Keywords

FormalPara Key Points

  • Vasectomy reversal is a safe and established option for achieving pregnancy post-vasectomy.

  • Microsurgical techniques are preferred to increase luminal patency rates.

  • Mini-incision vasectomy reversal, as described below, has demonstrated decreased postoperative pain and faster return to normal activity with no compromise to outcome.

  • Single mini-incision vasectomy reversal is a newer modification that is suitable for a subset of well-selected patients.

1 Introduction

Vasectomy reversal has a variety of described techniques, and these continue to evolve in current surgical practice. At the University of Toronto, we developed the “mini-incision ” for vasectomy reversal using the principles and instruments used for the no-scalpel vasectomy . This has now evolved, in selected cases, to “single mini-incision.”

By taking advantage of the compliance of the scrotal wall, a substantial length of vas deferens can be delivered through a mini-incision. By avoiding a longer incision, delivery of the testicle, and more extensive tissue dissection, we have shown a reduction in postoperative pain and a faster return to daily activities. This is achieved without compromising patient outcomes.

2 History

Vasectomy remains the most commonly performed urological procedure in North America, with over 500,000 vasectomies performed annually in the United States alone [1,2,3]. In 1974, the no-scalpel vasectomy was introduced and provided surgeons with a technique that minimized discomfort and post-procedural morbidity without compromising patient outcomes [4,5,6]. However, between 2% and 11% of vasectomized men will ultimately request a reversal of their vasectomy for a variety of reasons such as a new partner or death of a child [3].

As with most surgical procedures, vasectomy reversal techniques are in constant evolution. The origin of the techniques used for vasectomy reversal dates back to 1902, when Martin performed the first documented vasoepididymostomy for a man with obstructive azoospermia secondary to gonorrhea [1]. In 1909 he published a series of 11 azoospermic men who underwent vasoepididymostomies with a patency rate of 64% and pregnancy rate of 27%. Martin’s publication and the demonstrated effectiveness of his vasoepididymostomy technique helped to dispel the then widely held belief that such anastomoses were not worth pursuing given their technical difficulty and expected low success rates. Hagner subsequently reproduced these outcomes, in his series of 33 patients with reported patency and pregnancy rates of 64% and 48%, respectively. This solidified vasoepididymostomy as an effective technique in the management of obstructive azoospermia [1].

Quinby reported the first successful vasovasostomy in 1919 on a man who underwent vasectomy 8 years earlier [1]. O’Connor, Quinby’s former assistant, subsequently published a series of 14 vasectomy reversals using Quinby’s technique in 14 men, with an overall patency rate of 64% [1].

As the interest in family planning evolved over the ensuing decades, the rates of vasectomy increased substantially, as did the inevitable subsequent demand for vasectomy reversal.

3 Vasectomy Reversal Techniques

The original descriptions for vasectomy reversal were open surgical techniques sometimes aided by optical magnification. The earliest described techniques used thin silver wire for the vasal anastomosis , which ultimately evolved into the use of nonabsorbable 4-0 to 6-0 sutures during the 1970s [2]. The reported patency rates for these techniques ranged from 79% to 88% with pregnancy rates of 34–50%. These techniques were largely abandoned when the operating microscope became widely available in most centers.

Silber and Owen are both credited with the first description of a microsurgical vasovasostomy in humans in 1977, although several authors had previously described this technique using animal models [2]. The anastomoses were performed with an operating microscope using 16–25 times magnification and 9-0 nylon sutures in a one- or two-layer closure.

Further evolution and refinements of the original techniques occurred, and by the 1980s, the two-layer closure techniques described the use 10-0 nylon for the mucosal anastomosis and 8-0 or 9-0 nylon for the seromuscular layer. Goldstein invented and introduced the microspike vas approximator clamp and microdot suture placement technique. This allowed for greater stabilization of the vasal ends and more precise placement of the 10-0 anastomotic sutures, particularly useful when the vasal lumens are of disparate caliber [1, 7].

