British Journal of Urology (19151, 41, 309-314
Vas Anastomosis: a Return to Simplicity STANWOOD S . SCHMIDT
Division of Urology, University of California School of Medicine, San Francisco, California
The widespread use of vasectomy for elective sterilisation has resulted in an increasing number of requests for restoration of fertility. The author has been successful in restoring sperm to the ejaculate by vasovasostomy in a t least 80 % of 1 17 cases. Pregnancy has followed in the wives of 30% of these men. Many techniques have been proposed to facilitate the operation and to improve its outcome (Schmidt, 1956, 1961), but most of these innovations are no substitute for simplicity. Anastomosis of the vas is comparable to most other anastomoses, but it presents problems of its own which must be understood if it is to be successful. Anatomical and Pathological Conductions The vas deferens arises from the epididymis as a convoluted duct. Its convolutions are tortuous and sometimes it even doubles back upon itself. As it progresses, it gradually straightens and its wall thickens (Fig. 1). The location of the proposed anastomosis is determined of course by the site of the original vasectomy: optimal when in the straight vas with no significant defect in its length, less favourable in the convoluted portion. The operation is impossible when substantial lengths of vas have been resected. After vasectomy, the lumen of the proximal (testicular) vas dilates, thus thinning its wall (Schmidt, 1959) (Fig. 1). The outside diameter of the vas remains the same but the diameter of the lumen enlarges 2 to 4 times: the anastomosis, therefore, must join lumens of different sizes. In addition, the original vasectomy results in scarring of the sheath of the vas. This sheath facilitates spontaneous anastomosis (Rolnick, 1924). Most research on vas anastomosis is conducted by dividing the vas, then immediately anastomosing it with the sheath intact. In clinical practice, both the scarring of the sheath and the dilatation of the lumen make for different and more difficult conditions. Surgical Principles The best anastomosis is that which most simply ipproximates the opposing layers of tissueconsequently, the principles of end-to-end, mucosa-to-mucosa anastomosis are followed. Because of the thick walls of the vas, oblique cuts lack the advantages (greater circumference and area) seen in the thin-walled ureter. Thickness of the walls permits the anastomosis to be performed with only a few sutures. For the same reason, kinking of the vas does not occur, thus stents are not necessary. Stricture of the vas appears to be unimportant-pregnancies often occur after spontaneous anastomoses of minute diameter. The ends of the vas must be approximated without tension, a special problem when they are some distance apart and the weight of the testis is upon the anastomosis. The supporting fascia1 sheath must be sutured, so that the vas ends cannot be pulled apart, even with mild traction (Fig. 2). 309
310
BRITISH JOURNAL OF UROLOGY
Fig. 1
Fig. 2,4,5.
Fig. 1. Convoluted and straight vas with cross-sections showing wall thickness of proximal and distal vas. Note optimal site of vasectomy-in straight vas. Fig. 2. Sketch of fascia1 suture. Fig. 3. Obstructed epididymis with dilated seminiferous tubules. Fig. 4. Sutures in vas. Fig. 5. Needle guide and guide in use.
