Vasoepididymostomy: an insight into current practice patterns

Ujval S. Pathak, Adithya Balasubramanian, Jonathan A. Beilan, Mohit Butaney, Alexander J. Tatem, Nannan Thirumavalavan, Larry I. Lipshultz


Background: Vasectomy reversal (VR) is a specialized procedure currently offered by an increasing number of medical practitioners. One method of VR, vasoepididymostomy (VE), is considered the most challenging microsurgical technique within the field of reproductive urology. We surveyed reproductive urologists to assess current practice patterns regarding both intra-operative and post-operative considerations surrounding VE, with the hypothesis being that more experienced surgeons may have different practice patterns than less experienced surgeons.
Methods: An anonymous questionnaire was sent to members of the Society for Male Reproduction and Urology (SMRU). The survey included questions regarding case volume, preferred intra-operative techniques, and post-operative management strategies. Responses were collected using Survey Monkey (San Mateo, CA) and statistically analyzed with chi square tests.
Results: Three hundred and twenty SMRU members were contacted to participate in the survey; 74/320 (23.1%) participants completed the survey in its entirety. Respondents performed varying amounts of VR annually with most surgeons (24%) reporting between 11–20 VR per year and 15 surgeons (20.3%) performed over 60 per year. Comparing practitioners who performed ≤30 VR’s annually (n=46) to providers who performed >30 (n=28) revealed a significantly lower rate of VE in low-volume practitioners (≤20% vs. >20%, P<0.0001). The most commonly used technique to create the epididymotomy involved placing two 10-0 sutures into the tubule, followed by a sharp incision between the needles (74.3% of respondents). An intussusception anastomosis was the most commonly reported technique; 46.0% of participants utilize longitudinal stitch placement, while 35.1% place sutures horizontally. The most commonly reported time interval to evaluate the first post-reversal semen analysis (SA) was 6–8 weeks (39.2%). Participants were also asked to rank the progression of adjunctive therapies employed in the setting of a subpar post-reversal SA. Nonsteroidal anti-inflammatory drugs (NSAIDs) were the most popular first-line management option (52.7%). Corticosteroids were the most frequently employed second-line option (37.8%). Referral to an in vitro fertilization (IVF) center (9.5%) and repeat surgery (2.7%) were also options pursued by survey respondents. Most providers repeated the SA every 8–12 weeks (41.2%) while following sub-par SA parameters.
Conclusions: VE is a technically demanding procedure that requires both microsurgical expertise and appropriate post-operative care. Our analysis demonstrates that a higher VR operative volume is associated with a higher rate of conversion to VE. This indicates either more experienced surgeons are more likely to perform a VE when indicated or more experience surgeons are getting referred and/or performing more complex VRs.