Blackwell Science, LtdOxford, UKBJUBJU International1464-410XBJU InternationalJune 2004

939

Surgical Atlas
Vasovasostomy
D. SHIN
ET AL.

Surgical Atlas
Vasovasostomy
D. SHIN, W.W. CHUANG and L.I. LIPSHULTZ
Division of Male Reproductive Medicine and Surgery, Scott Department of Urology, Baylor
College of Medicine, Houston, Texas, USA

ILLUSTRATIONS by STEPHAN SPITZER, www.spitzer-illustration.com

PLANNING AND PREPARATION showed a direct relationship between

successful pregnancy rates and time since
INDICATIONS vasectomy, with the pregnancy rates being
76% after <3 years, 53% after 3–8 years, 44%
Vasectomy is a safe and effective form of after 9–14 years, and 30% after >15 years.
birth control chosen worldwide by ª 15% of Patients are counselled about realistic
all couples seeking advice for contraception expectations for success, given these
[1]. However, changing circumstances, e.g. predictive variables. Furthermore, sperm
remarriage, the death of children, or a change cryopreservation should be offered to all
of heart, have led 2–9% of men to request a patients at the time of reconstruction.
vasectomy reversal [2–4], the most common
indication for reconstructive microsurgery. Laboratory evaluations such as serum FSH or
Other indications for vasovasostomy include antisperm antibody testing is helpful but not
less common causes of vasal obstruction necessary before reconstruction.
secondary to infection such as gonorrhoea or
tuberculosis, or to iatrogenic vasal injury INTRAOPERATIVE CONSIDERATIONS
related to groin or scrotal surgery.
Intravasal fluid assessment
PATIENT SELECTION
The quality of the intravasal fluid has a
Overview direct impact on the surgeon’s choice of
microsurgical reconstruction technique. In
The choice of vasovasostomy depends on the general, if there is fluid containing sperm or
nature and extent of the obstruction, the sperm parts then a vasovasostomy should be
quality of the opposite testis and the quality done. If clear or copious fluid is encountered
of the intravasal fluid. However, the with no sperm, in a patient having a first
microsurgeon must always be prepared to vasovasostomy, then vasovasostomy may also
perform a more complicated be performed. If there is no fluid, or thick,
vasoepididymostomy if intraoperative inspissated, toothpaste-like fluid is
findings dictate this situation. encountered, a vasovasostomy will probably
not be successful and one should proceed to a
Assessment before surgery vasoepididymostomy.

Increasing intervals of obstruction have been Sperm granuloma

shown to have an adverse impact on the
success of microsurgical reconstruction. In The presence of a sperm granuloma often
1991, the Vasovasostomy Study Group [5] indicates a release of fluid into the

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D . S H I N ET AL.

surrounding tissues, which protects the • On-line monitor and camera; • #3 Knife handle;
epididymis from tubule rupture or • 3.3 Bishop Harmon forceps; • ‘Dennis’ blade holder.
dysfunction. • McPherson tying forceps;
• 0.12 Castroviejo suturing forceps; Suture Preferences:
Sperm granulomas have been associated with • Jacobson mosquito forceps;
better grades of sperm quality in the • #3 Jeweller forceps; • 10–0 nylon 2XBRM5 for inner layer of vas;
intraoperative vas but have not been shown • #5 Jeweller forceps; • 9–0 nylon HSV6 for outer layer of vas.
to be associated with better postoperative • Curved Castroviejo needle holder without
results [5]. The choice of microsurgical lock; SPECIFIC PATIENT POSITIONING
technique should not depend upon this factor • 12 cm Halsey needle holder;
alone. • Straight Iris scissors; • Table with central support and leg
• Vannas pattern dissecting scissors; extension;
SPECIFIC EQUIPMENT/MATERIALS: • Vannas pattern suture scissors. • Adjustable stools;
• Waterproof drapes;
• Operating microscope: Zeiss ZMS-414 Extras: • Prep (removing all betadine).
model;
• Standard microscope for checking • Nerve holder (1.5, 2.0, 2.5, 3.0, 3.5, 4.0);
testicular fluid; • Nonperforating towel clamps (ball tip);

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Figure 1

After the general anaesthetic induction, the

scrotal, genital and bilateral inguinal regions
are shaved and prepared as for standard
surgery. After draping, the operating
microscope is positioned at the head of the
bed on the patient’s left side. The surgeon is
seated on the patient’s right with the
microscope foot controls on the floor also on
the patient’s right side. The assistant sits
opposite the operating surgeon on the
patient’s left side. Microscope and viewing
monitor are placed at the head of the bed on
the patient’s left side in view of the operating
surgeon.

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Figure 2

An incision is made in the first hemiscrotum,

and the vas identified and isolated distal to
the level of obstruction.

