Montreal--As the controversy over whether to perform vasovasostomy or vasoepididymostomy for vasectomy reversal rages, two small studies have provided some new insight into when to choose one surgical technique over the other. One study demonstrates that expert surgeons can provide better results with vasoepididymostomy among patients with vasospermia, defined as no sperm in the vasal fluid, regardless of the condition of the vasal fluid. The second study suggests that the presence of sperm parts in the vasal fluid signals that vasovasostomy might be the better option.
While vasovasostomy is a simpler procedure that physicians become adept at more easily, vasoepididymostomy is required for secondary obstructions in the epididymis. But determining the presence of that obstruction is not always straightforward.
Criteria used to determine choice of procedure include the presence or absence of sperm or sperm parts in the fluid from the testicular end of the vas deferens or, in the absence of sperm or sperm parts, the gross appearance of the vasal fluid. However, these conditions can be determined only after surgery has begun, so physicians must be prepared to perform either procedure.
However, in expert hands, vasoepididymostomy should be performed when no sperm is seen in the testicular end of the vas deferens, regardless of the quality of the vasal fluid, countered Dharm Singh, MD, an attending urologist at Campbellton Regional Hospital, New Brunswick, Canada.
"A general urologist who is doing vasovasostomy, if he is not very confident in [performing] vasoepididymostomy, should send patients to a fellowship-trained urologist, rather than doing it himself. During the operation, if they find no sperm, what will they do? They will either close or they will do vasovasostomy," Dr. Singh told Urology Times.
Both urologists presented data on vasectomy reversal techniques at the American Society for Reproductive Medicine annual meeting.
In the retrospective chart review led by Dr. Singh, 97 patients who had undergone either a primary or redo vasectomy reversal between January 1999 and April 2004 were assessed for the type of surgery they received (ie, vasovasostomy or vasoepididymostomy) and subsequent patency rates. Patency was defined as the presence of sperm in the ejaculate.
Among the 75 patients who underwent a primary vasectomy reversal, 31% had at least one side with vasospermia. Twelve percent of these patients required bilateral vasoepididymostomy, which resulted in a patency rate of 100%, a rate higher than that reported for vasovasostomy in men with vasospermia, even when the vasal fluid is clear.
Among the 22 patients who underwent redo vasectomy reversal, 59% had at least one side with vasospermia. In this group, 36% of patients required bilateral vaso-epididymostomy, with a patency rate of only 63%, a rate significantly lower than the 100% rate achieved when vasoepididymostomy was performed the first time around.
"Not every urologist is confident in doing vasoepididymostomy because it is a difficult procedure to do. That's why some people do vasovasostomy even if there is no sperm from the testicular end of the vas deferens," Dr. Singh said.
"We think that, in expert hands, we should directly do the vasoepididymostomy [in the presence of vasospermia, even if the vasal fluid is clear] because at least we have sperm in the epididymis. There is no point in subjecting these patients to a second operation... if you can give the same or better success rate with the first operation."
Time is often of the essence for these patients because their female partners are aging even as they are attempting to regain fertility, he said. Cost is another important reason a second surgery should be avoided because many of these patients pay out of pocket.