AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Vasovasostomy and vasoepididymostomy are surgical procedures designed to bypass an obstruction in the male genital tract. These procedures are usually performed to restore fertility, although they are occasionally undertaken to relieve pain, such as that elicited by postvasectomy pain syndromes.

Vasovasostomy involves the anastomosis of segments of the vas deferens above and below an obstruction. The vast majority of vasovasostomies are performed to reverse a prior vasectomy, but the procedure occasionally is indicated for repair of an iatrogenic vasal injury secondary to prior surgery (eg, inguinal herniorrhaphy).

Vasoepididymostomy is a technically more demanding procedure than vasovasostomy. It involves anastomosis of the vas deferens to the epididymis in order to bypass an epididymal obstruction. This obstruction may be secondary to long-standing vasal obstruction resulting in damage to an epididymal tubule (epididymal blowout), or it may be the result of epididymal infections or trauma. These techniques have gained popularity in recent years because of advances in surgical techniques, optical magnification, and surgical instruments.

History of the Procedure

Surgical procedures to remove obstructions of the genital tract and to restore fertility have been attempted for almost 100 years. In 1903, Martin first reported a technique for vasoepididymostomy to treat an obstructed epididymis from a gonococcal infection. He described anastomosing the vas to a cut end of the epididymis using fine silver wires. This fistula technique of anastomosis remained the criterion standard for nearly 75 years, until advances in technique and instrumentation made direct, single tubule anastomosis feasible. In 1978, Silber first reported a technique for directly anastomosing the mucosa of the vas deferens to a single epididymal tubule. While this required more technical skill and magnification than the fistula technique, it allowed precise alignment of the vas and epididymal lumens, resulting in marked improvements in fertility rates.

Quinby reported the first successful vasovasostomy for vasectomy reversal in 1919. The anastomosis was performed over a strand of silkworm gut that was later removed. By 1948, O'Conor reported a practice survey revealing that 18% of urologists had performed a vasal anastomosis procedure at least once, and that the operation was successful in up to 40% of patients. Various techniques have been tried since O'Conor's survey, including the use of stents to improve patency rates for the macroscopic anastomosis. The next major advance occurred when Owen and Silber separately reported their techniques for microsurgical anastomosis in 1977. Silber reported patency rates of up to 94% using the 2-layer microsurgical technique for vasal anastomosis.

Problem

Azoospermia (the absence of sperm in the ejaculate) can result from an obstructed genital tract or a failure of spermatogenesis in the testicle. Vasovasostomies are indicated for an obstruction at the level of the vas deferens, while vasoepididymostomies treat epididymal obstructions. The site of obstruction often can be discerned by examination of the fluid from the vasal end or from the epididymal tubule as described later in this article. The goal of both procedures is to restore genital tract patency and ultimately to allow conception. These procedures are not indicated for nonobstructive causes of azoospermia.

Frequency

Vasectomy remains one of the most commonly performed operations in the United States and throughout the world. Despite careful preoperative counseling, up to 5% of the men who received a vasectomy ultimately desired a vasovasostomy to restore their fertility. The most common reason for requesting a vasovasostomy is a desire to have children with a new spouse following divorce from an original partner.

Primary genital tract obstruction occurs in 7.4% of infertile males who have not received a prior vasectomy. While the cause may be multifactorial (eg, including epididymal trauma, infection, congenital hypoplasia of the ductal system), a significant number of these patients are candidates for vasoepididymostomies for restoration of the patency of the seminal tract.

Etiology

Causes of vasal and epididymal obstruction are outlined in Table 1. Vasal obstruction is usually the result of an intentional division for sterilization, although it occasionally may be caused by iatrogenic injury during pediatric surgical procedures (eg, herniorrhaphies).

