Dr. Edward Martin described the first successful vasoepididymostomy with subsequent pregnancy in 1902. He constructed a side-to-side vasoepididymal fistula using silver wire sutures in a man with epididymal obstruction secondary to a previous gonococcal infection. His reconstruction involved aligning the vas deferens adjacent to a slash made in multiple epididymal tubules. In general, vasoepididymostomy techniques can be broadly categorized as ‘‘fistula formation’’ based on Martin’s original technique or ‘‘tubule-to-tubule’’ as described by Dr. Silber. As Dr. AJ Thomas pointed out in 1987, although Silber generally is credited for the single tubule-to-tubule anastomosis, VD 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 vassal lumen.
Martin’s surgical standard was used for over 70 years until Dr. Sherman Silber reported a new microsurgical end-to-end technique for vasoepididymostomy in 1978. The success of Martin's technique depended on formation of a fistula between the epididymal tubule and the vas deferens. The average patency rates in the best cases were reported in literature between 1902 to 1980's less than 50%, with only 10% to 20% having normal semen analysis. Scarring with either partial or complete closure of the fistula is the major cause of failure of this procedure.
Many variations of this end-to-end anastomosis have been developed, but the end-to-end approach gradually fell out favor with the advancement of end-to-side techniques, in which a single epididymal loop is isolated and the anterior wall of the loop is unroofed for the anastomosis to the vas deferens. Resection of the epididymis for end-to-end anastomosis can result in bleeding and difficulty identifying a patent tubule. Dr. LV Wagenknecht in 1980 was one of the early advocates of the end-to-side technique and Dr. AJ Thomas in 1987 popularized the end-to-side concept of anastomosis.
In 1998, Berger published his triangulation end-to-side technique, which involves placement of three double-armed 10-0 nylon sutures into the epididymis so that each suture forms one side of a triangle. An opening is made in the epididymal tubule and the sutures are brought inside-out, invaginating the tubule into the vasal lumen. Ninety-two percent patency was achieved in 12 men with this technique. At Cornell, we have achieved and reported similar results at the 1999 American Urologic Association Annual Meeting in Dallas, TX, by using this technique. Dr. Joel Marmar in 2000 reported 2-sutue transverse technique. However, this technique has not been adapted by many microsurgeons. In 2003, Chan, Li and Goldstein from Weill Cornell introduced a widely accepted innovative two-suture longitudinal intussusception vasoepididymostomy technique, in which two double-armed or single-armed 10-0 nylon sutures are placed longitudinally along the anterior surface of a single epididymal tubule. The needles are pulled through only after the tubular opening is made. The sutures are placed into the vas deferens from inside out at four points and, when the sutures are tied, the epididymal tubule intussuscepts into the vasal lumen. The advantage is there is a larger opening in the epididymal tubule and shorter operative time.
This new technique of longitudinal intussusception vasoepididymostomy that developed at Cornell has become the most preferred technique for many microsurgeons worldwide.
It is very important to understand that vasoepididymostomy is the most technically demanding microsurgical procedure in urology and clinical andrology. In addition, the decision as to which to do is highly based on the surgeon's abilities and familiarity with each procedure as well as intraoperative findings. Therefore, the clinical outcome of this procedure is highly dependent on surgeon’s technical perfection. Patients should also ask or check the surgeon’s microsurgical training background. Microsurgical vasoepididymostomy should only be attempted by experienced microsurgeons who perform the procedure frequently. Male infertility microsurgical technique must be learned in a good microsurgical lab, not on the patients.
End-to-side techniques of vasoepididymostomy have the advantage of being minimally traumatic to the epididymis and relatively bloodless and also it does not disturb the epididymal blood supply. Currently, the longitudinal end-to-side intussusception vasoepididymostomy technique has become a preferred microsurgical procedure at Cornell.