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Mini-Incision Microsurgical Vasectomy Reversal Using No-Scalpel Vasectomy Principles and Instruments
Surgical Techniques in Urology Mini-Incision Microsurgical Vasectomy Reversal Using No-Scalpel Vasectomy Principles and Instruments Keith Jarvi, Ethan D. Grober, Kirk C. Lo, and Geneviève Patry OBJECTIVES
METHODS
RESULTS
CONCLUSIONS
Men who have undergone a vasectomy have 2 options available to allow them to have biologically related children: vasectomy reversal or sperm retrieval with in vitro fertilization. Of the men who have undergone vasectomy, 2%-11% eventually undergo reversal. The high cost and reproductive risks associated with in vitro fertilization weigh against sperm retrieval with in vitro fertilization, and the surgical risks and postoperative recovery (eg, time off from work, postoperative pain) are important factors that couples consider before choosing vasectomy reversal. To reduce the morbidity of a vasectomy reversal, we have developed techniques to perform a microsurgical vasectomy reversal through a mini-incision in the scrotum. The vas deferens is grasped through the skin with the no-scalpel vasectomy ring forceps, a 1-cm incision is made through the skin and dartos directly on top of the elevated vas deferens, and the latter is delivered into the surgical field. The other side of the vas is delivered through the same incision in a similar fashion, and the anastomosis is performed with the usual technique. Application of the no-scalpel vasectomy principals and instruments have allowed us to minimize the scrotal incision (generally to ⱕ1 cm after closure) without compromising the quality of reversal or the operative time. Although the no-scalpel vasectomy technique has been proved to reduce morbidity compared with “standard” vasectomy, whether the use of the no-scalpel principles and instruments in a vasectomy reversal translates into a decrease in surgical morbidity is unknown. UROLOGY 72: 913–915, 2008. © 2008 Elsevier Inc.
I
n our present era, men who have undergone a vasectomy have 2 general options available to allow them to have biologically related children: vasectomy reversal or sperm retrieval (from the testis, epididymis or vas deferens) with in vitro fertilization (IVF). Although the number of men undergoing sperm retrieval with IVF is not known, 2%-11% of those who have undergone a vasectomy eventually undergo a reversal.1-3 Younger men are more likely to seek a vasectomy reversal. Although the expected pregnancy rate is an important consideration, couples consider a number of other issues when choosing between vasectomy reversal and IVF. In general, factors such as the high cost and reproductive risks associated with IVF weigh against sperm retrieval with IVF and the surgical risks and postoperative recovery (eg, time off work, postoperative pain) are important factors couples consider before choosing a vasectomy reversal. In our practice, men are typically off from work for 1-2 weeks after a vasectomy reversal. We were unable to find
From the Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada Reprint requests: Keith Jarvi, M.D., F.R.C.S.C., Mount Sinai Hospital, University of Toronto, 6th Floor, 60 Muray Street, Toronto, ON M5G 1X5 Canada. E-mail: [email protected] Submitted: April 7, 2008, accepted (with revisions): May 3, 2008
© 2008 Elsevier Inc. All Rights Reserved
any published studies that discussed the morbidity of a vasectomy reversal. In our experience, the length of time required to recover is a major factor in the couple’s decision to proceed with sperm aspiration with IVF rather than to undergo vasectomy reversal. Many reports have been published on techniques to improve the reproductive outcomes after vasectomy reversal (eg, use of microsurgery, multilayered closure, microdot techniques) but none on techniques to reduce the morbidity of this procedure.4-9 To reduce the morbidity of vasectomy reversal, we have developed techniques to perform microsurgical vasectomy reversal through a miniincision in the scrotum. In general, for similar operations, smaller surgical incisions are associated with less morbidity. The no-scalpel vasectomy technique is one example.10,11 The no-scalpel vasectomy technique is familiar to most urologists and involves the use of specialized equipment that allows the surgeon to perform a vasectomy through a much smaller opening in the scrotum compared with the incision required for the “standard” vasectomy. The no-scalpel vasectomy technique has been shown to reduce the patient’s time to recover and complication rates without compromising the efficacy of the vasectomy.11 0090-4295/08/$34.00 doi:10.1016/j.urology.2008.05.010
913
Figure 1. No-scalpel vasectomy ring forceps are used to atraumatically grasp and fix the abdominal end of the vas deferens approximately 5 mm from the site of vasectomy. Note, size of incision on opposite side (finished vasectomy reversal).
