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Editorial Commentary

Kolettis PN, D'Amico AM, Box L, Burns JR. Outcomes for vasovasostomy with bilateral intravasal azoospermia. J Androl. 2003;24:22-24.[Abstract/Free Full Text]

The authors have demonstrated that patients who underwent vasovasostomy (VV) in the presence of intravasal azoospermia experienced a patency rate of 80% (12 of 15 patients) and a pregnancy rate of 38% (5 of 13 patients) when the obstructive interval was less than 11 years, whereas 0% (0 of 7 patients) of those with an obstructive interval of more than 11 years achieved patency. The authors thereby establish a criterion for procedure selection (VV vs. vasoepididymostomy [VE]) in patients with intraoperative intravasal azoospermia and illustrate that VV in patients with an obstructive interval less than 11 years yields patency and pregnancy success rates that are similar to those obtained with VE, rendering the more technically difficult VE unnecessary for these patients and reserving it for those men with intravasal azoospermia and an obstructive interval of more than 11 years. The appearance of clear fluid on at least one side did not appear to affect the patency rate. The presence of sperm granuloma, which is associated with favorable outcome following VV (Silber, 1977; Belker et al, 1983) was not noted.

When the testicular end of the vas is cut, the convoluted vas is milked and fluid exuding from the lumen is assessed. Several observations based on the quantity, consistency, and color of the fluid have been made (Goldstein, 2002). Findings under the following circumstances are unequivocal: 1) if the fluid contains many sperm or sperm heads, a VV is performed; 2) if thick, white, toothpaste-like fluid devoid of sperm is found, epididymal obstruction is certain and VE is necessary; and 3) when copious, crystal-clear watery fluid squirts out of the vas it is usually devoid of sperm initially, but the prognosis is excellent following VV. If one waits and explores the contralateral side, rare long-tailed sperm will often appear on repeat sampling of the original side when given additional time. The authors describe clear fluid, but they do not characterize it as copious. Scant clear fluid is more problematic. Sperm granulomas at the vasectomy site are often associated with little or no fluid, but cannulation of the testicular end of the vas with a 24-gauge angiocatheter sheath and gentle barbotage with 0.1 cc saline while milking the convoluted vas will almost always reveal long-tailed, usually motile sperm. This may explain some of the good results reported when VV is performed with intravasal azoospermia. Scant, greasy, non—water-soluble, or clear or slightly opaque fluid devoid of sperm indicates a poor prognosis after VV. When in doubt, it can be helpful to open the tunica vaginalis and inspect the epididymis. A clear line of demarcation with markedly dilated tubules above and collapsed tubules below, or a visible or palpable sperm granuloma in the epididymis strongly suggests epididymal obstruction, and VE is thus indicated. Of course, VE should be performed only by microsurgeons with extensive VE experience; otherwise VV should be performed.

It may not be possible to make an absolute determination of the presence of epididymal obstruction, although many of the observations described above are taken into consideration when planning the reversal technique. While the time interval to secondary epididymal obstruction in an individual patient is likely variable, this study presents compelling evidence to use an obstructive interval of 11 years in selecting the appropriate procedure. Several factors such as obstructive interval, presence and quality of vasal fluid, presence of sperm granuloma, and microsurgical technique likely contribute to the outcome of VV when sperm are absent from the vas deferens. Studies such as this by Kolettis et al are necessary to foster the continued effort to optimize vasectomy reversal outcome.

	References

Top References

 
Belker AM, Konnak JW, Sharlip ID, Thomas AJ Jr. Intraoperative observations during vasovasostomy in 334 patients. J Urol. 1983;129:524 -527.[Medline]

Goldstein M. Surgical management of male infertility and other scrotal disorders. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ, eds. Campbell's Urology. 8th ed. Philadelphia: WB Saunders;2002 : 1532-1587.

Silber SJ. Sperm granuloma and reversibility of vasectomy. Lancet. 1977;2:588 -589.[Medline]

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