Curr Urol Rep04:61 )5 02( DOI 10.1007/s11934-015-0511-0
MEN’S HEALTH (R CARRION AND C YANG, SECTION EDITORS)
The Evolution of Vasectomy Reversal Ryan M. Dickey 1 & Alexander W. Pastuszak 2,3 & Tariq S. Hakky 3 & Aravind Chandrashekar 3 & Ranjith Ramasamy 3 & Larry I. Lipshultz 2,3
# Springer Science+Business Media New York 2015
Abstract In the USA, about 500,000 vasectomies are performed each year, with up to 6 % of men requesting reversal. The technique of vasectomy reversal has evolved from macrosurgical to the implementation of both microscopic and robotic technologies. The very earliest attempts at vasectomy reversal, the vasoepididymostomy and vasovasostomy, have remained central in the treatment of male infertility and will continue to be so for years to come. As seen throughout its history, urological microsurgery has consistently implemented advanced techniques and state-of-the art technology in its craft, and its continued refinement will allow for even more favorable outcomes in the lives of patients seeking restoration of fertility following vasectomy. Here, we review the evolution of vasectomy reversal and its current techniques. This article is part of the Topical Collection on Men’s Health * Larry I. Lipshultz [email protected] Ryan M. Dickey [email protected] Alexander W. Pastuszak [email protected] Tariq S. Hakky [email protected] Aravind Chandrashekar [email protected] Ranjith Ramasamy [email protected] 1
Baylor College of Medicine, Houston, TX, USA
2
Center for Reproductive Medicine, Baylor College of Medicine, Houston, TX, USA
3
Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
Keywords Vasectomy . Vasectomy reversal . Microsurgery . Vasovasostomy . Vasoepididymostomy . Epididymovasostomy
Introduction Approximately 500,000 vasectomies are performed yearly in the USA. Of these men, 6 % request vasectomy reversal [1, 2]. The practice of vasectomy reversal in humans is less than a century old, yet the technique has progressed from a macrosurgical one to a more highly developed state with the implementation of the microscope. The microsurgical techniques for vasovasostomy (VV) or epididymovasostomy (EV) may also be implemented for less common pathologies such as iatrogenic injury, post-vasectomy pain syndrome, and obstruction secondary to infection or inflammation. The use of microsurgical techniques is essential in vasectomy reversal and the treatment of male infertility, and these techniques have already been applied to a broad range of surgical problems. The following is a review of the historical and technical aspects of vasectomy reversal.
History With the increasing application of vasectomy for therapeutic, punitive, and eugenic purposes in the early twentieth century, the necessity of vasectomy reversal came to the forefront under medical, political, and religious pressure [3]. The American Edward Martin, known as the Bfounding father of modern clinical andrology^, performed the first EV in 1902 on a man with epididymitis and gonococcal urethritis, leading to the birth of a full-term infant [4, 5]. William C. Quinby later reported the first successful VV in 1919 on a man who
40
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Page 2 of 5
underwent vas resection in 1911 using a strand of silkworm gut for the anastomosis, assisted by Vincent O’Conor [6]. Vasectomy reversal continued to evolve, but limitations were evident in 1948 when an American Urological Association survey revealed patency and pregnancy rates of 38 and 19.5 %, respectively, following reversal [7]. The emergence of a microsurgical solution occurred in May 1974 when Sherman Silber, an American urologist, met Earl Owen, a plastic surgeon from Melbourne, Australia, at a Royal College of Surgeons conference in Sydney (telephone interview with Sherman Silber). Owen was a renowned microsurgeon and founder of the International Microsurgical Society in 1969, having performed the first VV in Australia in 1971 (telephone interview with Marc Goldstein). In 1973, Dr. Silber developed a microsurgical method to assist his studies of rat kidney transplantation using eyeglasses with ×2 magnification, 1-mm mosquito forceps, and 9-0 suture [8]. At the time of meeting Silber, Owen worked in organ transplantation. Owen’s partnership with Silber led him to specialize in urologic microsurgery, where he felt there was more opportunity for innovation (telephone interview with Sherman Silber). In 1975, Silber performed a two-layer VV using 9-0 and 10-0 nylon sutures and a Zeiss operating microscope at the University of California at San Francisco. This was the first publication of microsurgical VV performed in the USA [9]. Though it is unclear which of the two physicians, Silber or Owen, were first to perform VV, both men were foundational in the development of urologic microsurgery (telephone interview with Marc Goldstein). When compared with nonmicroscopic techniques, Silber’s microsurgical approach achieved higher success rates, reporting a spontaneous pregnancy rate of more than 71 % compared to 40 % using nonmicroscopic techniques [10, 11]. Following the success of microsurgical VV, Silber described an end-to-end EV in 1978, allowing surgeons to bypass obstruction in the 1– 2 mm epididymis and achieve greater patency than previous approaches [12]. This end-to-end procedure resulted in a patent connection between the vas deferens and the epididymis rather than the previous