An epididymal obstruction can be congenital, or it can be the result of an epididymal infection, trauma, or prior vasectomy. Congenital epididymal obstruction may occur in conjunction with atresia of the vas deferens, rendering surgical reconstruction impossible. This usually is associated with at least 1 genetic mutation that has been observed in the cystic fibrosis population. Fortunately, these men usually have no other phenotypic manifestations of cystic fibrosis. These patients sometimes have a normal vas deferens and disjunction of the vas deferens with the epididymis, and they benefit from a vasoepididymostomy.

An inflammatory obstruction of the epididymis can result from bacterial epididymitis. Neisseria gonorrhoeae usually affects only the distal epididymis, allowing a surgical bypass of the vas to the more proximal epididymis using a vasoepididymostomy.

Trauma to the epididymis is a relatively uncommon cause of an epididymal obstruction, but it may occur as a result of epididymal injury during scrotal surgeries (eg, spermatocelectomy, hydrocelectomy, testis biopsy).

An epididymal obstruction after a vasectomy is the most likely cause of an epididymal obstruction. The buildup of high intraluminal pressures within the epididymis after a vasectomy can result in rupture of the delicate epididymal tubule with resulting obstruction (eg, epididymal blowout). This phenomenon is more common in men who desire a reversal more than 10 years after their vasectomy and in patients who previously have a failed vasovasostomy.

Clinical

Patients desiring a vasovasostomy for vasectomy reversal self-refer for evaluation. All other patients present for an evaluation of infertility after a trial of unprotected intercourse. A careful physical examination suggests the diagnosis of vasal or epididymal obstruction that is amenable to a vasovasostomy or vasoepididymostomy, respectively. Men with a genital tract obstruction have testes of normal size (>20 cc volume or 4 cm length) and consistency. The epididymis feels prominent proximal to a site of obstruction and feels flat (empty) distal to an obstructed tubule. Dilation of the entire epididymis suggests an obstruction at either the junction of the epididymis with the vas deferens or in the vas deferens itself.

INDICATIONS

Section 3 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

The indications for a vasovasostomy are vasectomy reversal and relief of postvasectomy pain syndrome. The latter indication is infrequent and remains of controversial efficacy. Prior to undertaking a vasovasostomy for vasectomy reversal, obtain from a gynecologist a fertility evaluation of the patient's spouse to exclude concurrent causes of infertility.

Perform a vasoepididymostomy for the treatment of a genital tract obstruction at the level of the epididymis. An epididymal obstruction is suggested when there is azoospermia with a normal semen volume. Low-volume azoospermia (<1.5 mL) is more suggestive of ejaculatory duct obstruction than vasal or epididymal obstruction. Patients must have active sperm production in the testes, an obstructed epididymis, and a patent vas deferens to be considered a candidate for a vasoepididymostomy. For the above reasons, a testis biopsy is usually performed at the time of or prior to planned reconstruction to document active spermatogenesis. We prefer to conduct a biopsy at the time of reconstruction because this avoids the inevitable scarring that can make reconstruction at a later date more difficult.

RELEVANT ANATOMY

Section 4 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

To understand the surgical bypass procedures needed to restore sperm flow, it is important to have an understanding of basic anatomy and physiology of the seminal tract. Sperm is produced and then released into the seminiferous tubules. The sperm transits through the rete testis and ductuli efferentes into the epididymal tubule.

Epididymis

The epididymis consists of a single, highly convoluted epididymal tubule that is covered with tunica vaginalis. By convention, the epididymis is divided into the following anatomic segments: (1) the caput (head), (2) the corpora (body), and (3) the cauda (tail).

Knowledge of the exact function of the epididymis remains incomplete. Researchers have shown, however, that the proximal portion is involved in sperm maturation, whereas the distal region is the area of sperm storage. Vasoepididymal anastomosis to the more proximal epididymal tubule results in lower pregnancy rates because it bypasses a region of vital importance for sperm development.

