Vasectomy and Vasovasostomy

Symposium on Urologic Surgery

Vasectomy and Vasovasostomy Robert Kessler, M.D.*

Vasectomy has become an increasingly popular method of male contraception. It has been estimated that approximately 500,000 men undergo vasectomy for elective sterilization in the United States annually.n This number is most likely an underestimate, since there are many unreported cases. The widespread use of vasectomy has led to an increasing number of requests for vasovasostomies. Approximately two requests for reversal per 1000 vasectomies are made in the United States. 7 Because of the common use of both of these procedures, it is important to review and update the status of these techniques.

VASECTOMY The two most common indications for bilateral partial vasectomy are for male sterilization and for the prevention of post-prostatectomy epididymitis.

Anatomy and Physiology The vas deferens is palpable in the scrotum at the inferior portion of the spermatic cord (Fig. 1). 1 It is approximately 30 to 40 em in length, extending from the epididymis at the testicular end through the inguinal canal, coursing in front of the ureter as it swings medially and then enlarges in its ampullary portion behind the bladder to join a duct from the ipsilateral seminal vesicle to form the ejaculatory duct, which empties into the prostatic urethra. The vas deferens is composed of three layers of smooth muscle (outer and inner longitudinal and middle circular) that surround the mucosa forming the lumen. Exterior to the muscular layer is an adventitial sheath of connective tissue in which run the blood and nerve supply to the vas. The arterial supply to the vas is from the deferential artery, which is a branch of the inferior vesical artery. The connective tissue sheath of the vas also contains predominantly sympathetic (hypogastric) nerve fibers.

*Associate Professor of Surgery/Urology, Stanford University School of Medicine, Stanford, California

Surgical Clinics of North America- Vol. 62, No. 6, December 1982

971

972

RoBERT KEsSLER

AREA OF VASECTOMY

CONVOLUTED PORTION OF VAS

TESTICLE MEDIAN RAPHE Figure 1. The anatomy of the scrotal genitalia is shown.

These fibers release norepinephrine and most likely are responsible for the spontaneous motility of the vas that has been demonstrated in vivo. Norepinephrine has also been shown to significantly increase the force and frequency of vasal contractions. 10 The stereocilia that project into the lumen of the vas from the mucosa probably play a minor role in the transport of sperm from the vas into the posterior urethra. A significant number of patients who have undergone retroperitoneal lymph node dissection with interruption of the pelvic sympathetic nerve supply will be azoospermic. This lack of sperm from the ejaculate is .due to failure of emission rather than retrograde ejaculation, as evidenced by the absence of seminal vesicular fructose and sperm from post-masturbation urine samples. 2 Therefore, attempts at vasovasostomy may fail to restore fertility even after a technical success because of failure of restoration of the sympathetic nerve supply.

Techniques of Vasectomy Vasectomy should be limited to emotionally stable patients who have a clear understanding that it is a permanent form of sterilization. Too often, patients confuse the high surgical success rates following vasovasostomy with fertility, and any misunderstanding should be avoided. Most states do not require the knowledge and/or consent of the marital partner, but in our opinion, at the very least, the marital partner should be informed except in unusual circumstances. The purpose of the operative procedure is to provide permane·nt sterilization with minimal risk and avoidance of complications. For this reason, the procedure is most commonly performed under local anesthesia in a well-equipped outpatient facility. The various techniques of vasectomy are illustrated in Figure 2. Although they all have a high success rate, failures have been reported with each of the techniques. The procedure I use is a combination of excision with mucosal fulguration without ligatures. The scrotal vas is identified by traction on the ipsilateral testis and palpated between the thumb and fingers (Fig. 3A). It is elevated anteriorly to lie just underneath the scrotal skin.

~

CJJ

t'l

n

6 ~

><

;..

z

tl

~

CJJ

0

;;; CJJ

0

~ ~

><

FULGURATION OF MUCOSA OF BOTH ENDS WITH ELECTROCAUTERY

EXCISION OF SEGMENT OF VAS WITH SIMPLE LIGATION

EXCISION OF SEGMENT AND VASA TIED BACK ON ITSELF Figure 2.

EXCISION OF SEGMENT AND METAL CLIPS

EXCISION OF SEGMENT AND LIGATION OF VASA WITH INTERPOSITION OF FASCIA

A-E, The various techniques of vasectomy are illustrated.

<:0

~

974

RoBERT KEsSLER

Figure 3. The vas is isolated (A) and local anesthesia is injected (B and C).