fistulous tract obtained by simply approximating the vas deferens to the epididymis. An endto-side technique was introduced by L.V. Wagenknect at the University of Hamburg in 1983 and is still used currently by many urologic microsurgeons [13]. This technique would be further modified upon in 1986 by Ingemar Fogdestam, a Swedish plastic surgeon and former fellow at St. Vincent’s Hospital in Melbourne [14]. The EV would be further advanced by Larry I. Lipshultz, who used the microsurgical technique for correction of epididymal pathology not related to prior vasectomy, expanding microsurgery into more urologic areas [15]. Other advancements to the VV were made by Joel Marmar and Anthony Thomas, who described the transseptal crossed VV in 1985 [16]. In 1998, Richard Berger described the triangulation end-to-side EV, a broadly
implemented surgical technique [17]. Marc Goldstein later described the two-stitch longitudinal intussusception technique now preferred by many microsurgeons for its high patency rate and simplicity [18, 19]. The history of microsurgery in urology is not confined to the development of innovative surgical techniques, as many of the advances that drove acceptance of operative microscopy were unrelated to urologic practice. Orthopedic hand surgeon Robert Acland of the University of Louisville convinced Swiss instrument developers Werner Spingler and Eugen Tritt to develop finer suture and needles to facilitate more accurate suture placement [20]. Acland was also instrumental in determining optimal microsurgical ergonomics (telephone interview with Arnold Belker). Technical improvement of the microscope, including integration of refined fiber optics and intraoperative controls, is attributed to Peter Horenz [21]. Advancements such as xenon lamps, bipolar electrocautery, and variable magnification microscopes have all facilitated ease of use and contributed to better outcomes (telephone interview with Marc Goldstein). Contributions by urologists recognizing the need to optimize surgical tools during microsurgical dissection include development of the Lipshultz Pattern Scissors. Though the work of relatively few pioneers in microsurgery greatly advanced the field, formal training opportunities have proven essential. In the 1980s, the work of the Vasovasostomy Study Group, headed by Arnold Belker, is believed to have encouraged interest in urologic microsurgery through reporting of the outcomes of over 1400 microsurgical vasectomy reversals [22]. Formal fellowship training in urologic microsurgery was introduced by Larry I. Lipshultz in 1981, furthering the growth of the field and solidifying urologic microsurgery as an academic discipline while also improving patient outcomes [23].
Current Techniques As detailed in a technical discussion of vasectomy reversal by Lipshultz et al. [24], the most common procedures sought for reversal include the two-layer VV and the more technically demanding intussuscepted EV. Determination of which procedure is required can be predicted using clinical nomograms, but the final decision is made by examining the quality of the intraoperative fluid of the testicular vas [25]. A thorough preoperative evaluation should be performed including a detailed history of the patient’s vasectomy, prior fertility, and prior inguinal surgery, in addition to physical examination to determine presence or absence of sperm granuloma and testicular vasal segment length [26, 27]. If EV is predicted and the patient does not wish to undergo additional procedures of in vitro fertilization with intra-cytoplasmic sperm injection following surgery, cryopreservation should be considered. Choice of anesthesia is both surgeon and patient dependent; either a combination of
Curr Urol Rep04:61 )5 02(
local anesthetic and sedation or general anesthesia performed, though there are considerable advantages to general anesthesia. After preparing the surgical site, vertical paramedian scrotal incisions are made and the testes and spermatic cords are delivered. Downward traction of the vas deferens and adventitia on the testicular side is applied through a ball tip towel clamp, the vasal adventitia is dissected, and stay sutures are placed 1– 2 cm inferior to the transection site. While an Adson forcep holds the site of vasectomy, a 2–3-mm slotted nerve holder is placed on the vas at the transection site and a Dennis blade is passed quickly through the slot to transect the vas. The abdominal vas deferens is similarly isolated and divided. The fluid of the testicular vas is now examined. A 3-mL syringe fitted with a 25-French angiocatheter aspirates any fluid, which is examined under 400× magnification to determine the presence and quality of whole sperm, sperm motility, sperm parts, or degenerated cells. If the quality of the fluid is sufficient, a VV is determined suitable. The two vasal ends are then approximated, with careful attention that the ends overlap easily as to prevent any tension in the anastomosis. A 5-0 PDS approximating suture is placed through the adventitia of each vasal end symmetrically and tied securely. A two-layer VV is performed, first marking the 6 o’clock position on each vas with a micropoint marker. Interrupted 9-0 nylon stitches are placed at the 5, 6, and 7 o’clock positions through the vasal muscularis and adventitia. At the 6 o’clock position, an interrupted 10-0 nylon suture is passed through the mucosal layer. After