The technique for vasovasostomy, described by Lipshultz et al., is probably the most commonly used among modern microsurgeons [2]. With this technique, the testicles and spermatic cords are delivered via a single 4–6-cm midline or bilateral 4–6-cm paramedian scrotal incision(s). The vasectomy site is identified, and the healthy testicular and abdominal ends of the vas are mobilized. Care is taken to preserve as much perivasal adventitia and vasal blood supply as possible. 5-0 absorbable stay sutures are placed superficially on both the testicular and abdominal vas 1–2 cm from the intended transection sites. The testicular vas is then transected and the expressed fluid is examined immediately with light microscopy at 100–400 times magnification. This serves to confirm patency by identifying the presence of sperm or sperm parts in the fluid. The abdominal vas is transected in an identical fashion and its patency confirmed with saline vasogram (or methylene blue vasography with temporary insertion of a Foley catheter). Hemostasis is managed with bipolar electrocautery to minimize vasal injury.

If the intraoperative findings are suitable for vasovasostomy (copious thin fluid, presence of sperm or sperm parts, and normal vasography), the two vasal ends are approximated and stabilized either by placement within a vas approximator or microvascular clamp or by placing 1–2 adventitial holding stitches at the 6 o’clock position. The operating microscope is now brought into the field, and a two-layer anastomosis is begun. A double-armed 10-0 nylon mucosal suture is tied at the 6 o’clock position. Three to five additional 10-0 mucosal sutures are placed around the circumference of the vasal lumen and tied. Interrupted single-armed 9-0 nylon sutures are circumferentially placed in the seromuscular tissue to complete the second layer.

A common modification to this technique eliminates the delivery of the testicle in an effort to minimize postoperative morbidity [7]. With this technique, a 4–6-cm incision is made in the upper scrotum angled toward the external inguinal ring along the path of the vas deferens. This allows for the easy identification of the vasectomy site and mobilization of the testicular and abdominal vasal ends. The anastomosis is then performed in an identical fashion to the previous description.

The patency and pregnancy rates reported in the literature are widely variable and dependent on a number of preoperative, operative, and postoperative factors that may or may not have been controlled. It is universally accepted that the microsurgical approach yields superior patency and pregnancy rates compared to traditional anastomoses given the ability to more precisely place significantly smaller and less obstructive sutures [3]. Unpublished data also demonstrates that surgeons with microsurgery training experience superior outcomes, with an average patency rate of 89% compared to 53% in inexperienced hands [3]. The Vasovasostomy Study Group reviewed the outcomes of 1469 contemporary microsurgical vasovasostomies [3, 8]. They demonstrated a 97% patency rate and 76% pregnancy rate in men less than 3 years from their vasectomy. As the interval from vasectomy increases, the rates decline with a 71% patency rate and 30% pregnancy rate when 15 years or more have elapsed since the vasectomy. The Vasovasostomy Study Group also determined that there was no statistically significant difference in patency or pregnancy rates between one-layer and two-layer anastomosis, with the decision based on surgeon preference and experience [1, 8].

The morbidity of vasovasostomy has been poorly examined with no published studies comparing the various techniques. Postoperative pain, swelling, bruising, and subsequent limitation of activity are all commonly seen after vasectomy reversal, especially if the testicle and tunica vaginalis are delivered. Most men are counseled to wear supportive briefs for 2 weeks, to take 1–2 weeks off work, and to limit themselves to light physical exertion for 3–4 weeks.

We have already discussed many technical modifications that have been developed in an attempt to improve surgical outcomes, but none specifically developed to help reduce the morbidity of the procedure.

4 Mini-incision Vasectomy Reversal (MIVR)

The mini-incision and no-scalpel techniques for performing vasectomy are familiar to most urologists and have been shown to reduce complication rates and decrease recovery times without compromising vasectomy outcomes. In an effort to maintain the established effectiveness of microsurgical vasovasostomy , and to reduce postoperative morbidity, Jarvi et al. at the University of Toronto applied these principles to vasovasostomy [4, 9].

5 Technique of Mini-incision Vasectomy Reversal

The instruments required are a combination of those used for no-scalpel vasectomy and for traditional vasectomy reversal. The key additions are the inclusion of two ring vasectomy clamps and one sharp dissecting forceps, along with the normal microsurgical instruments required for the procedure.

Identical to the no-scalpel vasectomy, the vas deferens is palpated, manipulated, and stabilized through the scrotal skin in the mid to upper scrotum, using the three-finger technique previously described (Fig. 16.1). It is important to bring the vas deferens at least 1 cm lateral to the midline to be situated in the more pliable portion of the scrotal skin. The no-scalpel vasectomy ring clamp is then used to grasp the vas deferens either approximately 5 mm from the previous vasectomy site or directly onto the site of vasectomy occlusion (if possible) in an effort to minimize vasal injury (Fig. 16.2). Using the ring forceps, the abdominal vas is gently elevated to just below the scrotal skin, and a 15-blade scalpel is used to make a 1 cm skin incision directly over the vas (Fig. 16.3). This incision is deepened through the skin and dartos muscle layer using the combination of dissecting forceps plus diathermy, being careful not to injure the underlying vas. Once the vas is exposed, the second ring clamp is used to re-grasp the exposed vas within the incision and elevate it gently out of wound (Figs. 16.4 and 16.5). The vas is then carefully mobilized.

