International Journal of Urology (2000) 7, S35S38

Postgraduate Course: Operative Andrology

Diagnosis and treatment of post-herniorrhaphy vas
deferens obstruction
TADASHI MATSUDA
Department of Urology, Kansai Medical University, Osaka, Japan
Abstract Childhood inguinal herniorrhaphy (IH) is one of the most frequent causes of seminal tract obstruc-
tion. The incidence of vasal obstruction was found to be as high as 26.7% in subfertile patients
with a history of childhood IH. The distal end of the vas deferens was found at the internal
inguinal ring or in the pelvic cavity in 56.7% of cases, more than 3 cm of the vas deferens had
been resected in 37.9% of cases, and sperm was found in vasal uid in 45.5% of cases during cor-
rective surgery. Microsurgical two-layer vasovasostomy resulted in the postoperative appearance of
sperm in 39% of patients. In patients with postoperative azoospermia, a secondary epididymal
obstruction caused by a long-term vasal obstruction is a highly probable cause. Ipsilateral epididy-
movasostomy following successful inguinal vasovasostomy results in the postoperative appearance
of sperm in the ejaculate in 100% of the patients and a subsequent natural pregnancy rate of 50%.
The overall pregnancy rate among couples, following surgery in 18 patients, was 43%, excluding
pregnancies achieved by in vitro fertilization or intracytoplasmic sperm injection. Microsurgical
reanastomosis of the seminal tract resulted in high impregnation rates among partners of patients
with seminal tract obstruction caused by childhood IH. After receiving sufcient information on
each treatment modality, patients can choose their preferred treatment, either reanastomosis of the
seminal tract or assisted reproductive technology using epididymal or testicular sperm.
Introduction
Vas deferens obstruction caused by childhood inguinal
herniorrhaphy (IH) is one of the most common causes
of seminal tract obstruction. The success rate for
reanastomosis in post-herniorrhaphy patients is poorer
than that in vasectomy reversal patients. This may be
due to the technical difculty associated with micro-
surgical anastomosis in the inguinal region, and
because long-term obstruction has the potential to
cause secondary epididymal obstruction
1
or spermato-
genic failure.
2
This paper describes the diagnostic
methods, clinical ndings, surgical techniques and out-
comes of seminal tract reanastomosis, in patients with
vasal obstruction caused by childhood IH.
Methods
Diagnosis
Diagnosis of obstructive azoospermia is based on full
spermatogenesis in the majority of the seminiferous
tubules, the resulting presence of many sperm in the
testis, normal testes volume and normal levels of
serum FSH. If an azoospermic patient has a history of
bilateral herniorrhaphy and normal-sized testes, bilat-
eral vasal obstruction in the inguinal region is highly
probable, and a surgical approach to the inguinal
region under general anesthesia is recommended. In
our previous study, the incidence of vasal obstruction
was as high as 26.7% in subfertile patients with a his-
tory of childhood IH when unilateral obstruction was
carefully diagnosed (Table 1).
3
In patients with normal
seminal volume and normal ndings in the transrectal
ultrasonography, obstruction of the ejaculatory ducts
and congenital bilateral vas deferens atresia can be
ruled out. We believe that routine vasography with a
scrotal incision should play a limited role in diagnosis
and may even be potentially harmful. In cases of
obstruction in the inguinal region, it is difcult to pin-
point the obstruction site by vasography with a low
injection pressure. Secondary epididymal obstruction
may occur when the contrast medium is injected under
a high injection pressure in order to visualize the
inguinal vas deferens. We recommend that vasography,
S36 Postgraduate Course: Operative Andrology
when necessary, should be performed during vasova-
sostomy with a low injection pressure.
It is expected that the majority of obstructions
caused by IH are unilateral because 90% of childhood
IH is performed unilaterally. Some of the patients
with unilateral obstruction show oligozoospermia and
decreased function of the contralateral testis due to a
variety of reasons. The diagnosis of unilateral obstruc-
tion is difcult, mainly because it does not cause
azoospermia. Unilateral obstruction is suspected in
cases where there is a discrepancy between seminal
ndings and testicular volume or serum FSH levels.
Another diagnostic clue to obstruction is careful palpa-
tion of the scrotal contents. Palpation of the vas defer-
ens, when it is obstructed in the inguinal region, will
reveal that it is thicker than the contralateral non-
obstructed vas deferens.
3
Clinical ndings in cases of vas deferens
obstruction by IH
The distal vasal end
The site of obstruction in post-herniorrhaphy patients
varied from the pelvic cavity to the scrotum. An
evaluation of 20 patients revealed the distal (seminal
vesicle) end of the obstructed vasa was located at the
internal inguinal ring, or more distally in the pelvic
cavity, in 56.7% of the vasa examined (Table 2).
4
In
these cases, the vas deferens was probably ligated or
cut when the hernia sac was closed at the internal
inguinal ring during herniorrhaphy. Finding the distal
end was sometimes difcult. We opened the peritoneal
cavity and found the vasal end in the pelvic cavity by
palpation of the peritoneum in some cases. In one
case, however, no distal end of the vas deferens was
identied despite an extensive search extra- and
intraperitoneally. It is unclear whether this patient had
atresia of the unilateral vas deferens, or whether there
had been extensive resection of the distal vas deferens
at the time of herniorrhaphy. In 36.7% of the vasa,
more than 3 cm of the vas deferens had been resected
during previous inguinal herniorrhaphy, causing dif-
culties for the reconnection of the distal and proximal
ends of the vas deferens.
The proximal vasal end
Sperm was identied in uid obtained from 45.5%
of the obstructed vasa among the 20 patients
investigated.
4
Absence of sperm in the vasal uid is
apparently more common among post-herniorrhaphy
patients than among vasectomy reversal patients.
