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Vasovasostomy: Comparison of two microsurgical techniques
VASOVASOSTOMY:
COMPARISON
TWO MICROSURGICAL IRA D. SHARLIP, San Francisco,
OF
TECHNIQUES
M.D.
California
ABSTRACT - An easier technique of microsurgical uasovasostomy, a modijed one-layer anastomosis, is compared to double-layer anastomosis. In this preliminary report there is no difference between the modi$ed one-layer and double-layer techniques in per cent of patients postoperatiuely obtaining nor-mu1 sperm count and pregnancy. Since the modified one-layer technique is easier, faster, and less expensive, this technique deserues fkther clinical experience and evaluation. _ ____
Initial experience in applying microsurgical technique to vasectomy reversal holds promise for greater success than has been achieved in the past with conventional techniques of vasovasostomy. Though there are some reports of pregnancy rates in the range of 40 to 55 per cent using conventional techniques,“* most series report pregnancy rates of 20 to 25 per cent.3,4 Schmidt,5 using both optical loupes and the operating microscope for magnification, has achieved pregnancy in 42 per cent of his cases. The pregnancy rate using a detailed microsurgical technique has recently been reported to be over 70 per cent.6*7 Offsetting these improved results, microsurgical vasovasostomy has the disadvantages of increased operating time, greater cost, and a tedious technique requiring special training and experience. Currently, the microsurgical technique described in the literature on vasovasostomy is a double-layer technique,6,7 anastomosing the mucosa of the freshened ends of the vas deferens in the first layer and the muscularis in the second layer. A total of fourteen to eighteen separate sutures must be placed to perform this technique, which takes approximately one and one-half hours to complete for each side. Recently, Belker, Acland, and Juhala* have questioned whether a one-layer anastomosis might be adequate for this procedure, tentatively concluding that the two-layer anastomosis is superior.
UROLOGY
/ APRIL 1981
/ VOLUME
XVII, NUMBER
4
In an attempt to develop an easier and faster method of performing microsurgical vasovasostomy, a modified one-layer microsurgical anastomosis was used starting in 1976. This preliminary report describes the initial experience with this new microsurgical technique. Material
and Methods
In 1977, the double-layer technique and the modified one-layer technique were used in randomly alternating fashion. Both sides in each patient were performed with the same technique. This preliminary report concerns the 17 cases done in I977 which satisfied the following criteria: (1) no previous attempt at vasovasostomy, (2) minimum follow-up of at least six months, and (3) postoperative semen analysis personally performed by the author. The latter criterion was chosen to eliminate error generated by laboratory personnel inexperienced in semen analysis. Cases done prior to 1977 were not included in this report in order to eliminate any error that might have been due to microsurgical inexperience. One man who reported his wife pregnant was not included in this series because he did not submit semen for analysis. Another man, whose fifteen-month postoperative sperm count was 32 million/ml., was also excluded from this report because he and his wife had been using contraceptives since the vasovasostomy.
347
of microsurgical vasovasosFIGURE 1. Techniques tomy (A) double-layer and (B) modijed one-layer.
The double-layer technique consisted of six sutures of 9-O or 10-O nylon in the mucosal layer and ten sutures of 9-O nylon in the muscularis layer (Fig. 1A). The modified one-layer technique of microsurgical vasovasostomy consisted of 9-O nylon sutures placed through all layers of the vas deferens at the twelve, three, six, and nine-o’clock positions. The intervening spaces were then closed with one or two sutures of 9-O nylon placed through the muscularis only (Fig. 1B). In most cases only one muscularis suture was needed between the full thickness sutures to eliminate leak of seminal fluid. Consequently, a total of eight sutures effected the anastomosis in most cases. In both types of anastomosis, extravaginal exposure of the vasectomy site through a high scrotal incision was used. The scarred vas and, TABLE Case
No.
Date of Vasectomy
5 6 7 8 9 10 11 12 13 14
1971 1972 1970 1970 1971 1972 1974 1975 1968 1970 1972 1967 1960 1967
15 16 17
1963 1960 1964
1
2 3
*KEY: NF = no fluid aspirated;
I.
