History of Vasectomy Reversal
Section snippets
“Founding father of modern clinical andrology”
The birth of the reversal procedure goes back even further than O'Conor's era. A history of surgical reversal rightfully begins with the work of Edward Martin, Chief Surgeon at the University of Pennsylvania during the early years of the past century, although technically he performed vasoepididymostomies in men who had obstruction secondary to epididymitis, not vasectomy (Fig. 1). In 1902, Martin reported the first documented vasoepididymostomy in his study of 192 sterile couples and
Capacity for regeneration
H. C. Rolnick was another Chicago urologist at Northwestern University Medical School who contributed to the development of vasectomy and reconstructive surgery. In 1924, he published his series of 48 vasal surgeries in 25 dogs, in which he ligated, incised, or resected the vasa to determine their regenerative capacity.16 In the five dogs in which both vasa were ligated with catgut suture, all vasa were patent when checked after 21 to 38 days. In one of the dogs, the left vas deferens was
Vasovasostomy
In 1919, Quinby reported the first successful vasovasostomy in a man who had undergone bilateral vas resection in 1911.6 He created the anastomosis over a strand of silkworm gut, which was removed after 10 days.17 Quinby's assistant for this historic procedure was none other than O'Conor. O'Conor subsequently used Quinby's technique in 14 vasectomized patients, resulting in a patency rate of 64%.6 In the same article published in 1948, O'Conor reported the results of his survey of 1240
Etiologies of vasectomy reversal failure
Since the early studies of Rolnick, several groups have studied the causes of reversal surgery failures. Failures can be functional or anatomic.
Macrosurgical technique
A wide range of macrosurgical techniques for vasovasostomy has been reported. The main variation in technique seems to be the use or omission of loupe magnification and stenting. Stenting is the use of a suture, tube, or other foreign body to help keep the lumen of the vas deferens open after a reversal procedure. Stents usually but not always are removed during the postoperative period.
Amelar and Dubin favored a nonstented technique with 4× loupe magnification using eight 6-0 Prolene sutures.27
To stent or not to stent
Although “stent” and “splint” have been used interchangeably in the literature to describe the use of a foreign material to encourage patency of the vasal lumen during the time of epithelialization of the anastomosis, Montie and colleagues33 pointed out that a splint refers to something placed outside a structure to stabilize it whereas a stent is a compound for holding some form of graft in place. Stent, therefore, is the more accurate descriptor in this context. The use of exteriorized stents
Microsurgical technique
Owen47 and Silber,48, 49 working independently, are credited with the development of the microsurgical vasovasostomy technique for clinical use. The use of the microscope for the anastomosis of the vas deferens in animals had been previously evaluated by several groups.46, 50, 51 The earliest reference to microsurgical vasovasostomy in humans was by Silber in 1975.52 Most of the initial animal studies involved a one-layer anastomosis, but Silber determined that in humans a two-layer is
One layer or two?
Microsurgical vasovasostomy began as a double-layer technique and was quickly established as the gold standard. As with all surgical procedures, however, modifications were promoted as improvements on the original. Inevitably, several groups promoted the single-layer technique as a simpler alternative. Schroeder-Printzen and colleagues62 reviewed the outcomes for several series of double-layer and single-layer reversal surgeries. Patency and pregnancy rates (mean ±SD) in 12 series comprising
Vasography
Vasography had been in use for many years, as far back as 1909 by Martin (discussed previously). Although Martin used vasography to confirm patency of the distal vas deferens before performing an anastomosis of the vas deferens to the epididymis in a similar fashion to vasograms of today, vasography also has been used to test the anastomosis, more in line with the use of vasograms in a laboratory setting or microsurgical training.
In 1982, Hartig and Meyer assessed the safety of intraoperative
Vasoepididymostomy
Vasoepididymostomy techniques can be broadly categorized as “fistula formation” based on Martin's original technique or “tubule-to-tubule” as described by Silber.84 As Thomas pointed out, although Silber generally is credited for the single tubule-to-tubule anastomosis, Lespinasse had a similar idea 60 years earlier, wherein a 5-0 silk suture was passed through a single epididymal loop and the mucosal surface of the vasal lumen.84, 85
In 1978, Silber described his technique involving the direct
Reversal surgery in the age of assisted reproduction
Despite progress over the years with vasectomy reversal, the introduction of intracytoplasmic sperm injection (ICSI) led many to wonder if technically challenging microsurgical vasectomy reversals were worth the trouble. There are several important advantages to reversal surgery, including treatment of an affected man instead of his healthy partner, natural conception through sexual intercourse, and the ability to father more than one child after one procedure. If an experienced microsurgeon is
The future?
Surgical procedures are forever evolving, whether or not it is a simplification of mechanics or the application of new technology, surgeons always are looking for ways to streamline an operation and to nudge up success rates while reducing complications. Because suturing of the anastomosis is the most technically challenging step in the vasectomy reversal procedure, a wide variety of sutureless anastomotic techniques has been evaluated, including laser welding,93, 94 microclip,95 fibrin glue,96
Summary
Vasectomy reversal has come a long way since Martin performed the first anastomosis of the vas deferens and epididymis. Although its history is not as politically charged as that of vasectomy, the progress of reversal surgery has had its share of ups and downs, brilliant discoveries, and discouraging missteps (see Appendix). In the early part of the twentieth century, vasovasostomy and vasoepididymostomy were esoteric procedures, but by the 1970s, a majority of urologists had at least some
Acknowledgments
We thank Vanessa Lynne Dudley for creating the timeline layout in the Appendix.
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Cited by (29)
The management of obstructive azoospermia: a committee opinion
2019, Fertility and SterilityCitation Excerpt :The evaluation of nonobstructive azoospermia is covered in another document (2). Microsurgical techniques for the treatment of obstructive azoospermia were first introduced by Silber and Owen in 1977 and are considered the gold standard for reconstructive surgery involving the male reproductive tract (3–5). Scrotal or inguinal vasovasostomy may be employed for vasal obstruction secondary to vasectomy, iatrogenic vasal injury due to inguinal or scrotal surgery such as herniorrhaphy or hydrocelectomy, or solitary vasal obstruction secondary to infection or trauma.
Vasovasostomy
2018, Encyclopedia of ReproductionAngled vas cutter for vasovasostomy: Technique and results
2014, Fertility and SterilitySurgery for obstructive azoospermia
2023, Medecine de la ReproductionSurgical management of male infertility
2023, Australian Journal of General Practice
Funding source for this article was The Frederick J. and Theresa Dow Wallace Fund of the New York Community Trust.