placing a drop of methylene blue on the cut surface of the vas, additional mucosal sutures are placed by this stitch and tied down. Three to five equidistant mucosal stitches are placed and tied together only once all are placed (Fig. 1a). The mucosal sutures are then tied down sequentially. At the 12 o’clock position, a 9-0 nylon suture is placed through the seromuscular layer, and interrupted 9-0 sutures are placed circumferentially to complete the anastomosis. If the quality or quantity of the fluid from the testicular vas is not determined to be sufficient for VV, EV is then considered. Epididymal obstruction is believed to be caused by prolonged vasal obstruction after vasectomy, leading to Fig. 1 a Three to five 10-0 nylon mucosal sutures are placed and tied sequentially. b 10-0 sutures are placed through the vas deferens lumen bringing together the tubular wall
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chronic increase in intraluminal pressure and finally a Bblowout^ injury in the epididymal tubules, resulting in obstruction and possible formation of a vasal sperm granuloma [28••]. In such a case, the EV begins by opening the tunica vaginalis and exposing the testicle and epididymis. Under magnification, grasping the epididymis and observing any dilated tubules proximal to a point of demarcation may determine the location of obstruction. The epididymal tunic is opened caudally toward the caput until sperm are identified from a single isolated tubule. This ensures the location of the EV maximizes the distance in which sperm will travel to mature and increase motility. Microdissecting scissors are used to make a 0.5-cm opening in the tunic of the epididymis, and a dilated tubule is identified and dissected free. After identifying a suitable tubule, two 10-0 double-armed sutures are passed through the tubular wall at the 2 and 10 o’clock positions and are left in the wall and rotated laterally. A 0.5mm puncture is made in between the two needles using a 20gauge V-lance knife (Alcon Surgical), and the sutures are pulled through. The fluid is now examined for motile sperm under microscopy, and epididymal fluid is collected for sperm banking if desired by the patient. If sperm are present in the epididymal fluid, the EV can proceed. If sperm are present but none are motile, testicular sperm extraction for cryopreservation can be performed following the end of the procedure. In the event that no sperm are present, a new opening is made more proximally in the tunica and the above process is repeated. The abdominal vas is then passed through the tunica vaginalis of the testicle after being sufficiently mobilized. A 5-0 PDS suture is used to tie the vas to the tunica of the epididymis, and 9-0 nylon-interrupted sutures are passed through the edge of the epididymal tunic and the seromuscular layer of the vas. Using the two-suture intussusception approach, two double-armed 10-0 sutures are used. The two needles are brought through the inferior edge of the vasal lumen at the 4 and 8 o’clock positions and the 10 and 2 o’clock positions on the opposite side (Fig. 1b). A surgeon’s knot is tied in both sutures prior to tensioning the sutures. As
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an assistant brings down the vas to the tubule using a jeweler’s forceps, the first and second sutures are tied down. An outer layer of 9-0 sutures is used to bring together the epididymal tunic to the seromuscular vas. The tunica vaginalis is closed, the testicle is placed back into the scrotum, and subsequent layers are closed in the normal fashion [24]. An alternative technique pioneered by Peter Chan et al. [28••] known as longitudinal intussusception vasoepididymostomy (LIVE) simplifies the procedure while maintaining high patency rates. Four microdots are placed on the vasal ends to mark the placement of sutures on the vas. After securing the vas with 9-0 nylon sutures to the edge of the tunica epididymis, two 10-0 nylon double-armed microsutures are placed longitudinally on the epididymal tubule. The tubule is incised between the needles using a 15° ophthalmic knife. The fluid is then aspirated and examined under microscopy, and if found suitable, the needles are pulled through and placed through the four microdots on the vasal ends in an inside-out fashion. A 9-0 tension-reducing suture is placed to approximate the epididymal tunic to the vasal sheath in order to avoid tearing the 10-0 sutures out of the tubule during tying. Recently, a onelayer EV technique has also been described by creating a window in the tunica of the epididymis, fixing the opened epididymal tubule to the edges with four sutures, and anastomosing the vas deferens to this opening [29•]. Success rates of vasectomy reversal are dependent on the duration of occlusion, intraoperative vassal fluid quality, and selection of either VV or EV [24, 30]. If VV is performed within 3 years from vasectomy, the Vasovasostomy Study Group showed 97 % patency rate and 76 % pregnancy rate. If greater than 15 years from vasectomy, the patency rate fell to 71 % and pregnancy rate to 30 % [22]. A decreased interval in the grading of sperm quality as outlined by the group similarly results in a decreased pregnancy rate. When EV is indicated, the surgeon’s experience is particularly important, as patency rates have been reported varying from 31 to 92 % and pregnancy rates from 10 to 50 % [28••].