Sperm Right + + + + + NF _ NF NF -
when present, associated sperm granuloma were excised. Fluid was aspirated from the testicular end of the vas and examined in the operating room for the presence of sperm. The lumen of this end was irrigated with saline. The abdominal end of the vas was dilated with jeweler’s forceps and the lumina of both sides were marked by a 1:lO dilution of methylene blue. After the anastomosis was completed, spermatic fascia was brought together with interrupted 4-O Dexon to build support for the anastomosis. The dartos and skin were closed with 4-O Dexon. No drains were used. Results Seventeen cases satisfied the criteria for inclusion in this report. Table I shows the operative findings at the time of vasovasostomy. In all cases, the proximal vas lumen leading to the epididymis was dilated in comparison to the distal vas lumen on both sides. Despite this dilatation, no fluid could be aspirated from the proximal vas lumen on both sides in 2 cases and on one side in 3 cases. In these instances, the presence or absence of sperm in the vas fluid could not be determined. There appeared to be no correlation among the presence or absence of sperm in the vas fluid, presence or absence of sperm granuloma, and site of vasectomy. There was no correlation between the presence or absence of sperm in the vas fluid and the duration of the obstructive interval. Of the cases in which
Operativefindings
in Vas Fluid Left
+ + NF NF + NF -
+ NF + + + + = small, + + = moderate,
Gross Sperm Right
_ -
S
S
s-c
++ _
S S S S S
C
C
+
S
S
+
C C
C C
S S
S S S S
-t -
_ _
++ + + -
-
+ -
+
+++ -
+
+ -
Site of Vasectomy Right Left
Granuloma Left
-
+ _
+ + + -
at vasovasostomy”
+
-
S S S S
C
+ -
+ + + = large; S = straight vas, C = convoluted
S S S
s-c
s-c
s-c
S
vas, S-C = junction of s
and C.
348
UROLOGY
/ APRIL
1931
/
VOLUMEXVII.NUMBER4
Clinical data of all cases (17)
TABLE II.
Case NO.
~___ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Obstructive Interval (Yr.)
Technique of Vasovasostomy
6 5 7 7 6 5 3 2 9 7 5 10 17 10 14 17 13
Average
MOL MOL MOL MOL MOL MOL DL DL DL DL DL MOL MOL MOL DL DL DL
6 13 9 6 11 10 9 8 6 13 23 13 9 9 36 24 13
-
8.4 one-layer;
TABLE
Double-layer anastomosis Modified onelayer anastomosis
Obstructive interval Under 10 years Over 10 vears
Pregnancy
Postoperative 2 20
6 (75)
8 (100)
9
6 (67)
7 (77)
17
11 6
1
____
6 5 18 5 8 7 9 11 4
6 18 13 9.2
___-
WNL 3 60 per cent, grade 2+.
8
I
TOTALS
DL = double-layer;
Months from Vasovasostomy to Conception
WNL 25%/gr. 2 WNL WNL WNL WNL WNL WNL WNL WNL lO%/gr. I+ WNL WNL WNL WNL WNL WNL
54.9
III. Results of vasovasostomy by technique
No. of Cases
12 (71) 9 (82) 3 (50)
1
15 (88) 10 (91) 5 (83)
Sperm 10-20
and obstructive interval* Count (Million/ml.) o- 10 zero
Average Postoperative Sperm Count (Million/mI.)
0
0
0
46.4
1 (11)
1 (11)
0
62.4
1 1 (6) l(9) 0 ____
1
1 (6)
0 1 (17)
$
0
0 0
$
54.9
65.5 35.3
given in parentheses
vas fluid could be aspirated for analysis, 11 of 16 (69 per cent) obstructed for less than ten years showed the presence of sperm while 7 of 11 (64 per cent) obstructed for over ten years showed the presence of sperm. The site of the vasectomy had no effect on the technical adequacy of the anastomosis since microsurgical technique gives excellent visualization in all of the straight and convoluted vas deferens. Table II shows the clinical data and results of the 17 cases. Eleven of these men underwent vasovasostomy within ten years of vasectomy. The remaining 6 had an obstructive (vasectomy-to-vasovasostomy) interval of over ten
UROLOGY
42 15 60 60 125 160 26 70 40 90 33 75 2 23 23 24 65
12.8
*KEY:MOL = modified
*Percentages
Latest Postoperative -------Semen Analysis-------Postop. Sperm Count Motility Month (Million/ml.)
/ APRIL
1981
/
VOLUMEXVII,NUMBER4
years. Of the 17 cases, 9 were done with the modified one-layer technique and 8 with the double-layer technique. The average length of follow-up was 12.8 months, with a range of six to thirty-six months. Pregnancy occurred in 12 wives of the 17 cases or 71 per cent. The average time from operation to pregnancy in these cases was 9.2 months. Pregnancy occurred in 6 of the 9 cases done with the modified one-layer technique, and 6 of the 8 cases using the double-layer technique. Sperm counts over 20 million/ml. occurred in 15 of the 17 cases or 88 per cent. In the other 2 cases, counts were 2 and 15 million/ml. The average sperm count for
Repeat vasectomy specimen after miFIGURE 2. crosurgical vasovasostomy using modijed one-layer technique. Ex vivo x-ray film shows slight dilatation of proximal lumen (bottom half of specimen), slight stricture at anastomosis but clearly patent lumen, and normal distal lumen (top half of specimen).
