AsktheExpert

VASECTOMY REVERSAL MYTHS AND MISCONCEPTIONS DISPELLED

Philip Werthman, MD, FACS

Director, Center for Male Reproductive Medicine & Vasectomy Reversal

Clinical Assistant Professor of Urology

USC School of Medicine

Los Angeles, California

In this new section I will point out many myths and fallacies about vasectomy reversal and discuss truths versus marketing/advertising on the internet. There is loads of good information about reversals on the web but unfortunately there is more misinformation, that, if followed can actually be harmful to the patient and the success of the surgery. I am basing this information on scientific data, published studies and a combined 30 years of reversal experience between my partner and myself. While in Medicine there is not only one correct way of doing something there certainly are agreed upon optimal and sub-optimal or sub-standard approaches. I will try to point these out where possible.

1. How many layers are in the vas and how many sutures/ layers should be placed during a vasectomy reversal?

The vasal anatomy, the number of sutures a surgeon places and the layers that are re-approximated during a vasectomy reversal are linked because you must know how the vas is organized in order to understand how best to put it back together during a reversal.

The vas deferens is a muscular tube that transports the sperm from the epididymis (where the sperm are stored) up to the prostate. The vas has an outer diameter of 2-3 millimeters and an inside or luminal diameter of a third to half a millimeter (the size of a pen dot). The vas is about 18 inches long and it is comprised of 2 intrinsic layers. There is a thick muscular layer which is actually formed of 3 different bands of muscle that are interwoven and inseparable and are too small to be seen even under the operating microscope and a mucosal layer that lines the channel the sperm swim through inside of the vas. There is also an adventitial or connective tissue sheath that surrounds the vas but is not intrinsically part of it. This layer contains the vasal blood vessels and some small nerves. During a vasectomy, the vas is pulled out of the sheath and the muscle and mucosal layers are clipped, cut, cauterized and separated.

There are three types of microsurgical vasovasostomy techniques that are generally accepted; one-layer anastamosis, modified two-layer and formal two layer closures. Almost every recognized reversal specialist that I know will perform a formal 2 layer closure and on occasion will use a modified 2-layer technique. Some of the older reversal surgeons may still use the one layer anastamosis. Since there are 2 layers to the vas, the inner mucosa and the outer muscle layer, the two-layer approach theoretically allows for better alignment of the tissue without “bunching” it up. A common surgical philosophy is if God made a body part in a number of layers, that is the number that should be placed back together. I personally don’t like the one layer closure (unless the muscle layer on the proximal vas is very thinned out from dilation) because it is less precise and I worry that the vas tissue will bunch up and get squeezed together. Some surgeons close the vassal sheath over the 2 layer anastamosis and call that a three layered closure. In my experience this is usually not necessary and adds little to the procedure except to take tension off the reconnection. The majority of reversals don’t need this and if the 3rd layer is closed too-tightly or scars then it can squeeze off the actual lumen (inner channel) of the vas and cause the reversal to fail. I have seen this be the cause reversal failures in a number of patients. The is no reason to put in any more layers of suture than this, anything above and beyond this is overkill and could cause scarring. More is not always better except in the marketing world.

The goal of the microsurgical reversal is to perfectly align the vas and make the connection water -tight so the sperm won’t leak out from the suture line. The optimal number of sutures needed in a given procedure depends on the size of the vasal diameter and the difference in size between the two ends of the vas. Just like every other body part, some men have vas with larger diameters and some men have smaller caliber vasa. There is also usually a minor, but oftentimes substantial difference in size between the proximal (testicular) and distal ends of the vas. The testicular end of the vas usually dilates or enlarges after a vasectomy from buildup of fluid and sperm. The greater the discrepancy in size between the 2 ends of the vas means that more sutures could be needed to make the connection waterproof. In my experience the optimal number of mucosal sutures varies between 5 and 8 microsutues (10 nylon) and very, very rarely up to ten sutures. Too few sutures means that the connection might leak and too many sutures means that the delicate blood supply to the anastamosis (connection) could get cut off and that would lead to scarring and failure. Remember that the vas is not a simple pipe, it is living tissue and it must have a good blood supply to the area of the reconnection if it is to work. I have never been able to understand how doctors advertise that they regularly place 12 inner sutures, that they put a set number of sutures in every patient or that they close more than 3 layers of the vas, especially since no more layers exist. The surgeon and surgical technique should be versatile to give the best results for the individual patient’s condition, circumstance and needs.