P-750 A systematic review of vasovasostomy (VV) and vasoepididymostomy (VE) techniques for Vasectomy Reversal: How far have we come?
Authors: Rozen W , Heah R , Hunter-Smith D , Shahbaz S 
Published: June 2023

Abstract

Study question
A systematic review of current literature evaluating different techniques in performing vasovasostomy (VV) and vasoepididymostomy (VE) including robotic-assisted and minimally invasive techniques and their outcomes

Summary answer
Macrosurgical, microsurgical and robot-assisted techniques have evidence for use in vasectomy reversal. The use of robotic assistance in may have beneﬁt over standard techniques.

What is known already
While vasectomy is a common procedure worldwide, six percent of these patients request a reversal procedure. Reasons for this include change of mind, a new relationship, death of a child or wanting more children. While sperm harvest combined with in-vitro fertilisation (IVF) is an alternative, factors including timing of patency and durability of patency need to be considered prior to deciding between vasectomy reversal or sperm harvesting with IVF. In 1977, microsurgical techniques for vasovasostomy were described by Silber and Owen, and microsurgical vasectomy reversal procedures became more common following this. The evidence for differing approaches is lacking.

Study design, size, duration
A systematic literature review was performed using databases Medline and PubMed was performed, comprising studies between 1979 to July 30 2022. Systematic review and review articles of vasovasostomy and vasoepididymostomy were included. Original studies on robotic- assisted techniques and minimally invasive approaches were also included. Exclusion criteria included animal studies and non-English. Level of evidence was evaluated.

Participants/materials, setting, methods
From the eligible articles identified from the above criteria, data was extracted from review articles including techniques used for vasovasostomy and vasoepididymostomy. Surgical outcomes including pregnancy rates and postoperative patency were considered surgical outcomes and data was extracted regarding this from above articles. Data from original studies on minimally invasive techniques were also extracted from the above articles.

Main results and the role of chance
For vasovasostomy, techniques described in the literature include microscopic vasovasostomy, mini-incision microscopic vasovasostomy (MVV), mini incision MVV using Moon’s clamp, and robotic assisted vasovasostomy.
Described by surgeons as the “most technically challenging procedure”, the early approach to vasoepididymostomy comprised a 3-4cm scrotal incision for delivery of testis to provide adequate exposure to the entire epididymis and vas deferens.
When vasoepididymostomy was compared to vasovasostomy, prolonged recovery periods, increased pain and swelling were identified.
The techniques described for vasovasostomy comprise end-to end, end-to side, three-suture triangulation intussusception (TIVE), two-suture longitudinal intussusception (LIVE), deferential vessel-sparing LIVE, mini-incision vasoepididymostomy, robot-assisted vasoepididymostomy (RAVE).
Retrospective reviews of microsurgical vasovasostomy using a 2-layer anastomosis report patency rate of 85%, similar to reports from single layer repairs. Microsurgical techniques allow accurate apposition of narrow lumen ends, allowing unobstructed semen flow and low level evidence suggests high patency rates. Macrosurgical vasovasostomy may be more simple, less expensive and a quicker alternative. Elzanaty et al. found no clear difference between microsurgical and microsurgical vasovasostomy in terms of vasal patency. Both techniques appeared to be effective when performed by an experienced surgeon. Preliminary evidence for robotic assistance suggests a role in reduced morbidity and accuracy of repair.

Limitations, reasons for caution
With low level evidence for each technique, formal clinical guidelines are not forthcoming. Further evaluation and longer follow-up is required to assess clinical usage and true cost-benefit ratio. There is also a need for a standardised measurement tool to provide accurate and objective outcome measures to compare techniques.

Wider implications of the findings
This systematic review provides evidence for available techniques in vasovasostomy and vasoepididymostomy for vasectomy reversal. Outcome measurement tools are presented, highlighting the lack of standardised definitions of patency and failure. The current review enables surgeons performing vasectomy reversal to determine the most effective, efficient and cost-effective technique for their practice.

Trial registration number
‘Not applicable'