Simplifying vasectomy reversal without compromising outcomes: a single-surgeon series

Introduction

Despite the ongoing search for alternative forms of male contraception (1), vasectomy remains the most successful solution with very low morbidity rates. The challenges of successfully reversing the procedure nonetheless remain problematic.

In 1971, Owen, an Australian-based surgeon and early proponent of microsurgery (2), developed a two-layer unilateral vasovasostomy (VV) technique, utilising five to six 10-0 nylon mucosal sutures and seven to 13 8-0 nylon muscular sutures, over a temporary 3-0 nylon stent. Patency rate was 98% (49/50) and pregnancy rate was 72% (36/50) (3). A 10-year update by Owen found a 92% patency rate (439/475) and 82% pregnancy rate (390/475) (4). For the last 5 years, Owen employed a simplified modified single-layer technique utilising an average of 12 8-0 nylon full-thickness sutures reinforced by an interrupted serosal layer.

Despite this, the two-layer technique gained further popularity through Silber, who preferred 9-0 nylon for both mucosal and muscular layers; achieving a 71% pregnancy rate for an unselected cohort (5). Unaltering his surgical technique over 30 years, Silber reported a large single surgeon VV series with 94% patency (1,281/1,357) and 92.5% pregnancy (6). Goldstein boasts the most impressive two-layer series yet reported with a 99.5% patency rate and 54% pregnancy rate, using eight 10-0 mucosal and eight 9-0 muscularis sutures (7). The two-layer technique has arguably since been considered the gold standard for VV.

Yet, in the absence of any randomised trials, a 2015 meta-analysis found no statistical difference in the patency and pregnancy rates of several studies comparing the outcomes of single and two-layer VV (8). Considerably faster operating times for single-layer surgery were reported by Fischer (96 vs. 167 minutes) (9), Lee (120 vs. 150 minutes) (10), Sharlip (135 vs. 180 minutes) (11), and Nyame (120 vs. 165 minutes) (12). Other advantages of a single-layer approach include a lesser demand for superlative microsurgical skill and reduced costs.

We report the results of a UK surgeon’s modified microsurgical single-layer VV. In a similar vein to the single-layer, 8-0 nylon VV originally pioneered by Owen in 1979, this study describes an even further simplified approach, by halving the amount of 8-0 suture material used. Hence instrumentation of the vas deferens is minimised and shorter operating times are achieved. The average internal vas diameter is only 560 microns (13), with a lumen area of 235 microns². Less passage of suture through this delicate structure allows for fewer technical errors, such as ‘back-walling’ or mucosal tearing. It is theorised that this uncomplicated approach still allows for excellent anastomotic alignment and a secure anastomosis, whilst curtailing subsequent vasal tissue reaction and ischaemia from excessive suture material and mucosal manipulation. We present this article in accordance with the STROBE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-23-604/rc).

Methods

Data was retrospectively collected from medical records on men presenting for vasectomy reversal between 2010 and 2022 to a single micro-surgical fellowship-trained andrological surgeon in Hampshire, UK. Demographic information included age at vasectomy, time to vasectomy reversal and semen analysis results. Intra-operative data collected included length of vasal gap, gap location (convoluted or straight vas) and quality of seminal fluid expressed from the cut proximal vas.

Patients were fully counselled pre-operatively, with their partner where possible. Alternatives such as surgical sperm retrieval were discussed, but no patients were denied surgery on the basis of obstructive interval alone.

The procedure was performed under general anaesthetic through a single midline scrotal incision. The testes were in turn externalised and the tunica vaginalis opened along the length of the cord to allow both ends of the divided vas to be easily identified. Scarred tissue was dissected between vasal ends which were both sharply incised with a perfectly perpendicular blade. The abdominal end was assessed for patency with gentle passage of a 0-nylon suture. Vasal fluid was expressed from the testicular end and the consistency macroscopically assessed. Only if there was complete absence or toothpaste-like discharge was an ipsilateral vasoepididymostomy (VE) performed (bilateral cases were excluded from this series).

A de-tensioning 4-0 Vicryl suture in peri-vasal fascia assisted with luminal approximation, careful bipolar haemostasis was accomplished, and a Goldstein Microspike approximator clamp applied (14). Under a ‘Leica’ surgical microscope (Wetzlar, Germany), a single-layer, six-point, 8-0 nylon anastomosis was performed. Three evenly spaced, backwall full-thickness sutures were placed (at 4, 6, and 8 o’clock) before tying sequentially (the knots external to the lumen). The Microspike clamp was rotated as required to facilitate suture placement, and a further three further full thickness front wall sutures were placed (2, 12, and 10 o’clock) then tied. A micro-vessel dilator was used at surgeon discretion if there was discrepancy in lumen size or the mucosa difficult to appreciate. In some cases, a further 1–2 interrupted 8-0 seromuscular (i.e., superficial) sutures were placed to close any sizeable discrepancies in external luminal circumference. For patients that required unilateral VE with VV, an intussusception technique was used.

