Microsurgical Vasovasostomy

ABSTRACT: Over 3% of patients who have had a vasectomy now ask for reversal of their sterility in the United Kingdom, with divorce rates of more than one in three. Patency rates following vaso/asostomy using the usual methods with either no magnification or a loupe commonly result in patency rates of about 60–65% with ensuing fertility in about half of these cases. The thick‐walled vas has a lumen diameter of less than 1 mm, and there is often considerable disparity between proximal and distal ends resulting in obstruction as a major cause of failure. Division in the convoluted part of the vas, which is not uncommon, makes anastomosis even more difficult. Only accurate microsurgical anastomosis will consistently create optimal conditions for continuity without stenosis or leakage.The present paper describes the technique used and outcome of patency and fertility obtained in a personal series of the first 103 cases of microsurgical vasovasostomy, employing a two‐layer anastomosis carried out over a 5‐year period between 1 and 6 years ago. Ten had had a failed reversal operation elsewhere. A two‐layer microsurgical method of end‐to‐end anastomosis was employed, using a fine intraluminal nylon splint as a guide, which was withdrawn before the last interrupted suture was tied. Initially 8/0 Vicryl was used, and subsequently, with more experience, 10/0 Ethilon was employed.Sperm in the ejaculate was achieved in the whole series of bilateral primary operations in 85% rising to 94% with the use of 10/0 suture material and more experience. The patency results obtained match well those of previous microsurgical series, the largest recent one of Belker et al (1991) reporting 86% patency from five institutions, similar to whether a two‐layer or a modified one‐layer anastomosis was employed. However, a two‐layer anastomosis with approximation of the mucosa first is likely to attain more accurate results, particularly in the presence of disparity between the distal and proximal lumina, which is the usual finding (Owen and Kapila, 1984; Silber, 1988). It is for this reason that the two‐layer method was employed, and the results have been very gratifying with the patency rates achieved.Sperm concentration, quality, and motility improved in half the patients over the next 12 months. Fertility over a range of 12 months to 6 years postoperatively was 64% if vasectomy had been performed less than 10 years before, and 39% if 10 years or more had elapsed. In patients with previously failed reversal attempts elsewhere, 40% attained sperm in the ejaculate and half of these became fertile.The additional time and effort required for a microsurgical approach to vasovasostomy were worthwhile to obtain these results.