Vasectomy Reversal Elizabeth Peacock PGY-3 MUSC Urology Grand Rounds
Urology Grand Rounds July 6, 2010 Elizabeth Peacock, MD Urology Resident, PGY-3 Title: Vasectomy Reversal Objectives of Presentation: To review surgical options for vasectomy reversal In accordance with the ACCME Essentials & Standards, anyone involved in planning or presenting this educational activity will be required to disclose any relevant financial relationships with commercial interests in the healthcare industry. Speakers who incorporate information about off-label or investigational use of drugs or devices will be asked to disclose that information at the beginning of their presentation. Speakers Disclosure Information The Medical University of South Carolina designates this educational activity for a maximum of _1_ AMA PRA Category 1 Credit(s). Physicians should only claim credit commensurate with the extent of their participation in the activity.
Introduction Surgical management of male infertility has advanced significantly during the last 10 years Surgical treatments are divided into procedures for: Diagnostic procedures Sperm production Sperm delivery Focus on sperm delivery after vasectomy with vasovasostomy and vasoepididymostomy Forste et al, 1995
Epidemiology Approximately 12% of men aged 20-39 years in the US have had a vasectomy Most commonly performed urologic procedure Over 500,000 vasectomies are performed every year
Epidemiology National Center for Health Statistics: 43% of first marriages end in separation/ divorce within 15 years After divorce, many change their mind about permanent sterility Up to 6% of men who underwent vasectomy, will ultimately desire a reversal Potts et al, 1999
Options Biologically related children Vasectomy reversal Sperm extraction with IVF & ICSI Other options Donor sperm Adoption Remaining without children Discussion of risk, benefit, cost, ease of performance, and potential success rates.
Workup Health and reproductive history of both patient and partner Physical exam for man Recommend gynecologic consult for female partner
Options Vasovasostomy Vasoepididymostomy Required if secondary obstruction of epididymis is present Time-related phenomenon
Vasovasostomy vs Vasoepididymostomy Fuchs & Burt (2002) 62% of patients that underwent reversal 15 years or more after vasectomy required either unilateral or bilateral vasoepididymostomy
Vasoepididymostomy? Quality of fluid found in the proximal (testicular) vas at time of reversal Light microscopy at 400x Sterile glass slide covered with few drops of NS or LR
Microscopy Poor quality: Thick, pasty, devoid of sperm Creamy, only debris present No fluid after milking of vas toward cut end Irrigation of vas with 0.1-0.2mL 0.2mL of saline with 24g plastic angiocath reveals no sperm Consider vasoepididymostomy
Microsurgery vs Non-microsurgery Microsurgery Superior in patency and pregnancy rates
Technique Patency and pregnancy rates do not appear to be significantly different in multilayer vs single-layer layer technique Physician dependent Belker et al, 1991
Instruments In mid 1970s, microsurgical vasectomy reversal was first reported No specific instruments existed for urologists at that time for microsurgery Used ophthalmologist instruments Silber, 1977 Owen, 1977
Instruments
Anesthesia Local anesthesia with IV sedation Epidural anesthesia General anesthesia Decision based on surgeon comfort, length of procedure (>3 hrs), patient anxiety, anatomy of vas & epididymis, thickened or tight scrotum, and extent of vasal or epididymal mobilization needed
Principals of Success Sufficient mobilization to prevent any tension on anastomosis Perivasal adventitia must remain intact Stripping blood supply may lead to ischemia, narrowing, and ultimately occlusion Precise approximation of cut lumen Avoid sperm leakage and sperm granuloma that could disrupt the lumen
Surgical Technique: Preparing the Vas for Anastomosis 1 to 1.5cm incision made directly over the cut vas Dissect proximally and distally to vasectomy site Sufficient to allow freshly cut ends to slightly overlap one another