Fig. 3
VAS
ANASTOMOSIS:
A RETURN TO SIMPLICITY
311
The actual anastomosing sutures are responsible for approximating the layers of the vas wall and for making the anastomosis “watertight”. Non-reactive, monofilament sutures of fine diameter are best. They should be placed through the entire thickness of the vas wall, into the lumen. Because of the thickness of the wall, these sutures create a tight, leak-proof anastomosis, making stents and splints1 unnecessary; fibrin and clot rapidly seal the anastomosis. The vas must be sutured with precision. Optical aids are a great advantage. The author uses a loupe (magnification 24) when freeing the ends of the vas and when placing the fascial sutures, and the operating microscope (magnification 10 to 16) while placing the anastomosing sutures. Technique The operation is best done under light general anaesthesia on an out-patient basis : hospitalisation is unnecessary. The point of interruption can usually be palpated as a defect in the vas. One can often feel the nodular thickening of a spermatic granuloma or of vasitis nodosa of the proximal vas (present in approximately 23 % of patients). A 3 to 4 cm incision is made in the scrotum. The fascia of the scrotum is spread apart so that the vas can be grasped with Allis clamps above and below the point of obstruction. Longitudinal incisions are made in the sheath of the vas down to, but not entering, the vas. Transverse cuts are then made to freshen the ends, care being taken to conserve all possible length. Only if a spermatic granuloma is found is it necessary to resect the scarred end of the vas. The underlying fascia is freed for 2 to 3 mm from each end to prevent its being interposed in the anastomosis. Patency of the distal vas is determined next by injecting normal saline solution into it through a blunted 23 gauge hypodermic needle. This is done easily if no obstruction exists. When obstruction does exist, its site can be determined by probing with a 2-0 nylon suture. Patency of the proximal vas is proven by the appearance of spermatic fluid. This fluid will be either clear or milky; it may lack sperms, show only sperm heads or show motile sperms. Once released, it often continues to flow and must be removed from the wound by sponging or by irrigation. If no fluid can be expressed by milking the vas, one should expose and inspect the epididymis : in 10 to 20 % of all patients, an obstruction will be found; dilated tubules, either patchy or extending partly down the epididymis will be seen with the naked eye (Fig. 3). For such cases an epididymovasostomy can be tried. When sperms are found in either vas, the outlook is excellent for sperm to appear in the ejaculate. Among the cases cited (Table 11) only 2 of 8 failures showed sperm at operation. When the vas is shown to be patent, a single suture of 4-0 nylon is placed in the fascia to approximate the vas ends (Fig. 2). This suture is held and tied only after the anastomosing sutures are placed in the vas and tied. Next, 3 sutures are placed (Fig. 4) at 120”intervals through the full thickness of the vas, using preferably Ethicon 8718-H, a &-O polypropylene suture with needles at both ends which permits the needles to be placed into the lumen on each side and then out through the vas walls. It is important to place the first 2 sutures posteriorly, next to the fascial suture since this is the point of potential leakage, being hidden after these sutures are tied. The upper suture is placed last. Additional sutures, not entering the lumen, can be placed anteriorly if necessary. Bonney clamps, modified by shortening the tubular portion to 8’’, are excellent for holding the vas ends while placing these sutures. If double-armed sutures are not available, single-armed sutures can be used, with a needle guide marking the lumen and thus preventing the needle from crossing and obliterating the lumen (Fig. 5). This needle guide also holds the vas firm, permitting easy insertion of the suture needle. 1 The use of endosplints in vas anastomosis has proven less than satisfactory: the splints are often displaced and apparently extruded out through the vas and ejaculated. For that reason the author has abandoned this technique.
312
BRITISH JOURNAL OF UROLOGY
Table I Vas Anastomosis Follow-up Questionnaire (sent Autumn, 1973)
Answers No answer
Number of Cases
Per Cent
37 16
69.8 30.2
Additional fascia1 sutures can be placed over the anastomosis, and the skin is then closed. A sterile dressing and a scrota1 support are applied. The support is worn for 14 days to immobilise the scrotum. Bathing is permitted after 48 hours and sexual intercourse may be resumed in 10 days. Testing for sperm is commenced after 1 month. Reason for Failure 1. One or both epididymides will be found to be obstructed in 10 to 20 %of patients : epididymovasostomy may then be attempted, but its success rates are poor. 2. In some cases an excess of vas will have been resected, making uniting of the ends impossible. 3. Leakage from the anastomosis can result in the formation of a spermatic granuloma. The inflammation and scarring associated with this lesion may obstruct the anastomosis. If, for this or any other technical reasons the operation fails, it can be attempted again with good hope for success. 