With a l V2 inch 25 gauge needle, l to 2 ml of l per cent lidocaine without epinephrine is injected underneath the vas and the needle passes in and out of the scrotal skin under the vas (Fig. 3B). A towel clip is then placed under the vas (Fig. 3C), the needle is removed, and another l to 2 ml of lidocaine is injected perivasally. An incision measuring l to 2 em is then made directly over the vas (Fig. 4A), and the vas is delivered from the wound with another towel clip (Fig. 4B). The connective tissue sheath surrounding the vas is incised and approximately l to 2 em of vas is extruded (Fig. 4C). A l to l% em segment of vas is excised (Fig. 4D), the lumen is fulgurated (Fig. 4E), and the vas is dropped back into the scrotum without closure of the skin edges (Fig. 4F). All bleeding vessels are carefully coagulated and the wound is copiously irrigated. Postoperatively, the patientis placed at bed rest. Scrotal support and icepacks are used until the next morning, and instructions are given to avoid intercourse and heavy lifting or heavy straining for seven days. The patient is told that he is still fertile and should use some type of contraceptive until a semen sample, taken six weeks postoperatively after 20 ejaculations, shows no sperm microscopically in 20 high power fields. If any sperm are present in the ejaculate, either motile or not, the patient is cautioned that he is still not sterile until azoospermia is present.

975

VASECTOMY AND V ASOVASOSTOMY

"'>.

a

~

:';;

"'> '0

"0' ;:l

·a ..<:: C)

2 "' 0 .'3;:l I.;

"' ,..."

..<::

~

.,(: ~

" I.;

;:l

-~

0

""'

976

ROBERT KESSLER

Complications of Vasectomy The postoperative morbidity following bilateral partial vasectomy can vary from minor scrotal edema at the vasectomy sites to more serious complications that may require another operative procedure. The latter complications include sperm granuloma secondary to extravasation of sperm; scrotal abscess, hematocele possibly secondary to failure of coagulation or ligation of the deferential artery, and failure of the vasectomy secondary to recanalization. Sperm granulomas are more common after the use ofligatures rather than electrofulguration alone, 4 since if the ligatures are too loose they can slip off and if too tight, they may cause necrosis of the ends of the vas. In either case, extravasation of sperm can occur from the testicular end of the vas. The most common causes of failure of vasectomy are spontaneous recanalization with or without sperm granuloma and failure to properly recognize the vas on one side. Other less serious complications include vasitis, epididymitis, and adhesions between the vasa and the skin. Although there have been studies reporting generalized adverse effects of vasectomy such as autoimmune disorders 6 and increased atheromata, 1 to date there have been no well-controlled series supporting either of these studies.

Conclusion Vasectomy is a safe, reliable, increasingly popular, and inexpensive method of male contraception. -Most patients who have undergone this surgery would go through the experience again and are satisfied with the results. Until such time as a contraceptive pill becomes available for men that will induce sterilization with no undesirable side effects, vasectomy will remain the most popular type of male sterilization.

VASOVASOSTOMY The tremendous increase in the popularity of vasectomy now has a predictable side effect: an increasing demand for vasovasostomy to restore fertility. The question of whether a microsurgical technique yields statistically better results than a macrosurgical technique in terms of surgical success (return of sperm to the ejaculate) and pregnancy rates, is not settled. It is clear that both techniques can yield satisfactory rates of pregnancy if done meticulously by a surgeon who performs the operation frequently. In the only study comparing macroscopic and micr'oscopic techniques at a single institution, there was no significant difference in results using either technique. 5

Indications The most common motive that leads patients to request vasovasostomy is a remarriage. Less common reasons include loss of children, change of heart in a patient with no proven fertility, and, rarely, chronic testicular pain or concern about the adverse effects of vasectomy, most commonly atherosclerosis.

