0022-5347 /78/1201-0078$02.00/0 Vol. 120, July Printed in U.SA.
THE JOURNAL OF UROLOGY
Copyright © 1978 by The Williams & Wilkins Co.
VASOVASOSTOMY: THE FLAP TECHNIQUE TERENCE J. FITZPATRICK From the Department of Urology, Kaiser Permanente Medical Center, Los Angeles, California
ABSTRACT
The approximation of 2 pairs of broad, transverse vas flaps at right angles to the reanastomosis perma1;1ently ~idens the opening into each vas lumen. All patients undergoing this procedure had sperm m the eJaculates 5 weeks postoperatively and by 6 months there was a pregnancy rate of 64 per cent. A new simplified vas reversal technique that specifically ensures continued wide patency of the vasovasostomy site has been developed and used clinically. An extra wide vas lumen is created at the site of reanastomosis by the accurate apposition of 2 pairs of large, transverse bivalved vas flaps that, when approximated at right angles to the reanastomosis, permanently widen the opening into each vas lumen. This flap technique prevents sperm leakage, luminal stenosis and sperm granuloma. The simplicity of the procedure is one of the advantages over the interluminal anastomosis. L 2 With the ever-increasing number of clinical requests for vas reversal this technique can be performed reliably within the stricture-prone convoluted portion of the vas deferens. Expertise with the operating room microscope is unnecessary, no luminal splints are required and the technique can be accomplished without specially trained operating room assistants. 3 All 14 subjects operated upon had viable sperm in the ejaculates 6 weeks postoperatively. Ninety per cent of the sperm counts were within a normal range with more than 30 million per cubic centimeter. By 6 months postoperatively there was a pregnancy rate of 64 per cent.
to approximate the lumina and vas walls on each end and on each side of the paired flaps (part C of figure). The approximation of the sutures aligns the anastomosis and prevents sperm leakage and granuloma. Each pair of bivalved flaps lies at right angles to the reanastomosed vas deferens and, when sutured together, permanently widens the opening into each vas lumen. Interrupted 6-zero prolene sutures are used to approximate the carefully preserved fascia of the vas over the vasovasostomy site (partD of figure). This procedure permanently fixes the anastomosis in place and adds additional support and blood supply. The scrotal incision is approximated loosely with 3-zero chromic sutures. The patients usually are discharged from the hospital in 24 hours. RESULTS AND DISCUSSION
Silber and associates have stated that when the sperm count and mobility decrease rather than increase after vas reversal the anastomosis is probably stricturing down. 1 Our success has been owing to the use of our vas flap technique. Unlike all other vas reversal procedures an enlarged vas lumen is assured at the very site of potential postoperative vas strictures. Fourteen patients, ranging from 27 to 43 years old, cooperated in this preliminary study. All patients underwent vas reversal by the same surgeon and all had sperm in the ejaculate 6 weeks postoperatively, with an average of 31 million per cubic centimeter. Motility averaged 50 per cent in 10 patients less than 35 years old whose previous vasectomy had been done within 5 years of vas reversal. By 3 months postoperatively there was a pregnancy rate of 50 per cent. By 6 months postoperatively the average sperm count had risen to 55 million. All patients continued to have sperm in the ejaculate and the motility of 50 per cent maintained or bettered itself in every instance, confirming the remarkable spermatogenic recovery of the testis. The pregnancy rate had increased to 64 per cent. The time required for new, fully formed sperm to develop is approximately 74 days. 4 In the present series 3 pregnancies occurred less than 2 months after vas reversal. This fact confirms that sperm trapped within the vas and epididymis owing to the previous vasectomy are capable of impregnation. Unfortunately, it is apparent that the majority of vasectomies are not being performed above the proximal convoluted portion of the vas. In our series 70 per cent of the anastomoses required the approximation of the cut end of the convoluted vas. The vas wall varied from being thick to usually thin, depending on the site selected for the anastomosis and the location and symmetry of its vas lumen. It may be that in the past the failure to align the more asymmetrical proximal end of the vas properly to the more symmetrical distal end has commonly led to strictures, with subsequent reduced sperm
TECHNIQUE
The vas deferens and its area of previous vas ligation identified through a 3 cm. midline scrotal incision. A longitudinal incision is made through its overlying, densely adherent fascia to expose the proximal and distal normal vas. The perivasal fascia with its accompanying blood and nerve supply should be preserved carefully. The fascia prevents retraction of the cut ends of the vas and is used later to envelop and strengthen the vasovasostomy site. Transverse incisions are made through the walls of the normal proximal and distal vas. The site of the previous vas ligation is excised. A glass slide is smeared with the spermatic fluid from the proximal end of the vas for immediate sperm identification. With the aid of an Optiviser Binocular Loupe No. 5, microsurgical jewellers' forceps are used to identify and dilate the proximal and distal vas lumina. To facilitate the anastomosis it has been necessary at times to straighten 1 cm. of proximal convoluted vas by freeing its outermost fibrous attachments. The tip of a straight pediatric fine-tip dissector is introduced into the dilated lumen of each cut end of the vas and bivalved for approximately 3 mm. (part A of figure). The lumina beyond the newly created pairs of vas flaps are identified again and dilated with microsurgical forceps. Beginning from within each of the proximal and distal vas lumina, 6-zero double-swedged on prolene sutures are passed through each of the side walls of the lumina, just beyond the incision creating the bivalved flaps (part B of figure). Three additional 6-zero double-swedged on prolene sutures are used Accepted for publication August 12, 1977. 78
A, vas bivalved. B, placement of first pair of double-swedged sutures just beyond bivalved flaps. C, anastomosis of bivalved flaps at right angles to vas enlarges vasovasostomy lumen. D, completed reanastomosis and reapproximation of its fascia.