Figure 2. Both abdominal and testicular side of vas mobilized and secured with vessel loops. Vas defect lies between two vessel loops.
We applied the no-scalpel vasectomy principles and instruments to develop techniques to perform microsurgical vasectomy reversal through a mini-incision in the scrotum.
SURGICAL TECHNIQUE The area of the vasal defect is carefully palpated through the scrotal skin. Using a 3-finger technique, as described for no-scalpel vasectomy, we elevate the vas deferens on the abdominal side of the vasectomy to lie close to the skin10,11 (Fig. 1). The no-scalpel vasectomy ring forceps are then used to atraumatically grasp and fix the abdominal end vas deferens approximately 5 mm from the site of the vasectomy. If a large sperm granuloma is present, making this maneuver more difficult, the vas deferens can be grasped further from the site of the vasectomy on the abdominal side. The ring forceps are then used to pull and gently elevate the abdominal end of the vas just beneath the scrotal skin. A 1-cm incision with a scalpel is then made through the skin and dartos directly on top of the elevated vas deferens. Care must be taken to not cut beyond the dartos layer so not to injure the vas below. The ring forceps is then replaced to hold the vas deferens directly inside the incision. The vas deferens is then carefully mobilized and freed for a length of approximately 1 cm, and a vessel loop is placed around the vas deferens, at which point, the ring forceps can be removed. The vas deferens on the testicular side of the vasectomy defect is then palpated and elevated using the 3-finger technique, before being grasped with the ring forceps placed through the scrotal incision. The testicular side of the vas deferens is then gently pulled through the scrotal incision and mobilized (Fig. 2). We do not incise the vas deferens until both the proximal and the distal parts of the vas deferens have been mobilized. Next, stay stitches of 5-0 Bio-Syn are placed through the superficial muscularis layer of the vas deferens, and the vas deferens 914
Figure 3. Illustration of final scrotal incision size.
are cut in the usual fashion. A vas approximator is then used to control the vasa and bring the ends of the vas deferens into close proximity. Finally, high-contrast backing for the microsurgical field is placed under the vas deferens, and an anastomosis is performed in the usual fashion. Despite the small size of the incision, the scrotal skin and dartos is quite compliant and flexible and the edges can be “stretched” to increase the opening. This smaller incision does not impede the mobilization of the vas deferens or the positioning of the cut ends of the vas deferens before the anastomosis. After the anastomosis is complete, the vas deferens is returned to the scrotum, and the incision is closed with dissolvable sutures. Typically, 1 interrupted stitch closing the dartos and 1 interrupted subcuticular stitch are all that are required to close the scrotal opening. The incisions are generally ⱕ1 cm after closure (Fig. 3). This is a simple technique we have successfully used on all primary vasovasostomies (10 cases) without any changes in operating time and no complications. We have 2 provisos. UROLOGY 72 (4), 2008
First, the technique is predicated on the ability to confidently palpate the site of the vasectomy. Although this is relatively easy in most men coming for a primary vasectomy reversal, it is, in our experience, more difficult to be sure of this site in men who are seeking a repeat vasectomy reversal. If the site of the vasectomy is not easily palpated, we would recommend using a larger incision. Second, this technique has to be abandoned if vasoepididymostomy is required.
CONCLUSIONS Application of the no-scalpel vasectomy principals and instruments has allowed us to minimize the scrotal incision required for vasectomy reversal without compromising the quality of, or the time required for, the mobilization of the vas deferens or the vasal anastomosis. Previously, similar to descriptions from other investigators, we had made scrotal incisions 2-3 cm in length.12,13 Using the no-scalpel instruments and principals, the scrotal incisions are ⬍1 cm. This is a simple, rapid technique that could be easily used by urologists familiar with the no-scalpel vasectomy techniques. Although the no-scalpel vasectomy technique has been proved to reduce morbidity compared with the “standard” vasectomy, whether the use of the no-scalpel principles and instruments in a vasectomy reversal translates into a decrease in surgical morbidity is unknown.
