Loupe-Assisted Vasovasostomy Using a Prolene Stent: A Simpler Vasectomy Reversal Technique

Vasovasostomy: A systematic review and meta-analysis comparing macroscopic, microsurgical, and robot-assisted microsurgical techniques

BACKGROUND AND OBJECTIVES

Vasovasostomy is a cost-effective procedure for the reversal of vasectomy. A water-tight adequately blood-supplied mucosal anastomosis is required for better outcomes. This review aimed to compare the outcome of vasovasostomy performed by three different techniques: macroscopic, pure microsurgical, and robot-assisted microsurgical techniques.

METHODS

Scopus, Web of Science, PubMed, Embase, and Cochrane library databases were searched for relevant studies from January 1901 to June 2023. We conducted our quantitative syntheses using the inverse variance method in OpenMeta software. The study's protocol was registered on PROSPERO.

RESULTS

This review involved 95 studies of different designs, with a total sample size of 48,132. The majority of operations were performed bilaterally, and participants were monitored for up to 10 years. The pooled patency rate was the highest following robot-assisted vasovasostomy (94.4%), followed by pure microsurgical vasovasostomy (87.5%), and macroscopic vasovasostomy (83.7%). The pooled pregnancy rate following purely microsurgical vasovasostomy was higher than that of macroscopic vasovasostomy (47.4 vs. 43.7%). Definitive pregnancy rates in robotic vasovasostomy are yet to be determined.

CONCLUSION

Patency outcomes for vasovasostomy were best with robot-assisted microsurgical technique, followed by pure microsurgical technique, and conventional macroscopic technique. Further investigations of robot-assisted microsurgical vasovasostomy outcomes and randomized control trials are required to support this evidence.

Reinforcing vasal suture technique improves sperm concentration and pregnancy rates in men undergoing vasovasostomy for vasectomy reversal

Background

Vasovasostomy (VV) is a well-described surgical technique with few notable modifications since microsurgical adaptation in the 1970s. Although contemporary reversal success rates are 70-90%, these most often are based on a lenient definition of >0 sperm (patency) and include only VV procedures. With stricter definitions, success rates drop >30%. To improve outcomes, a novel surgical technique (reinforcing vasal suture, ReVas) was developed, and outcomes were compared prior to and following implementation.

Methods

A prospective registry of sequential patients undergoing vasectomy reversal was queried from Jan 2014 to June 2019. The ReVas technique was implemented in Jan 2018, wherein the abdominal and testicular vasa are secured side-to-side to alleviate strain on the anastomosis. Primary outcomes were changes in sperm concentration: >0/mL, >100,000/mL, >1 million/mL, >5 million/mL, >15 million/mL, and most recent. Secondary outcome was pregnancy rate. Demographic, clinical, and select operative variables were statistically compared between ReVas (+) and (-) cohorts.

Results

A total of 200 men underwent reversal, of whom 169 represented first-time attempts (61 receiving the new technique) and comprise the current cohort. ReVas (+) and (-) cohorts were similar in demographic, clinical, and operative factors with the exception of operative time [longer in ReVas (+) group]. Median duration since vasectomy was 9 years, and 68.6% of men received a bilateral VV. Follow-up was significantly longer in the ReVas (-) arm (37 vs. 10 months). All primary outcomes were significantly higher in the ReVas (+) cohort, with odds ratios ranging from 5.8 to 11.1 (P<0.01 to 0.0001). Pregnancy rates within the first 2 years post reversal were also 8.1× higher in the ReVas (+) group (P=0.02). A subset of men with bilateral VV exhibited a 95% likelihood of achieving >15 million/mL in ReVas (+) men compared to 54% in ReVas (-). Multivariable analysis confirmed ReVas as an independent predictor of success.

Conclusions

Implementation of the ReVas technique resulted in significantly higher sperm concentrations, which were particularly pronounced when stricter success criteria were used. Patients were also 8.1× more likely to achieve a pregnancy within the first 2 years, confirming clinical relevance. External validation is warranted.