Outcome and late failures compared in 4 techniques of microsurgical vasoepididymostomy in 153 consecutive men.
OBJECTIVE
Vasoepididymostomy remains one of the most technically challenging procedures in all of microsurgery. The technique has evolved from an end-to-end, to an end-to-side technique, then to intussusception end-to-side methods. We recently reported the superiority of 2-suture longitudinal and 3-suture triangulation intussusception techniques in rats. In the present study we report our results in humans. We evaluated all vasoepididymostomies performed by 1 surgeon from January 1992 until the present for patency, pregnancy and for disappearance of sperm after initial return of sperm to the ejaculate.


METHODS
We recorded the results of 153 consecutive vasoepdidymostomies done by 1 surgeon (MG) from January 1992 until February 2004. Four techniques were used, namely end-to-end (EE), end-to-side (ES), 3-suture triangulation intussusception (TIVE) and 2-suture longitudinal intussusception (LIVE). Data collected included technique, months of followup, sperm density, motility and morphology (WHO 1992 criteria), pregnancy outcome and late failures. Late failures were defined as having return of sperm to the ejaculate after vasoepididymostomy and then becoming azoospermic on at least 2 subsequent semen analyses.


RESULTS
A total of 153 men underwent bilateral vasoepididymostomies. The most recent 17 were LIVE, preceeded by 38 TIVE, 32 ES and 66 EE. Mean followup for the groups were 17.2 (LIVE), 70.8 (TIVE), 116.7 (ES) and 140.2 (EE) months, respectively. Intact sperm were seen in the ejaculates of 12 men (80%) in the LIVE group, 16 in the TIVE group (84%), 20 in the ES group (74%) and 30 men in the EE group (73%). Motile sperm were found in the ejaculates of 10 of 15 (67%) in the LIVE group, 13 of 19 (68%) in the TIVE group, 10 of 27 (37%) in the ES group and 20 of 41 (49%) in the EE group (p =0.2). Mean times for return of sperm to the ejaculate were 2.9, 2.8, 2.8 and 3.5 months, respectively. Pregnancies were reported by 4 men in the LIVE group all before 12 months, 6 in the TIVE group and 3 were by 12 months, and 4 each by the ES and EE groups with 3 and 2 by 12 months (p =0.07). Thus far, there have been no late failures in the LIVE group, only 1 in the TIVE group (8%), 5 in the ES group (50%) and 6 in the EE group (30%) (p =0.04).


CONCLUSIONS
Although vasoepididymostomy remains a technically demanding microsurgical procedure, recent technical innovations of TIVE and LIVE offer better or comparable outcomes compared with EE and ES procedures with the use of fewer sutures, which simplifies the performance of the anastomosis. In addition, the late failure rate is lower with the use of the intussusception techniques (LIVE and TIVE) with only 1 late failure in 22 men with return of sperm to the ejaculate procedures (4%) compared with 11 of 30 (37%) in the nonintussusception groups (p =0.006).
Schiff
Jonathan
J
Department of Urology, Cornell Institute for Reproductive Medicine, Weill Medical College of Cornell University, The New York, New York 10021, USA.
Chan
Peter
P
Li
Philip S
PS
Finkelberg
Sam
S
Goldstein
Marc
M
D000714:Anastomosis, Surgical; D004822:Epididymis / Q000601:surgery*; D006801:Humans; D008297:Male; D008866:Microsurgery / Q000379:methods*; D013081:Sperm Motility; D013536:Suture Techniques; D016896:Treatment Outcome; D014669:Vasovasostomy / Q000379:methods*