"4 × 4 vasovasostomy": A simplified technique for vasectomy reversal.
OBJECTIVE
An ideal vasovasostomy procedure requires precise mucosal approximation with a watertight anastomosis. The standard two-layer microdot technique requires multiple sutures within each layer and is a technically difficult operation to perform. We describe a two-layered technique which adheres to the principles of tubular anastomosis, but is simpler and provides excellent results.


METHODS
Patients with secondary infertility following a previous vasectomy underwent the modified two-layered vasovasostomy. Two 8-0 polyamide sutures were placed at 5 and 7 o'clock positions in the sero-muscular layer to approximate the two ends of the vas. Next, four double-armed, 10-0 polyamide sutures were sequentially placed, inside out in the mucosa of the vasal ends, at 3, 6, 9, and 12 o'clock positions and tied. Two additional sero-muscular sutures were placed at 1 and 11 o'clock positions to complete the anastomosis. Patients with a suspected proximal block in the epididymis underwent a vasoepididymostomy. Semen analysis was performed at 6 weeks after surgery.


RESULTS
Between the period February 2008 and August 2009, eight men underwent vasectomy reversal using the 4 × 4 technique. The procedure was performed bilaterally in six men whereas two patients underwent a two-suture, longitudinal intussusception vasoepididymostomy on the second side. Mean operative time was 90 min per patient. All men had sperm in the ejaculate at the first semen analysis. There were no complications.


CONCLUSIONS
The "4 × 4" modified two-layer vasovasostomy is a simple technique that can be performed in quick time with excellent results. It may allow a common ground between the complex microdot two-layer technique and the over-simplified single-layer procedure.
Department of Urology, All India Institute of Medical Sciences, New Delhi, India.
Rajeev
R
Kumar
Satyadip
S
Mukherjee