all 17 cases was 54.9 million/ml. No patient was azoospermic. Seven of the 9 cases (77 per cent) done by the modified one-layer technique and all of the 8 cases (100 per cent) using the double-layer technique had sperm counts over 20 million/ml. Sperm counts over 10 million/ml. occurred in 16 of the 17 cases (94 per cent). This included 8 of the 9 cases (89 per cent) using the modified one-layer technique and all 8 cases (100 per cent) using the double-layer technique (Tables II and III). In 15 of the 17 patients, sperm motility eventually became greater than 60 per cent and the quality of motility became greater than 2 plus. It was common to find the recovery in motility lagging behind the recovery in sperm count by three to six months. Sperm morphology was not evaluated carefully in every case in this early series and will not be discussed here. Of the 2 patients who did not achieve normal sperm motility, one was in the modified one-layer group and the other was in the double-layer group. These were Case 1, whose latest sperm count, 15 million/ml., was associated with motility of 25 per cent, grade 2, and whose wife became pregnant in the fifth postoperative month; and Case 11, whose count, 33 million/ml., was associated with motility of 10 per cent, grade
350
l+, and whose wife did not become pregnant. It is also interesting to note that Case 13, with the lowest sperm count in the series, 2 million/ml., had normal motility of 75 per cent, grade 2+, and normal morphology. Eleven of the men underwent vasovasostomy within ten years of vasectomy. Six of these men had a modified one-layer anastomosis and 5 had a double-layer anastomosis. Of the 11, pregnancy resulted in 9 cases (81 per cent). All 11 (100 per cent) had sperm counts of over 10 million/ml., and 10 of the 11 (91 per cent) had sperm counts in excess of 20 million/ml. The average sperm count was 65.5 million/ml. Using the modified one-layer technique, pregnancy occurred in all of the 6 wives (100 per cent). The occurrence of sperm counts greater than 10 million/ml. was 6 of 6 (100 per cent) and greater than 20 million/ml. 5 of 6 (83 per cent). Using the double-layer technique, 3 of 5 men (60 per cent) impregnated their wives. All 5 men (100 per cent) had sperm counts in excess of both 10 and 20 million/ml. Six men had an obstructive interval of ten to seventeen years. The modified one-layer technique was used in 3 of these men and the double-layer technique in the other 3. Three pregnancies were achieved in these 6 cases (50 per cent), all using the double-layer technique. Sperm counts over 20 million/ml. occurred in 5 of 6 cases (83 per cent). The average sperm count was 35.3 million/ml. For the modified one-layer technique, no pregnancy occurred and 2 of the 3 patients had sperm counts over 20 million/ml. (67 per cent). For the double-layer technique, three pregnancies occurred in 3 cases (100 per cent). All 3 of these men (100 per cent) had sperm counts over 20 million/ml. The statistical significance of the higher pregnancy rate with the double-layer technique in these 6 patients awaits verification by results of a larger series than is available for this preliminary report. The average skin-to-skin operating time for the double-layer technique was approximately ninety minutes per side (three hours for bilateral vasovasostomy), and for the modified onelayer technique was sixty to sixty-five minutes per side (two to two and one-quarter hours for bilateral vasovasostomy). Figure 2 is an ex vivo vasogram of a l-cm. section of vas deferens obtained at the time of repeat vasectomy. The patient had undergone his first vasectomy in 1971. In 1976, vasovasostomy using the modified one-layer microsurgical
UROLOGY
/ APRIL 1981 i
VOLUME
XVII, NUMBER 4
Repeat vasectomy specimen after microsurgical vasovasostomy using modijied one-layer techFIGURE 3. nique. (A) Section taken from normal cas between vasovasostomy site and epididymis. (B) Section taken through anastomosis showing several nylon sutures, patent lumen similar to normal vas lumen (see Fig. 2).
