VIEWS: 3 PAGES: 3 POSTED ON: 8/25/2012
Ann R Coll Surg Engl 1997; 79: 420-422 Reversal of vasectomy using a macroscopic technique: a retrospective study Robert G Mason FRCSGIas* John C Bull FRCS Senior House Officer in Surgery Consultant Surgeon Philip G Connell BDS LRCP MRCSt Senior House Officer in Surgery Crawley Hospital, Crawley, West Sussex Key words: Reversal of vasectomy; Vasovasostomy Eighty-five men underwent vasectomy reversal in our Method department between 1981 and 1994. All operations were performed without the aid of magnification. The We identified all vasectomy reversal operations that were results of semen analysis was available in 66 and the performed by one surgeon (JCB) from our theatre patency rate was 74%. A postal survey was sent to records. To allow adequate post-procedure follow-up, patients we could follow up, and among those who patients operated on after 1994 were not included. All replied the pregnancy rate was 41% (16/39 respon- dents). These results are similar to those found by patients were sent a postal questionnaire asking about any others using a macroscopic reversal of vasectomy and subsequent pregnancies. The records of semen analysis since the operator does not rely on the use of a were also reviewed. The operations were all performed microscope, which both incurs an added cost and under the same conditions and the procedure changed requires extra expertise, we feel that the operation as little. Patients were given a general anaesthetic, the vasa described has a part to play in the management of were explored through two oblique groin incisions (all men seeking reversal of vasectomy. patients had a bilateral procedure), and an end-to-end vasovasostomy was performed. As the senior author has presbyopic vision, he performed the anastomosis with the aid of reading glasses. Neither loupes nor microscopes Vasectomy reversal is required in up to 3% of men who were employed. A single layer transmural anastomosis undergo vasectomy (1). It therefore has the potential to using eight 6/0 prolene sutures was performed and in all impose a significant burden on any surgical practice. cases the lumen were stented with 1/0 nylon for 5 days. Since the first report by O'Conor (2), many techniques The operation time averaged 1 h. After discharge, all have been described, either macroscopic or involving the patients were followed up in outpatients for removal of aid of loupe or operating microscope magnification, and the stents and given instructions to return in 12 weeks varying success rates have been reported. We describe a with a semen sample. They were then discharged to the method of macroscopic vasectomy reversal and the results care of their general practitioner. achieved. We also review the results of similar studies and highlight the main causes of failure. Results In all, 85 patients were identified who had vasectomy reversal performed between 1981 and 1994. They ranged in age from 26 years to 53 years (mean 38.3 years). Present appointments: Seminal analysis was available in only 66 (78%). Of these, * Research Fellow, Royal Postgraduate Medical School, London sperm were present in 49 giving a patency rate of 74% t Senior House Officer in Plastic Surgery, St Thomas' Hospital, (Table I). Only 79 were sent a questionnaire (six lost to London follow-up, or no address) and of these 39 replied, giving a Correspondence to: Mr J C Bull, Consultant Surgeon, Crawley response rate of 49%. The results of our questionnaire Hospital, Crawley, West Sussex RH 1l 7DH revealed that four had not tried for a pregnancy (10%), 16 Reversal of vasectomy 421 Table I. Clinical data and results of questionnaires (mean) Table III. Results of previous studies Age at vasectomy reversal 26-53 years (38.3 years) No of Patency Pregnancy Interval between vasectomy Author cases (%) (%) and reversal 1-17 years (8.29 years) Interval for successful patients 1-15 years (7.7 years)* White and Sheridan (5) 33 64 17 Interval for unsuccessful Lee (6) 300 84 35 4-17 years (8.0 years)* Dewire and Lawson (7) 32 89 41 patients Patency rate 74% Griffiths (8) 15 73 26.6 Pregnancy rate 41% Kessler and Freiha (9) 83 92 45 Sibler (10) 282* 91 81 * Difference not significant (P <0.1) Belker et al. (11) 1012*t 86 52 Wicklund and Alexander (12) 2685t 49 21 * Microscopic technique Table II. Comparison of semen quality with pregnancy outcome* t Collective review Sperm count No of men (%) Pregnancy rate (%) suggest that a patency rate of between 84% and 92% is Fertile 13 (37) 9/13 (69) possible and a pregnancy rate of 35% and 45% may also Subfertile 12 (34) 7/12 (58) be achieved (Table III). A recent survey of Welsh Azoospermia 10 (28) surgeons and urologists revealed that 43% used no * Data from patients responding to questionnaire magnification, while only 3% used a microscope (5). Undeniably, microscopic repair, especially with a two- layered technique, such as that described initially by had achieved pregnancy (41%) and 19 had not been Sibler (13) and Fox (4) gives better results. However, not successful (49%). only does the operator require an expensive operating We also found that the time between vasectomy and the microscope but also the frequent use of the skills required reversal operation varied from 1 to 17 years (mean 8.29 to maintain the necessary expertise. Whatever the years). The mean time in 'successful' couples was 7.7 technique used, the most important considerations years (range 1-15 years) and for 'unsuccessful' couples appear to be meticulous surgical technique to enable the was 8.0 years (range 4-17 years), this difference is not production of a leak-proof anastomosis to prevent sperm significant (P < 0.1). granulomata formation and subsequent scarring/vas We looked further at the results of the group obstruction as well as a limited mobilisation in order to completing the questionnaire (Table II) and their semen minimise disturbance to the blood supply. Variations in quality as defined by the WHO (3). The criterion for operative