977

VASECTOMY AND V ASOVASOSTOMY

Surgical Technique Between 1976 and 1978, 96 patients undetwent macroscopic vasovasostomy at Stanford. 3 Two surgeons performed all of the operations. The patency rate was 92 per cent and the pregnancy rate was 49 per cent. All operations were performed as an outpatient procedure in the operating room under spinal or general anesthesia. We used a nonsplinted technique with surgical ocular lou pes of 4 X magnification. The previous vasectomy sites are palpated through bilateral scrotal incisions, and all scar tissue is excised until normal healthy vas is identified both proximally and distally. The proximal testicular vasa are gently milked to obtain fluid to determine the presence or absence of sperm. Then, with a 2-0 nylon suture as a guide, two through and through 9-0 nylon sutures are placed 90 degrees apart on the anterior surface of the vas for mucosal alignment and a 7-0 prolene suture is placed superficially through the seromuscular layer in between the 9-0 nylon sutures (Fig. 5). The 7-0 prolene is tied first to bring the edges of the vas in close alignment, then the two 9-0 nylon sutures can be tied without tension (Fig. 6). The vas is then rotated 180 degrees and two 9-0 nylon sutures and one 7-0 prolene suture are placed as previously described (Fig. 7). Once again, the 7-0 suture is tied first followed by the 9-0 sutures (Fig. 8). Finally, any gaps that are seen in the anastomotic line are closed with interrupted 7-0 prolene sutures through the seromuscular layers in order to create a leakproof anastomosis (Fig. 9). Care must be taken to avoid entering the lumen with the 7-0 sutures. PostiJperatively, a supporter and ice packs are applied to the scrotum overnight and the patient is placed at bed rest for five days. He is instructed to avoid heavy lifting, straining, and sexual intercourse for three weeks and is seen in follow-up at one month for a semen analysis. 2-0 NYLON

9-0 PROLENE

Figure 5.

A-D, The initial suture placements for vasovasostomy are shown.

978

ROBERT KESSLER

Figure 6. A-D, For the initial sutures, the 7-0 prolene is tied first, then the 9-0 nylon sutures are tied.

Figure 7.

A-D, The technique of suturing the posterior surface of the vas is illustrated.

979

VASECTOMY AND V ASOV AS OSTOMY

7-0

D Figure 8. A-D, The technique for tying the posterior sutures is shown.

B Figure 9. A and B, Any gaps in the anastomotic line are closed with interrupted 7-0 prolene sutures through the seromuscular layers.

980

ROBERT KESSLER

Sperm may be present as early as one month but in some cases may initially appear as late as six months. Decreased motility is common at one month but, as with the count, usually increases until it reaches its peak at approximately six months after surgery.

Complications of Vasovasostomy The complications that can occur following vasectomy reversal surgery are similar to postvasectomy complications and include scrotal edema, scrotal abscess, hematocele, vasitis, epididymitis, vasocutaneous adhesions, and sperm granuloma. The most common complication is failure to restore fertility. This occurs most often in the patient with an adequate sperm count and poor motility. The significant discrepancy between surgical and pregnancy success rates has been attributed to the presence of antisperm antibodies after vasovasostomy, 8 but a more recent study found no relationship between the presence of these antibodies and subsequent fertility. 9 Further studies are required to determine whether an immunologic event is the cause of the discrepancy between surgical and preganancy success rates.

Conclusion Vasovasostomy, whether macrosurgical or microsurgical, can be a highly successful procedure. Fertility rates following this operation have shown a steady increase over the past three decades. Understanding the factors that prevent fertility in the presence of a technically successful vasovasostomy will make this surgery potentially more reversible and can only yield higher rates of success.

REFERENCES l. Alexander, N.J., and Clarkson, T. B.: Vasectomy increases the severity of diet-induced atherosclerosis in macaca fascicularis. Science, 201:538, 1978. 2. Kedia, K. R., Markland, C., and Fraley, E. E.: Sexual function following high retroperitoneal lymphadenectomy. J. Urol., 114:237, 1975. 3. Kessler, R., and Freiha, F. S.: Macroscopic vasovasostomy. Fertil. Steril., 36:531, 1981. 4. Klapproth, H. J., and Young, I. S.: Vasectomy, vas ligation and vas occlusion. Urology, 1:292, 1973. 5. Lee, L., and McLoughlin, M. G.: Vasovasostomy: A comparison of macroscopic and microscopic techniques at one institution. Fertil. Steril., 33:54, 1980. 6. Roberts, H. J.: Thrombophlebitis after vasectomy. New Engl. J. Med., 284:1330, 1971. 7. Schmidt, S. S.: Principles of vasovasostomy. Con temp. Surg., 7:13, 1975. 8. Sullivan, M. J., and Howe, G. E.: Correlation of circulating antisperm antibodies to functional success in vasovasostomy. J. Urol., 117:189, 1977. 9. Thomas, A. J., Jr. Pontes, J. E., Rose, N. R., et a!.: Microsurgical vasovasostomy: Immunologic consequences and subsequent fertility. Fertil. Steril., 35:447, 1981. 10. Ventura, W. P., Freund, M., Davis, J., eta!.: Influence of norepinephrine on the motility of the human vas deferens: A new hypothesis of sperm transport by the vas deferens. Fertil. Steril., 24:68, 1973. 11. Westoff, C. F., and Jones, E. F.: Contraception and sterilization in the United States, 1965-1975. Fam. Flann. Perspect., 9:4, 1977.

Division of Urology Room S-287 Stanford Medical Center Stanford, California 94305