counts and poor motility. If no luminal strictures develop the testis and epididymis have remarkable spermatogenic recovery within a few months. The new vas reanastomosis flap technique with its extra wide lumina returns the ever-increasing number of requests for vas reversal back to the average urologist's armamentarium. The bleak outlook for successful vasovasostomy may no longer exist. The more conventional end-to-end anastomotic splinting techniques, within the convoluted portion of u,~~-HAH.,
REFERENCES
1. Silber, S. S., Galle, J. and Friend, D.: Microscopic vasovasos-
tomy and spermatogenesis. ,J. Ural., 117: 299, 1976. 2. Schmidt, S. S.: Vas anastomosis. A return to simplicity. Brit. J. Urol., 47: 309, 1975. 3. Lingardh, G., Duchek, M., Nelson, C. E. and Winklad, B.: Vasovasostomy suture technique: an experimental study in the dog. Urol. Res., 2: 1974. 4. Karafin, L. and Kendall, Urology. New York: Harper & Row, Publishers, Inc., vol. 2, chapt. 21, p. 4, 1973.
THE JOURNAL OF UROLOGY
Copyright © 1978 by The Williams & Wilkins Co.
VASOVASOSTOMY: THE FLAP TECHNIQUE TERENCE J. FITZPATRICK From the Department of Urology, Kaiser Permanente Medical Center, Los Angeles, California
ABSTRACT
The approximation of 2 pairs of broad, transverse vas flaps at right angles to the reanastomosis perma1;1ently ~idens the opening into each vas lumen. All patients undergoing this procedure had sperm m the eJaculates 5 weeks postoperatively and by 6 months there was a pregnancy rate of 64 per cent. A new simplified vas reversal technique that specifically ensures continued wide patency of the vasovasostomy site has been developed and used clinically. An extra wide vas lumen is created at the site of reanastomosis by the accurate apposition of 2 pairs of large, transverse bivalved vas flaps that, when approximated at right angles to the reanastomosis, permanently widen the opening into each vas lumen. This flap technique prevents sperm leakage, luminal stenosis and sperm granuloma. The simplicity of the procedure is one of the advantages over the interluminal anastomosis. L 2 With the ever-increasing number of clinical requests for vas reversal this technique can be performed reliably within the stricture-prone convoluted portion of the vas deferens. Expertise with the operating room microscope is unnecessary, no luminal splints are required and the technique can be accomplished without specially trained operating room assistants. 3 All 14 subjects operated upon had viable sperm in the ejaculates 6 weeks postoperatively. Ninety per cent of the sperm counts were within a normal range with more than 30 million per cubic centimeter. By 6 months postoperatively there was a pregnancy rate of 64 per cent.