UROLOGY 72 (4), 2008
References 1. Trussell J, Guilbert E, Hedley A. Sterilization failure, sterilization reversal, and pregnancy after sterilization reversal in Quebec. Obstet Gynecol. 2003;101:677-684. 2. Marmar JL, Sharlip I, Goldstein M. Results of vasovasostomy or vasoepididymostomy after failed percutaneous epididymal sperm aspirations. J Urol. 2008;179:1506-1509. 3. Holman CD, Wisniewski ZS, Semmens JB, et al. Population-based outcomes after 28,246 in-hospital vasectomies and 1,902 vasovasostomies in Western Australia. BJU Int. 2000;86:1043-1049. 4. Belker AM, Thomas AJ Jr, Fuchs EF, et al. Results of 1,469 microsurgical vasectomy reversals by the Vasovasostomy Study Group. J Urol. 1991;145:505-511. 5. Fischer MA, Grantmyre JE. Comparison of modified one- and two-layer microsurgical vasovasostomy. BJU Int. 2000;85:10851088. 6. Goldstein M, Li PS, Matthews GJ. Microsurgical vasovasostomy: The microdot technique of precision suture placement. J Urol. 1998;159:188-190. 7. Silber SJ. Microscopic technique for reversal of vasectomy. Surg Gynecol Obstet. 1976;143:630-631. 8. Silber SJ. Vasectomy and its microsurgical reversal. Urol Clin North Am. 1978;5:573-584. 9. Loughlin KR. Complications of vasovasostomy. Urol Clin North Am. 1988;15:243-248. 10. Li SQ, Goldstein M, Zhu J, et al. The no-scalpel vasectomy. J Urol. 1991;145:341-344. 11. Nirapathpongporn A, Huber DH, Krieger JN. No-scalpel vasectomy at the King’s birthday vasectomy festival. Lancet. 1990;335: 894-895. 12. Belker AM. Vasectomy reversal. Urol Clin North Am. 1987;14:155166. 13. Practice Committee of the American Society for Reproductive Medicine. Vasectomy reversal. Fertil Steril. 2006;86:S268-S271.
915
METHODS
RESULTS
CONCLUSIONS
Men who have undergone a vasectomy have 2 options available to allow them to have biologically related children: vasectomy reversal or sperm retrieval with in vitro fertilization. Of the men who have undergone vasectomy, 2%-11% eventually undergo reversal. The high cost and reproductive risks associated with in vitro fertilization weigh against sperm retrieval with in vitro fertilization, and the surgical risks and postoperative recovery (eg, time off from work, postoperative pain) are important factors that couples consider before choosing vasectomy reversal. To reduce the morbidity of a vasectomy reversal, we have developed techniques to perform a microsurgical vasectomy reversal through a mini-incision in the scrotum. The vas deferens is grasped through the skin with the no-scalpel vasectomy ring forceps, a 1-cm incision is made through the skin and dartos directly on top of the elevated vas deferens, and the latter is delivered into the surgical field. The other side of the vas is delivered through the same incision in a similar fashion, and the anastomosis is performed with the usual technique. Application of the no-scalpel vasectomy principals and instruments have allowed us to minimize the scrotal incision (generally to ⱕ1 cm after closure) without compromising the quality of reversal or the operative time. Although the no-scalpel vasectomy technique has been proved to reduce morbidity compared with “standard” vasectomy, whether the use of the no-scalpel principles and instruments in a vasectomy reversal translates into a decrease in surgical morbidity is unknown. UROLOGY 72: 913–915, 2008. © 2008 Elsevier Inc.
