Weill Medical College
Cornell Institute for Reproductive Medicine
Center for Male Reproductive Medicine and Microsurgery
"State-of-the-Art Compassionate Care for the Infertile Couple"
Although the number of American men who undergo vasectomy has stabilized at about
500,000 annually, the number requesting surgical reversal has grown dramatically. Estimates
indicate that 2 to 6 percent of vasectomized men ultimately seek reversal. In the United States,
divorce with subsequent remarriage is by far the most common reason given for requesting
reversal. In developing countries, the death of a child is the most common reason. In
Bangladesh, for example, 5 percent of all couples who choose sterilization experience the
death of a child within 1 year after operation. Before the refinement of microsurgical
techniques, results of vasectomy reversal were relatively poor, with pregnancy rates varying
from 5 to 30 percent. The technical problems inherent in creating an accurate, leakproof
anastomosis of structures with a luminal diameter of only 0.3mm are formidable. Microsurgical
techniques of reversal now result in return of sperm to the ejaculate in over 90 percent of men
and yield pregnancy rates in the patient's partner of better than 50 percent. |
We have developed a microsurgical three-layer technique of vasovasostomy that facilitates precision suture placement. The technique involves mapping of the planned suture exit points with " microdots" placed on the cut ends of the vas deferens with a microtip marking pen. Microdots are placed at 12, 3, 6 and 9. o'clock position. Four additional dots are placed between each of the previous 4 dots. Exactly 8 mucosal sutures (double armed 10-zero monofilament sutures) are used for each anastomosis (Figure 1, 2). The anastomosis is completed with 8 muscularis sutures (9-zero monofilament) and 6 to 8 sutures ( 6-zero monofilament) approximating the vasal sheath (Figure 3, 4).
In a series of 194 consecutive vasovasostomy procedures using this technique a patency rate of 99.5% was achieved at Cornell. Pregnancy rates of 54% (crude) and 64% (excluding female factor infertility) were observed for the first 100 subjects of this cohort.
Conclusions: The microdot technique ensures precision suture placement and facilitates the anastomosis of lumens of discrepant diameters by exact mapping of each planned suture. The microdot method separates the planning from the placement. Patency rates using the microdot technique approach 100%. (Microsurgical Vasovasostomy: The Microdot Technique of Precision Suture Placement. Marc Goldstein, Philip Shihua Li and Gerald J. Mattews., J. Urol., 159:188-190, 1998)
Figure 1: Microdots are placed at 12, 3, 6 and 9 o'clock position. Four additional dots are placed between each of the previous 4 dots. Exactly 8 mucosal sutures are used for each anastomosis. Mapping planned suture exit points eliminates dog-ears and leaks when anastomosing lumens of discrepant diameter.
Figure 2: Sutures (double aramed 10-0 monofilament 70 micron sutures) are exited precisely throughh the center of each microdot.
Figure 3: Vas deferens has been rotated 180 degree following placement of first 4 mucosal and 3 muscularis (9-0 sutures).
Figure 4: Mucosal anastomosis is completed.
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