technique was performed. The patient’s postoperative sperm counts were 10 million/ml. at two months, 20 million/ml. at six months, and 75 million/ml. at sixteen months. His wife became pregnant in the eleventh postoperative month and delivered a normal full-term boy in the nineteenth postoperative month. A repeat vasectomy was performed in the twenty-fourth postoperative month, excising the previous vasovasostomy site. Clear patency of the lumen with a slight stricture at the anastomosis is demonstrated. Figure 3A shows the histologic picture of the normal but dilated vas proximal to the vasovasostomy site in this patient. Comparison to Figure 3B, which shows the histology of the vasovasostomy site itself, demonstrates the patent and epithelialized lumen with several adThis illustration demonjacent nylon sutures. strates that histologic appearance of the vasovasostomy site is almost that of the adjacent normal vas. Comment It is particularly interesting that in Case 10, no sperm were present in the vas fluid on either side during surgical procedure. Nevertheless, this patient’s wife became pregnant in the fourth postoperative month and the patient’s single postoperative sperm count, done at thirteen months, was 90 million/ml. Recently, it has become apparent that the absence of sperm in the vas fluid may indicate more proximal seminal duct obstruction, frequently in the epididymis, as a secondary effect of vasectomy. This case and 2 others in the author’s personal experience with over 200 microsurgical vasovasostomies indicate that the absence of vasal
UROLOGY
/ APRIL I%1
/ VOLUME
XVII. NCTklBER 4
sperm is not an absolute prognosticator for failure of vasovasostomy. The double-layer technique of microsurgical vasovasostomy has the advantage of precise mucosa-to-mucosa alignment, thus creating a smooth epithelial anastomosis, if stricture of the muscularis and/or perivasal tissue does not occur. However, the technique leaves knots of permanent suture material just outside the mucosa, a factor which may promote perimucosal fibrosis with subsequent stricture of the delicate anastomosis. The technique is difficult to perform and requires about three hours of operating time for bilateral surgery, even after the surgeon has acquired the necessary microsurgical training and experience. The modified one-layer technique has the theoretical disadvantage of a less accurate mucosa-to-mucosa approximation. Nevertheless, sperm leakage, granuloma formation, and matching of disparate luminal sizes appear not to be a problem with the modified one-layer anastomosis if one judges by the equivalent sperm counts and pregnancy rates of this technique and the double-layer technique. In addition, the modified one-layer technique offers the significant advantages of being easier to perform and requiring less time to complete. The ease of the technique is due to two factors. First, there is the need for fewer sutures (eight to twelve versus fourteen to eighteen for the double-layer technique). Second, the modified one-layer technique requires less technical facility and dexterity to master. Training, ample and experience in microsurgery are practice, still necessary for the surgeon to be able to approach the procedure with the expectation of
351
success, but the demands on the surgeon with this technique are less than with the doublelayer technique. These factors reduce operating time, and therefore, operating expenses by 25 to 33 per cent. In the author’s personal experience with over 200 microsurgical vasovasostomies, approximately one-half have been done with each of the two techniques. The average skin-to-skin operating time for the double-layer technique has been three hours and for the modified one-layer technique two hours to two hours and fifteen minutes. The modified onelayer technique also has the theoretical advantage that all of the knots are tied outside the wall of the vas. Only four sutures pass through the lumen, and there are no perimucosal knots. Thus, the chance for fibrosis and subsequent stricture formation in the critical perimucosal zone is reduced. What yet remains to be established in the clinical problem of vasectomy reversal is the degree of accuracy and the delicacy of anastomotic technique which are necessary to achieve consistent success. The tolerable limits of mucosal alignment, muscular alignment, and perianastomotic fibrosis may require a double-layer miHowever, it is possible crosurgical technique. that a simpler and faster microsurgical techone-layer technique, such as the modified or perhaps even a nonmicrosurgical nique, technique, may produce sufficient accuracy for successful vasectomy reversal. At the present time, microsurgical technique appears to be at least as successful as conventional techniques of vasovasostomy and initial results of this and other serie$*’ indicate probable superiority.
352
The ultimate criteria of success for any technique are postoperative sperm counts and pregnancy rates. In this limited series of patients, there seems to be no difference in these parameters between the double-layer and the modified one-layer microsurgical techniques. Since the modified one-layer microsurgical technique offers several distinct advantages over the double-layer technique, the modified one-layer technique of microsurgical vasovasostomy deserves further clinical experience and evaluation. 3838 California Street San Francisco, California 94118 ACKNOWLEDGMENT. To Dr. Anthony Eason for his help in obtaining the vasectomy specimen shown in Figures 2 and 3; and Dr. Emil Tanagho and the staff of the Department of Urology, University of California, San Francisco, where much of this work was done.
References 1. Phadke GM, and Phadke AG: Experiences in the reanastomosis of the vas deferens, J. Urol. 97: 888 (1967). 2. Middleton RG, and Henderson D: Vas deferens reanastomosis without splints and without magnification, ibid. 119: 763 (1978). 3. Derrick FC, Yarbrough W, and D’Agostino J: Vasovasostomy: results of questionnaire of members of the American Urological Association, ibid. 110: 556 (1973). 4. Dorsey JW: Sur@cal correction of post-vasectomy sterility, ibid. 110: 554 (1973). 5. Schmidt SS: Vasovasostomv. Urol. Clin. North Am. 5: 585 (1978). 6. Silber SB: Microscopic vasectomy reversal, Fertil, Steril. 28: 1191 (1977). 7. Owen ER: Microsurgical vasovasostomy: a reliable vasectomy reversal, Aust. N. Z. J. Surg. 47: 305 (1977). 8. Belker AM, Acland RD, and Juhala CA: Microsurgical twolayer vasovasostomy: word of caution, Urology 11: 616 (1978).
