T he American Society for Reproductive Medicine issued the following guideline:
"Since it is seldom possible to determine pre-operatively if vaso-epididymostomy will be required in a man undergoing vasectomy reversal, only surgeons skilled in both vaso-epididymostomy and vasovasostomy should perform vasectomy reversal"
Let’s first have a look at some definitions and terminology:
Microsurgery – 24X Magnification
Surgery is performed with magnification provided by an operating microscope. This is a large piece of equipment that stands on a foot-piece on the floor of the operating theatre. The eyepieces (for Urologist and assistant) are positioned above the operating field. Some operating microscopes also project the magnified image onto a high definition flatscreen monitor, so that the scrub sister and other theatre personnel can follow the progress of the operation.
Surgical Loupe Magnification – 4X Magnification
Loupes look like normal glasses that a surgeon puts on but they have special lenses that provide some magnification.
Prof Zarrabi using an Operating Microscope
Surgical Loupes
The anatomical structures involved in vasectomy reversal surgery are very small:
- The lumen / inside canal of the vas deferens that the Urologist has to re-connect during vasectomy reversal is often less than half a millimeter in size (0.4 – 1.5mm)
- The lumen / inside canal of the epididymis is less than 1/10 of a millimeter in size (0.08mm).
The sutures that should be used for vasectomy reversal are very thin:
- The recommended suture is a 10-0 nylon thread with a thickness of 0.02mm – barely visible with the naked eye.
- Although thicker sutures are easier for the Urologist to handle (especially if he is not using an operating microscope), they have the disadvantages of not providing a watertight seal and of causing scar tissue that may block the delicate tube a few weeks after the operation.
It is certainly possible to re-connect the vas deferens using only loupe magnification or even no magnification, but these techniques have much lower success rates than microsurgical procedures.
It is, however, not possible to do an accurate re-connection of the vas deferens to the epididymal tube – simply because it is too small a structure to see and to work on without proper magnification. The Urologist will only know during the operation if a vaso-epididymostomy is required (up to 60% of cases) and if he is not operating with a microscope he will not be able to perform the required procedure. Most Urologists will then just continue with re-connection of the vas deferens – a useless exercise that is sure to fail in these cases because of the blockage in the epididymis which has not been dealt with. (See Important Decisions).
To ensure the highest chance of success with your vasectomy reversal, an accurate and watertight reconstruction is essential. The exact location of every stitch must be controlled, whether the re-connection is to the vas deferens or the epididymis. Your Urologist must have the skill, knowledge and equipment to diagnose epididymal blockage (intra-operative semen analysis using an additional 400X magnification microscope) and to then modify the operation if required (vaso-epididymostomy in stead of vasovasostomy). If there is no epididymal blockage and only a simple vasovasostomy is needed, a precise two-layer closure using the appropriate suture materials should be performed.