Vas deferens

At the terminal end of the epididymis, a thick muscle wall forming the proximal end of the vas deferens (also called the convoluted tubule) surrounds the tubule. The vas deferens follows the spermatic cord, courses through the inguinal canal, and enters the pelvis via the internal inguinal ring. From the pelvis, the vas travels posteromedially over the junction of the ureter with the bladder, passes behind the bladder, and enters the prostate posteriorly. Contraction of the well-developed muscular wall of the vas deferens serves to propel sperm from the epididymis into the prostatic urethra via the ejaculatory ducts.

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Other Tests

• Vasectomy reversal
• • Men requesting a vasovasostomy or vasoepididymostomy reversal require no further workup as long as their scrotal examination reveals normal-sized testicles, and they have not developed any fertility-impacting medical conditions (eg, history of chemotherapy, radiation therapy) since their original vasectomy.
  • In the case of small testes or history of a potentially gonadotoxic insult to the testis, perform a testis biopsy at the time of, or prior to, the procedure to document normal sperm production.

• Nonvasectomy reversal
• • To be a candidate for a vasoepididymostomy, men with normal semen volume azoospermia must have active sperm production, an epididymal obstruction, and a patent vas deferens. Normal serum gonadotropin levels (eg, follicle-stimulating hormone [FSH]) suggest normal spermatogenesis, although occasionally a patient with an interruption in the normal sperm development (maturation arrest) has normal FSH levels.
  • Definitive proof of normal sperm production is required and can be provided by a testis biopsy at the same time as the planned reconstruction (or at an earlier date).
  • At the time of planned reconstruction, perform a vasogram to confirm patency of the entire vas deferens and ejaculatory duct. Performing a vasogram at an earlier time may result in extensive scarring of the vas, rendering definitive reconstruction more difficult.
  • Perform a vasogram by cannulating the lumen of the proximal vas deferens with a fine needle (30-gauge lymphangiogram needle, #6657, Becton, Dickinson and Company, Franklin Lakes, NJ) or by making a partial-thickness transverse incision in the vas deferens and introducing a small Angiocath. Gently inject 5-8 mL of half-strength contrast in an antegrade direction.
  • Obtain a pelvic radiograph to demonstrate the flow through the vas into the posterior urethra and bladder.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Preoperative details

Perform both vasovasostomy and vasoepididymostomy in an outpatient setting. Uncomplicated vasovasostomies require 2-3 hours of operative time and often are performed under local anesthesia with mild sedation to facilitate patient comfort.

Vasoepididymostomies may take up to 4 hours; therefore, give the patient either a continuous epidural block or a general anesthesia. For both procedures, pay attention to the patient's positioning to ensure safety and comfort. Pad all pressure points. Abduct the arms at less than a 45° angle, or tuck them at the patient's side to prevent prolonged hyperextension and plexus injury. Administer a broad-spectrum antibiotic 30 minutes prior to surgery.

Intraoperative details

Vasovasostomy

Create a vertical scrotal incision directly over the prior vasectomy site. A 2-cm incision is commonly used, allowing access to the vas deferens. Some patients with multiple prior scrotal surgeries or with dense adhesions sometimes require a larger incision for delivery of the testis, epididymis, and proximal vas deferens. The vas deferens is mobilized above and below the vasectomy site. The 2 key components of vas mobilization are to mobilize an adequate length to ensure a tension-free anastomosis and to retain the perivasal vessels with the vas to allow a well-vascularized anastomosis, thus avoiding ischemia with resultant stenosis.

Squarely cut the vas deferens with a scalpel below and above the vasectomy site to provide clean edges for the anastomosis. Collect fluid from the proximal vas, and examine it under the microscope. The presence of spermatozoa is associated with the best prognosis for future fertility, although clear fluid without spermatozoa also portends a good outcome. If available, cryopreserve the sperm in case reconstruction fails.