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 VASOVASOSTOMY

Figure 3

A 5/0 chromic suture is placed in the serosa of

the testicular vas, and the vas transected
using a nerve holder and ‘super’ blade. The
upside vas is then tied off with a 3/0 chromic
freehand tie. Vasal fluid is aspirated from the
testicular vas and examined under ¥ 400
magnification. The image is projected on the
monitor for the operating surgeon to verify
the presence of sperm parts. The vas is then
identified and isolated proximal to the level of
obstruction. It is transected in the same
manner described above.

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D . S H I N ET AL.

Figure 4

The abdominal vas is gently dilated with fine

forceps.

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Figure 5

The abdominal vas is irrigated with a 24 F

angiocath to verify patency.

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Figure 6

The testicular and abdominal vas ends are

brought in close proximity with 5/0
polydioxanone in the perivasal tissue.

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Figure 7

A fine-tip marking pen is used to mark the 6

o’clock position.

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Figure 8

A 9/0 nylon suture on a HSV needle

(Sharpoint) is used to re-appose the serosa
layer. Sutures are placed in the serosa at the 5,
6 and 7 o’clock position.

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Figure 9

10/0 nylon on 2 × BRM5 needle is used to

place sutures in the vasal mucosa.

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Figure 10

Sutures are placed at the 4, 6, 8 o’clock

positions within the mucosa.

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Figure 11

Five additional stitches are then placed at the

1, 3, 9, 11 and 12 o’clock position.

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Figure 12

The mucosal sutures are then tied.

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Figure 13

9/0 nylon suture is used to place sutures in

the vasal serosa to complete the outer
anastomosis.

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POSTOPERATIVE CARE vasovasostomy. The delayed closure rate of REFERENCES

initially patent anastomoses is 3–6% per year
All patients enter the recovery room with an for vasovasostomies [6]. Excellent results can 1 Liskin L, Pile JM, Quillin WF.
athletic supporter filled with dressing to keep be obtained by repeat vasovasostomy. Vasectomy-safe and simple. Popul Rep
the scrotum elevated. After 24 h, all dressings 1983; 11: 61–99
from inside the athletic supporter are An aggressive vasectomy resulting in a long 2 Fenster H, McLoughlin MG.
removed except for one or two gauze pads. A segment of vas removal may necessitate Vasovasotomy-microscopic versus
special cellophane-coated gauze (TelfaTM) more vigorous mobilization of the vas. macroscopic techniques. Arch Androl
remains on the suture line for 48 h. The Consequently, there is a greater potential for 1981; 7: 201–4
supporter should remain in place for 2 weeks devascularization, fibrosis and tension on the 3 Heidenreich A, Altmann P, Engelmann
or as long as it helps to avoid any discomfort. anastomosis. Careful preparation and UH. Microsurgical vasovasotomy versus
It is very important to apply ice packs to the dissection is recommended to minimize the microsurgical epididymal sperm
scrotum the night after surgery and the higher risk for failure. aspiration/testicular extraction of sperm
following day to prevent haematoma combined with intracytoplasmic sperm
formation. Pain medications and antibiotics Vasectomy at a lower site, e.g. in the injection. Eur Urol 2000; 37: 609–14
are routinely prescribed to reduce pain and convoluted vas, presents a greater technical 4 Jequire AM. Is vasectomy of long term
prevent infection. Physical exertion should be challenge for vasovasostomy. The wall of the benefit? Vasectomy related infertility: a
avoided for at least 2 weeks after surgery; convoluted vas is more delicate than the wall major and costly medical problem. Hum
patients may resume normal activity 48 h of the straight vas, and can be easily ruptured Reprod 1998; 13: 1757–60
after surgery, and sexual intercourse may if not handled gently. Successful division of 5 Belker AM, Thomas AJ, Fuchs EF et al.
resume 10 days after surgery. The first semen the convoluted vas requires that the tubule be Results of 1469 microsurgical vasectomy
sample is analysed 6 weeks after surgery. straightened, because the convoluted vas reversals by the Vasovasotomy Study
not only bends backwards on itself but Group. J Urol 1991; 145: 505
also rotates on its longitudinal axis. The 6 Jarow JP, Sigman M, Buch JP, Oates
FROM SURGEON TO SURGEON convoluted vas can be divided by initially RD. Delayed appearance of sperm after
dissecting the larger convolutions and then end-to-side vasoepididymostomy. J Urol
POTENTIAL PROBLEMS carefully dividing the intravasal attachments. 1995; 153: 1156–8
This technique unwinds the convoluted vas
The most common cause of failure is stenosis and provides a straight segment which is ideal
or obstruction at the site of the previous for transection.

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