A New Surgical Approach: Mini Incision Microsurgical Vasoepididymostomy
By Philip Werthman, M.D., M.M.H., F.A.C.S.
Five percent of the more than 500,000 men who undergo vasectomy each year subsequently change their mind. Those patients now have two options to restore their fertility: vasectomy reversal and sperm harvesting combined with in vitro fertilization (IVF).
Each procedure has its advantages and drawbacks, but vasectomy reversal is the only option that allows a couple to conceive naturally and is also the most cost-effective alternative for family building after vasectomy. IVF might allow couples to potentially conceive more rapidly than a reversal and might be necessary when a contributing female factor to the couples’ infertility is present or when a reversal is unsuccessful. The disadvantages of IVF include a significant increase in costs, the need for the female partner to take hormone injections, and the increased risk of multiple births and potential birth defects.
However, not all vasectomy reversals are considered successful and result in restoration of motile sperm to the ejaculate. A common, yet avoidable, reason for reversal failure is unrecognized epididymal obstruction resulting in the performance of a vasovasostomy in a situation that necessitated a vasoepididymostomy. It has been estimated that up to 30% of reversal failures can be attributed to this scenario. The criteria for performing vasoepididymostomy have been clearly defined, but the procedure itself is considered the most technically challenging in reproductive surgery. As such, it yields lower patency rates than microsurgical vasovasostomy and, therefore, lower pregnancy rates as well.
Several recent advances in microsurgical techniques have increased the ease and precision of performing the delicate anastomosis between an epididymal tubule and the lumen of the vas deferens and have led to improved chances of conception. Traditionally, vasoepididymostomy is approached by way of a scrotal incision large enough for complete exteriorization of the testis to provide the surgeon with the adequate exposure to the entire epididymis and the vas deferens. Many surgeons also perform an extensive dissection of the vas deferens and spermatic cord. In contrast, vasovasostomy is commonly performed through a smaller incision without delivery of the testis. For these reasons, vasoepididymostomy is usually associated with longer recovery times and increased pain and swelling compared with vasovasostomy.
When presented with options, fertility patients generally prefer procedures that afford minimal discomfort, inconvenience, and encroachment on their lifestyle. It has been observed that men who are very active or concerned about postoperative pain and prolonged recovery might opt for a less-invasive sperm harvesting procedure and thereby steer their partners to IVF despite the increased costs, relative risks, and associated emotional stress. In an effort to reduce the discomfort and shorten the postoperative recovery associated with scrotal surgery, a less-invasive surgical approach to vasoepididymostomy has been developed and is described here.
With the patient under general anesthesia, a 1.0 to 2.0-cm incision is made on the scrotal skin directly over the palpable defect at the vasectomy site. The overlying Dartos muscle layer is incised with electrocautery. A no-scalpel vasectomy ring clamp is used to grasp the vasectomy scar, and the vas deferens is dissected proximally and distally, freeing the scarred portion of the vas from the surrounding cord structures. With the aid of the operating microscope, the testicular end of the vas is transected from the vasectomy scar. A drop of vasal fluid is placed on the microscope slide and examined for the presence of sperm. Thick, white, “pasty” fluid that is devoid of sperm is indicative of an epididymal “blowout” and epididymal obstruction. This observation necessitates performance of a vasoepididymostomy rather than a vasovasostomy.
The abdominal vas is further dissected distally for a short distance and similarly transected at the junction of the vasectomy scar at a point at which the tissue appears healthy. The vas lumen is cannulated with a 24-gauge angiocatheter and irrigated with 5 ml of saline to confirm its patency. The vasectomy scar is discarded.
The testis is grasped between the surgeon’s left thumb and forefinger and gently pushed up under the incision so that the tunica vaginalis overlying the upper pole is accessible. Two small hemostats are used to grasp the upper extent of the tunica vaginalis overlying the epididymis, and a small incision is made between the clamps, opening the tunica and providing access to the epididymis. A Babcock clamp is carefully placed around the distal (body/tail junction) portion of the epididymis, so that its jaws rest in the lateral sulcus. Clamp placement should avoid compression of the epididymis or any area proximal to the future anastomotic site. The epididymis is then rotated up through the small incision and exteriorized. The Babcock clamp functions to elevate and fix the epididymis in place just outside the skin incision. The epididymis is then explored under the operating microscope to select an area of dilated tubules for the anastomosis.
