There are two different techniques for reversing a vasectomy: vasovasostomy and epididymovasostomy. Both techniques involve bypassing the obstruction in the reproductive tract. Vasovasostomy is the preferred method of vasectomy reversal when sperm are identified in the vas deferens at the time of surgery. Epididymovasostomy is the preferred method when sperm are not seen in the vas deferens.
Vasectomy reversal performed by vasovasostomy is done using an operating microscope that provides magnification 25 times the normal image size. This is important since the size of the vas deferens is about the same as a piece of spaghetti and should be sewn in two-layers to offer the highest pregnancy rates. Microscopic suture (10-0 nylon) unseen by the naked eye is used during the vasectomy reversal. It is important to use this fine suture to prevent leakage of sperm and to minimize obstruction of the lumen of the vas deferens by the suture itself. The cost of the suture itself is over $900 per vasectomy reversal!
The initial step during a vasectomy reversal is to identify whether or not there are sperm in the testicular end of the vas deferens. If sperm are identified, then a vasovasostomy can be performed successfully using microsurgical technique. If sperm are not identified then a secondary epididymal obstruction has developed and re-connecting the vas deferens at the site of vasectomy will universally be unsuccessful. This occurs 30% of the time and is dependent on several factors such as the time since your vasectomy and the site of your vasectomy. If sperm are not seen then an epididymovasostomy will be required in order to reverse the vasectomy. (see below)
The next step in a vasectomy reversal is to re-approximate the ends of the vas deferens in a tension-free manner. The 10-0 Nylon suture provides a water-tight closure for the sperm to travel through the vas deferens. If larger sized suture is used, it can cause obstruction in the vasal lumen itself.
The typical appearance of the vasal lumen after it has been precisely sewn together using 10-0 nylon suture. The suture is made of the finest non-reactive material to prevent scarring of the lumen after the surgery.
An outer layer of 9-0 nylon suture is placed to reinforce the inner layer and to relieve tension from the important inner layer. Numerous interrupted sutures are placed around the outer layer ensuring a tension-free closure.
Epididymovasostomy is required during vasectomy reversal when there is absent sperm in the vas deferens. This signifies that a secondary epididymal obstruction has developed upstream from the vasectomy site. This situation is encountered in approximately 40% of individuals after a vasectomy. Epididymovasostomy can only be performed using a high powered operating microscope, under general anesthesia, by microsurgeons using the finest suture (10-0 nylon).
The epididymis is opened and a single tubule is isolated to bypass the obstruction that has developed.
The vas deferens is then attached to the epididymis using fine sutures (9-0 nylon). This attachment brings the vas deferens into close proximity of the single epididymal tubule.
The single epididymal tubule is sewn to the inner lumen of the vas deferens using microscopic sutures to create a water-tight closure, similar to vasovasostomy.
Additional fine sutures are placed in the outer layer of the epididymis to secure the vas deferens in place and to release tension off of the fine inner sutures.
This final lower power image shows the relationship of the testis, epididymis and the bypass site after an epididymovasostomy. Sperm are made in the testis, stored in the epididymis and bypass the second obstruction through the bypass site.
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