I
n our present era, men who have undergone a vasectomy have 2 general options available to allow them to have biologically related children: vasectomy reversal or sperm retrieval (from the testis, epididymis or vas deferens) with in vitro fertilization (IVF). Although the number of men undergoing sperm retrieval with IVF is not known, 2%-11% of those who have undergone a vasectomy eventually undergo a reversal.1-3 Younger men are more likely to seek a vasectomy reversal. Although the expected pregnancy rate is an important consideration, couples consider a number of other issues when choosing between vasectomy reversal and IVF. In general, factors such as the high cost and reproductive risks associated with IVF weigh against sperm retrieval with IVF and the surgical risks and postoperative recovery (eg, time off work, postoperative pain) are important factors couples consider before choosing a vasectomy reversal. In our practice, men are typically off from work for 1-2 weeks after a vasectomy reversal. We were unable to find
From the Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada Reprint requests: Keith Jarvi, M.D., F.R.C.S.C., Mount Sinai Hospital, University of Toronto, 6th Floor, 60 Muray Street, Toronto, ON M5G 1X5 Canada. E-mail: [email protected] Submitted: April 7, 2008, accepted (with revisions): May 3, 2008
© 2008 Elsevier Inc. All Rights Reserved
any published studies that discussed the morbidity of a vasectomy reversal. In our experience, the length of time required to recover is a major factor in the couple’s decision to proceed with sperm aspiration with IVF rather than to undergo vasectomy reversal. Many reports have been published on techniques to improve the reproductive outcomes after vasectomy reversal (eg, use of microsurgery, multilayered closure, microdot techniques) but none on techniques to reduce the morbidity of this procedure.4-9 To reduce the morbidity of vasectomy reversal, we have developed techniques to perform microsurgical vasectomy reversal through a miniincision in the scrotum. In general, for similar operations, smaller surgical incisions are associated with less morbidity. The no-scalpel vasectomy technique is one example.10,11 The no-scalpel vasectomy technique is familiar to most urologists and involves the use of specialized equipment that allows the surgeon to perform a vasectomy through a much smaller opening in the scrotum compared with the incision required for the “standard” vasectomy. The no-scalpel vasectomy technique has been shown to reduce the patient’s time to recover and complication rates without compromising the efficacy of the vasectomy.11 0090-4295/08/$34.00 doi:10.1016/j.urology.2008.05.010
913
Figure 1. No-scalpel vasectomy ring forceps are used to atraumatically grasp and fix the abdominal end of the vas deferens approximately 5 mm from the site of vasectomy. Note, size of incision on opposite side (finished vasectomy reversal).
Figure 2. Both abdominal and testicular side of vas mobilized and secured with vessel loops. Vas defect lies between two vessel loops.
We applied the no-scalpel vasectomy principles and instruments to develop techniques to perform microsurgical vasectomy reversal through a mini-incision in the scrotum.
SURGICAL TECHNIQUE The area of the vasal defect is carefully palpated through the scrotal skin. Using a 3-finger technique, as described for no-scalpel vasectomy, we elevate the vas deferens on the abdominal side of the vasectomy to lie close to the skin10,11 (Fig. 1). The no-scalpel vasectomy ring forceps are then used to atraumatically grasp and fix the abdominal end vas deferens approximately 5 mm from the site of the vasectomy. If a large sperm granuloma is present, making this maneuver more difficult, the vas deferens can be grasped further from the site of the vasectomy on the abdominal side. The ring forceps are then used to pull and gently elevate the abdominal end of the vas just beneath the scrotal skin. A 1-cm incision with a scalpel is then made through the skin and dartos directly on top of the elevated vas deferens. Care must be taken to not cut beyond the dartos layer so not to injure the vas below. The ring forceps is then replaced to hold the vas deferens directly inside the incision. The vas deferens is then carefully mobilized and freed for a length of approximately 1 cm, and a vessel loop is placed around the vas deferens, at which point, the ring forceps can be removed. The vas deferens on the testicular side of the vasectomy defect is then palpated and elevated using the 3-finger technique, before being grasped with the ring forceps placed through the scrotal incision. The testicular side of the vas deferens is then gently pulled through the scrotal incision and mobilized (Fig. 2). We do not incise the vas deferens until both the proximal and the distal parts of the vas deferens have been mobilized. Next, stay stitches of 5-0 Bio-Syn are placed through the superficial muscularis layer of the vas deferens, and the vas deferens 914
Figure 3. Illustration of final scrotal incision size.