technique exist, with some authors advocating a normal fertility is a count of >20 million sperm/ml, side-to-side anastomosis (14) as opposed to the end-to- progressive motility of 50% and morphologically normal end technique used in our study. The use of a luminal forms in at least 30%. In total, 13 men (37%) had normal stent is also subject to debate (15), but we feel that it postoperative sperm quality, 12 men (34%) were allows accurate opposition of the two ends of the vas subfertile in one or more of the parameters, and 10 men during a macroscopic repair and that it prevents sperm (28%) had no sperm present. Of the 13 with 'fertile' leakage during anastomotic healing. In our fairly large counts, nine men (69%) had a successful outcome, study, 85 procedures were performed over 14 years giving whereas for the 'subfertile' group seven of 12 had a an average of six per year. We believe this does not successful outcome (58%). constitute regular use, and we have no other applications for a microscope on a general surgery/urology firm. Our results bear some comparison with other published Discussion series on macroscopic repair (Table II) in terms of patency rate, but obviously the pregnancy rate must be As vasectomy is a popular and reliable form of birth examined with caution as only 39 patients (49%) control, it is inevitable that vasectomy reversal will responded to our questionnaire, but this is likely to be continue to be requested for a variety of reasons, most owing to the mobile population presenting for reversal of commonly owing to a change of partner following divorce vasectomy as well as the possible bias of successful/ or separation (1). Vasectomy reversal holds a fairly low unsuccessful repondents. The length of time between priority in an ever stretched national health service and vasectomy and its reversal has been found to have an the provision of a quick, reliable and low cost technique is important bearing on the success of the operation (11), therefore desirable. Many recent reports of techniques for but we found that there was no significant difference vasectomy reversal have relied on the use of an operating between the means in our successful and unsuccessful microscope and the results, both in terms of patency rate cases. Furthermore, it was found when looking at the and pregnancy rate appear to be superior to those results of those with patent vasa after surgery, that an achieved by surgeons employing a macroscopic techni- equal percentage of those operated on 10 years or more que (4). after vasectomy, and those who were being reversed after The best reported results of a macroscopic repair less than 10 years, had a normal sperm count. However, 422 R G Mason et al. since our study yielded a patency rate lower than that in 4 Fox M. Vasectomy reversal-microsurgery for best results. some reports it is possible that a number of cases which BrJ7 Urol 1994; 73: 449-53. may have been reversed by a superior technique have 5 White AET, Sheridan WG. Reversal of vasectomy and the artificially lowered the percentage achieving a normal general surgeon. Br J Clin Pract 1994; 48: 238-9. sperm count 1-9 years after vasectomy. Failure to achieve 6 Lee HY. A 20 year experience with vasovasostomy. J Urol 1986; 136: 413-15. fertility after reversal of vasectomy can often be attributed 7 Dewire DM, Lawson RK. Experience with macroscopic to the production of antisperm antibodies which, when vasectomy reversal at the Medical College of Wisconsin. present in high titres, leads to impairment of fertility; Winsconsin Med J 1994; March: 107-9. however, despite the immunological basis of the problem, 8 Griffiths CL. Reversal of vasectomy: vasovasostomy. J R it remains refractory to treatment (16). Anastomotic Army Med Corp 1987; 133: 87-8. blockage or stenosis appears to be the most important 9 Kessler R, Freiha F. Macroscopic vasovasostomy. Fertil cause of failure. In one reported series of patients Steril 1981; 36: 531-2. undergoing exploration of the scrotum after unsuccessful 10 Sibler SJ. Pregnancy after vasovasostomy for vasectomy reversal procedures, 12 out of 23 azoospermic cases were reversal: a study of factors affecting long term return of found to have blocked vasa and repeat vasovasostomy fertility in 282 patients followed for 10 years. Hum Reprod resulted in normal sperm counts (17). 1989; 4: 318-22. 11 Belker et al. Results of 1469 microsurgical vasectomy To summarise, we feel that macroscopic techniques reversals by the vasovasostomy study group. J Urol 1991; have a place in the reversal of vasectomy, as it offers 145: 505-11. satisfactory results and is an easier procedure for the 12 Wicklund R, Alexander NJ. Vasovasostomy: evaluation of surgeon dealing with relatively few cases. Good counsel- success. Urology 1979; 13: 532-4. ling to prospective patients detailing the possibility of 13 Sibler SJ. Microscopic vasectomy reversal. Fertil Steril 1977; success is necessary. A cost saving benefit is also apparent 28: 1191-1202. in units where the hardware for microscopic surgery is not 14 Hendry WF. Vasectomy and vasectomy reversal. Br J Urol available. 1994; 73: 337-44. 15 Thomas AJ, Pontes JE, Buddhdev H, Pierce JM. Vasova- sostomy: evaluation of four surgical techniques. Fertil Steril References 1979; 32: 324-8. 16 Hendry WF et al. Comparison of prednisolone and placebo in subfertile men with antibodies to spermatozoa. Lancet 1 Howard G. Who asks for vasectomy reversal and why? BMJ 1990; 335: 85-8. 1982; 285: 490-92. 17 Royle MG, Hendry WF. Why does vasectomy reversal fail? 2 O'Conor VJ. Anastomosis of the vas deferens after BrJ Urol 1985; 57: 780-83. purposeful division for sterility. J Urol 1948; 59: 229-33. 3 World Health Organisation. WHO Laboratory Manual for Received 18 April 1997 the Examination of Human Semen and Sperm-Cervical Mucus Interaction. 3rd Edition. New York: Cambridge University Press, 1992: 43-4.
Pages to are hidden for
"Reversal of vasectomy using macroscopic technique"Please download to view full document