4. Scarring can occur at the point of emergence of a splint (Fernandes, Shah and Draper, 1968). an additional reason for not using one. 5. Postvasectomy autoimmunity to sperm often occurs (Ansbacher, 1973). The spermatic granulomas frequently present after vasectomy deposit spermatic protein into the tissues. This extravasation appears to be directly related to antibody level (Alexander, 1973). The role of sperm autoimmunity in causing sterility is still vague. Two different antibodies have been described. Their effects can sometimes be seen upon semen examination under the microscope. When an immobilising antibody exists, all sperms appear non-motile and thus dead. When the agglutinating antibody is present, the sperms are actively motile but are clumped so that they are unable to separate from one another and to move normally (Fig. 6). Prevention of autoimmunity to sperm is tied to the prevention of sperm spillage: consequently, the vas is sealed at the time of vasectomy as a measure against the development of spermatic granuloma, and sperm spillage is carefully avoided at vasovasostomy. Prednisone may be useful in overcoming this immunity: the author and other urological surgeons (Charney, 1973) have seen cases improved by the administration of this drug, but further evidence corroborating their experience is necessary. Possibilities for treating the seminal fluid itself have not been explored ; however, Schoysman reports that freezing and thawing released sperm from agglutination (Schoysman, 1973). A marked discrepancy exists between success as judged by sperm appearing in the ejaculate (patency) and as judged by pregnancies (fertility). After the operation, sperm counts are often low and sometimes sperm do not appear until months later. Two reasons for these phenomena are possible: (a) After vasectomy, the tubules of the epididymis dilate. Their walls are thin and, when dilated, become even thinner. Just as a chronically dilated ureter seldom regains its tone or its ability to peristalse after obstruction is corrected, the epididymis may be the site of a similar condition-slowing sperm transport and causing many sperms to die before they reach the vas; the epididymis, in other words, has become adynamic. (h) After vasectomy, balance is reached between sperm production and sperm absorption. Phagocytosis accounts for sperm absorption
313
VAS ANASTOMOSIS: A RETURN TO SIMPLICITY
Fig. 6. Agglutinated sperm.
Table I1 Results of Vas Anastomosis 18 months’ results by techniques described (53 patients)
Never tested postoperatively Tested postoperatively (some information) Sperm No sperm Pregnancies Failures No sperm found at operation Sperm found at operation Not tested at operation Spermatic granuloma of vas
Number of Cases
Per Cent
9 44 36 8 8 (to date) 8 5 2 1
12
81.8 18.2 16 15.2 9.5 3.8 1.9 22.6
Previous 4-year results by various methods (64patients) ~
Pregnancies Sperm and/or pregnancies
-~ -~
_.
20 50
31 78
314
BRITISH JOURNAL OF UROLOGY
and is far more active than in the normal. Phagocytosis may also remain hyperactive so that only few sperms escape it. In these cases and in those of autoimmunity, the operation is a technical success but pregnancy does not ensue. One peculiar circumstance frequently accompanies the anastomosis : follow-ups may be difficult to secure. As a rule, the operation is done during a second marriage, often to please the new wife, and the man is more or less indifferent about its success. He feels that he has done his part by undergoing the operation-and many a man rejects testing, for he fears a failure that would force him to undergo further surgery or that might disrupt his marriage. As shown in Table I only about 70% of the patients of the cited series (Table 11) answered a questionnaire sent in 1973. Information on others was secured at different times.
Summary Vas anastomosis is successful in restoring sperm to the ejaculate in 80 to 90% of cases. A simple, end-to-end, mucosa-to-mucosa anastomosis performed with non-absorbable, monofilament sutures is, in the author’s opinion, the best procedure. Pregnancies follow in about one-third of the cases.
References ALEXANDER, N. (1973). Personal communication. ANSBACHER, R. (I 973). Vasectomy: sperm antibodies. Fertility and Sterility, 24, 788-792. CHARNEY, C. (1973). Personal communication. FERNANDES, M.. SHAH.K. N. and DRAPER,J. W. (1968). Vasovasostomy : improved microsurgical technique. Journal of Urology, 100,763-766. H. C. (1924). Regeneration of the vas deferens. Archives of Surgery, 9, 188-203. ROLNICK, SCHMIDT, S. S. (1956). Anastomosis of the vas deferens: an experimental study. I. Journal of Urology, 75, 300-303. SCHMIDT, S. S. (1959). Anastomosis of the vas deferens: an experimental study. 111. Dilatation of the vas following obstruction. Journal of Urology, 81, 206207. SCHMIDT, S. S. (1961). Anastomosis of the vas deferens: an experimental study. 1V. The use of fine polyethylene tubing as a splint. Journal of Urology, 85, 838-841. SCHOYSMAN, R. (1973). Personal communication.
The Author Stanwood S. Schmidt, MD, Research Associate in Urology. Requests for reprints to: M-478, University of California, San Francisco, California 94143 (Dr Schmidt).
