revealed some inconsistency among the
f
ndings of the
remaining 2 studies by I
2
criteria (Q
¼
2.8; df
¼
1;
P
¼
.1;
I
2
¼
64%).
COMMENT
More than 20 years have passed since the landmark study
of the Vasovasostomy Study Group
3
; yet, these results are
still often cited to patients desiring VR. A review of the
literature
revealed
postreversal
patency
percentages
ranging from approximately 69% to 98%
18,19
with
achievement of pregnancy in 37%-93% of couples.
20,21
The precise extent to which the presence of sperm in
the intraoperative vasal
fl
uid is associated with post-
operative patency remains uncertain. To help clarify and
quantify the available evidence to better counsel patients
desiring VR, we performed a focused systematic review and
meta-analysis of 1239 patients undergoing VV in 6
retrospective studies. Our
f
ndings suggest that the pres-
ence of whole sperm or sperm parts in the vasal
fl
uid during
VR is positively associated with postoperative patency.
This conclusion relies on indirect comparisons of retro-
spective studies with a majority of data coming from 2
cohorts,
importantly
in
fl
uencing
the
meta-analytic
outcome.
A
f
nding of intravasal azoospermia during VR creates a
dif
f
cult decision for the surgeon who must determine
whether VV or vasoepididymostomy (VE) is the best
choice for vasal reconstruction. Because microscopic ex-
amination of vasal
fl
uid is not universally performed,
certainly some of the failures with VV may have occurred
in patients who actually required a VE because of
epididymal obstruction. Of course, performing VE rather
than VV is an intraoperative decision, and it remains
dif
f
cult to determine before surgery which patients will
have epididymal obstruction and require VE. For our
Table 1.
Characteristics of studies reporting outcomes on microsurgical vasovasostomy
First Author
Y
Sperm Present in Vasal Fluid
Sperm Absent in Vasal Fluid
Mean
Age (y)
Mean Obstructive
Interval (mo)
Patent (N)
Not Patent (N)
Patent (N)
Not Patent (N)
Belker
3
1991
437
49
50
33
36.0
84.0
Sheynkin
14
2000
0
0
7
8
40.1
108.0
Sigman
15
2004
51
1
6
0
39.0
118.8
Kolettis
6
2005
26
8
0
0
42.0
120.0
Bolduc
17
2007
468
83
36
19
37.2
82.0
Smith
16
2014
10
1
0
0
40.2
82.8
Records identified through
database searching
(n = 546)
Screening
Included
Eligibility
Identification
Additional records identified
through other sources
(n = 5)
Records after duplicates removed
(n = 530)
Records screened
(n = 209)
Records excluded
(n = 165)
Full-text articles
assessed for eligibility
(n = 33)
Full-text articles excluded
1. Non-microsurgical technique
2. No patency outcomes
3. Large VE component
4. < 10 patients
5. Duplicate patient population
(n=38)
Studies included in
qualitative synthesis
(n = 6)
Studies included in
quantitative synthesis
(meta-analysis)
(n = 6)
Figure 1.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
fl
ow diagram of study selection. VE,
vasoepididymostomy.
UROLOGY 85 (4), 2015
811