Positioning for Anastomosis Suture method vs vas clamp
Transection of Vas Secure vasal vessels with 7-07 Prolene just proximal to point of transection Inspect cut end of vas after transection and gently dilate with forceps Do not dilate with lacrimal duct probes
Vasal Fluid Collection Collect few drops of fluid from testicular end onto glass slide Vasovasostomy: Sperm or sperm parts in large numbers Clear, copious fluid with no visible sperm Vasoepididymostomy: Thick, pasty and devoid of sperm Contains only few sperm heads
Multi-layer layer Vasovasostomy 9-00 suture through muscularis and adventitia at 5- and 7-o clock 7 position Double armed 10-0 0 suture through lumen at posterior 6-o clock 6 position and tied
Multi-layer layer Vasovasostomy 3 to 5 more sutures placed equidistant to close lumen but left untied Tied alternatively with the most lateral suture
Multi-layer layer Vasovasostomy 9-00 suture used to bring muscularis together
Multi-layer layer Vasovasostomy Interrupted 9-09 suture to bring adventitia together to further enhance blood supply
Modified Single-layer layer Vasovasostomy Shown to be as effective as multilayer closure Simpler, uses fewer sutures, and requires less microsurgical skill Requires same precise technique to maximize success
Modified Single-layer layer Vasovasostomy Double armed 10-0 suture passed full thickness through edge of proximal and distal lumen at 6-6 then 4- and 8-o clock 8 position and tied Three more placed at 10-,12,12-,, and 2-o clock 2 positions and tied
Modified Single-layer layer Vasovasostomy Completed by closing muscularis and adventia by placing two 9-09 sutures between each 10-0 0 full thickness sutures
Sperm Retrieval Some surgeons suggest simultaneous sperm retrieval and cryopreservation at time of reversal in the event the operation is unsuccessful Only 8% to 14% of patients use their cryopreservered sperm Schrepferman et al, 2001 Glazier et al, 1999
Sperm Retrieval With an overall patency rate of at least 86%, less than 15% would have a need to use it, and only if they wished to pursue IVF-ICSI ICSI Depending on patient preference, motile sperm can attempted to be harvested from vas for preservation Otherwise, testis biopsy and sperm extraction if no motile sperm in vas
Post-operative operative Care Ice pack to scrotum first 12 hours Light activity for 1 week No heavy exercise or sexual activity for 3 weeks Semen analysis at 1 month post-op op then q3 months after that for one year Most with sperm present within 4 weeks No sperm by 6 months = failure
Vasovasostomy: : Complications Scrotal ecchymosis,, small hematoma most common Occasionally, large granuloma present at site of vasectomy Potential for testicular blood supply to be injured during excision resulting in atrophy Better to go around granuloma rather than excising Secondary obstruction leading to azoospermia Reported in 3% to 12% of men Glazier et al, 1999 Kolettis et al, 2002
Vasovasostomy: : Outcomes Belker et al, 1991 Average patency rate was 86% Average pregnancy rate was 52% Years of Obstruction 30% in men with vasectomy over 15 yrs prior Patency (%), Sperm Present Pregancy (%) < 3 86/89 (97) 56/74 (76) 3-8 525/600 (88) 253/478 (53) 9-14 205/261 (79) 92/209 (44) 15 + 32/45 (71) 11/37 (30)
Vasovasostomy: : Outcomes Age of female partner has also been more carefully studied as it pertains to vasectomy reversal success As expected, females approaching or over age 40 have lower rates of success Fuchs and Burt, 2002
Vasovasostomy: : Outcomes Most studies with large numbers of patients have generally found: Patency rates of 75% to 85% Pregnancy rates of 45% to 70% A review of largest number of patients to undergo vasectomy reversal by a single surgeon (4,010 cases) Patency rate of 94% Silber and Grotjan, 2004 Campbell s Urology
Vasovasostomy: : Outcomes Failure after first attempt Second attempt with experienced surgeon has led to pregnancy rates between 27% and 57% Campbell s Urology