Vas Anastomosis: a Return to Simplicity STANWOOD S . SCHMIDT
Division of Urology, University of California School of Medicine, San Francisco, California
The widespread use of vasectomy for elective sterilisation has resulted in an increasing number of requests for restoration of fertility. The author has been successful in restoring sperm to the ejaculate by vasovasostomy in a t least 80 % of 1 17 cases. Pregnancy has followed in the wives of 30% of these men. Many techniques have been proposed to facilitate the operation and to improve its outcome (Schmidt, 1956, 1961), but most of these innovations are no substitute for simplicity. Anastomosis of the vas is comparable to most other anastomoses, but it presents problems of its own which must be understood if it is to be successful. Anatomical and Pathological Conductions The vas deferens arises from the epididymis as a convoluted duct. Its convolutions are tortuous and sometimes it even doubles back upon itself. As it progresses, it gradually straightens and its wall thickens (Fig. 1). The location of the proposed anastomosis is determined of course by the site of the original vasectomy: optimal when in the straight vas with no significant defect in its length, less favourable in the convoluted portion. The operation is impossible when substantial lengths of vas have been resected. After vasectomy, the lumen of the proximal (testicular) vas dilates, thus thinning its wall (Schmidt, 1959) (Fig. 1). The outside diameter of the vas remains the same but the diameter of the lumen enlarges 2 to 4 times: the anastomosis, therefore, must join lumens of different sizes. In addition, the original vasectomy results in scarring of the sheath of the vas. This sheath facilitates spontaneous anastomosis (Rolnick, 1924). Most research on vas anastomosis is conducted by dividing the vas, then immediately anastomosing it with the sheath intact. In clinical practice, both the scarring of the sheath and the dilatation of the lumen make for different and more difficult conditions. Surgical Principles The best anastomosis is that which most simply ipproximates the opposing layers of tissueconsequently, the principles of end-to-end, mucosa-to-mucosa anastomosis are followed. Because of the thick walls of the vas, oblique cuts lack the advantages (greater circumference and area) seen in the thin-walled ureter. Thickness of the walls permits the anastomosis to be performed with only a few sutures. For the same reason, kinking of the vas does not occur, thus stents are not necessary. Stricture of the vas appears to be unimportant-pregnancies often occur after spontaneous anastomoses of minute diameter. The ends of the vas must be approximated without tension, a special problem when they are some distance apart and the weight of the testis is upon the anastomosis. The supporting fascia1 sheath must be sutured, so that the vas ends cannot be pulled apart, even with mild traction (Fig. 2). 309
310
BRITISH JOURNAL OF UROLOGY
Fig. 1
Fig. 2,4,5.
Fig. 1. Convoluted and straight vas with cross-sections showing wall thickness of proximal and distal vas. Note optimal site of vasectomy-in straight vas. Fig. 2. Sketch of fascia1 suture. Fig. 3. Obstructed epididymis with dilated seminiferous tubules. Fig. 4. Sutures in vas. Fig. 5. Needle guide and guide in use.