Fascial and tunica layers were closed using running 4-0 Vicryl and the testis returned to the scrotum before the process was repeated on the opposite side. Bupivacaine cord blocks and closure of dartos and skin were performed following bilateral VV. Patients were discharged on the same day and counselled to use supportive underwear and avoid ejaculation for 4 weeks.

Semen analysis was performed 3 months postoperatively. The presence of motile sperm within the ejaculate was evidence of patency restoration. Sperm counts were noted as being azoospermic, oligospermic (<15 million/mL) or normozoospermic (≥15 million/mL).

The Southampton Clinical Research Institute waived the requirement for ethics approval and informed consent for this clinical audit. It was registered with the Trust Clinical Effectiveness Department of University Hospital Southampton and was conducted in accordance with the principles of the Helsinki Declaration (as revised in 2013).

Statistical analysis

Using the software package STATA (StataCorp, College Station, TX, USA), univariate analysis was performed to assess the influence of key intra-operative variables on patency rate. Categorical data was evaluated using Pearson’s chi-squared test, including obstruction interval, quality of vasal fluid and laterality of the procedure.

Results

Over a 12-year period [2010–2022], 237 men underwent microsurgical vasectomy reversal (Table 1).

The median age of men at vasectomy was 34 (range, 21–50) years. The median age at vasectomy reversal was 42 (range, 26–63) years. The median obstructive interval in this cohort was 7.3 (range, 1.2–34.5) years.

Eight men included in the study had unilateral VE. Five men were excluded from the study as they underwent bilateral VE due to absent or toothpaste like vasal fluid. The mean operative time for patients undergoing bilateral VV in this series was 87 minutes, and 109 minutes for the eight patients that underwent VE on one side.

One hundred and eighty-three men (77.2%) undergoing VV completed a semen analysis at 3 months following surgery. An overall patency rate of 85.8% was achieved (motile sperm present), with 53.8% having a sperm count greater than 15 million/mL on initial 3-month assessment (Table 2).

Although a deterioration in macroscopic quality of seminal fluid was noted with obstructive interval (Table 3), the macroscopic quality of vasal fluid expressed from the cut proximal vas did not strongly correlate with 3-month patency rate and sperm count (Table 4). Sixty-one percent of men with viscous or minimal fluid achieved patency at 3 months.

There was no statistical difference in surgical outcomes between VV involving the convoluted or straight vas (P=0.94). Nor was there any difference in patency rates between short and long (>4 cm) reconstructed vasal gaps (P=0.72). However, a very long gap length prevented bilateral VV in ten patients.

In total, a subgroup of 20 men (8.4%) underwent unilateral VV reconstruction only (ten with excessive gap length, five with failed exploration of a dry epididymis and five with a solitary testis). There was no statistical difference between core demographics (age, obstructive interval) of this subgroup and the overall cohort (Table 5). Fertility outcomes were equivalent, with an overall 3-month patency rate of 83.3% (P=0.73).

Pregnancy outcomes were not systematically collected during this period. Overall, only 7.2% (17/237) of men self-reported subsequent pregnancies, with the longest obstructive interval leading to pregnancy being 30 years.

Four complications occurred: a haematoma, a scrotal wall abscess (both requiring surgical drainage), and two minor wound infections treated with antibiotics.

Discussion

The adoption of vasectomy as a sterility procedure contentiously arose out of eugenic programs and the forcible sterilisation of prison populations in the early 20^th century (15). It’s reputation nonetheless evolved following the Second World War to become regarded as a safe and effective birth control method. However, its irreversibility was a major limitation.

For various reasons, life circumstances and outlooks can change. The advent of microsurgical VV allowed the notion of permanency of this contraceptive method to be challenged. Despite a decline in popularity over the preceding 20 years, it is estimated that 10–20,000 vasectomies are still performed annually in the UK (16) with up to 500 reversals performed each year equivalent to a reversal rate of approximately 2% (17).

Although success can never be guaranteed, the Vasovasostomy Study Group (VVSG) observed in their review of 1,247 men who had first-time microsurgical VV, that 86% had sperm within their ejaculate on postoperative semen analysis, and an overall pregnancy rate of 52% (18). Using a simplified microsurgical technique, our 3-month patency rate of 85.8% is consistent with this landmark study, which remains the benchmark of VV outcomes.

For obstructive intervals of <3, 3–8, 9–14, and ≥15 years, we found declining patency rates of 96.3%, 90.5%, 80.0%, and 74.1%, respectively (P=0.04). This is comparable to the VVSG, which also found a negative correlation over the same reported interval periods, with patency rates of 97%, 88%, 79%, and 71%, respectively.

Microsurgical VV has been shown to deliver superior outcomes compared to both macroscopic and loupe-assisted VV (19). However, despite the trend over the last 50 years of two-layer repair being recognised as the gold standard, reported benefits over single-layer VV remains contentious (8).

Our anastomotic technique upholds the essential principles of achieving mucosal apposition with sharp straight edges that is both water-tight and tension free, with the benefit of precision that microsurgical magnification allows. Whilst the outcomes in this series may simply reflect an experienced microsurgeon, we believe the results do benefit from fewer sutures. Compared to two-layer VV and methods that place in excess of 12 sutures, our approach requires less manipulation and traumatisation of the vas. Fewer sutures are thought to result in less strangulation of tissue with potentially better preservation of vascularity. There is also less risk of reducing luminal diameter due to too many sutures or ‘back-walling’.