A small puncture is created in the upper extent of the tunica vaginalis superior and lateral to the epididymis, through which the abdominal vas is transferred down into the intratunical space. This is accomplished by placing a fine hemostat clamp into the intratunical space and creating another small hole from inside the tunica vaginalis at its cephalad extent near the vas. Through this hole, the clamp is used to grasp the perivasal tissue at the freshly cut end of the abdominal portion of the vas, and the vas is brought down so it lies next to the epididymis. A 5-0 nylon suture is placed through the edge of the upper window in the tunica vaginalis and through the perivasal tissue 1 to 2 cm distal to the cut end of the abdominal vas to secure it in position in the intratunical space. This ensures that the end of the vas lies in continuity with the epididymal tubule without tension and also prevents the abdominal vas from retracting superiorly.
A small incision is made in the tunic of the epididymis overlying the selected dilated tubules, and a single tubule is carefully dissected using the tips of a microsurgical dilating forceps or scissor. The vas is approximated to the area first by connecting the posterior wall of the vasal muscularis to the posterior epididymal tunic opening using 9-0 nylon sutures. This should bring the vasal mucosa into direct contact with the selected epididymal tubule. The mucosal anastomosis is then performed using the two-suture longitudinal intussusception technique previously described. Two double-arm 10-0 nylon sutures are placed in parallel fashion longitudinally through the anterior wall of the epididymal tubule. A small incision is made between the two sutures with a microknife or needle edge, and the exuded epididymal fluid is examined for the presence of sperm. If sperm are present, the anastomosis is continued, and the 10-0 sutures are placed through the vasal mucosa in their corresponding positions, and each suture is tied to itself, thereby intussuscepting the epididymal tubule into the vasal mucosa. The muscularis is closed interiorly with 9-0 nylon suture. (Fig. 1), completing the anastomosis. The Babcock clamp is removed from around the epididymis, and the anastamotic area is carefully rotated back into the scrotum. The scrotum is irrigated with 10 mL of bupivacaine 0.25%, and the tunica vaginalis is closed with running 4-0 Vicryl suture. The Dartos and skin layers are closed individually with running 4-0 Vicryl sutures.
Two patients with epididymal obstruction underwent vasoepididymostomy using the mini-incision approach. The first patient had a solitary left testis, had undergone vasectomy, and then had undergone a failed vasoepididymostomy. The operative report from the initial reversal procedure described an anastamosis to a distal epididymal tubule.
The second patient presented with azoospermia and a history of bilateral epididymitis. A testicular biopsy was performed that showed normal spermatogenesis consistent with epididymal obstruction.
Both patients chose to proceed with mini-scrotal exploration and vasoepididymostomy instead of sperm harvesting with IVF.
The 2 patients underwent a total of three mini-incision microsurgical vasoepididymostomies. The procedures were uneventful and were performed as described. The average total operating time was 55 minutes per side.
Postoperative pain control was satisfactorily achieved with acetaminophen, avoiding the need for narcotics.
At the initial 1-month follow-up examination, neither patient had scrotal swelling or ecchymosis nor did either patient complain of postoperative discomfort, swelling, or bruising. This is in contrast to the experience reported by most of my patients who have undergone traditional vasoepididymostomy. Most significantly, both patients had motile sperm detected on semen analysis at four to six weeks postoperatively, demonstrating that this approach can facilitate a successful anastamosis with minimal discomfort to the patient. The first patient also reported that he achieved a pregnancy with his wife.
Vasectomy reversal, specifically vasoepididymostomy, is performed using a large scrotal incision with exteriorization of the scrotal contents. Until now, this level of exposure was necessary to adequately access the epididymis and the abdominal vas deferens distal to the vasectomy site.
Intuitively, a large scrotal incision and extensive surgical dissection will be associated with pain, swelling, and a longer recovery time. Logically, a smaller incision with minimal dissection should lead to less pain and a quicker recovery.
This technique is almost akin to a vasoepididymostomy in situ. It is less invasive, does not require exteriorization of the scrotal contents, requires less dissection and less mobilization of scrotal structures, and has led to quicker recovery and less postoperative pain than the current traditional approach for vasoepididymostomy.
Several advances have been made in the anastamotic technique of vasoepididymostomy that have increased the technical success of the operation and chances of conception. The mini-incision vasoepididymostomy approach does not compromise the anastamosis or harm the epididymis, because both patients who underwent the procedure had a return of sperm to the ejaculate within several months, with one patient initiating a pregnancy within one year of the procedure. It is important to avoid placing the Babcock clamp directly on the epididymis proximal to the area of proposed anastamosis, because this could theoretically damage the delicate epididymal tubules.
When faced with the options for conception of either vasectomy reversal versus IVF with sperm harvesting, some men will chose the less-invasive sperm harvesting procedure. The anticipation of pain and prolonged recovery, whether justified or not, can influence this choice despite the significant increase in costs and risks to the female partner associated with IVF. The mini-incision approach was developed in an effort to help male patients experiencing post-vasectomy infertility and to further improve the vasoepididymostomy procedure.