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About
Microsurgery
Brief
History of Pioneer Surgeons
Dr.
Julius Jacobson, a vascular surgeon, developed a
technique for suturing small vessels in experimental
dogs and coined the term "microsurgery" in 1959.
He performed, in 1961, a successful vas
reconnection in Vermont. Other physicians applied
similar techniques to the vas deferens in the 1960's,
using microscopes and small instruments and sutures.
Dr. Earl Owen, an Australian,
initially began his microsurgery interest with infants
to correct congenital defects. But he subsequently
researched a technique for microsurgical vas deferens
repair using the Macque Monkey, and in 1971 he performed
his first clinical microsurgical vasectomy reversal.
In the mid and late 1970's he published reports of his
successful results. This remarkable surgeon has
done over 4300 microscopic reversals. One of his
recent research interests is limb transplantation!
Dr. Sherman Silber, an American
urologist, introduced the microsurgical technique to the
U.S. after studying in Australia, and also after
conducting experiments in rats. He has
the world's largest published series of greater than 4,000
patients over a 30 year period.
Benefit of
Microsurgery
The driving force of these
innovations was to improve reversal results. The
ideal study to evaluate microscopic vas reversal in
comparison with traditional non-microsurgical reversal (conventional instruments and sutures, without the use of
a microscope) has never been done and likely will never
be done. The only prospective study of the two
methods is a small study done in India with significant
design problems when viewed to compare the two
techniques. A multi-center, double-blinded,
randomized trial would be needed to evaluate the two
techniques in a rigorous, scientific manner.
Simply put, this study would treat two different groups
of patients whose overall characteristics (years since
vasectomy, patient age, etc.) were the same. One
group would receive the conventional repair, and the
other group would receive the microscopic procedure,
depending on a decision made by chance (not at all
acceptable to the usual patient). The other nearly
impossible part of this study would be neither the
patients nor the investigators evaluating the results
would know the type of operation received.
Without the completion of this type
of study, there will likely continue to be some
controversy regarding the merits of each type of
surgery. There are certainly good surgeons and
urologists who are performing the traditional reversal
and obtaining good results. However, without going
into a detailed description of the surgical literature,
the consensus opinion evaluating the available evidence
regards microscopic microsurgical vasectomy reversal to
be superior in patency (patients with motile sperm in
fluid) and pregnancy rates. Pregnancy rates are
30-40% below the 85-95% patency rates in most
microsurgical series.
What
Microsurgical Technique is Best?
There are a variety of microsurgical
techniques for connecting the two ends of the vas
deferens (the anastamosis). No one microsurgical
technique has been proven to be better than the others.
Two different types of anastamosis have been extensively
discussed in the urologic literature: the two
layer technique (first described by Dr. Owen) and the
modified two layer technique (first described by Dr. Ira
Sharlip as the modified one layer repair). One of
the main differences between the two procedures is this:
during the two layer technique, the inner layer sutures
are tied within the wall of the vas deferens (tube), but
in the modified two layer anastamosis, the knots of the
sutures passing through the inner layer are on the
outside of the vas.
At least five studies have shown no
difference in results between the two techniques.
The most widely known, The Vasovasostomy Study Group (VVSG),
stated, "The patency and pregnancy rates were no better
after 2-layer microsurgical vasovasostomy than after
modified 1-layer microsurgical procedures..."
What is
the Impact of Anesthesia?
It is important to also note the
VVSG (the five center study group involving over 1400
microsurgical patients) found no significant difference
in results between patients who had local anesthesia and
those who had general anesthesia. Most first time
procedures were done with local anesthesia.
Who Does
Microscopic Vas Reversal?
Although most vasectomy reversals
are done by urologists, other physicians, including
general surgical specialists (general surgeons), have
trained in microsurgery and perform vas reversals.
The recent U.S. survey did not include general surgeons,
but a recent small region survey in England was sent to
both general surgeons and urologists. The authors
state that 24 urologists and 14 general surgeons
reported performance of vasectomy reversal. This
gives evidence that surgeons who have a wide range of
interests and training are involved in vas reversals.
This has been true from the beginnings of microsurgical
vasectomy reversal, as seen in the careers of Dr. Julius
Jacobson and Dr. Earl
Owen, who may be considered the father of microsurgical
vasectomy reversal.
Top of page
  Bibliography
Jacobson JH, Suarez EL.
Microsurgery in anastamosis of small vessels. Surg Forum
1960; 2:243-247.
Owen ER. Microsurgical
vasovasostomy: a reliable vasectomy reversal. Aust N Z J
Surg. 1977 Jun;47(3):305-9.
Silber SJ, Grotjan HE.
Microscopic vasectomy reversal 30 years later: a
summary of 4010 cases by the same surgeon. J
Androl 2004 Nov-Dec;25(6):845-59.
Sharlip ID.
Vasovasostomy: comparison of two microsurgical
techniques. Urology. 1981 Apr;17(4):347-52.
Belker AM, Thomas AJ,
Fuchs EF, Konnak JW, Sharlip ID. Results of 1,469
microsurgical vasectomy reversals by the Vasovasostomy
Study Group. J Urol. 1991 Mar,145(3):505-11.
Crain DS, Roberts JL,
Amling CL. Practice patterns in vasectomy reversal
surgery: result of a questionnaire study among
practicing urologists. J Urol. 2004
Jan:171(1):311-15.
Wood S, Montazeri N,
Sajjad Y, Troup S, Kingsland CR. Current practice
in the management of vasectomy reversal and
unobstructive azoospermia in Merseyside & North Wales: a
questionnaire-based survey. BJU Int. 2003
Jun;91(9):839-44.
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