UROLOGY
/
APRIL
1981
/
VOLUME
XVII, NUMBER
4
COMPARISON
TWO MICROSURGICAL IRA D. SHARLIP, San Francisco,
OF
TECHNIQUES
M.D.
California
ABSTRACT - An easier technique of microsurgical uasovasostomy, a modijed one-layer anastomosis, is compared to double-layer anastomosis. In this preliminary report there is no difference between the modi$ed one-layer and double-layer techniques in per cent of patients postoperatiuely obtaining nor-mu1 sperm count and pregnancy. Since the modified one-layer technique is easier, faster, and less expensive, this technique deserues fkther clinical experience and evaluation. _ ____
Initial experience in applying microsurgical technique to vasectomy reversal holds promise for greater success than has been achieved in the past with conventional techniques of vasovasostomy. Though there are some reports of pregnancy rates in the range of 40 to 55 per cent using conventional techniques,“* most series report pregnancy rates of 20 to 25 per cent.3,4 Schmidt,5 using both optical loupes and the operating microscope for magnification, has achieved pregnancy in 42 per cent of his cases. The pregnancy rate using a detailed microsurgical technique has recently been reported to be over 70 per cent.6*7 Offsetting these improved results, microsurgical vasovasostomy has the disadvantages of increased operating time, greater cost, and a tedious technique requiring special training and experience. Currently, the microsurgical technique described in the literature on vasovasostomy is a double-layer technique,6,7 anastomosing the mucosa of the freshened ends of the vas deferens in the first layer and the muscularis in the second layer. A total of fourteen to eighteen separate sutures must be placed to perform this technique, which takes approximately one and one-half hours to complete for each side. Recently, Belker, Acland, and Juhala* have questioned whether a one-layer anastomosis might be adequate for this procedure, tentatively concluding that the two-layer anastomosis is superior.
UROLOGY
/ APRIL 1981
/ VOLUME
XVII, NUMBER
4
In an attempt to develop an easier and faster method of performing microsurgical vasovasostomy, a modified one-layer microsurgical anastomosis was used starting in 1976. This preliminary report describes the initial experience with this new microsurgical technique. Material
and Methods
In 1977, the double-layer technique and the modified one-layer technique were used in randomly alternating fashion. Both sides in each patient were performed with the same technique. This preliminary report concerns the 17 cases done in I977 which satisfied the following criteria: (1) no previous attempt at vasovasostomy, (2) minimum follow-up of at least six months, and (3) postoperative semen analysis personally performed by the author. The latter criterion was chosen to eliminate error generated by laboratory personnel inexperienced in semen analysis. Cases done prior to 1977 were not included in this report in order to eliminate any error that might have been due to microsurgical inexperience. One man who reported his wife pregnant was not included in this series because he did not submit semen for analysis. Another man, whose fifteen-month postoperative sperm count was 32 million/ml., was also excluded from this report because he and his wife had been using contraceptives since the vasovasostomy.
347
of microsurgical vasovasosFIGURE 1. Techniques tomy (A) double-layer and (B) modijed one-layer.
The double-layer technique consisted of six sutures of 9-O or 10-O nylon in the mucosal layer and ten sutures of 9-O nylon in the muscularis layer (Fig. 1A). The modified one-layer technique of microsurgical vasovasostomy consisted of 9-O nylon sutures placed through all layers of the vas deferens at the twelve, three, six, and nine-o’clock positions. The intervening spaces were then closed with one or two sutures of 9-O nylon placed through the muscularis only (Fig. 1B). In most cases only one muscularis suture was needed between the full thickness sutures to eliminate leak of seminal fluid. Consequently, a total of eight sutures effected the anastomosis in most cases. In both types of anastomosis, extravaginal exposure of the vasectomy site through a high scrotal incision was used. The scarred vas and, TABLE Case
No.
Date of Vasectomy
5 6 7 8 9 10 11 12 13 14
1971 1972 1970 1970 1971 1972 1974 1975 1968 1970 1972 1967 1960 1967
15 16 17
1963 1960 1964
1
2 3
*KEY: NF = no fluid aspirated;
I.