are cut in the usual fashion. A vas approximator is then used to control the vasa and bring the ends of the vas deferens into close proximity. Finally, high-contrast backing for the microsurgical field is placed under the vas deferens, and an anastomosis is performed in the usual fashion. Despite the small size of the incision, the scrotal skin and dartos is quite compliant and flexible and the edges can be “stretched” to increase the opening. This smaller incision does not impede the mobilization of the vas deferens or the positioning of the cut ends of the vas deferens before the anastomosis. After the anastomosis is complete, the vas deferens is returned to the scrotum, and the incision is closed with dissolvable sutures. Typically, 1 interrupted stitch closing the dartos and 1 interrupted subcuticular stitch are all that are required to close the scrotal opening. The incisions are generally ⱕ1 cm after closure (Fig. 3). This is a simple technique we have successfully used on all primary vasovasostomies (10 cases) without any changes in operating time and no complications. We have 2 provisos. UROLOGY 72 (4), 2008
First, the technique is predicated on the ability to confidently palpate the site of the vasectomy. Although this is relatively easy in most men coming for a primary vasectomy reversal, it is, in our experience, more difficult to be sure of this site in men who are seeking a repeat vasectomy reversal. If the site of the vasectomy is not easily palpated, we would recommend using a larger incision. Second, this technique has to be abandoned if vasoepididymostomy is required.
CONCLUSIONS Application of the no-scalpel vasectomy principals and instruments has allowed us to minimize the scrotal incision required for vasectomy reversal without compromising the quality of, or the time required for, the mobilization of the vas deferens or the vasal anastomosis. Previously, similar to descriptions from other investigators, we had made scrotal incisions 2-3 cm in length.12,13 Using the no-scalpel instruments and principals, the scrotal incisions are ⬍1 cm. This is a simple, rapid technique that could be easily used by urologists familiar with the no-scalpel vasectomy techniques. Although the no-scalpel vasectomy technique has been proved to reduce morbidity compared with the “standard” vasectomy, whether the use of the no-scalpel principles and instruments in a vasectomy reversal translates into a decrease in surgical morbidity is unknown.
UROLOGY 72 (4), 2008
References 1. Trussell J, Guilbert E, Hedley A. Sterilization failure, sterilization reversal, and pregnancy after sterilization reversal in Quebec. Obstet Gynecol. 2003;101:677-684. 2. Marmar JL, Sharlip I, Goldstein M. Results of vasovasostomy or vasoepididymostomy after failed percutaneous epididymal sperm aspirations. J Urol. 2008;179:1506-1509. 3. Holman CD, Wisniewski ZS, Semmens JB, et al. Population-based outcomes after 28,246 in-hospital vasectomies and 1,902 vasovasostomies in Western Australia. BJU Int. 2000;86:1043-1049. 4. Belker AM, Thomas AJ Jr, Fuchs EF, et al. Results of 1,469 microsurgical vasectomy reversals by the Vasovasostomy Study Group. J Urol. 1991;145:505-511. 5. Fischer MA, Grantmyre JE. Comparison of modified one- and two-layer microsurgical vasovasostomy. BJU Int. 2000;85:10851088. 6. Goldstein M, Li PS, Matthews GJ. Microsurgical vasovasostomy: The microdot technique of precision suture placement. J Urol. 1998;159:188-190. 7. Silber SJ. Microscopic technique for reversal of vasectomy. Surg Gynecol Obstet. 1976;143:630-631. 8. Silber SJ. Vasectomy and its microsurgical reversal. Urol Clin North Am. 1978;5:573-584. 9. Loughlin KR. Complications of vasovasostomy. Urol Clin North Am. 1988;15:243-248. 10. Li SQ, Goldstein M, Zhu J, et al. The no-scalpel vasectomy. J Urol. 1991;145:341-344. 11. Nirapathpongporn A, Huber DH, Krieger JN. No-scalpel vasectomy at the King’s birthday vasectomy festival. Lancet. 1990;335: 894-895. 12. Belker AM. Vasectomy reversal. Urol Clin North Am. 1987;14:155166. 13. Practice Committee of the American Society for Reproductive Medicine. Vasectomy reversal. Fertil Steril. 2006;86:S268-S271.
915