Fig. 16.1
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The vas deferens is identified and secured using the three-finger technique

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Fig. 16.2
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Abdominal end of the vas deferens is grasped with a ring vasectomy clamp approximately 5 mm away from vasectomy defect. Clamp is then elevated

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Fig. 16.3
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Using a scalpel, the skin and dartos is opened directly over the vas deferens for a length of 8–10 mm

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Fig. 16.4
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A second vasectomy ring clamp is used to grasp the vas within the incision

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Fig. 16.5
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The abdominal end of the vas is gently delivered through the incision

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A perivasal window is created with a combination of blunt and sharp dissection for a length of approximately 1 cm. Care is taken to preserve the vasculature within the perivasal adventitia. The vas is finally secured with a vessel loop (Figs. 16.6 and 16.7). At every step, meticulous hemostasis, with the judicious use of microscopic bipolar cautery, is essential as vessels in the dartos and subcutaneous layer may be difficult to control after they retract into the scrotum.

Fig. 16.6
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A sharp dissecting forcep is used to isolate a small 1–1.5 cm perivasal window

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Fig. 16.7
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The abdominal end of the vas is secured with vessel loops

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With the abdominal end of the vas mobilized and secured , the testicular end of the vas is palpated through the incision beyond the identified vasectomy site and is re-grasped with the ring forceps through the same mini-incision in the scrotal skin. The vas is gently delivered via the incision, mobilized, and secured in a manner identical to the abdominal vas (Fig. 16.8). Using this technique, a substantial portion of the vas can be delivered through the mini-incision given the inherent compliance of the scrotal skin (Fig. 16.9). Care must be taken during the mobilization of the testicular vas as the convoluted portion is often encountered and is very easily injured. Stay sutures of 5-0 Biosyn or PDS are placed through the superficial seromuscular layer of the vas approximately 5–10 mm away from the anticipated transection site on both the abdominal and testicular vas. These stay sutures have a dual function. They allow control of the vasal ends; aiding in positioning of the vas approximator and preventing retraction into the incision but can also can be tied after the anastomosis is complete, relieving tension on the repair.

Fig. 16.8
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With the abdominal end of the vas secured, the testicular end of the vas is delivered through the same incision and mobilized in an identical fashion to the abdominal end (note the vasectomy defect between the clamps)

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Fig. 16.9
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Both vasal ends can be easily delivered through the mini-incision

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With both vasal ends secured, each vas is then transected, stabilizing the vas over the forceps, as shown, which acts as a backboard for cutting (Fig. 16.10). We recommend the use of a fresh 15-blade scalpel each time. A commercially available vas approximator clamp or small vascular clamp is then used to control the vasal ends and bring them into close proximity to each other just outside the incision. Finally, a solid, high-contrast backing is placed beneath both the vasal ends and the vas approximator clamp to improve visualization of the sutures and provide support during the microscopic anastomosis (Fig. 16.11). This can be easily fashioned from plastic available in the OR, e.g., light handle or diathermy holster.

Fig. 16.10
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Stay sutures of 5-0 Biosyn or PDS are placed superficially into the seromuscular layer of the vasal ends approximately 1 cm from the intended transection site. The ends are then transected with a scalpel

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Fig. 16.11
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The vasal ends are secured in place in a vas approximator clamp. A pre-cut plastic backboard is placed under the vasa and clamp to stabilize prior to anastomosis

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The anastomosis is then performed under operating microscope magnification in a standard fashion. We begin by placing 4 × 10-0 double-armed nylon sutures through the mucosal and smooth muscle layer anteriorly in an inside out fashion on both vasa. Once all four anterior sutures are placed, they are tied. The second anterior layer is then completed by placing 3 × 9-0 single-armed nylon sutures between the tied 10-0 sutures incorporating the seromuscular layers only. Once the 9-0 sutures are tied, the vas approximator is rotated to expose the posterior wall of the vasa. The patency of the two vasal lumens is easy to assess visually under magnification and can also be confirmed by gentle probing with a jeweler forceps. Two to three additional 10-0 nylon sutures are then placed through the posterior mucosal layer depending on luminal size disparity between the two ends. Once they are tied, three additional 9-0 nylon seromuscular sutures are placed between the 10-0 sutures to complete the two-layer anastomosis. As previously mentioned, the 5-0 stay sutures can be tied loosely together to prevent tension on the anastomosis, or they can be removed at this point.