Our modified single-layer VV uses less bulk of non-absorbable nylon, with no knots sited within the muscularis (adjacent to the mucosa). Although nylon has good tensile strength, histological studies have shown in multi-layer VV it causes high rates of intimal fibrosis and microscopic sperm granuloma formation (20). Rates of transient fertility (late failure) up to 12% have been reported in two-layer VV (21), with mean time to secondary azoospermia of 9 months (22). Belker found the rate of transient fertility to be twice as high in two- vs. single-layer VV (4.1% vs. 1.8%) (23). The transient fertility rate with our technique could not be assessed as we did not routinely perform semen analysis beyond 3 months.

The perceived benefits of our technique relate to the efficiency and ease of handling 8-0 (0.04 mm) compared to 9-0 (0.03 mm) or 10-0 (0.02 mm) nylon, passing full thickness instead of mucosal sutures, and performing fewer sutures overall. Whilst finer suture material may have been adequate, surgeon preference was for 8-0 nylon due to the higher tensile strength theoretically lowering the risk of anastomotic breakdown. This less complex approach decreases the risk of mucosal tearing, anastomotic ischaemia and poorly placed sutures, and as long as a secure well-aligned anastomosis can be achieved to allow proper healing, then we feel there are diminishing returns from applying more and more sutures.

The learning curve is likely flatter than two-layer VV for budding reconstructive microsurgeons, and the procedure takes up to an hour less time (9). Modified single-layer VV using 9-0 nylon, has been priced at over $1,000 US dollars (USD) cheaper than conventional 10-0 two-layer VV, with savings of $590 USD in suture material alone (12).

Microscopic examination of vasal fluid with Silber grading is used by many to help guide intra-operative decision making. However, its role remains contentious amongst experts. The VVSG found patency rates of 75% and 60% even for the poorest of Silber grades 4 (sperm heads only) and 5 (no sperm parts), respectively (18). Microscopic assessment is not routinely performed in our hospital. We utilised macroscopic appearance, performing VE only for absent or toothpaste like vasal fluid. We found that the macroscopic quality of intra-operative vasal fluid was not strongly associated with patency outcomes. Sixty-one percent of patients with minimal or viscous fluid achieved patency compared to 92% of patients with copious or watery fluid.

Neither site of repair (convoluted or straight vas) nor length of vasal defect (greater than 4 cm) influenced patency rate. This supports our belief that this technique adequately copes with the irregular luminal size seen in the convoluted vas, and that 8-0 nylon sufficiently reduces tension on the anastomosis across larger defects. No difference in outcomes were noted in the 8.4% of men that underwent unilateral VV.

Although patency is a legitimate measure of technical procedural success, pregnancy is the ultimate desired outcome. A limitation of our study is the paucity of pregnancy data, a consequence of follow up not extending beyond 3 months if semen parameters were acceptable. Three-month semen analysis was deemed a reasonable assessment point, as mean time following VV to patency and motility are 1.7 and 2.2 months, respectively (24). Since no standard definition of patency exists within the literature, we have reported two outcomes: the presence of motile sperm, and normozoospermia (sperm concentration greater than 15 million/mL) (25).

In total, 21.5% of men never completed a 3-month semen analysis despite receiving correspondence from the surgeon urging them. Presumably some achieved early pregnancy spoiling their curiosity to assess VV patency. Others may have moved areas or undergone changed circumstances. Similar loss to follow up (19%) was reported by the VVSG (18). Schwarzer reported in his series of 1,708 VV a 32% loss to follow up with no semen analysis (26).

Future VV studies are now turning their attention to the difference in patency and pregnancy outcomes of conventional microsurgery vs. robotic VV (27). Factoring in longer operative time, increased cost, steeper learning curve and absence of pregnancy outcomes with robotic VV, conventional microsurgery appears to have the upper hand, for the time being (28). For now, our study confirms that excellent patency rates approaching 90% can be achieved with microsurgical VV. It supports modified single-layer VV as a robust alternative with multiple advantages when compared to the classic two-layer technique. Indeed, as things currently stand, the ‘gold standard’ mantle does not rest securely upon any one microsurgical approach.

Conclusions

This large contemporary single-surgeon series of simplified microsurgical VV technique demonstrates that fewer sutures and manipulation of the vas deferens can help achieve similar patency outcomes to the traditionally described two-layer technique, with shorter operating times and lower costs. We also found that this technique can produce similar outcomes in the convoluted vas, and in unilateral repair. Future work will involve correlating the surgical outcomes of this technique to longer-term outcomes and pregnancy rates.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-23-604/rc

Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-23-604/dss

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-23-604/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-23-604/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The Southampton Clinical Research Institute waived the requirement for ethics approval and informed consent for this clinical audit. It was registered with the Trust Clinical Effectiveness Department of University Hospital Southampton and was conducted in accordance with the principles of the Helsinki Declaration (as revised in 2013).

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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