Surgeons have tried various methods for performing the vasovasostomy anastomosis, depending on the degree of magnification (loupes, microscope) and the type of procedure (modified 1-layer versus formal 2-layer). The procedure of choice is the formal 2-layer anastomosis performed under microscope magnification (Image 1). Initially, place 9-0 nylon seromuscular sutures in the posterior cut ends of the vas at the 5 o'clock and 7 o'clock positions and tie. Next, place interrupted 10-0 nylon mucosal sutures, and tie to approximate the luminal ends of the deferens. Usually, 5-7 sutures are needed to complete the luminal anastomosis. Finally, 4 additional 9-0 nylon seromuscular sutures are placed to complete the anastomosis.

The modified 1-layer vasovasostomy (Image 2) represents an excellent alternative technique to the formal 2-layer anastomosis. While it does not allow as precise a mucosal realignment, the procedure is technically less demanding, requires less magnification, and produces comparable outcomes. Initially, a 9-0 nylon suture is passed through the entire vas wall, traveling in sequence through the serosa and mucosa of one end of the vas, entering the mucosa of the other end, and exiting through the serosa. Tie this suture. Two 8-0 nylon seromuscular sutures are placed on either side of the 9-0 suture and tied. Repeat this pattern in each quadrant of the anastomosis, resulting in a total of 4 luminal sutures and 8 seromuscular sutures.

Vasoepididymostomy

Create a vertical scrotal incision of adequate length to allow easy delivery of the testis, epididymis, and vas deferens. The vas deferens is isolated on the medial side of the spermatic cord and mobilized to the most proximal normal area, preferably the convoluted tubule. At this point, transect the vas deferens, and carefully tunnel the proximal end of the distal vas through the cord structures so that the end is positioned adjacent to the lateral edge of the epididymis. Take great care to transpose the vas deferens with its associated blood vessels.

Under the operating microscope, examine the epididymis to identify any obvious site of obstruction. If no such area is identified, incise the tunica albuginea of the epididymal tail, and apply gentle pressure to assist in extrusion of a single epididymal tubule. Careful dissection with microscissors allows the exposure of a single loop of tubule. Unroof this tubule with the scissors, and examine the fluid for sperm. If sperm are not observed, repeat this process more proximally on the epididymis until sperm are found.

While several types of vasoepididymal anastomosis have been described, the author prefers the end-to-side technique (Image 3) described by Thomas. Initially, use two 9-0 nylon sutures to secure the seromuscular layer of the vas to the epididymal tunic, which places the luminal edge of the vas near the epididymal lumen. Place three or four 10-0 nylon sutures equidistant from each other to secure the mucosa of the vas to the epididymal tubule. Finally, use six to eight 9-0 nylon sutures to approximate the length of the seromuscular layer of the vas to the epididymal tunic.

Postoperative details

Following the procedure, observe the patient for several hours in an ambulatory surgery center. Discharge the patient after he has recovered from anesthesia, voided, and reached intake tolerance. Provide the patient with a prescription for several doses of an oral narcotic (eg, Tylenol with Codeine); however, most patients find that Extra-Strength Tylenol is sufficient to relieve postoperative discomfort.

After surgery, place a fluff gauze dressing over the incision, which is removed 48 hours later. Instruct the patient to return immediately if any signs of bleeding or infection occur. Slight redness or tenderness around the incision is normal.

Patients may return to work 3 days after the procedure. While showering is allowed within 2 days of surgery, do not allow the patient to soak the incisions under water (tub, pool) until 2 weeks after surgery to avoid premature dissolution of the absorbable sutures used for the skin closure. The patient may resume nonstrenuous exercise within a week after the procedure, but he should wait at least 3 weeks before resuming strenuous activities such as jogging. Instruct the patient to refrain from postsurgical sexual activity for a full month.

