small and underpowered. Given the lack of a single modern

deFnitive study, we investigated perioperative factors for associ-

ations with patency following microsurgical VV in a large series

from two experienced surgeons.

MATERIALS AND METHODS

Charts of 1331 consecutive men who underwent bilateral

microsurgical VV by two expert microsurgeons (S.±.M. and

L.I.L.) between 2006 and 2013 were reviewed. The institutional

review board at both the institutions approved the study. Patient

age, OI, presence of sperm granuloma, intraoperative Fndings,

post-operative semen analysis (SA) results, and pregnancies

were recorded. Patients were included only if gross ²uid quality

and the presence or absence of spermatozoa from both testicular

vasa were known.

Microsurgical VV with a two-to-three layer end-to-end anasto-

mosis was performed as described previously (Lipshultz

et al.

2009). Prior to vasal anastomosis, the gross appearance of the

vasal ²uid was categorized in two groups as either ‘clear or opa-

que’ or ‘thick or creamy’. Vasal spermatozoa were microscopi-

cally examined by the surgeon and categorized as whole (motile

or non-motile), fragments (sperm heads or short tails), or absent

(azoospermia). When no spermatozoa were detected, delicate

barbotage of the proximal vas was performed with

0.2 mL nor-

mal saline and the specimen was reexamined. The decision to

perform VV rather than EV was based on speciFc intraoperative

Fndings (as assessed by the surgeon) and not on age or OI. VV

was not performed when creamy, pasty, or gelatinous ²uid and

azoospermia in combination were identiFed. Patients were

asked to provide a SA 4

–

6 weeks after surgery and every

2 months thereafter. In general, follow-up was obtained for up

to 1 year after VR or until conception. Post-operative patency

was deFned as the return of at least 1

motile spermatozoa

to the ejaculate or report of natural conception.

Differences in sample medians were assessed using the

Mann

–

Whitney

–

Wilcoxon test. Differences among categorical

variables were assessed using ±isher’s exact test. Perioperative

variables were examined in univariate and multivariable logistic

regression models for associations with post-operative patency.

Statistical signiFcance was deFned as a two-tailed

value

0.05.

All analyses were performed using R version 3.0.0 (R ±oundation

for Statistical Computing, Vienna, Austria).

RESULTS

Overall, 1331 patients from two institutions met study inclu-

sion criteria (Table 1). Overall, 1307 patients achieved post-oper-

ative patency (98%) while 24 remained obstructed (2%). Among

the 981 patent patients with available SA data, the median sperm

density was 32 million/mL [interquartile range (IQR): 15

–

59]

and the median sperm motility was 41% (IQR: 20

–

56). ±our hun-

dred and ten patients reported natural pregnancy. The median

age at VV for patients who became patent was 39 (IQR: 35

–

44)

years while that for patients who remained obstructed was 40

(IQR: 36

–

45) years (

0.22). The corresponding median OIs

were 7 (IQR: 4

–

11) and 7 (IQR: 5

–

13) years, respectively

(

0.21).

The proportion of patients with granulomas in the patent and

obstructed subgroups was similar (

0.13). Minor between-

group differences noted for gross ²uid quality (

0.03) and sur-

geon

(

0.02)

disappeared

after

Bonferroni

correction.

SigniFcant between-group differences in microscopic ²uid char-

acteristics were noted (

). Patency following bilateral

VV approached 99% (1107/1121) when whole spermatozoa were

visualized on at least one side and was 92% (71/77) when bilat-

eral or unilateral sperm parts (with azoospermia on the other

side) were identiFed. Interestingly, when bilateral azoospermia

was identiFed successful patency was still achieved in 71% (10/

14) of men. These data are further stratiFed by gross ²uid quality

in Table 2.

According to unadjusted logistic regression analysis, age, OI,

and the presence of a granuloma (bilateral or unilateral vs.

absent) were not signiFcantly associated with post-operative

patency (Table 3). Gross ²uid quality (bilateral or unilateral clear

vs. other) and surgeon (#1 vs. #2) were associated with post-

operative patency with odds ratios (ORs) of 3.4 (95% CI: 1.3

–

8.6;

0.01) and 4.0 (95% CI: 1.3

–

11.9;

0.01), respectively.

The identiFcation of motile or non-motile whole spermatozoa

[bilateral or unilateral whole spermatozoa vs. other (i.e., bilateral

or unilateral sperm fragments or azoospermia)] greatly increased

the odds of post-operative patency with an unadjusted OR of

12.0 (95% CI: 5.4

–

26.8;

). IdentiFcation of bilateral

or unilateral sperm fragments vs. azoospermia was also associ-

ated with increased odds of postoperative patency but did not

reach statistical signiFcance (OR: 3.5; 95% CI: 0.9

–

13.6;

0.08).

In a multivariable model adjusted for age, OI, granuloma

Table 1

Perioperative characteristics of men undergoing bilateral microsur-

gical vasovasostomy

Patent

(

1307)

Obstructed

(

24)

No.

Granuloma

0.13

Bilateral present

175

13.2

0.2

Unilateral present

280

21.1

0.3

Absent

848

64.0

1.3

Missing

Gross Fuid quality

0.03

Bilateral clear/opaque

984

73.9

1.1

Unilateral clear/opaque

217

16.3

0.2

Bilateral creamy/thick

106

8.0

0.5

Microscopic characteristics

0.001

Bilateral whole spermatozoa

837

69.1

0.7

Unilateral whole spermatozoa

270

22.3

0.5

Bilateral sperm fragments

4.9

0.3

Unilateral sperm fragments

1.0

0.2

Bilateral azoospermia

0.8

0.3

Missing

119

Surgeon

0.02

1250

93.9

1.5

4.3

0.3

Table 2

Patency following bilateral microsurgical vasovasostomy

Bilateral

clear/opaque

(%)

Unilateral

clear/opaque

(%)

Bilateral

thick/creamy

(%)

Bilateral whole spermatozoa

699/704 (99)

94/95 (99)

44/46 (96)

Unilateral whole spermatozoa

155/159 (97)

81/83 (98)

34/34 (100)

Bilateral sperm fragments

18/20 (90)

17/17 (100)

23/26 (88)

Unilateral sperm fragments

8/11 (73)

3/3 (100)

–

Bilateral azoospermia

10/13 (77)

––

Missing

92/92 (100)

22/22 (100)

6/6 (100)

2015 American Society of Andrology and European Academy of Andrology

Andrology

, 2015, 3, 532–535

533

INTRAVASAL SPERMATOZOA AND PATENCY A±TER VV

ANDROLOGY