Fertil Steril. 2014 Mar;101(3):636-639.e2. doi: 10.1016/j.fertnstert.2013.11.014. Epub 2013 Dec 17.
Angled vas cutter for vasovasostomy: technique and results.
Abstract
OBJECTIVE:
To describe the technique and results of bilateral vasovasostomy using a 3-mm vas cutting forceps angled at 15° (catalog no. NHF-3.15; ASSI) for vasal transection.
DESIGN:
Retrospective chart review. Institutional review board approval was granted by Western Institutional Review Board.
SETTING:
Single vasectomy reversal center.
PATIENT(S):
Men who underwent a bilateral vasovasostomy at a single institution by a single surgeon between 2001 and 2012 and had a minimum of one semen analysis postoperatively or a reported natural conception.
INTERVENTION(S):
Before September 14, 2010, a straight-edge vas cutter was used on all vasovasostomy connections; 375 men received a bilateral vasovasostomy and met follow-up criteria. Beginning on September 14, 2010, an angled cutter was used on all vasovasostomy patients, with 194 men meeting the exclusion criteria.
MAIN OUTCOME MEASURE(S):
A minimum of 1 × 10(6) sperm reported on a postoperative semen analysis, or a reported natural conception was used to establish patency.
RESULT(S):
The overall vasovasostomy patency rate using the angled vas cutter was 99.5% and was 95.7% using the straight vas cutter.
CONCLUSION(S):
The development of an angled vas cutter provides an increased surface area for vasal wound healing to allow for larger tissue diameter for better healing, resulting in high patency rates after vasovasostomy.
Copyright © 2014 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.
KEYWORDS:
Vasovasostomy; patency
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This is the isolated vas deferens at the time of a reversal. You can see the clips and a mass effect of the body’s attempt at healing the vasectomy “trauma.” This is called a sperm granuloma. Note the vas tubes going into the mass of healing and clips. Both sides are normal in appearance and normal caliber.
What a granuloma does is act as a “pop off” valve and releases some degree of pressure on the testicles. This in turn makes for less damage to the testicles and allows them to rebound sooner from a reversal. In many cases it will also improve the character of the fluid at the time of the reversal (which is also a favorable finding for the percentages of success).
So, if you are considering a reversal and in the shower examine yourself and feel a knot along the course of the vas tube above the testicle, this is a favorable sign and that you may have a better than average success rate for both patency and pregnancy.
Just a small and interesting caveat for the couple thinking about reversing a vasectomy.
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Intraoperative decision making and challenging situations
Choosing between a VV and EV
The decision to perform a VV or an EV should be based on both the macroscopic and microscopic appearance of the fluid expressed from the testicular vasal segment. Clear fluid portends better patency and pregnancy rates while thick, pasty fluid is associated with worse outcomes (11,16). Microscopically, the presence of whole sperm predicts a better outcome than the appearance of sperm heads only or no sperm at all (17). Historically, the Silber scale has been used to evaluate the microscopic quality of the sample to guide the choice between VV and EV (11,12).
On the basis of recent work from Smith et al. which showed greater than 90% patency rates in men with a sample demonstrating sperm heads only and/or short tails, regardless of macroscopic fluid quality, the authors now put less emphasis on this variable and will perform a VV in any scenario in which sperm parts are seen (18). An EV is reserved for those cases in which neither whole sperm nor sperm parts are identified.
There are also circumstances in which fluid from the testicular vas initially shows no sperm but the quality of the sample changes over a short period of time. This is likely due to an accumulation of material near the vasectomy site that must clear in order for more proximal sperm-containing fluid to be expressed. If no sperm are seen on the initial side, the authors will often explore the contralateral side and then re-sample the first side after some time has passed. Not infrequently, this has yielded sperm-containing fluid and allowed for a VV.
The above finding is something to consider for the couple desiring a vasectomy reversal. In a sense, the decision making process is the confluence of expense, logistics of having the procedure, travel, experience of the surgeon, time since vasectomy and how important ones decision is based on whether a 10% chance of needing something that very few urologists do well or frequently (VE) makes in your “decision journey.”
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Helping families with a blessed addition with vasectomy reversal.