Follow-up

Instruct the patient to return to the office for a wound check in approximately 7 days. Obtain a semen analysis 3 months postsurgery. In patients who have had a vasoepididymostomy, the anastomosis is often slow to function. In this population, semen analyses are repeated quarterly for a year or until sperm are present. If no sperm are present by 18 months after the surgery, consider the operation a failure, and advise the patient about the alternatives (ie, repeat procedure, sperm extraction with in vitro fertilization, donor insemination, adoption). Repeat surgical reconstructions with vasoepididymostomies and vasovasostomies can be performed, but these are technically more demanding because of extensive scarring and should be undertaken only by an experienced microsurgeon. With that caveat, the success rates for these procedures are comparable to those of initial reconstructions.

COMPLICATIONS

Section 7 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Hematoma, infection, and testicular atrophy are the main complications of both procedures. Hematoma and infection have occurred in less than 0.5% of our patient population.

Hematoma is largely preventable by careful attention to hemostasis throughout the dissection. Our practice is to close the incision in 2 separate layers, with the first consisting of the tunica vaginalis and dartos muscle and the second consisting of the dermal edges. In this way, we have avoided the hematomas that can plague scrotal surgery. Infection is a similarly rare occurrence.

Testicular atrophy remains the most dreaded complication. Atrophy results from injury to the internal spermatic artery as it traverses through the spermatic cord. In most cases, this is avoidable by careful dissection of the vas from the adjacent cord. In addition, this injury can occur in patients receiving vasoepididymostomies if great care is not taken when the vas is tunneled through the spermatic cord and placed in proximity to the epididymis.

OUTCOME AND PROGNOSIS

Section 8 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Vasovasostomy

As shown in Table 2, experienced hands can obtain patency rates in excess of 90% and pregnancy rates of more than 50%. The following 3 factors portend the best surgical outcomes:

• The time interval since the vasectomy is one important factor. The Vasovasostomy Study Group, the largest multicenter group to assess vasovasostomy efficacy, found that if the interval was less than 3 years from the vasectomy, patency was 97% and pregnancy was 76%. In men more than 15 years from their vasectomies, patency and pregnancy rates fell to 71% and 30%, respectively.


• A second important factor was the microsurgical experience level of the surgeon. A urologist who performs the procedure without any magnification (ie, the so-called macroscopic vasovasostomy) has significantly worse surgical results with pregnancy rates ranging from 19-55%. When the microsurgical technique is used, the success rates are markedly improved, regardless of whether the surgeon used a modified 1-layer or formal 2-layer anastomosis.


• Lastly, the presence of sperm and the quality of the fluid from the proximal vas is predictive of surgical success. Patency rates in men with sperm in the proximal vas fluid at the time of vasovasostomy exceed 90% versus 60% in men without sperm in the proximal vas. In the setting of no sperm in their fluid, clear fluid predicts a higher success rate than thick, opalescent fluid.

Vasoepididymostomy

Following vasoepididymostomy, 58-85% of the patients have patency and between 11-56% of patients induce pregnancy.

While the level of epididymal anastomosis does not affect patency rates, pregnancy rates are highest with the most distal epididymal anastomosis (cauda) because of the important sperm maturation that occurs during transit through the epididymis.

FUTURE AND CONTROVERSIES

Section 9 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

The main controversy with surgical bypass procedures of the genital tract relates to their role in light of recent advances in sperm extraction and assisted reproduction techniques. Since its advent by Palermo in 1992, intracytoplasmic sperm injection (ICSI) has revolutionized the treatment of obstructive and nonobstructive azoospermia. With the success of this technique, some authorities have questioned the need for vasovasostomy and vasoepididymostomy procedures.

Despite advances, cost and safety issues seem to favor surgical reconstruction over sperm extraction with ICSI. A cost analysis by Kolettis shows a significant cost advantage to vasoepididymostomies over ICSI. Expect the cost savings to be even more dramatic with the vasovasostomy population, given the higher pregnancy rates elicited by this population.

The safety concerns associated with ICSI, including ovarian hyperstimulation syndrome, increased risk of multiple births, and a theoretical risk of increased fetal malformations (eg, hypospadias), further supports the selection of surgical reconstruction.