Fig. 3
VAS
ANASTOMOSIS:
A RETURN TO SIMPLICITY
311
The actual anastomosing sutures are responsible for approximating the layers of the vas wall and for making the anastomosis “watertight”. Non-reactive, monofilament sutures of fine diameter are best. They should be placed through the entire thickness of the vas wall, into the lumen. Because of the thickness of the wall, these sutures create a tight, leak-proof anastomosis, making stents and splints1 unnecessary; fibrin and clot rapidly seal the anastomosis. The vas must be sutured with precision. Optical aids are a great advantage. The author uses a loupe (magnification 24) when freeing the ends of the vas and when placing the fascial sutures, and the operating microscope (magnification 10 to 16) while placing the anastomosing sutures. Technique The operation is best done under light general anaesthesia on an out-patient basis : hospitalisation is unnecessary. The point of interruption can usually be palpated as a defect in the vas. One can often feel the nodular thickening of a spermatic granuloma or of vasitis nodosa of the proximal vas (present in approximately 23 % of patients). A 3 to 4 cm incision is made in the scrotum. The fascia of the scrotum is spread apart so that the vas can be grasped with Allis clamps above and below the point of obstruction. Longitudinal incisions are made in the sheath of the vas down to, but not entering, the vas. Transverse cuts are then made to freshen the ends, care being taken to conserve all possible length. Only if a spermatic granuloma is found is it necessary to resect the scarred end of the vas. The underlying fascia is freed for 2 to 3 mm from each end to prevent its being interposed in the anastomosis. Patency of the distal vas is determined next by injecting normal saline solution into it through a blunted 23 gauge hypodermic needle. This is done easily if no obstruction exists. When obstruction does exist, its site can be determined by probing with a 2-0 nylon suture. Patency of the proximal vas is proven by the appearance of spermatic fluid. This fluid will be either clear or milky; it may lack sperms, show only sperm heads or show motile sperms. Once released, it often continues to flow and must be removed from the wound by sponging or by irrigation. If no fluid can be expressed by milking the vas, one should expose and inspect the epididymis : in 10 to 20 % of all patients, an obstruction will be found; dilated tubules, either patchy or extending partly down the epididymis will be seen with the naked eye (Fig. 3). For such cases an epididymovasostomy can be tried. When sperms are found in either vas, the outlook is excellent for sperm to appear in the ejaculate. Among the cases cited (Table 11) only 2 of 8 failures showed sperm at operation. When the vas is shown to be patent, a single suture of 4-0 nylon is placed in the fascia to approximate the vas ends (Fig. 2). This suture is held and tied only after the anastomosing sutures are placed in the vas and tied. Next, 3 sutures are placed (Fig. 4) at 120”intervals through the full thickness of the vas, using preferably Ethicon 8718-H, a &-O polypropylene suture with needles at both ends which permits the needles to be placed into the lumen on each side and then out through the vas walls. It is important to place the first 2 sutures posteriorly, next to the fascial suture since this is the point of potential leakage, being hidden after these sutures are tied. The upper suture is placed last. Additional sutures, not entering the lumen, can be placed anteriorly if necessary. Bonney clamps, modified by shortening the tubular portion to 8’’, are excellent for holding the vas ends while placing these sutures. If double-armed sutures are not available, single-armed sutures can be used, with a needle guide marking the lumen and thus preventing the needle from crossing and obliterating the lumen (Fig. 5). This needle guide also holds the vas firm, permitting easy insertion of the suture needle. 1 The use of endosplints in vas anastomosis has proven less than satisfactory: the splints are often displaced and apparently extruded out through the vas and ejaculated. For that reason the author has abandoned this technique.
312
BRITISH JOURNAL OF UROLOGY
Table I Vas Anastomosis Follow-up Questionnaire (sent Autumn, 1973)
Answers No answer
Number of Cases
Per Cent
37 16
69.8 30.2
Additional fascia1 sutures can be placed over the anastomosis, and the skin is then closed. A sterile dressing and a scrota1 support are applied. The support is worn for 14 days to immobilise the scrotum. Bathing is permitted after 48 hours and sexual intercourse may be resumed in 10 days. Testing for sperm is commenced after 1 month. Reason for Failure 1. One or both epididymides will be found to be obstructed in 10 to 20 %of patients : epididymovasostomy may then be attempted, but its success rates are poor. 2. In some cases an excess of vas will have been resected, making uniting of the ends impossible. 3. Leakage from the anastomosis can result in the formation of a spermatic granuloma. The inflammation and scarring associated with this lesion may obstruct the anastomosis. If, for this or any other technical reasons the operation fails, it can be attempted again with good hope for success. 