Vasoepididymostomy: Epididymal Obstruction
Vasoepididymostomy: Epididymal Obstruction Epididymal obstruction rarely occurs within 4 years of vasectomy Occurs in at least 60% on one or both sides in patients more than 15 years after vasectomy Palpable fullness of epididymis > 4 yrs after vasectomy Fuchs and Burt, 2002
Vasoepididymostomy In 1901, Dr Edward Martin at University of Pennsylvania reported the first human vasoepididymostomy Several years later, reported a series of 14 men who underwent the procedure 6 men (43%) with sperm in semen 3 men (21%) fathered a child Martin el at, 1902 Martin, 1909
Vasoepididymostomy Side-to to-side method with four fine silver wires in vasal lumen to create fistula
Vasoepididymostomy Side-to to-side method of anastomosis was standard until 1978 Silber described the microsurgical anastomosis of vas lumen to transversely end-cut epididymal tubule Patency and pregnancy rates were much higher Silber, 1978
Vasoepididymostomy: Operative Approach Vertical incision in scrotum Testis biopsy to confirm spermatogenesis Deliver testis out of scrotum Transect vas at either straight or convoluted portion of vas Free vas for sufficient length
Vasoepididymostomy: Anastomosis End-to to-end Technique End-to to-side Technique Intussusception Technique All should be within tunica vaginalis,, which can be closed over the testis at the end of the procedure
Vasoepididymostomy: End-to to-end Technique Silber 1978 Best suited for distal epididymal obstruction Epididymal tubule larger and wall thicker
Vasoepididymostomy: End-to to-side Technique Far less dissection required Less bleeding and therefore a more clear surgical field
Vasoepididymostomy: Intussusception Technique Differs from end-to to-side technique in that the lumen is opened after the sutures are positioned in the epididymal loop Berger, 1998
Vasoepididymostomy: Complications Infection Hematoma Injury to arterial blood supply to testis Prolonged surgical time
Vasoepididymostomy: Outcomes Silber (1989) 139 pts 70% patency, 56% pregnancy with end-to-end anastomosis Kolettis & Thomas (1997) 55 pts 85% patency, 44% pregnancy with end-to-side Schrepferman (2001) 18 pts 50% patency, 13% pregnancy with end-to-side and intussusception anastomosis
Results Patency and pregnancy results after vasoepididymostomy vary greatly Surgical technique Level of obstruction Age and reproductive capacity of the female partner Skill of the surgeon Wide variation in the results achieved by many good surgeons, further emphasizing the technical difficulty in performing this procedure
Conclusions Patency and pregnancy rates are not significantly different between multilayer and single-layer layer vasovasostomy The longer the time from vasectomy, the greater the chance of epididymal obstruction Vasoepididymostomy remains a technically demanding procedure with variable outcomes based on several factors, including surgeon skill
Questions
References Potts JM, Pasqualotto FF, Nelson D, et al: Patient characteristics associated with vasectomy reversal. J Urol 1999;161:1835-1839. 1839. Fuchs EF, Burt RA: Vasectomy reversal performed 15 years or more after vasectomy: Correlation of pregnancy outcome with partner age and with pregnancy results of in vitro fertilization with intracytoplasmic sperm injection. Fertil Steril 2002;77:516-519. 519. Belker AM, Thomas AJ Jr,, Fuchs EF, et al: Results of 1,469 microsurgical vasectomy reversals by the Vasovasostomy Study Group. J Urol 1991;145:505-511. 511. Schrepferman CG, Carson MR, Sparks AE, Sandlow JI: Need for sperm retrieval and cryopreservation at vasectomy reversal. J Urol 2001;166:1787-1789. Glazier DB, Marmar JL, Mayer E, et al: The fate of cryopreserved sperm acquired during vasectomy reversals. J Urol 1999;161:463-466. 466. Silber SJ, Grotjan HE: Microscopic vasectomy reversal 30 years later: A summary of 4,010 cases by the same surgeon. J Androl 2004;25:845-859. 859. Figures acquired from Campbell s s Urology, Chapter 20