to approximate the lumina and vas walls on each end and on each side of the paired flaps (part C of figure). The approximation of the sutures aligns the anastomosis and prevents sperm leakage and granuloma. Each pair of bivalved flaps lies at right angles to the reanastomosed vas deferens and, when sutured together, permanently widens the opening into each vas lumen. Interrupted 6-zero prolene sutures are used to approximate the carefully preserved fascia of the vas over the vasovasostomy site (partD of figure). This procedure permanently fixes the anastomosis in place and adds additional support and blood supply. The scrotal incision is approximated loosely with 3-zero chromic sutures. The patients usually are discharged from the hospital in 24 hours. RESULTS AND DISCUSSION
Silber and associates have stated that when the sperm count and mobility decrease rather than increase after vas reversal the anastomosis is probably stricturing down. 1 Our success has been owing to the use of our vas flap technique. Unlike all other vas reversal procedures an enlarged vas lumen is assured at the very site of potential postoperative vas strictures. Fourteen patients, ranging from 27 to 43 years old, cooperated in this preliminary study. All patients underwent vas reversal by the same surgeon and all had sperm in the ejaculate 6 weeks postoperatively, with an average of 31 million per cubic centimeter. Motility averaged 50 per cent in 10 patients less than 35 years old whose previous vasectomy had been done within 5 years of vas reversal. By 3 months postoperatively there was a pregnancy rate of 50 per cent. By 6 months postoperatively the average sperm count had risen to 55 million. All patients continued to have sperm in the ejaculate and the motility of 50 per cent maintained or bettered itself in every instance, confirming the remarkable spermatogenic recovery of the testis. The pregnancy rate had increased to 64 per cent. The time required for new, fully formed sperm to develop is approximately 74 days. 4 In the present series 3 pregnancies occurred less than 2 months after vas reversal. This fact confirms that sperm trapped within the vas and epididymis owing to the previous vasectomy are capable of impregnation. Unfortunately, it is apparent that the majority of vasectomies are not being performed above the proximal convoluted portion of the vas. In our series 70 per cent of the anastomoses required the approximation of the cut end of the convoluted vas. The vas wall varied from being thick to usually thin, depending on the site selected for the anastomosis and the location and symmetry of its vas lumen. It may be that in the past the failure to align the more asymmetrical proximal end of the vas properly to the more symmetrical distal end has commonly led to strictures, with subsequent reduced sperm
TECHNIQUE
The vas deferens and its area of previous vas ligation identified through a 3 cm. midline scrotal incision. A longitudinal incision is made through its overlying, densely adherent fascia to expose the proximal and distal normal vas. The perivasal fascia with its accompanying blood and nerve supply should be preserved carefully. The fascia prevents retraction of the cut ends of the vas and is used later to envelop and strengthen the vasovasostomy site. Transverse incisions are made through the walls of the normal proximal and distal vas. The site of the previous vas ligation is excised. A glass slide is smeared with the spermatic fluid from the proximal end of the vas for immediate sperm identification. With the aid of an Optiviser Binocular Loupe No. 5, microsurgical jewellers' forceps are used to identify and dilate the proximal and distal vas lumina. To facilitate the anastomosis it has been necessary at times to straighten 1 cm. of proximal convoluted vas by freeing its outermost fibrous attachments. The tip of a straight pediatric fine-tip dissector is introduced into the dilated lumen of each cut end of the vas and bivalved for approximately 3 mm. (part A of figure). The lumina beyond the newly created pairs of vas flaps are identified again and dilated with microsurgical forceps. Beginning from within each of the proximal and distal vas lumina, 6-zero double-swedged on prolene sutures are passed through each of the side walls of the lumina, just beyond the incision creating the bivalved flaps (part B of figure). Three additional 6-zero double-swedged on prolene sutures are used Accepted for publication August 12, 1977. 78
A, vas bivalved. B, placement of first pair of double-swedged sutures just beyond bivalved flaps. C, anastomosis of bivalved flaps at right angles to vas enlarges vasovasostomy lumen. D, completed reanastomosis and reapproximation of its fascia.
counts and poor motility. If no luminal strictures develop the testis and epididymis have remarkable spermatogenic recovery within a few months. The new vas reanastomosis flap technique with its extra wide lumina returns the ever-increasing number of requests for vas reversal back to the average urologist's armamentarium. The bleak outlook for successful vasovasostomy may no longer exist. The more conventional end-to-end anastomotic splinting techniques, within the convoluted portion of u,~~-HAH.,
REFERENCES
1. Silber, S. S., Galle, J. and Friend, D.: Microscopic vasovasos-
tomy and spermatogenesis. ,J. Ural., 117: 299, 1976. 2. Schmidt, S. S.: Vas anastomosis. A return to simplicity. Brit. J. Urol., 47: 309, 1975. 3. Lingardh, G., Duchek, M., Nelson, C. E. and Winklad, B.: Vasovasostomy suture technique: an experimental study in the dog. Urol. Res., 2: 1974. 4. Karafin, L. and Kendall, Urology. New York: Harper & Row, Publishers, Inc., vol. 2, chapt. 21, p. 4, 1973.
