures, the outer layer of the anastomosis is completed with up to 12 interrupted 9-0 nylon sutures from the vasal sheath to the epididymal tunic taking care not to injure the nearby epididymal tubules. The testis and epididymis are returned to the tunica vaginalis, the testis is replaced in the scrotum, and incisions are closed.
After the Surgery:
Following surgery, patients use an ice pack for 20 minutes on and 20 minutes off for 48 hours to the operative site. Patients avoid ejaculating, exercise, straining, or heavy lifting for 3 weeks. Scrotal support is worn for 6 weeks. Although complications are infrequent, the most common is scrotal blood collection (hematoma) which resolves without any additional procedures. Recurrent closure of the vas deferens is another possibility postoperatively, although this occurs rarely following VV less than 6% of cases and in 4% to 35% following VE depending on surgeon technique. Semen analyses are performed at 4 to 6 weeks postoperatively and then every 3 months. Patients with motile sperm in the ejaculate postoperatively typically cryopreserve especially following VE or redo surgery.
For more information about the initial male infertility workup, surgical results, and factors affecting surgical outcomes, please visit the Center for Male Health and Reproduction site. You may also contact us with any additional questions and our physician team will respond.
–Matthew Wosnitzer, M.D.
June 1, 2014