Vasectomy Reversal Procedure - Dr. Turek's Microsurgical Method

Dr. Turek has undergone fellowship training in microsurgery and also has a history of teaching residents and fellows the vasectomy reversal procedure for 15 years. He is considered a master surgeon. Surgery for vasectomy reversal is performed in an ambulatory care facility on a come-and-go basis. A general anesthetic is most commonly used, as this offers Dr. Turek the least interruption by patient movement for this difficult, exacting microsurgery. A regional anesthetic such as a spinal or epidural block, can also be used. The patient returns home or to a hotel room after the vasectomy reversal procedure, but Dr. Turek requests that out-of-town patients stay in the San Francisco area for at least one day following the vasectomy reversal procedure before returning home.

The actual operating time for a vasectomy reversal procedure can range from 2-4 hours, depending on its complexity. About half of that time, Dr. Turek evaluates the vas deferens and epididymis to decide whether and where an epididymal obstruction exists, and the other half is spent reconnecting the system with microsurgery.

After anesthesia and scrubbing the scrotum with soap and water, the vas deferens is exposed through a 1-2 cm incision in the upper scrotum on each side, just below the pubic hair. The vas deferens is gently placed into a grooved nerve clamp and cut sharply in half with a special blade under the microscope, both above and below the vasectomy site. A special bipolar microcautery is used to judiciously control any bleeding.

One end of the vas deferens, termed the abdominal end, is flushed with salt solution to ensure that the vas deferens is open from the scrotum to the prostate (a “saline vasogram”). The testicle end of the vas deferens is then inspected for fluid. This fluid is examined in the operating room under a second microscope for color, consistency and sperm. This information is used to decide whether or not a secondary epididymal obstruction is present (see Table). If sperm are found at the testis end of the vas deferens, then it is assumed that an epididymal obstruction has not occurred and a vas deferens-to-vas deferens reconnection (vasovasostomy) is planned. If sperm are not found, then an epididymis to vas deferens connection (epididymovasostomy) is needed to restore sperm flow. Other, more subtle findings that can be observed in the fluid—including sperm fragments and clear, good quality fluid without any sperm—require keen surgical decision-making to successfully treat. This again emphasizes the strong role that surgical experience plays in the success of vasectomy reversal procedures.

For a vasovasostomy, two microsurgical approaches are possible and Dr. Turek has extensive experience with both procedures. Neither vasovasostomy procedure has proven superior to the other. What is most important for success, however, is that the surgeon use high-power optical magnification to perform the vasovasostomy, as success rates are significantly higher with an operating microscope. One approach is the modified 1-layer vasovasostomy and the other is a formal, two-layer vasovasostomy. The technical differences in suture placement between these two vasovasostomy procedures are shown in the figure below.

For this discussion, we will outline the 2-layer vasovasostomy.The two freshened ends of the vas deferens are brought closer together, off tension, by placing small sutures (size 7-0) in the tissue around the vas deferens. A vas-approximating clamp can also be used. The formal microsurgical connection is then begun. First the “back wall,” outer (serosal) sutures (size 9-0) are placed, tying the knots on the outside to protect the lumen. Then, the inner (mucosal) layer of sutures is placed with ultrafine (10-0) suture in the lumen of the vas deferens. Dr. Turek uses 6 such sutures within the lumen, locating them approximately every 60 degrees around the circumference. The first three are placed and tied, which helps “triangulate” the vas deferens lumen to facilitate optimum placement of the remaining sutures using microsurgery (see figure below):

Then, the remaining inner layer sutures are placed microsurgically, followed by the remaining outer layer sutures to complete the 2-layer vasovasostomy. This is buttressed with more sutures (size 7-0) placed circumferentially around the sheath of the vas deferens to further strengthen the connection during vasovasostomy. The completed vasovasostomy is then placed back into the scrotum and local anesthesia is given to ensure a comfortable, pain-free recovery. A similar surgical procedure is performed on the opposite side through a corresponding incision. A scrotal support is placed. Local anesthesia keeps the surgical area numb for 2-4 hours after the procedure. Dr. Turek’s vasovasovasostomy patients take an average of 6 pain pills over the next several days after the procedure and can return to light activity (short walks, working at desk) within 3 days of surgery. Heavy physical activity, including sexual intercourse or sports, is limited to 2 or 3 weeks after surgery, depending on whether a vasovasostomy or epididymovasostomy is performed.

For a vasectomy reversal procedure termed epididymovasostomy, there are also two microsurgical approaches; Dr. Turek is experienced with both. Again, neither procedure has proven superior to the other, although Dr. Turek certainly has a preference for epididymovasostomy surgery.

Overall, the epididymovasostomy procedure involves a similar surgical incision as vasovasostomy; however, the testis is usually delivered into the field for this more complex microsurgery. After the findings from the vasal fluid are reviewed showing epididymal obstruction, the epididymis is exposed by opening the outer testis covering (tunica vaginalis). The epididymis is inspected and an individual tubule selected that Dr. Turek’s experience suggests may contain moving sperm. From this point on, one of two epididymovasostomy procedures is used. In the mucosa-to-mucosa, end to side method of vasectomy reversal, an opened epididymal tubule is microsurgically connected to the cut end of the vas deferens with 4 to 6 small (10-0) simple sutures placed around the circumference of each. This “inner” layer is supported with an “outer” layer of radial 9-0 sutures to strengthen the epididymovasostomy.

Recently, a novel “invagination” epididymovasostomy was described as an alternative to the mucosa-to-mucosa epididymovasostomy. With this procedure, one, two or three “vest” sutures of 10-0 suture are placed near the opening of the epididymal tubule to allow the epididymal tubule to “invaginate” into the vas deferens, theoretically creating an epididymovasostomy with an improved watertight seal and better chances for success. Dr. Turek was an early adopter of this invagination epididymovasostomy method for vasectomy reversal and has had excellent success using it. Once the vas-deferens-epididymis connection is completed, the covering around the testis is replaced and the skin incision closed with absorbable suture.

Postoperative care for epididymovasostomy is basically the same as vasovasostomy. Dr. Turek limits heavy physical activity for 3 weeks after an epididymovasostomy procedure. Occasionally (5%), small, painless rubber drains are placed in the scrotum during the procedure, to minimize any potentially harmful collections of fluid or blood that may accumulate after surgery. Drains are usually painlessly removed the day after epididymovasostomy surgery.

Dr. Turek’s vasectomy reversal procedure