decision to include case series, primarily to illustrate the

ciencies in the available data. This decision did not

signi

cantly affect the pooled OR as evidenced by our

sensitivity analysis in which these studies were excluded.

Although the current literature-based meta-analysis has

provided the most comprehensive assessment, yet, of

vasal sperm and postoperative patency, it has relied on

aggregated published data rather than on individual pa-

tient data, which would be preferred. Undoubtedly, there

is also publication bias in reporting only good outcomes

after VR, despite the fact that this bias was not obviously

detected in our statistical analyses. We were also unable

to control for surgical technique, although this may also

be construed as a strength, as an analysis using a large

number of surgeons may imply reproducibility. However,

it must be noted that the number of men who had VV

performed when sperm were absent in the vasal

ﬂ

uid was

much smaller than the comparison group of men who had

sperm present. Many men with intravasal azoospermia

likely would have undergone EV, which would bias our

analysis. Nonetheless, despite the limitations of the data,

we believe our study is robust in critically evaluating the

published literature on the presence of sperm in vasal

ﬂ

uid during VV.

Our meta-analysis emphasizes the need for more pro-

spective studies of VR outcomes with standardized

reporting measures if we are to truly de

ne measures of

surgical success. We recommend that future studies

include data on age (both patient and partner), length of

obstructive interval, gross intravasal

ﬂ

uid appearance (ie,

clear, cloudy, creamy, or pasty), presence of intravasal

whole sperm and/or sperm parts (ie, sperm heads or tails

alone), length of testicular vas remnant, presence of

granuloma, and achievement of patency and pregnancy.

Larger prospective studies involving concomitant mea-

surement and reporting of these variables are needed

in particular to address the important question of whether

the presence of vasal sperm constitutes a useful indepen-

dent clinical factor for intraoperative decision making.

CONCLUSION

We have performed a systematic review and meta-analysis

of VV outcomes in the current era. The OR of post-

operative patency was approximately 4 times higher given

the presence of intravasal sperm or sperm parts as opposed

to their absence at the time of VR. There was marked

variability in outcomes and factors reported. Our review

highlights the poor methodological quality of existing

evidence and underscores the need for more thorough

follow-up and higher standards of reporting in the future.

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APPENDIX

UPPLEMENTARY

ATA

Supplementary data associated with this article can be found,

in the online version, at

http://dx.doi.org/10.1016/j.urology.

2014.09.005

UROLOGY 85 (4), 2015

813