How I Perform a Vasectomy Reversal: Why Technique Matters
I have spent much of my career performing vasectomy reversals and male reproductive microsurgery. Over that time, I have continually refined the operation around one basic principle: restore the normal pathway for sperm while causing as little trauma as possible to everything around it.
A vasectomy reversal is a very delicate operation. We are reconnecting a channel that is only a fraction of a millimeter in diameter. Success depends on meticulous microsurgical technique, but I believe it also depends on something that is discussed far less often: how much unnecessary tissue trauma occurs while getting to that tiny channel.
My approach is deliberately minimally invasive, highly coordinated, and designed to make every part of the operation as precise and efficient as possible.
A Vasectomy Reversal Through an Incision Less Than an Inch
The incision I use for a vasectomy reversal is typically less than one inch long.
That is significantly different from the way many traditional vasectomy reversals have been performed.
I do not routinely make a large scrotal incision, and I do not deliver the testicle out of the scrotum simply to obtain exposure. I expose only the area I need in order to find the vas deferens, evaluate it, and perform the reconstruction.
There is a reason for that.
Every time a surgeon dissects more tissue, there is an opportunity for more bleeding, swelling, inflammation, postoperative discomfort, and scar formation. If I can perform the same microsurgical reconstruction without disturbing those tissues, I see no reason to disturb them.
The incision we use today is so small that we do not even place a traditional bandage over it anymore. At the end of surgery, the tiny opening is closed and sealed with a small amount of surgical adhesive.
For me, that small incision is not just cosmetic. It represents the philosophy behind the entire operation: minimal dissection, minimal tissue trauma, and maximum microsurgical precision.
Vasovasostomy or Vasoepididymostomy?
There are two different operations that may be necessary during a vasectomy reversal.
The first is a vasovasostomy, where I reconnect the two ends of the vas deferens at the site of the original vasectomy.
The second is a vasoepididymostomy, where I bypass a secondary blockage and connect the vas deferens directly to a tiny epididymal tubule.
Which operation a patient needs often cannot be known with certainty before surgery.
Once I identify the vas and remove the scarred portion created by the previous vasectomy, I examine the fluid coming from the testicular side of the vas under the microscope.
If the findings show that the pathway between the testicle, epididymis, and vas remains open, I can perform a vasovasostomy.
If there has been a secondary blockage in the epididymis, however, simply reconnecting the vas at the original vasectomy site will not solve the problem. The blockage has to be bypassed with a vasoepididymostomy.
Recognizing that distinction during surgery is critically important.
My No-Touch Vasectomy Reversal
One of the most important parts of my technique is what I call the No-Touch Vasectomy Reversal.
The inner channel of the vas deferens, the lumen, is extraordinarily small and lined with very delicate mucosa. Some vasectomy reversal techniques use metal probes or dilators that are inserted into this channel to widen it before the connection is made.
I do not do that.
I do not place an instrument inside the vasal lumen simply to stretch or dilate it.
The reason is straightforward. If you traumatize the delicate lining of a microscopic channel, you can create inflammation. Inflammation can lead to scar formation, and scar formation can cause the same channel we just reconstructed to narrow or close.
My philosophy is that the inside of the vas should be handled as little as possible.
Instead, under high-powered microscopic visualization, I precisely align the two ends of the vas and reconstruct them using extremely fine microsurgical sutures. The goal is a meticulous, watertight connection while leaving the delicate mucosa as undisturbed as possible.
I believe this attention to minimizing tissue injury is one of the reasons we have been able to achieve very high success rates with very few complications.
When I Need to Bypass the Epididymis
The technically more difficult operation is the vasoepididymostomy.
Here, instead of reconnecting one end of the vas to the other, I am connecting the vas deferens directly to an individual tubule of the epididymis.
These tubules are extraordinarily small and delicate.
Traditionally, surgeons performing a vasoepididymostomy make a much larger opening in the scrotum and actually deliver the testicle and epididymis outside the scrotum in order to gain sufficient exposure.
I believed there had to be a less traumatic way to accomplish the same operation.
That led me to develop the Mini-Incision Microsurgical Vasoepididymostomy.
With this technique, I am able to access the vas deferens and epididymis through a very small incision without exteriorizing the testicle or opening up the entire scrotum. I identify an appropriate epididymal tubule under the operating microscope, open it, evaluate the fluid for sperm, and when appropriate, connect the vas directly to that microscopic tubule.