Sperm Right + + + + + NF _ NF NF -
when present, associated sperm granuloma were excised. Fluid was aspirated from the testicular end of the vas and examined in the operating room for the presence of sperm. The lumen of this end was irrigated with saline. The abdominal end of the vas was dilated with jeweler’s forceps and the lumina of both sides were marked by a 1:lO dilution of methylene blue. After the anastomosis was completed, spermatic fascia was brought together with interrupted 4-O Dexon to build support for the anastomosis. The dartos and skin were closed with 4-O Dexon. No drains were used. Results Seventeen cases satisfied the criteria for inclusion in this report. Table I shows the operative findings at the time of vasovasostomy. In all cases, the proximal vas lumen leading to the epididymis was dilated in comparison to the distal vas lumen on both sides. Despite this dilatation, no fluid could be aspirated from the proximal vas lumen on both sides in 2 cases and on one side in 3 cases. In these instances, the presence or absence of sperm in the vas fluid could not be determined. There appeared to be no correlation among the presence or absence of sperm in the vas fluid, presence or absence of sperm granuloma, and site of vasectomy. There was no correlation between the presence or absence of sperm in the vas fluid and the duration of the obstructive interval. Of the cases in which
Operativefindings
in Vas Fluid Left
+ + NF NF + NF -
+ NF + + + + = small, + + = moderate,
Gross Sperm Right
_ -
S
S
s-c
++ _
S S S S S
C
C
+
S
S
+
C C
C C
S S
S S S S
-t -
_ _
++ + + -
-
+ -
+
+++ -
+
+ -
Site of Vasectomy Right Left
Granuloma Left
-
+ _
+ + + -
at vasovasostomy”
+
-
S S S S
C
+ -
+ + + = large; S = straight vas, C = convoluted
S S S
s-c
s-c
s-c
S
vas, S-C = junction of s
and C.
348
UROLOGY
/ APRIL
1931
/
VOLUMEXVII.NUMBER4
Clinical data of all cases (17)
TABLE II.
Case NO.
~___ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Obstructive Interval (Yr.)
Technique of Vasovasostomy
6 5 7 7 6 5 3 2 9 7 5 10 17 10 14 17 13
Average
MOL MOL MOL MOL MOL MOL DL DL DL DL DL MOL MOL MOL DL DL DL
6 13 9 6 11 10 9 8 6 13 23 13 9 9 36 24 13
-
8.4 one-layer;
TABLE
Double-layer anastomosis Modified onelayer anastomosis
Obstructive interval Under 10 years Over 10 vears
Pregnancy
Postoperative 2 20
6 (75)
8 (100)
9
6 (67)
7 (77)
17
11 6
1
____
6 5 18 5 8 7 9 11 4
6 18 13 9.2
___-
WNL 3 60 per cent, grade 2+.
8
I
TOTALS
DL = double-layer;
Months from Vasovasostomy to Conception
WNL 25%/gr. 2 WNL WNL WNL WNL WNL WNL WNL WNL lO%/gr. I+ WNL WNL WNL WNL WNL WNL
54.9
III. Results of vasovasostomy by technique
No. of Cases
12 (71) 9 (82) 3 (50)
1
15 (88) 10 (91) 5 (83)
Sperm 10-20
and obstructive interval* Count (Million/ml.) o- 10 zero
Average Postoperative Sperm Count (Million/mI.)
0
0
0
46.4
1 (11)
1 (11)
0
62.4
1 1 (6) l(9) 0 ____
1
1 (6)
0 1 (17)
$
0
0 0
$
54.9
65.5 35.3
given in parentheses
vas fluid could be aspirated for analysis, 11 of 16 (69 per cent) obstructed for less than ten years showed the presence of sperm while 7 of 11 (64 per cent) obstructed for over ten years showed the presence of sperm. The site of the vasectomy had no effect on the technical adequacy of the anastomosis since microsurgical technique gives excellent visualization in all of the straight and convoluted vas deferens. Table II shows the clinical data and results of the 17 cases. Eleven of these men underwent vasovasostomy within ten years of vasectomy. The remaining 6 had an obstructive (vasectomy-to-vasovasostomy) interval of over ten
UROLOGY
42 15 60 60 125 160 26 70 40 90 33 75 2 23 23 24 65
12.8
*KEY:MOL = modified
*Percentages
Latest Postoperative -------Semen Analysis-------Postop. Sperm Count Motility Month (Million/ml.)
/ APRIL
1981
/
VOLUMEXVII,NUMBER4
years. Of the 17 cases, 9 were done with the modified one-layer technique and 8 with the double-layer technique. The average length of follow-up was 12.8 months, with a range of six to thirty-six months. Pregnancy occurred in 12 wives of the 17 cases or 71 per cent. The average time from operation to pregnancy in these cases was 9.2 months. Pregnancy occurred in 6 of the 9 cases done with the modified one-layer technique, and 6 of the 8 cases using the double-layer technique. Sperm counts over 20 million/ml. occurred in 15 of the 17 cases or 88 per cent. In the other 2 cases, counts were 2 and 15 million/ml. The average sperm count for
Repeat vasectomy specimen after miFIGURE 2. crosurgical vasovasostomy using modijed one-layer technique. Ex vivo x-ray film shows slight dilatation of proximal lumen (bottom half of specimen), slight stricture at anastomosis but clearly patent lumen, and normal distal lumen (top half of specimen).
