Vasovasostomy and vasoepididymostomy

Abstract

Vasovasostomy almost always is performed for the reversal of an elective vasectomy. Vasoepididymostomy, which involves anastomosis of the vas deferens to the epididymal tubule, is required to bypass an obstruction in the epididymis that may result from congenital conditions, infection or from obstruction within the epididymis after a vasectomy. Patients who consider these procedures should be counselled about the possibility of undergoing surgical or percutaneous needle aspiration to obtain spermatozoa for in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) as an alternative to surgical reconstruction. During a vasectomy reversal, the surgeon's decision to performvasovasostomy or vasoepididymostomy is influenced by the sperm quality in the intraoperative vas fluid and the gross appearance of that fluid. If spermatozoa are absent from the vas fluid, the cause could be a back-pressure-induced rupture of the epididymal tubule with subsequent obstruction to the passage of spermatozoa. In such cases, vasoepididymostomy is required. The results of both vasovasostomy and vasoepididymostomy are significantly better when these procedures are performed withmicrosurgery than when microsurgery is not used. Comparable results of vasovasostomy are obtained with microsurgical modified one-layer and two-layer anastomoses, although the author prefers the two-layer method for reasons explained in the text. When vasoepididymostomy is required, it may be difficult to determine the locationwithin the epididymis at which the obstruction is present. If the point of obstruction is unclear, the surgeon should sample the epididymal tubular fluid at the lowest accessible level in the epididymis and subsequently at progressively higher epididymal levels until a level is reached at which spermatozoa are present in the tubule. The anastomosis is performed at the lowest level at which spermatozoa are found to be present in the epididymal tubular fluid. The microsurgical method of vasoepididymostomy creates a direct connection of the mucosa of the vas deferens to the edges of the epididymal tubule. A modified microsurgical method of vasoepididymostomy creates an end-to-side intussusception of the epididymal tubule into the lumen of the vas. The latter method is simpler to perform and seems to obtain results that are comparable to those of the more tedious alternative, microsurgical end-to-side anastomotic method. The results of vasovasostomy become progressively poorer as the time from the vasectomy until its reversal lengthens. Spermatozoa should appear in the semen within 2 months after vasovasostomy, but may not appear until as long as 12-18 months after vasoepididymostomy. The average postoperative interval until a pregnancy occurs after vasovasostomy is 12 months. There are few reports of the average interval until a pregnancy occurs after vasoepididymostomy. © 2006 Springer-Verlag Berlin Heidelberg.