Vasectomy Reversal | Vasectomy Reversals

Purpose: Conventional microscope-assisted vasovasostomy (MAVV) is a technically difficult procedure that is most successful in the hands of well-trained microsurgeons. Robotics may help surgeons overcome the microsurgical challenges of tremor, limited dexterity, miniaturized instrumentation and the use of fine suture. This initial experience determines the feasibility of a robotic-assisted vasovasostomy (RAVV) and compares performance measures with those of conventional MAVV.

Materials and Methods: One surgeon performed 10 vasovasostomies with a modified 1-layer technique and 9-0 suture on fresh human vas specimens-5 RAVV using the da Vinci robot and 5 MAVV using standard microsurgical instrumentation. Prespecified performance measures and adverse haptic events (broken sutures, bent needles or loose stitches) were recorded. Patency was evaluated by instilling saline through the anastomoses.

Results: The mean operating time and the number of adverse haptic events were higher for the RAVV than for the MAVV (84 vs. 38 minutes [P=0.01]; 2.4 vs. 0.0 events [P=0.03]). The number of needle passes required for the six full-thickness stitches was similar in both groups (16.8 vs. 15.2 passes [P=0.55]). Although no tremor occurred during the RAVV, minimal to moderate amounts occurred during MAVV. Minimal fatigue was noted for both groups. Patency was confirmed in all 10 operations.

Conclusions: The use of RAVV in this human ex vivo vas model was feasible. While the RAVV took longer to perform and was associated with adverse haptic events, the elimination of tremor and the comparable patency rates suggest that it may be a viable surgical alternative for microsurgical vasovasostomy.

Objective: Common contemporaneous methods for performing vasovasostomy include the two layer vasovasostomy and the modified one layer vasovasostomy, both of which require at least 12 sutures. The intussuscepted vasoepididymostomy is now an accepted and commonly used method for anastomosing the epididymis to the vas deferens. We postulated that the principle of intussusception could be adapted to vasovasostomy to create a widely patent, water-tight and simply crafted anastomosis.

Methods: We compared the two layer VV (2LVV) technique to the Intussusception VV (IVV) with respect to patency, leak and ease of performance as assessed by anastomotic time and number of haptic events. We performed 5 IVV's and 5 2LVV's on human vasa deferentia. The IVV is performed using 9-0 Nylon double armed suture (2.5 cm). The technique incorporates the principles of a horizontal mattress closure. The 1 st suture is placed with both needles passed full thickness from outside to inside the lumen on the left hand sided vas, one at 5:30 and one at 6:30 on a clock face. The other 2 sutures are placed in a similar fashion but at the 1:30/2:30 and 9:30/10:30 locations. All needles are passed from inside the lumen to outside the lumen on the right hand side of the vas deferens in matching positions. Three 9-0 nylon sutures (remnants) are then placed through the muscularis to further bolster the anastomosis. The 2LVV was performed as previously described. We recorded the anastomotic time, # sutures used, suture breakage, needle damage, patency as assessed by irrigation and suture passage, and presence or absence of leak. Following completion of the patency/leak tests, all specimens were opened to subjectively assess patency at the anastomosis and to determine if one technique produced wider anastomoses.

Results: Objectively, the average anastomotic time for the 2LVV and the IVV were 36 minutes and 20 minutes, respectively (p<0.001). A total of 3 sutures were used for each of the IVV's. All 10 anastomoses were patent and no leaks were dependent. There were two haptic events (bent needles) both in the 2LVV group. The lumens of the IVV anastomoses appeared larger than the lumen of the same vas distant from the anastomosis. This was not observed in the 2LVV specimens where the lumen at the anastamosis was similar to the lumen in the remainder of the vas segment.

Discussion: This pilot study demonstrates that the intussuscepted vasovasostomy is a technically simple method for vasal approximation associated with a high ex-vivo patency rate. It appears that this technique, by incorporating the principle of the horizontal mattress, provides a lumen at the anastomosis that is larger than the lumen elsewhere in the vas. Definitive statements regarding the clinical superiority of this technique must await in vivo stuadies.

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Dr. Wayne Kuang lectures at the world-renowned Cleveland Clinic at the 2nd Annual International Reproductive Medicine Symposium about Vasectomy Reversal.

Since 2004, Dr. Kuang has been investigating and publishing his research on applications of robotic technology such as the da Vinci surgical system to microsurgical vasectomy reversal. Aimed at helping overcome the human limitations of tremor and limited dexterity, the technology is still evolving. Dr. Kuang firmly believes that there may be a role for robotic technology in the not so distant future. Controlled clinical studies by male fertility specialists will need to be performed first.