Vasovasostomy and Vasoepididymostomy

Vasectomy reversal is a microsurgical reconstruction that restores continuity of the excurrent duct — either vasovasostomy (VV), a vas-to-vas anastomosis, or vasoepididymostomy (VE), a vas-to-epididymis anastomosis when the epididymis is also obstructed. The intra-operative appearance of the intravasal fluid dictates which operation is performed. General anaesthesia is preferred to limit motion artefact under the operating microscope. The management context (patient selection, reversal-vs-ICSI counselling, patency predictors) is covered in the Male Infertility topic, and the sterilisation procedure on the Vasectomy page; this page is the operative reference.

Indications and Patient Selection

• Reconstruction anastomoses the vas to the most distal site containing sperm. Higher patency and pregnancy rates follow a bilateral vasovasostomy, intact sperm at the reconstruction site, and a shorter obstructive interval.
• Reconstruction vs sperm retrieval + ICSI — reconstruction is preferable when the female partner has normal fertility; IVF/ICSI is favoured with female factors or a very remote vasectomy (> 25 years). The one contraindication to reconstruction is non-obstructive azoospermia.
• Anti-sperm antibodies (common after vasectomy) are not a deterrent to reversal.

Choosing Vasovasostomy vs Vasoepididymostomy

After transecting the vas, fluid is coaxed from the testicular end and examined for spermatozoa; the operation is chosen on its appearance:

Intravasal fluid	Operation
Clear, thin, watery (± sperm)	Vasovasostomy
Thick, dry, "toothpaste-like," spermless	Vasoepididymostomy (only onto a sperm-containing tubule)

Spermless, thick fluid signals epididymal obstruction, mandating a vasoepididymostomy onto a sperm-containing tubule.

Preparation and Positioning

Shave and prep the scrotum with an iodine- or chlorhexidine-based solution; prepare both groins if there is prior inguinal surgery or a large vasectomy gap (an inguinal reversal may be needed). Position the patient supine and as far toward the foot of the table as possible; the surgeon and assistant support the ulnar aspect of the hands, wrists, and forearms to minimise tremor. Set the microscope, foot pedals, and low-setting bipolar within reach.

Instruments and Sutures

Microsurgery requires an operating microscope, straight microforceps with a tying platform, a curved non-locking microneedle holder, toothed tissue microforceps, a vas clamp (Microspike), jeweller microforceps, micro-tip bipolar cautery (low setting), microscissors, and a 15° microknife. Support kit: glass slides with coverslips and capillary tubes, a microirrigator (a 10-mL syringe with a 24-gauge angiocatheter), and a bench microscope. Sutures: 9-0 nylon and double-armed 10-0 nylon on 70 µm tapered needles.

Preparing the Vas Deferens

A palpable straight-portion vasectomy site is reached through a small 1.5 cm median-raphe incision (isolating the site with a penetrating towel or no-scalpel-vasectomy clamp); bilateral high scrotal incisions are an alternative (delivering the testis with the tunica vaginalis intact), extended toward the inguinal region for a large gap or a VE. Isolate a healthy segment ~1 cm from the vasectomy site without stripping the adventitia (preserving the anastomotic blood supply), and transect it with a 90° perpendicular cut (a #10/#11 blade or an ultrasharp blade in a slotted nerve-holding clamp); a stay suture prevents migration. Examine the testicular-end fluid for sperm, then cannulate the abdominal end with the 24-gauge microirrigator and inject saline to confirm patency (free flow = patent). Approximate the ends tension-free with the vas clamp or perivasal sutures, irrigating copiously.

Vasovasostomy

Modified One-Layer Closure

Six 9-0 nylon sutures per layer. Place three full-thickness sutures (mucosa + muscularis + adventitia, incorporating the lumen) on the anterior wall and tie them, then interpose seromuscular 9-0 sutures between each. Rotate the vas clamp 180°, place three more full-thickness sutures (untied, then tied together), and interpose three more seromuscular sutures to complete the anastomosis.

Two-Layer Anastomosis

Uses double-armed 10-0 nylon (70 µm tapered needle). Place three 9-0 posterior-wall sutures (muscularis + adventitia) at the 4, 6, and 8 o'clock positions. Begin the inner (mucosal) layer with a 10-0 double-armed suture placed "inside-out" at the posterior 6 o'clock, then add adjacent sutures either side (tied once both are in), and place 3–5 more equidistant sutures anteriorly, left untied until all are placed — each catching only a little mucosa and minimal muscularis. Stain the lumen with indigo carmine and map placement with the microdot technique. Complete the outer layer with interrupted 9-0 sutures in the remaining muscularis/adventitia, ensuring a tension-free, leak-free anastomosis.

Vasoepididymostomy

When the vasal fluid is spermless (epididymal obstruction), anastomose the vas to an epididymal tubule. Confirm abdominal-end patency, place a 5-0 or 6-0 PDS stay suture in the vasal adventitia for atraumatic handling, and draw the vas through an opening in the tunica vaginalis so the anastomosis is entirely intravaginal.

End-to-Side (the standard)

Inspect the epididymis for dilated, opalescent tubules likely to contain motile sperm. Create a window in the epididymal tunica, open a single tubule to a size matching the vasal lumen, and examine the effluent for sperm. Anchor the vasal stay suture to the epididymal tunica, place 9-0 back-wall sutures (vasal adventitia/muscularis to tunica), then a direct lumen-to-lumen anastomosis (9-0 or double-armed 10-0 nylon) — visualised with indigo carmine, anterior sutures placed before tying. A second 9-0 muscularis/adventitia layer completes it.

End-to-End

The tubule is completely transected and a direct lumen-to-lumen anastomosis performed.

Intussusception (LIVE)

Classically, three triangulating sutures are placed into the tubule before it is incised. The authors' preferred modification — longitudinal intussusception vasoepididymostomy (LIVE) — places two 10-0 double-armed sutures longitudinally in the isolated tubule (needles left in situ), incises between them, and on tying intussuscepts the tubule into the vas; a second 9-0 layer finishes it as for the end-to-side repair.

Postoperative Care and Outcomes

• Discharge the same day; reduce activity for 2 weeks, with ice on day 1 and scrotal support; narcotics are usually needed for ≤ 48 hours and light work resumes in ~72 hours.
• Delay ejaculation for 3 weeks to reduce anastomotic sperm leak, granuloma, and stricture.
• Obtain a semen analysis at ~6–8 weeks, repeated at increasing intervals (e.g. 1, 3, and 6 months) until pregnancy; cryopreserve sperm once they appear (late stricture can occur), and consider a redo if azoospermia persists at 6 months.
• Motile sperm appear within ~6 months after vasovasostomy, but their return may be delayed up to 15 months or more after vasoepididymostomy.