The Future of Vasectomy Reversal Microsurgical practice in urology is likely to evolve, particularly with the growing use and availability of the Da Vinci surgical robot, which has been applied to vasectomy reversal [31, 32, 33•]. Several advantages of robotic surgery over pure microsurgery have been described, particularly in VV, including decreased operative time, decreased learning curve when compared to traditional microsurgical techniques, increased ease and precision of suture placement, and increased patency [34]. Though better instrumentation and magnification are needed before widespread application of robotics, possible current applications include vas deferens repair in the deep pelvis, ureteral repairs, and as a general remedy for fine tremors. Looking further, technological
advancements may lead to entirely new procedures. For example, the intraoperative use of high magnification may assist to identify and harvest germ line stem cells from the sub-basement membrane of azoospermic men. Subsequent in vitro culture and injection into the vasa efferentia or rete testes could be used to repopulate the germ cell line (telephone interview with Sherman Silber, Marc Goldstein). Additionally, a sutureless VV may become a reality as biomaterials improve, as a novel method of reinforcing a single suture layer anastomosis already exists. Cyanoacrylate, a sutureless biomaterial, was shown to decrease operative time when compared to suture groups with similar patency [35•]. Ideally, incremental implementation of techniques such as these will decrease the time and complexity of vasectomy reversal, helping urologic microsurgeons achieve better outcomes and decreasing operative time patients must endure.
Conclusion Vasectomy reversal has progressed from a tenuous macrosurgical approach in the early twentieth century to a highly refined and predictable microsurgical technique seen today, utilizing both microscopic and robotic technologies. The very earliest attempts of vasectomy reversal, the EV and VV, have remained central in the treatment of infertility reversal and will continue to be so for years to come. As seen throughout its history, urological microsurgery has consistently implemented advanced techniques and state-of-the art technology in its craft, and its continued refinement will allow for even more favorable outcomes in the lives of patients seeking restoration of fertility following vasectomy. Compliance with Ethics Guidelines Conflict of Interest Ryan M. Dickey, Alexander W. Pastuszak, Tariq S. Hakky, Aravind Chandrashekar, Ranjith Ramasamy, and Larry I. Lipshultz each declare no potential conflicts of interest. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.
References Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance 1.
Eisenberg ML, Henderson JT, Amory JK, Smith JF, Walsh TJ. Racial differences in vasectomy utilization in the United States: data from the national survey of family growth. Urology. 2009;74(5):1020–4. doi:10.1016/j.urology.2009.06.042.
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Potts JM, Pasqualotto FF, Nelson D, Thomas Jr AJ, Agarwal A. Patient characteristics associated with vasectomy reversal. J Urol. 1999;161(6):1835–9. Kim HH, Goldstein M. History of vasectomy reversal. Urol Clin North Am. 2009;36(3):359–73. doi:10.1016/j.ucl.2009.05.001. Jequier AM. Edward Martin (1859–1938). The founding father of modern clinical andrology. Int J Androl. 1991;14(1):1–10. Martin E, Carnett JB, Levi JV, Pennington ME. The surgical treatment of sterility due to obstruction at the epididymis; together with a study of the morphology of human spermatozoa. Univ Pennsylvania Med Bull. 1902;15(1):2–15. O’Conor VJ. Anastomosis of the vas deferens after purposeful division for sterility. J Urol. 1948;59(2):229–33. Derrick Jr FC, Yarbrough W, D’Agostino J. Vasovasostomy: results of questionnaire of members of the American Urological Association. J Urol. 1973;110(5):556–7. Silber SJ, Crudop J. Kidney transplantation in inbred rats. Am J Surg. 1973;125(5):551–3. Silber SJ. Microsurgery in clinical urology. Urology. 1975;6(2): 150–3. Silber SJ. Microscopic vasectomy reversal. Fertil Steril. 1977;28(11):1191–202. Silber SJ. Perfect anatomical reconstruction of vas deferens with a new microscopic surgical technique. Fertil Steril. 1977;28(1):72–7. Silber SJ. Microscopic vasoepididymostomy: specific microanastomosis to the epididymal tubule. Fertil Steril. 1978;30(5):565–71. Klosterhalfen H, Wagenknecht LV, Becker H, Huland H, Schirren C. Surgical results of epididymovasostomy and vaso-vasostomy. Der Urologe Ausg A. 1983;22(1):25–8. Fogdestam I, Fall M, Nilsson S. Microsurgical epididymovasostomy in the treatment of occlusive azoospermia. Fertil Steril. 1986;46(5): 925–9. Fenster H, McLoughlin MG. Epididymovasostomy for epididymal obstruction. In: Lipshultz LI, Corriere Jr JN, Hafez ESE, editors. Surgery of the male reproductive tract. Clinics in andrology. Netherlands: Springer; 1980. p. 38–46. Lizza EF, Marmar JL, Schmidt SS, Lanasa Jr JA, Sharlip ID, Thomas AJ, et al. Transseptal crossed vasovasostomy. J Urol. 1985;134(6):1131–2. Berger RE. Triangulation end-to-side vasoepididymostomy. J Urol. 1998;159(6):1951–3. McCallum S, Li PS, Sheynkin Y, Su LM, Chan P, Goldstein M. Comparison of intussusception pull-through end-to-side and conventional end-to-side microsurgical vasoepididymostomy: prospective randomized controlled study in male Wistar rats. J Urol. 2002;167(5):2284–8. Chan PT, Brandell RA, Goldstein M. Prospective analysis of outcomes after microsurgical intussusception vasoepididymostomy. BJU Int. 2005;96(4):598–601. doi:10.1111/j.1464-410X.2005. 05691.x. History—Microsurgery. S & T Microsurgical http://www. microsurgery.ch/index.php?id=23&L=1. Accessed 6/10/2014.
