During their fellowship training, future vasectomy reversal experts learn that meticulous surgical technique is vital to optimal microsurgical outcomes. The latest techniques typically take an experienced microsurgical expert 2.5 to 3 hours of operative time, and sometimes longer depending on the situation. An operating microscope is always used (not ‘surgical loupes’ which are less powerful smaller scopes which are worn on the surgeon’s head) as are extremely fine 9-0 and 10-0 sutures (the higher the number, the smaller the size of the suture). As described previously, fellowship trained microsurgical experts almost always use general or spinal anesthesia as the patient must remain completely motionless during the procedure to allow precision surgery. For this reason, I do not personally know of any of my fellowship-trained colleagues who use only local anesthesia for reversals. Vasectomy reversals can be performed in one of two ways:
a) Vasovasostomy- ‘vas-to-vas’ connection
b) Vasoepididymostomy- ‘vas-to-epididymis’ connection
In a 'vas-to-vas'connection, the blocked areas (where the vas deferens had been cut, tied, burned, etc. during the original vasectomy procedure) are removed and the two ends of the tube carefully re-attached. The epididymis is the structure which wraps around the side of the testicle, and is where sperm maturation takes place. In a 'vas-to-epididymis' connection, the vas deferens is attached to one of these delicate epididymal tubules. The epididymal tubules are smaller than the vas deferens, and therefore it takes less scar tissue to block them off. Therefore, a vas-to-vas connection has a higher chance of success, and is always performed if possible.
Vas-to-epididymis connections are more technically difficult to perform and take longer to complete than a vas-to-vas connection. At any vasectomy reversal, either of these connections might be necessary. Which type of connection that will be needed is not known until the time of the procedure, when the tied-off or clipped end of the vas deferens going towards the testicle is opened up. A drop of the vasal fluid from each side is then examined microscopically and the results tell the surgeon what type of connection will be needed. “Favorable” fluid typically contains sperm or sperm parts and indicates that a vas-to-vas connection can be performed. “Unfavorable” fluid is seen when either no fluid comes out or thick creamy fluid with no sperm is seen, and this finding indicates that a vas-to-epididymis connection will be necessary.
Most non-Urologists and General Urologists do not know how to adequately perform at vas-to-epididymis connection, a skill that is typically only learned during 1-2 years of microsurgical fellowship training. If “unfavorable” fluid is found at the time of a reversal and the surgeon does not know how to perform a vas-to-epididymis connection, then the reversal will almost invariably be unsuccessful on that side. Typically, the more years which have passed since the time of the vasectomy increases the chances of needing a vas-to-epididymis connection. This is why the websites of many non-fellowship trained experts place a limit on who they will see based upon the number of years since the vasectomy was performed (e.g. “For Men with Vasectomy Performed 9 years out or Less”). These surgeons are trying to decrease the chance that they will be confronted with a situation in which a vas-to-epididymis connection is needed during the operation, since they likely have not been trained in these advanced microsurgical techniques. The problem is that, although the chance of needing a vas-to-epididymis connection increases with time, it may be necessary to perform at any number of years since the vasectomy. In my practice, I routinely find “unfavorable” fluid requiring a vas-to-epididymis connection in men who are 9 years or less out from their vasectomy, and have personally had patients as little as one year out from their vasectomy who have needed a vas-to-epididymis connection.
We always hope that a vas-to-vas connection can be performed, as the chances for success are higher. However, it is very important that your vasectomy reversal doctor know how to perform a vas-to-epididymis connection if needed so that the proper reversal procedure can be performed no matter what the findings in the vasal fluid are at the time of the procedure.
