History
It is important to obtain a thorough history from all patients requesting VR. Important factors to consider are pre-vasectomy fertility of both the patient and his partner. The age of the partner, previous parity, and any concurrent medical issues she may have that can affect the outcome of future pregnancy. [8] By far, the most important prognostic factor for successful reversal is the occlusion duration. [9]
Obtaining information about post-vasectomy complications such as infection or hematoma can prepare the surgeon for intra-operative peri-testicular inflammation that can make re-anastomosis more challenging. [9]
Testosterone replacement therapy (TRT) has been well documented to negatively impact spermatogenesis. Any TRT the patient is currently taking should be discontinued well before VR as it can influence intra-operative decision-making. Inability to identify sperm on intra-operative vasal fluid can lead the surgeon to pursue the more technically challenging VE, which can also negatively impact outcomes and pregnancy rates. [8]
Patients and their partners should be counseled regarding the risk and benefits of surgical reconstruction, as well as the alternatives. In-vitro fertilization, microsurgical testicular sperm extraction, donor sperm insemination, and adoption are all viable options. Should couples proceed with vasectomy reversal, cryopreservation of sperm intra-operatively can provide more options of fertility in the future should vasectomy reversal be inadequate for natural conception. [9]
Any history of previous inguinal or pelvic surgeries should also be documented for completeness.
Physical Examination
Physical examination should consist of a thorough testicular exam. Documenting the presence of a palpable vasal defect, sperm granuloma, and if possible, the length of the proximal (testicular) vasal segment can be helpful in operative planning.
Presence of a varicocele is also an important exam finding which can significantly impact fertility rate and can be surgically corrected at the time of VR. [8]
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Sperm is produced in the seminiferous tubules and then transits through the rete testis, through the efferent duct, and into the epididymal tubule. Image reprinted with permission from Cleveland Clinic.
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Vasovasostomy modified one-layer technique: (A) A 9-0 nylon suture is passed through the entire vas wall, traveling full thickness through both ends. (B) Two 8-0 nylon seromuscular sutures are placed on either side of the 9-0 suture. (C) This pattern is repeated in each quadrant of the anastomosis, resulting in a total of 4 luminal sutures and 8 seromuscular sutures.
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Vasovasostomy formal two-layer technique: (A) 9-0 nylon seromuscular sutures are placed in the posterior end of the vas at the 5- and 7-o'clock positions. (B) Six interrupted 10-0 nylon mucosal sutures are then placed to approximate the luminal ends of the deferens. (C) Finally, 4 additional 9-0 nylon seromuscular sutures complete the second layer of the anastomosis.
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Vasoepididymostomy end-to-side technique: (A) Two 9-0 nylon sutures are used to secure the seromuscular layer of the vas to the epididymal tunic. (B) Four 10-0 nylon sutures are then placed to secure the mucosa of the vas to the epididymal tubule. (C) Finally, six to eight 9-0 nylon sutures are used to secure the seromuscular layer of the vas to the epididymal tunic.
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Table 1. Surgically Correctable Causes of Ductal Obstruction
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Table 2. Microsurgical Vasovasostomy
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Table 3. Microsurgical Vasoepididymostomy
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J stent insertion for the treatment of malignant obstruction. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
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Vasectomy reversal. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