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Horenz PG. Microscope with correlatable fixation target. Google Patents; 1986. 22. Belker AM, Thomas Jr AJ, Fuchs EF, Konnak JW, Sharlip ID. Results of 1,469 microsurgical vasectomy reversals by the Vasovasostomy Study Group. J Urol. 1991;145(3):505–11. 23. Interview with Larry Lipshultz. 2014, May 13. 24. Lipshultz LI, Rumohr JA, Bennett RC. Techniques for vasectomy reversal. Urol Clin North Am. 2009;36(3):375–82. doi:10.1016/j. ucl.2009.05.011. 25. Smith RP, Khanna A, Kovac JR, Badhiwala N, Coward R, Lipshultz LI. The significance of sperm heads and tails within the vasal fluid during vasectomy reversal. Indian J Urol IJU J Urol Soc India. 2014;30(2):164–8. doi:10.4103/0970-1591.126898. 26. Boorjian S, Lipkin M, Goldstein M. The impact of obstructive interval and sperm granuloma on outcome of vasectomy reversal. J Urol. 2004;171(1):304–6. doi:10.1097/01.ju.0000098652.35575. 85. 27. Witt MA, Heron S, Lipshultz LI. The post-vasectomy length of the testicular vasal remnant: a predictor of surgical outcome in microscopic vasectomy reversal. J Urol. 1994;151(4):892–4. 28.•• Chan PT. The evolution and refinement of vasoepididymostomy techniques. Asian J Androl. 2013;15(1):49–55. doi:10.1038/aja. 2012.80. This article provides a description of the evolution of EV, including the history of its development, preoperative evaluation, and various techniques. Also described is a technique pioneered by the authors known as LIVE. 29.• Hussein A. A new one-layer epididymovasostomy technique. BJU Int. 2014. doi:10.1111/bju.12839. This article details an innovative alternative technique for EV, describing a simplification of the procedure with reasonable outcomes in a small number of patients. 30. Belker AM. Predictors of success in microsurgical correction of vasal and epididymal obstruction. Curr Urol Rep. 2001;2(6):443–7. 31. Kuang W, Shin PR, Matin S, Thomas Jr AJ. Initial evaluation of robotic technology for microsurgical vasovasostomy. J Urol. 2004;171(1):300–3. doi:10.1097/01.ju.0000098364.94347.02. 32. Parekattil SJ, Atalah HN, Cohen MS. Video technique for human robot-assisted microsurgical vasovasostomy. J Endourol Endourol Soc. 2010;24(4):511–4. doi:10.1089/end.2009.0235. 33.• Parekattil SJ, Cohen MS. Robotic surgery in male infertility and chronic orchialgia. Curr Opin Urol. 2010;20(1):75–9. doi:10. 1097/MOU.0b013e3283337aa0. This article includes the historical development of microsurgery and provides in-depth analysis of several common robotic urologic microsurgical procedures including vasectomy reversal. 34. Parekattil SJ, Gudeloglu A. Robotic assisted andrological surgery. Asian J Androl. 2013;15(1):67–74. doi:10.1038/aja.2012.131. 35.• Hakky TS, Duboy AJ, Lipshultz LI, Carrion RE. Absorbable cyanoacrylate for use in microsurgical vasovasotomy: a novel method to reinforce the anastomosis. American Society Of Andrology Meeting 2014. The authors describe an innovative application of biomaterials in VV, decreasing operative time while maintaining similar patency compared to current techniques.
MEN’S HEALTH (R CARRION AND C YANG, SECTION EDITORS)
The Evolution of Vasectomy Reversal Ryan M. Dickey 1 & Alexander W. Pastuszak 2,3 & Tariq S. Hakky 3 & Aravind Chandrashekar 3 & Ranjith Ramasamy 3 & Larry I. Lipshultz 2,3
# Springer Science+Business Media New York 2015
Abstract In the USA, about 500,000 vasectomies are performed each year, with up to 6 % of men requesting reversal. The technique of vasectomy reversal has evolved from macrosurgical to the implementation of both microscopic and robotic technologies. The very earliest attempts at vasectomy reversal, the vasoepididymostomy and vasovasostomy, have remained central in the treatment of male infertility and will continue to be so for years to come. As seen throughout its history, urological microsurgery has consistently implemented advanced techniques and state-of-the art technology in its craft, and its continued refinement will allow for even more favorable outcomes in the lives of patients seeking restoration of fertility following vasectomy. Here, we review the evolution of vasectomy reversal and its current techniques. This article is part of the Topical Collection on Men’s Health * Larry I. Lipshultz [email protected] Ryan M. Dickey [email protected] Alexander W. Pastuszak [email protected] Tariq S. Hakky [email protected] Aravind Chandrashekar [email protected] Ranjith Ramasamy [email protected] 1
Baylor College of Medicine, Houston, TX, USA
2
Center for Reproductive Medicine, Baylor College of Medicine, Houston, TX, USA
3
Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
Keywords Vasectomy . Vasectomy reversal . Microsurgery . Vasovasostomy . Vasoepididymostomy . Epididymovasostomy
Introduction Approximately 500,000 vasectomies are performed yearly in the USA. Of these men, 6 % request vasectomy reversal [1, 2]. The practice of vasectomy reversal in humans is less than a century old, yet the technique has progressed from a macrosurgical one to a more highly developed state with the implementation of the microscope. The microsurgical techniques for vasovasostomy (VV) or epididymovasostomy (EV) may also be implemented for less common pathologies such as iatrogenic injury, post-vasectomy pain syndrome, and obstruction secondary to infection or inflammation. The use of microsurgical techniques is essential in vasectomy reversal and the treatment of male infertility, and these techniques have already been applied to a broad range of surgical problems. The following is a review of the historical and technical aspects of vasectomy reversal.