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Media file 1:  Initial placement of two 9-0 nylon seromuscular sutures (A) followed by circumferential mucosal 10-0 nylon sutures (B)
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Media file 2:  Placement of 10-0 nylon sutures into opened epididymal tubule (A) followed by placement of a suture through vasal mucosa (B). Sutures are tied to complete inner layer, and several 9-0 nylon sutures are placed to approximate the epididymal tunic to the seromuscular edge of the vas deferens (C). (From the Cleveland Clinic Foundation, with permission).
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Media type:  Illustration

Media file 3:  End-to-side vasoepididymostomy technique
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Media file 4:  Table 1. Surgically correctable causes of ductal obstruction
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Media file 5:  Table 2. Microsurgical vasovasostomy
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Media file 6:  Table 3. Microsurgical vasoepididymostomy
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REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

• Belker AM, Thomas AJ Jr, Fuchs EF, Konnak JW, Sharlip ID. Results of 1,469 microsurgical vasectomy reversals by the Vasovasostomy Study Group. J Urol. Mar 1991;145(3):505-11. [Medline].
• Berardinucci D, Zini A, Jarvi K. Outcome of microsurgical reconstruction in men with suspected epididymal obstruction. J Urol. Mar 1998;159(3):831-4. [Medline].
• Dewire DM, Thomas AJ. Microsurgical end-to-side vasoepididymostomy. In: Goldstein M, ed. Surgery of Male Infertility. Philadelphia, Pa: WB Saunders Co; 1995:128-34.
• Fogdestam I, Fall M, Nilsson S. Microsurgical epididymovasostomy in the treatment of occlusive azoospermia. Fertil Steril. Nov 1986;46(5):925-9. [Medline].
• Hernandez J, Sabanegh ES. Repeat vasectomy reversal after initial failure: overall results and predictors for success. J Urol. Apr 1999;161(4):1153-6. [Medline].
• Kolettis PN, Thomas AJ Jr. Vasoepididymostomy for vasectomy reversal: a critical assessment in the era of intracytoplasmic sperm injection. J Urol. Aug 1997;158(2):467-70. [Medline].
• Marmar JL. Management of the epididymal tubule during an end-to-side vasoepididymostomy. J Urol. Jul 1995;154(1):93-6. [Medline].
• Martin E, Carnett JB, Levi JV. The surgical treatment of sterility due to obstruction at the epididymis. Together with a study of the morphology of human spermatozoa. Medical Bulletin: University of Pennsylvania. 1903;15:2.
• O'Conor VJ. Anastomosis of the vas deferens after purposeful division for sterility. JAMA. 1948;136:162.
• Owen ER. Microsurgical vasovasostomy: a reliable vasectomy reversal. Aust N Z J Surg. Jun 1977;47(3):305-9. [Medline].
• Palermo G, Joris H, Devroey P, Van Steirteghem AC. Pregnancies after intracytoplasmic injection of single spermatozoon into an oocyte. Lancet. Jul 4 1992;340(8810):17-8. [Medline].
• Silber SJ. Microscopic vasoepididymostomy: specific microanastomosis to the epididymal tubule. Fertil Steril. Nov 1978;30(5):565-71. [Medline].
• Silber SJ. Epididymal extravasation following vasectomy as a cause for failure of vasectomy reversal. Fertil Steril. Mar 1979;31(3):309-15. [Medline].
• Silber SJ. Perfect anatomical reconstruction of vas deferens with a new microscopic surgical technique. Fertil Steril. Jan 1977;28(1):72-7. [Medline].
• Thomas AJ. Vasoepididymostomy. In: Thomas AJ, Nagler HM, eds. Atlas of Surgical Management of Male Infertility. New York: Igaku-Shoin; 1995:62-70.
• Thomas AJ Jr. Vasoepididymostomy. Urol Clin North Am. Aug 1987;14(3):527-38. [Medline].

Article Last Updated: Oct 18, 2006