Microsurgical reconstruction of the ductal system is done in cases of congenital (since birth) blockage between the testes and the prostate, and for acquired causes as well. Acquired causes include previous prostatectomy or cystectomy (removal of the prostate or bladder), testicular and epididymal infection or surgery, vasal injury from hernia surgery, and failed prior vasectomy reversal.

It is important to thoroughly evaluate every patient considering a vasectomy reversal. The history and physical exam are used to determine whether one is a candidate for reconstruction. The time from vasectomy is important. While we have successful patients 30 years after the vasectomy, the literature shows a decrease in pregnancy rate after 15 years. On exam, the cut ends of the vas are identified. After the vasectomy, the pressure of the obstruction is either realized in the vas or the epididymis. When sperm leaks from the vas after a vasectomy, a sperm granuloma may form. A sperm granuloma is a small knot that forms because the body recognizes the sperm as foreign, and a reaction ensues. The reaction creates the palpable knot. Because the sperm has leaked from the cut end of the vas, the rest of the ductal system is not under pressure. In this case, the two ends of the vas deferens are reconnected. If the obstruction is realized in the epididymis, then it dilates, and the pressure may affect the sperm that get to the vas, if they get there at all. In this case, the distal end of the vas (on the prostate side) is connected to the epididymis.

Because the patients who are azoospermic (no sperm in the ejaculate) may or may not be obstructed, one or more hormonal tests may be drawn. For more discussion regarding azoospermia, click here.

The operation is performed in the same way every time by two microsurgeons who have operated together for more than a decade. The surgery is typically performed at the Surgical Center at UCLA Medical Center. The patient signs the informed consent. He is brought to the operating room, and a time out confirms that the patient and operation to be performed is correct. The patient is prepped, and an incision is made over the vas deferens closest to the testes and the blocked end of the vas is opened. The fluid that comes from it is examined to determine if sperm are present, and if the quality of the fluid is sufficiently thin to suggest that the obstruction does not lie more proximally in the epididymis. If sperm is present and motile, present and whole but not moving, or the fluid is watery, the two ends of the vas are put back together with a 90% or greater chance of returning sperm through the ejaculate. This operation is called a vaso-vasostomy. The two ends of the vas are reconnected in two layers. The inner layer is put together with 9-0 and 10-0 suture using from four to eight interrupted stitches. The outer layer consists of six to eight interrupted sutures of 9-0 nylon. These sutures are finer than your hair.

If the sperm is not present and the fluid is thick, then the epididymis is connected to the distal vas. Just as in the first surgery, this distal end is prepared to be able to reach the other side. In this case, that side is the epididymis. The epididymal covering is opened, and a dilated or swollen tubule is chosen to connect to the vas. Two sutures of 10-0 nylon are placed in parallel in direction of the tubule. A small ophthalmic blade is used to incise the tubule between the sutures. The fluid that flows from this tubule is examined under the microscope, and should contain whole motile sperm. If it does, the vas is brought to this tubule and connected. The 10-0 sutures have two needles each, and the vas and epididymal tubule are connected at four points. This also draws the tube into the vasal lumen or opening. The outer layer consists of six to eight 9-0 nylon sutures. The patency rate for this surgery is 75%. Both sides are performed in the same manner. After the surgery, ejaculation is prohibited for two weeks for vaso-vasostomy, and three weeks for epididymo-vasostomy.

A semen analysis is performed at six weeks post-operatively to determine the success of the surgery. For epididymo-vasostomy, it may take 12 months to see if the operation is a success. Because the epididymovasostomy operation is more difficult and tenuous, the patent is encouraged to bank sperm post-operatively. The average time for pregnancy following reconstruction is 14 months. This depends on a number of factors, including maternal age and fertility potential. Complications include infection, pain, bleeding, failure, and testicular injury. The testis may stay higher than before the surgery, depending how the vasectomy was done and which surgery was undertaken.