History With the increasing application of vasectomy for therapeutic, punitive, and eugenic purposes in the early twentieth century, the necessity of vasectomy reversal came to the forefront under medical, political, and religious pressure [3]. The American Edward Martin, known as the Bfounding father of modern clinical andrology^, performed the first EV in 1902 on a man with epididymitis and gonococcal urethritis, leading to the birth of a full-term infant [4, 5]. William C. Quinby later reported the first successful VV in 1919 on a man who
40
Curr Urol Rep04:61 )5 02(
Page 2 of 5
underwent vas resection in 1911 using a strand of silkworm gut for the anastomosis, assisted by Vincent O’Conor [6]. Vasectomy reversal continued to evolve, but limitations were evident in 1948 when an American Urological Association survey revealed patency and pregnancy rates of 38 and 19.5 %, respectively, following reversal [7]. The emergence of a microsurgical solution occurred in May 1974 when Sherman Silber, an American urologist, met Earl Owen, a plastic surgeon from Melbourne, Australia, at a Royal College of Surgeons conference in Sydney (telephone interview with Sherman Silber). Owen was a renowned microsurgeon and founder of the International Microsurgical Society in 1969, having performed the first VV in Australia in 1971 (telephone interview with Marc Goldstein). In 1973, Dr. Silber developed a microsurgical method to assist his studies of rat kidney transplantation using eyeglasses with ×2 magnification, 1-mm mosquito forceps, and 9-0 suture [8]. At the time of meeting Silber, Owen worked in organ transplantation. Owen’s partnership with Silber led him to specialize in urologic microsurgery, where he felt there was more opportunity for innovation (telephone interview with Sherman Silber). In 1975, Silber performed a two-layer VV using 9-0 and 10-0 nylon sutures and a Zeiss operating microscope at the University of California at San Francisco. This was the first publication of microsurgical VV performed in the USA [9]. Though it is unclear which of the two physicians, Silber or Owen, were first to perform VV, both men were foundational in the development of urologic microsurgery (telephone interview with Marc Goldstein). When compared with nonmicroscopic techniques, Silber’s microsurgical approach achieved higher success rates, reporting a spontaneous pregnancy rate of more than 71 % compared to 40 % using nonmicroscopic techniques [10, 11]. Following the success of microsurgical VV, Silber described an end-to-end EV in 1978, allowing surgeons to bypass obstruction in the 1– 2 mm epididymis and achieve greater patency than previous approaches [12]. This end-to-end procedure resulted in a patent connection between the vas deferens and the epididymis rather than the previous fistulous tract obtained by simply approximating the vas deferens to the epididymis. An endto-side technique was introduced by L.V. Wagenknect at the University of Hamburg in 1983 and is still used currently by many urologic microsurgeons [13]. This technique would be further modified upon in 1986 by Ingemar Fogdestam, a Swedish plastic surgeon and former fellow at St. Vincent’s Hospital in Melbourne [14]. The EV would be further advanced by Larry I. Lipshultz, who used the microsurgical technique for correction of epididymal pathology not related to prior vasectomy, expanding microsurgery into more urologic areas [15]. Other advancements to the VV were made by Joel Marmar and Anthony Thomas, who described the transseptal crossed VV in 1985 [16]. In 1998, Richard Berger described the triangulation end-to-side EV, a broadly
implemented surgical technique [17]. Marc Goldstein later described the two-stitch longitudinal intussusception technique now preferred by many microsurgeons for its high patency rate and simplicity [18, 19]. The history of microsurgery in urology is not confined to the development of innovative surgical techniques, as many of the advances that drove acceptance of operative microscopy were unrelated to urologic practice. Orthopedic hand surgeon Robert Acland of the University of Louisville convinced Swiss instrument developers Werner Spingler and Eugen Tritt to develop finer suture and needles to facilitate more accurate suture placement [20]. Acland was also instrumental in determining optimal microsurgical ergonomics (telephone interview with Arnold Belker). Technical improvement of the microscope, including integration of refined fiber optics and intraoperative controls, is attributed to Peter Horenz [21]. Advancements such as xenon lamps, bipolar electrocautery, and variable magnification microscopes have all facilitated ease of use and contributed to better outcomes (telephone interview with Marc Goldstein). Contributions by urologists recognizing the need to optimize surgical tools during microsurgical dissection include development of the Lipshultz Pattern Scissors. Though the work of relatively few pioneers in microsurgery greatly advanced the field, formal training opportunities have proven essential. In the 1980s, the work of the Vasovasostomy Study Group, headed by Arnold Belker, is believed to have encouraged interest in urologic microsurgery through reporting of the outcomes of over 1400 microsurgical vasectomy reversals [22]. Formal fellowship training in urologic microsurgery was introduced by Larry I. Lipshultz in 1981, furthering the growth of the field and solidifying urologic microsurgery as an academic discipline while also improving patient outcomes [23].