The vas is then returned to the scrotum and the operating microscope removed from the operative field. Hemostasis of the skin edges and dartos muscle is managed with electrocautery. Typically, only one stitch is needed for closure. The opening in the skin is typically 8–10 mm in length (Fig. 16.12). Postoperatively, a local incision block is performed using 5 cm3 of 0.25% bupivacaine on each side. All patients are discharged home the same day with a prescription for 20 tablets of mild analgesia and are counseled to use a scrotal support for 7 days, refrain from sexual intercourse for 2 weeks, and avoid strenuous exercise and heavy lifting for 3 weeks. Office follow-up is arranged for 4 weeks postoperatively and semen analysis is arranged for around 3 months postoperatively and then every 3 months until pregnancy is achieved.

Fig. 16.12
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Final incision length of <1 cm

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For primary or redo vasectomy reversals, the mini-incision approach is technically feasible in the majority of men. Rarely, extensive scarring or very distal defects may preclude the use of the mini-incision technique.

6 Outcome of Mini-incision Vasectomy Reversal

Using a single surgeon’s data, 164 consecutive vasectomy reversals from 2004 to 2010 were reviewed [9]. All patients were followed up 4 weeks after surgery. Patients were asked to quantify the number of days required for return of work and resumption of daily activities after surgery. Postoperative complications were recorded. Pain scores were documented using a validated post-vasectomy pain scale subsequently adapted to vasectomy reversals [10]. Semen analysis was also carried out at 2 and 4 months postoperatively and evaluated according to WHO 1992 criteria [11].

Of the 164 men, 139 underwent bilateral vasectomy reversal with 55% having a mini-incision technique. The patency rate for the mini-incision technique was 96% and was not statistically different from the patency rate of men who had undergone the traditional incision vasectomy reversal. Mean semen parameters also did not differ between the two incisions.

Fifty-three men completed the pain and recovery assessment including 20 men who underwent mini-incision vasectomy reversal. Reported pain severity in the mini-incision group was significantly less during the first 48 hours after surgery, compared to men who underwent vasectomy reversal using the traditional incision. By 1 week, there was no statistically significant difference in pain scores (Fig. 16.13).

Fig. 16.13
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Pain severity during the first 48 h following surgery was less among patients who received a bilateral MIVR compared to patients who received a traditional incision VR

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Following the mini-incision vasectomy reversal, patients returned to self-reported “normal everyday activities” 2 days earlier compared to men following traditional incision vasectomy reversal. Time to return to work however was not different between the two groups and averaged 5 days for both.

To date over 3000 mini-incision vasectomy reversals have been performed by three different surgeons at the University of Toronto and is the preferred technique (>98%) for vasovasostomy.

7 Single Mini-incision Vasectomy Reversal (SMIVR)

Our newer modification of the above technique. For certain patients with a compliant scrotum and a short, favorably sited vasectomy defect, the vasa can be manipulated centrally allowing both VVs to be performed through a single midline incision (Fig. 16.14).

Fig. 16.14
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Single mini-incision vasectomy reversal

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In a single surgeon’s series of 320 patients [12, 13], the outcomes were comparable to bilateral MIVR. When comparing postoperative pain, 120 patients with SMIVR were compared to 200 with BMIVR. SMIVR patients reported significantly less pain immediately post-surgery and up to 1 week post-surgery. SMIVR patients reported quicker complete pain resolution, shorter duration of analgesic usage, and a faster return to work [13] (Fig. 16.15).

Fig. 16.15
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Pain scores and functional recovery

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8 Conclusion

Surgical techniques remain in constant evolution and vasectomy reversal is no exception. Mini-incision vasectomy reversal (MIVR) takes advantage of scrotal wall compliance and readily available surgical instruments. By avoiding delivery of the testicle and the associated tissue dissection, there are significant gains in reduction of postoperative pain and early return to normal activity. This is achieved without compromising outcome. Single mini-incision vasectomy reversal may be a viable alternative in certain patients with favorable anatomy.