all 17 cases was 54.9 million/ml. No patient was azoospermic. Seven of the 9 cases (77 per cent) done by the modified one-layer technique and all of the 8 cases (100 per cent) using the double-layer technique had sperm counts over 20 million/ml. Sperm counts over 10 million/ml. occurred in 16 of the 17 cases (94 per cent). This included 8 of the 9 cases (89 per cent) using the modified one-layer technique and all 8 cases (100 per cent) using the double-layer technique (Tables II and III). In 15 of the 17 patients, sperm motility eventually became greater than 60 per cent and the quality of motility became greater than 2 plus. It was common to find the recovery in motility lagging behind the recovery in sperm count by three to six months. Sperm morphology was not evaluated carefully in every case in this early series and will not be discussed here. Of the 2 patients who did not achieve normal sperm motility, one was in the modified one-layer group and the other was in the double-layer group. These were Case 1, whose latest sperm count, 15 million/ml., was associated with motility of 25 per cent, grade 2, and whose wife became pregnant in the fifth postoperative month; and Case 11, whose count, 33 million/ml., was associated with motility of 10 per cent, grade
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l+, and whose wife did not become pregnant. It is also interesting to note that Case 13, with the lowest sperm count in the series, 2 million/ml., had normal motility of 75 per cent, grade 2+, and normal morphology. Eleven of the men underwent vasovasostomy within ten years of vasectomy. Six of these men had a modified one-layer anastomosis and 5 had a double-layer anastomosis. Of the 11, pregnancy resulted in 9 cases (81 per cent). All 11 (100 per cent) had sperm counts of over 10 million/ml., and 10 of the 11 (91 per cent) had sperm counts in excess of 20 million/ml. The average sperm count was 65.5 million/ml. Using the modified one-layer technique, pregnancy occurred in all of the 6 wives (100 per cent). The occurrence of sperm counts greater than 10 million/ml. was 6 of 6 (100 per cent) and greater than 20 million/ml. 5 of 6 (83 per cent). Using the double-layer technique, 3 of 5 men (60 per cent) impregnated their wives. All 5 men (100 per cent) had sperm counts in excess of both 10 and 20 million/ml. Six men had an obstructive interval of ten to seventeen years. The modified one-layer technique was used in 3 of these men and the double-layer technique in the other 3. Three pregnancies were achieved in these 6 cases (50 per cent), all using the double-layer technique. Sperm counts over 20 million/ml. occurred in 5 of 6 cases (83 per cent). The average sperm count was 35.3 million/ml. For the modified one-layer technique, no pregnancy occurred and 2 of the 3 patients had sperm counts over 20 million/ml. (67 per cent). For the double-layer technique, three pregnancies occurred in 3 cases (100 per cent). All 3 of these men (100 per cent) had sperm counts over 20 million/ml. The statistical significance of the higher pregnancy rate with the double-layer technique in these 6 patients awaits verification by results of a larger series than is available for this preliminary report. The average skin-to-skin operating time for the double-layer technique was approximately ninety minutes per side (three hours for bilateral vasovasostomy), and for the modified onelayer technique was sixty to sixty-five minutes per side (two to two and one-quarter hours for bilateral vasovasostomy). Figure 2 is an ex vivo vasogram of a l-cm. section of vas deferens obtained at the time of repeat vasectomy. The patient had undergone his first vasectomy in 1971. In 1976, vasovasostomy using the modified one-layer microsurgical
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Repeat vasectomy specimen after microsurgical vasovasostomy using modijied one-layer techFIGURE 3. nique. (A) Section taken from normal cas between vasovasostomy site and epididymis. (B) Section taken through anastomosis showing several nylon sutures, patent lumen similar to normal vas lumen (see Fig. 2).