Current Techniques As detailed in a technical discussion of vasectomy reversal by Lipshultz et al. [24], the most common procedures sought for reversal include the two-layer VV and the more technically demanding intussuscepted EV. Determination of which procedure is required can be predicted using clinical nomograms, but the final decision is made by examining the quality of the intraoperative fluid of the testicular vas [25]. A thorough preoperative evaluation should be performed including a detailed history of the patient’s vasectomy, prior fertility, and prior inguinal surgery, in addition to physical examination to determine presence or absence of sperm granuloma and testicular vasal segment length [26, 27]. If EV is predicted and the patient does not wish to undergo additional procedures of in vitro fertilization with intra-cytoplasmic sperm injection following surgery, cryopreservation should be considered. Choice of anesthesia is both surgeon and patient dependent; either a combination of
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local anesthetic and sedation or general anesthesia performed, though there are considerable advantages to general anesthesia. After preparing the surgical site, vertical paramedian scrotal incisions are made and the testes and spermatic cords are delivered. Downward traction of the vas deferens and adventitia on the testicular side is applied through a ball tip towel clamp, the vasal adventitia is dissected, and stay sutures are placed 1– 2 cm inferior to the transection site. While an Adson forcep holds the site of vasectomy, a 2–3-mm slotted nerve holder is placed on the vas at the transection site and a Dennis blade is passed quickly through the slot to transect the vas. The abdominal vas deferens is similarly isolated and divided. The fluid of the testicular vas is now examined. A 3-mL syringe fitted with a 25-French angiocatheter aspirates any fluid, which is examined under 400× magnification to determine the presence and quality of whole sperm, sperm motility, sperm parts, or degenerated cells. If the quality of the fluid is sufficient, a VV is determined suitable. The two vasal ends are then approximated, with careful attention that the ends overlap easily as to prevent any tension in the anastomosis. A 5-0 PDS approximating suture is placed through the adventitia of each vasal end symmetrically and tied securely. A two-layer VV is performed, first marking the 6 o’clock position on each vas with a micropoint marker. Interrupted 9-0 nylon stitches are placed at the 5, 6, and 7 o’clock positions through the vasal muscularis and adventitia. At the 6 o’clock position, an interrupted 10-0 nylon suture is passed through the mucosal layer. After placing a drop of methylene blue on the cut surface of the vas, additional mucosal sutures are placed by this stitch and tied down. Three to five equidistant mucosal stitches are placed and tied together only once all are placed (Fig. 1a). The mucosal sutures are then tied down sequentially. At the 12 o’clock position, a 9-0 nylon suture is placed through the seromuscular layer, and interrupted 9-0 sutures are placed circumferentially to complete the anastomosis. If the quality or quantity of the fluid from the testicular vas is not determined to be sufficient for VV, EV is then considered. Epididymal obstruction is believed to be caused by prolonged vasal obstruction after vasectomy, leading to Fig. 1 a Three to five 10-0 nylon mucosal sutures are placed and tied sequentially. b 10-0 sutures are placed through the vas deferens lumen bringing together the tubular wall
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chronic increase in intraluminal pressure and finally a Bblowout^ injury in the epididymal tubules, resulting in obstruction and possible formation of a vasal sperm granuloma [28••]. In such a case, the EV begins by opening the tunica vaginalis and exposing the testicle and epididymis. Under magnification, grasping the epididymis and observing any dilated tubules proximal to a point of demarcation may determine the location of obstruction. The epididymal tunic is opened caudally toward the caput until sperm are identified from a single isolated tubule. This ensures the location of the EV maximizes the distance in which sperm will travel to mature and increase motility. Microdissecting scissors are used to make a 0.5-cm opening in the tunic of the epididymis, and a dilated tubule is identified and dissected free. After identifying a suitable tubule, two 10-0 double-armed sutures are passed through the tubular wall at the 2 and 10 o’clock positions and are left in the wall and rotated laterally. A 0.5mm puncture is made in between the two needles using a 20gauge V-lance knife (Alcon Surgical), and the sutures are pulled through. The fluid is now examined for motile sperm under microscopy, and epididymal fluid is collected for sperm banking if desired by the patient. If sperm are present in the epididymal fluid, the EV can proceed. If sperm are present but none are motile, testicular sperm extraction for cryopreservation can be performed following the end of the procedure. In the event that no sperm are present, a new opening is made more proximally in the tunica and the above process is repeated. The abdominal vas is then passed through the tunica vaginalis of the testicle after being sufficiently mobilized. A 5-0 PDS suture is used to tie the vas to the tunica of the epididymis, and 9-0 nylon-interrupted sutures are passed through the edge of the epididymal tunic and the seromuscular layer of the vas. Using the two-suture intussusception approach, two double-armed 10-0 sutures are used. The two needles are brought through the inferior edge of the vasal lumen at the 4 and 8 o’clock positions and the 10 and 2 o’clock positions on the opposite side (Fig. 1b). A surgeon’s knot is tied in both sutures prior to tensioning the sutures. As
