A vasovasostomy may be performed on an outpatient basis with local anesthesia, but also may be performed on an outpatient basis with epidural or general anesthesia. Local anesthesia is preferred by most of my patients, the majority of whom choose this technique. With proper preoperative and intraoperative sedation, patients sleep lightly through most of the procedure. Because of the length of time often required for bilateral microsurgical vasoepididymostomy, epidural or general anesthesia and overnight hospitalization are usually necessary. Factors influencing the preoperative choice for vasovasostomy or vasoepididymostomy in patients undergoing vasectomy reversal are considered. The preoperative planned choice of vasovasostomy or vasoepididymostomy for patients having vasectomy reversal described herein does not have the support of all urologists who regularly perform these procedures. My present approach has evolved as the data reported in Tables 1 and 2 have become available, but it may change as new information is evaluated. However, it offers a logical method for planning choices of anesthesia and inpatient or outpatient status for patients undergoing vasectomy reversal procedures.
PIP: The basis for choosing either vasovasostomy or vasoepididymostomy for reversal of vasectomy or vas obstruction by microsurgical outpatient procedures, and management of these patients, are summarized, with diagrams and photographs included. Prior to surgery, it is impossible to determine whether a person needs one procedure or the other. When operative procedures have begun, those with sperm or clear vas fluid are candidates for vasovasostomy. Those without sperm, or with cloudy fluid, will require vasoepididymostomy under general or epidural anesthesia, which takes 4-6 hr. No extensive data on outcome of pregnancy after microsurgical vasoepididymostomy are available. The author's patients with outpatient 2-layer microsurgical vasovasostomy have had 62% pregnancy rate so far; 14% more men show normal mobile sperm counts. Most of the operations are done under local anesthesia using lidocaine and bupivacaine, perhaps with sedation, through a 2-3 cm incision. Only general instructions for the 2 procedures are included here. The author prefers "end-to-side" microsurgical vasoepididymostomy, combined with 1 or more microdissections to find the most caudal area of the epididymis where mobile sperm are present. For those who must contain costs, as these operations are not usually covered by health insurance, the postoperative recovery, if needed, is obtained by hospitalizing the patient overnight after the procedure. Costs of vasovasostomy, not including surgeon's fee, ranged from $1144 for local, outpatient, to $2066 for general anesthesia and inpatient care.