The technique allows me to perform one of the most technically demanding operations in reproductive microsurgery while keeping the dissection remarkably limited.
Why Experience Also Makes the Operation More Efficient
Another important part of my approach is efficiency.
Having performed thousands of these procedures, the operation is highly coordinated. Every step has a purpose, the instruments are organized around the flow of the case, and there is very little wasted motion.
That means I am often able to complete the procedure in considerably less time than surgeons who perform vasectomy reversals less frequently.
I do not believe speed for the sake of speed is valuable. Precision always comes first.
But when experience allows a surgeon to perform the same meticulous operation more efficiently, that matters to the patient. A shorter operation generally means less time under anesthesia and less overall physiologic stress.
There is also an important distinction between operating quickly and operating efficiently. I am never trying to rush the microsurgical portion of the procedure. Rather, years of repetition eliminate unnecessary steps and wasted time.
The goal is simple: do everything that needs to be done, do it precisely, and do nothing that does not need to be done.
Why I Use General Anesthesia
I perform my vasectomy reversals under general anesthesia.
Some surgeons perform vasectomy reversals under local anesthesia or intravenous sedation. I understand the appeal of trying to avoid general anesthesia, but I do not believe that is the optimal approach for this particular operation.
The channel I am reconstructing can be approximately one-third of a millimeter in diameter, essentially the size of a tiny dot. The sutures are placed under an operating microscope with extraordinary precision.
At that scale, even small movements matter.
I want the patient to be completely comfortable and completely still while I am placing sutures into a microscopic structure. I do not want a patient shifting because of discomfort, reacting to traction, coughing, becoming anxious, or moving unexpectedly while I am placing a suture through tissue measured in fractions of a millimeter.
General anesthesia gives me a controlled and motionless surgical field while also ensuring that the patient is comfortable throughout the procedure.
In my opinion, that creates the best environment for performing the most precise operation possible.
When combined with an efficient, highly coordinated procedure, the goal is not prolonged anesthesia. Quite the opposite. The goal is to provide the ideal surgical conditions while keeping the overall anesthesia time as short as reasonably possible.
Less Surgery Can Sometimes Be Better Surgery
There is a tendency in surgery to think that greater exposure makes an operation better or safer.
After decades of microsurgery, I do not necessarily believe that.
Sometimes the more sophisticated operation is the one in which the surgeon learns how to accomplish the same goal while disturbing less normal anatomy.
That is particularly important in the scrotum, where unnecessary dissection can lead to swelling, bleeding, inflammation, and postoperative discomfort.
If I can perform a precise microsurgical reconstruction through an incision under an inch, without delivering the testicle and without unnecessarily manipulating the surrounding tissues, that is the approach I prefer.
Microsurgery Is in the Details
Patients will sometimes describe vasectomy reversal as simply “putting the tubes back together.”
Technically, that is true.
But those tubes contain channels that are microscopic. Sometimes there is another blockage that has to be recognized during surgery. Sometimes a much more difficult bypass to an epididymal tubule is required.
And the smallest technical details can make a significant difference.
That is why my approach combines several principles I have developed and refined throughout my career:
A very small incision. Minimal dissection. No routine exteriorization of the testicle. No instruments placed into the vasal lumen to dilate it. Meticulous microsurgical reconstruction. A highly coordinated procedure with minimal wasted motion. General anesthesia to provide a completely still and comfortable surgical environment. And, when necessary, a Mini-Incision Microsurgical Vasoepididymostomy through essentially the same limited exposure.
Microsurgery is the focus of my practice. After performing thousands of these operations, I have learned that precision is not only about what a surgeon does.
It is also about what the surgeon chooses not to do.
Do not make a bigger incision if a smaller one will accomplish the job.
Do not expose the testicle if it does not need to be exposed.
Do not dissect normal tissue unnecessarily.
Do not put instruments into a microscopic channel simply because that is how the operation has traditionally been performed.
Do not expose a patient to more anesthesia time than necessary.
And do not compromise precision.
My goal with every vasectomy reversal is simple: restore the natural pathway for sperm as precisely as possible while leaving everything else as close to untouched as possible.
That is how I perform a vasectomy reversal.