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an assistant brings down the vas to the tubule using a jeweler’s forceps, the first and second sutures are tied down. An outer layer of 9-0 sutures is used to bring together the epididymal tunic to the seromuscular vas. The tunica vaginalis is closed, the testicle is placed back into the scrotum, and subsequent layers are closed in the normal fashion [24]. An alternative technique pioneered by Peter Chan et al. [28••] known as longitudinal intussusception vasoepididymostomy (LIVE) simplifies the procedure while maintaining high patency rates. Four microdots are placed on the vasal ends to mark the placement of sutures on the vas. After securing the vas with 9-0 nylon sutures to the edge of the tunica epididymis, two 10-0 nylon double-armed microsutures are placed longitudinally on the epididymal tubule. The tubule is incised between the needles using a 15° ophthalmic knife. The fluid is then aspirated and examined under microscopy, and if found suitable, the needles are pulled through and placed through the four microdots on the vasal ends in an inside-out fashion. A 9-0 tension-reducing suture is placed to approximate the epididymal tunic to the vasal sheath in order to avoid tearing the 10-0 sutures out of the tubule during tying. Recently, a onelayer EV technique has also been described by creating a window in the tunica of the epididymis, fixing the opened epididymal tubule to the edges with four sutures, and anastomosing the vas deferens to this opening [29•]. Success rates of vasectomy reversal are dependent on the duration of occlusion, intraoperative vassal fluid quality, and selection of either VV or EV [24, 30]. If VV is performed within 3 years from vasectomy, the Vasovasostomy Study Group showed 97 % patency rate and 76 % pregnancy rate. If greater than 15 years from vasectomy, the patency rate fell to 71 % and pregnancy rate to 30 % [22]. A decreased interval in the grading of sperm quality as outlined by the group similarly results in a decreased pregnancy rate. When EV is indicated, the surgeon’s experience is particularly important, as patency rates have been reported varying from 31 to 92 % and pregnancy rates from 10 to 50 % [28••].
The Future of Vasectomy Reversal Microsurgical practice in urology is likely to evolve, particularly with the growing use and availability of the Da Vinci surgical robot, which has been applied to vasectomy reversal [31, 32, 33•]. Several advantages of robotic surgery over pure microsurgery have been described, particularly in VV, including decreased operative time, decreased learning curve when compared to traditional microsurgical techniques, increased ease and precision of suture placement, and increased patency [34]. Though better instrumentation and magnification are needed before widespread application of robotics, possible current applications include vas deferens repair in the deep pelvis, ureteral repairs, and as a general remedy for fine tremors. Looking further, technological
advancements may lead to entirely new procedures. For example, the intraoperative use of high magnification may assist to identify and harvest germ line stem cells from the sub-basement membrane of azoospermic men. Subsequent in vitro culture and injection into the vasa efferentia or rete testes could be used to repopulate the germ cell line (telephone interview with Sherman Silber, Marc Goldstein). Additionally, a sutureless VV may become a reality as biomaterials improve, as a novel method of reinforcing a single suture layer anastomosis already exists. Cyanoacrylate, a sutureless biomaterial, was shown to decrease operative time when compared to suture groups with similar patency [35•]. Ideally, incremental implementation of techniques such as these will decrease the time and complexity of vasectomy reversal, helping urologic microsurgeons achieve better outcomes and decreasing operative time patients must endure.
Conclusion Vasectomy reversal has progressed from a tenuous macrosurgical approach in the early twentieth century to a highly refined and predictable microsurgical technique seen today, utilizing both microscopic and robotic technologies. The very earliest attempts of vasectomy reversal, the EV and VV, have remained central in the treatment of infertility reversal and will continue to be so for years to come. As seen throughout its history, urological microsurgery has consistently implemented advanced techniques and state-of-the art technology in its craft, and its continued refinement will allow for even more favorable outcomes in the lives of patients seeking restoration of fertility following vasectomy. Compliance with Ethics Guidelines Conflict of Interest Ryan M. Dickey, Alexander W. Pastuszak, Tariq S. Hakky, Aravind Chandrashekar, Ranjith Ramasamy, and Larry I. Lipshultz each declare no potential conflicts of interest. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.
References Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance 1.
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