4. Scarring can occur at the point of emergence of a splint (Fernandes, Shah and Draper, 1968). an additional reason for not using one. 5. Postvasectomy autoimmunity to sperm often occurs (Ansbacher, 1973). The spermatic granulomas frequently present after vasectomy deposit spermatic protein into the tissues. This extravasation appears to be directly related to antibody level (Alexander, 1973). The role of sperm autoimmunity in causing sterility is still vague. Two different antibodies have been described. Their effects can sometimes be seen upon semen examination under the microscope. When an immobilising antibody exists, all sperms appear non-motile and thus dead. When the agglutinating antibody is present, the sperms are actively motile but are clumped so that they are unable to separate from one another and to move normally (Fig. 6). Prevention of autoimmunity to sperm is tied to the prevention of sperm spillage: consequently, the vas is sealed at the time of vasectomy as a measure against the development of spermatic granuloma, and sperm spillage is carefully avoided at vasovasostomy. Prednisone may be useful in overcoming this immunity: the author and other urological surgeons (Charney, 1973) have seen cases improved by the administration of this drug, but further evidence corroborating their experience is necessary. Possibilities for treating the seminal fluid itself have not been explored ; however, Schoysman reports that freezing and thawing released sperm from agglutination (Schoysman, 1973). A marked discrepancy exists between success as judged by sperm appearing in the ejaculate (patency) and as judged by pregnancies (fertility). After the operation, sperm counts are often low and sometimes sperm do not appear until months later. Two reasons for these phenomena are possible: (a) After vasectomy, the tubules of the epididymis dilate. Their walls are thin and, when dilated, become even thinner. Just as a chronically dilated ureter seldom regains its tone or its ability to peristalse after obstruction is corrected, the epididymis may be the site of a similar condition-slowing sperm transport and causing many sperms to die before they reach the vas; the epididymis, in other words, has become adynamic. (h) After vasectomy, balance is reached between sperm production and sperm absorption. Phagocytosis accounts for sperm absorption
313
VAS ANASTOMOSIS: A RETURN TO SIMPLICITY
Fig. 6. Agglutinated sperm.
Table I1 Results of Vas Anastomosis 18 months’ results by techniques described (53 patients)
Never tested postoperatively Tested postoperatively (some information) Sperm No sperm Pregnancies Failures No sperm found at operation Sperm found at operation Not tested at operation Spermatic granuloma of vas
Number of Cases
Per Cent
9 44 36 8 8 (to date) 8 5 2 1
12
81.8 18.2 16 15.2 9.5 3.8 1.9 22.6
Previous 4-year results by various methods (64patients) ~
Pregnancies Sperm and/or pregnancies
-~ -~
_.
20 50
31 78
314
BRITISH JOURNAL OF UROLOGY
and is far more active than in the normal. Phagocytosis may also remain hyperactive so that only few sperms escape it. In these cases and in those of autoimmunity, the operation is a technical success but pregnancy does not ensue. One peculiar circumstance frequently accompanies the anastomosis : follow-ups may be difficult to secure. As a rule, the operation is done during a second marriage, often to please the new wife, and the man is more or less indifferent about its success. He feels that he has done his part by undergoing the operation-and many a man rejects testing, for he fears a failure that would force him to undergo further surgery or that might disrupt his marriage. As shown in Table I only about 70% of the patients of the cited series (Table 11) answered a questionnaire sent in 1973. Information on others was secured at different times.
Summary Vas anastomosis is successful in restoring sperm to the ejaculate in 80 to 90% of cases. A simple, end-to-end, mucosa-to-mucosa anastomosis performed with non-absorbable, monofilament sutures is, in the author’s opinion, the best procedure. Pregnancies follow in about one-third of the cases.
References ALEXANDER, N. (1973). Personal communication. ANSBACHER, R. (I 973). Vasectomy: sperm antibodies. Fertility and Sterility, 24, 788-792. CHARNEY, C. (1973). Personal communication. FERNANDES, M.. SHAH.K. N. and DRAPER,J. W. (1968). Vasovasostomy : improved microsurgical technique. Journal of Urology, 100,763-766. H. C. (1924). Regeneration of the vas deferens. Archives of Surgery, 9, 188-203. ROLNICK, SCHMIDT, S. S. (1956). Anastomosis of the vas deferens: an experimental study. I. Journal of Urology, 75, 300-303. SCHMIDT, S. S. (1959). Anastomosis of the vas deferens: an experimental study. 111. Dilatation of the vas following obstruction. Journal of Urology, 81, 206207. SCHMIDT, S. S. (1961). Anastomosis of the vas deferens: an experimental study. 1V. The use of fine polyethylene tubing as a splint. Journal of Urology, 85, 838-841. SCHOYSMAN, R. (1973). Personal communication.
The Author Stanwood S. Schmidt, MD, Research Associate in Urology. Requests for reprints to: M-478, University of California, San Francisco, California 94143 (Dr Schmidt).