technique was performed. The patient’s postoperative sperm counts were 10 million/ml. at two months, 20 million/ml. at six months, and 75 million/ml. at sixteen months. His wife became pregnant in the eleventh postoperative month and delivered a normal full-term boy in the nineteenth postoperative month. A repeat vasectomy was performed in the twenty-fourth postoperative month, excising the previous vasovasostomy site. Clear patency of the lumen with a slight stricture at the anastomosis is demonstrated. Figure 3A shows the histologic picture of the normal but dilated vas proximal to the vasovasostomy site in this patient. Comparison to Figure 3B, which shows the histology of the vasovasostomy site itself, demonstrates the patent and epithelialized lumen with several adThis illustration demonjacent nylon sutures. strates that histologic appearance of the vasovasostomy site is almost that of the adjacent normal vas. Comment It is particularly interesting that in Case 10, no sperm were present in the vas fluid on either side during surgical procedure. Nevertheless, this patient’s wife became pregnant in the fourth postoperative month and the patient’s single postoperative sperm count, done at thirteen months, was 90 million/ml. Recently, it has become apparent that the absence of sperm in the vas fluid may indicate more proximal seminal duct obstruction, frequently in the epididymis, as a secondary effect of vasectomy. This case and 2 others in the author’s personal experience with over 200 microsurgical vasovasostomies indicate that the absence of vasal
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sperm is not an absolute prognosticator for failure of vasovasostomy. The double-layer technique of microsurgical vasovasostomy has the advantage of precise mucosa-to-mucosa alignment, thus creating a smooth epithelial anastomosis, if stricture of the muscularis and/or perivasal tissue does not occur. However, the technique leaves knots of permanent suture material just outside the mucosa, a factor which may promote perimucosal fibrosis with subsequent stricture of the delicate anastomosis. The technique is difficult to perform and requires about three hours of operating time for bilateral surgery, even after the surgeon has acquired the necessary microsurgical training and experience. The modified one-layer technique has the theoretical disadvantage of a less accurate mucosa-to-mucosa approximation. Nevertheless, sperm leakage, granuloma formation, and matching of disparate luminal sizes appear not to be a problem with the modified one-layer anastomosis if one judges by the equivalent sperm counts and pregnancy rates of this technique and the double-layer technique. In addition, the modified one-layer technique offers the significant advantages of being easier to perform and requiring less time to complete. The ease of the technique is due to two factors. First, there is the need for fewer sutures (eight to twelve versus fourteen to eighteen for the double-layer technique). Second, the modified one-layer technique requires less technical facility and dexterity to master. Training, ample and experience in microsurgery are practice, still necessary for the surgeon to be able to approach the procedure with the expectation of
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success, but the demands on the surgeon with this technique are less than with the doublelayer technique. These factors reduce operating time, and therefore, operating expenses by 25 to 33 per cent. In the author’s personal experience with over 200 microsurgical vasovasostomies, approximately one-half have been done with each of the two techniques. The average skin-to-skin operating time for the double-layer technique has been three hours and for the modified one-layer technique two hours to two hours and fifteen minutes. The modified onelayer technique also has the theoretical advantage that all of the knots are tied outside the wall of the vas. Only four sutures pass through the lumen, and there are no perimucosal knots. Thus, the chance for fibrosis and subsequent stricture formation in the critical perimucosal zone is reduced. What yet remains to be established in the clinical problem of vasectomy reversal is the degree of accuracy and the delicacy of anastomotic technique which are necessary to achieve consistent success. The tolerable limits of mucosal alignment, muscular alignment, and perianastomotic fibrosis may require a double-layer miHowever, it is possible crosurgical technique. that a simpler and faster microsurgical techone-layer technique, such as the modified or perhaps even a nonmicrosurgical nique, technique, may produce sufficient accuracy for successful vasectomy reversal. At the present time, microsurgical technique appears to be at least as successful as conventional techniques of vasovasostomy and initial results of this and other serie$*’ indicate probable superiority.
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The ultimate criteria of success for any technique are postoperative sperm counts and pregnancy rates. In this limited series of patients, there seems to be no difference in these parameters between the double-layer and the modified one-layer microsurgical techniques. Since the modified one-layer microsurgical technique offers several distinct advantages over the double-layer technique, the modified one-layer technique of microsurgical vasovasostomy deserves further clinical experience and evaluation. 3838 California Street San Francisco, California 94118 ACKNOWLEDGMENT. To Dr. Anthony Eason for his help in obtaining the vasectomy specimen shown in Figures 2 and 3; and Dr. Emil Tanagho and the staff of the Department of Urology, University of California, San Francisco, where much of this work was done.
References 1. Phadke GM, and Phadke AG: Experiences in the reanastomosis of the vas deferens, J. Urol. 97: 888 (1967). 2. Middleton RG, and Henderson D: Vas deferens reanastomosis without splints and without magnification, ibid. 119: 763 (1978). 3. Derrick FC, Yarbrough W, and D’Agostino J: Vasovasostomy: results of questionnaire of members of the American Urological Association, ibid. 110: 556 (1973). 4. Dorsey JW: Sur@cal correction of post-vasectomy sterility, ibid. 110: 554 (1973). 5. Schmidt SS: Vasovasostomv. Urol. Clin. North Am. 5: 585 (1978). 6. Silber SB: Microscopic vasectomy reversal, Fertil, Steril. 28: 1191 (1977). 7. Owen ER: Microsurgical vasovasostomy: a reliable vasectomy reversal, Aust. N. Z. J. Surg. 47: 305 (1977). 8. Belker AM, Acland RD, and Juhala CA: Microsurgical twolayer vasovasostomy: word of caution, Urology 11: 616 (1978).
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