5
Sec-
ondary epididymal obstruction due to long-term vasal
obstruction is a cause of azoospermia after patent
vasovasostomy. In vasectomy reversal, the incidence of
epididymal obstruction was reported to increase when
the obstruction interval was longer than 10 years and
there was no sperm granuloma.
1
In post-herniorrhaphy
vasal obstruction patients, secondary epididymal ob-
struction is likely because the obstruction interval is
lengthy and there is no sperm granuloma. Vasovasos-
tomy is required, even though there are no sperm in the
vasal uid in post-herniorrhaphy vasal obstruction
patients. Secondary epididymal obstruction can be
overcome with ipsilateral epididymovasostomy. In six
patients with post-vasovasostomy azoospermia and
patent vasovasostomy, we performed ipsilateral epi-
didymovasostomy, resulting in a normal sperm density
in all patients and three natural pregnancies.
The surgical technique
Under general intubated anesthesia, the inguinal canal
is re-opened and the spermatic cord is exposed. The
proximal (testicular) vas deferens is identied at
the external inguinal ring and followed upward to the
internal inguinal ring until the obstruction site is iden-
tied. If the distal vasal end is not found in the canal,
the posterior oor of the canal is incised and the pelvic
Table 1 Incidence of vas deferens obstruction caused
by childhood inguinal herniorrhaphy (IH) in subfertile
patients
Total subfertile patients evaluated 723*
Patients with childhood IH 54 (100%)
Bilateral operation 10
Unilateral operation 45
Vas deferens obstruction 15 (27.8%)
Bilateral obstruction 3
Unilateral obstruction 12
* Excluding one patient who was referred because of
known bilateral obstruction.
Table 2 Locations of the distal end of the obstructed vasa
Location of distal end No. vasa
Pelvic cavity, internal ring 16
Inguinal canal 9
External ring, scrotum 2
No distal vas deferentia 1
Total 28
Third Asian and Oceanic Congress of Andrology S37
cavity is opened. Opening the peritoneum is some-
times helpful to nd the distal vas deferens.
During surgical procedures involving the inguinal
canal, it is most important to preserve blood supply to
both ends of the vas deferens. To reconnect both ends,
more of the vas deferens must be separated from the
spermatic cord in post-herniorrhaphy patients than in
patients undergoing vasectomy reversal. Furthermore,
the deferential artery is usually obstructed at the vasal
obstruction site. We believe that devascularlization of
the vas deferens is a frequent cause of vasovasostomy
failure. Great care must be taken not to injure the dif-
ferential vessels supplying blood in a retrograde way
from the testis. In cases of epididymovasostomy fol-
lowing ipsilateral inguinal vasovasostomy, the straight
part of the vas deferens was cut as proximally as pos-
sible without cutting the vasal artery in order to main-
tain the blood supply to the proximal vas deferens
from the epididymis or testis.
In cases where a lengthy part of the vas deferens
was resected at IH, the distal vas deferens deep in the
pelvic cavity must be separated to perform vasovasos-
tomy. In order to spare the missing part of the vas def-
erens, the vas deferens is passed through a hole just
cephalad to the pubic bone without passing the
inguinal canal. It was reported that 712.2 cm of the
vas deferens could be gained from retroperitoneal
mobilization of the vas deferens and delivery through
the external ring.
6,7
Crossed vasovasostomy of the
bilateral vasa is the treatment of choice in selected
patients.
8
Crossed vasovasostomy, both scrotal and
suprapubic, is technically easier than inguinal vasova-
sostomy, although much attention must be paid to pre-
serve vasal vascularity.
Microsurgical two-layer vasovasostomy, according
to Silber, is mandatory for post-herniorrhaphy vasal
obstruction.
9
Six to ten mucosal sutures with 10-0
nylon were followed by eight to ten muscular sutures
with 9-0 nylon. There is a large discrepancy in the
diameter of the vas deferens between the proximal and
distal ends. In vasectomy reversal, the proximal vas
deferens does not distend much when a sperm granul-
oma is present at the proximal end. The granuloma is
caused by sperm leakage at the end, which results in a
decrease in the intravasal pressure.
10
In patients with
obstruction caused by childhood IH, on the other hand,
no granuloma is formed at the proximal end of the vas
deferens because the obstruction occurred many years
before the start of sperm production from the testis. A
longer period of obstruction also enhances distension
of the proximal vasal end. In order to anastomose the
two ends in a water-tight fashion, the two layer tech-
nique under operative microscopy is required. A multi-
institutional study on seminal tract reanastomosis in
Japan conrmed that the two-layer method showed a
better patency rate than the one-layer method among
133 post-herniorrhaphy patients (unpublished data).
Following vasal anastomosis, the posterior and ante-
rior walls of the inguinal canal are closed and the scro-
tal contents are xed with wide tapes. The patient must
subsequently wear tight underwear for at least one
month and sexual intercourse is prohibited for 3 weeks.
Results
Since 1985, the author has treated 28 post-herniorrha-
phy patients with vasal obstruction, 18 were azoosper-
mic and 10 were not. In 44% of the 18 azoospermic
patients, sperm was found in the postoperative ejacu-
late after the initial vasovasostomy, and impregnation
was achieved in three of the patients partners, two by
natural intercourse and one by intracytoplasmic injec-
tion of sperm (ICSI) (Table 3). In seven patients who
showed no sperm in the vasal uid and persistent
azoospermia, postoperative vasography showed patent
anastomosis, and ipsilateral epididymovasostomy was
subsequently performed in six patients. All six patients
showed normal sperm density after the second opera-
tion and ve achieved impregnation of their partners
Table 3 Surgical outcomes of microsurgical reanastomosis of seminal tracts in patients with vasal obstruction caused by
childhood inguinal herniorrhaphy (IH)
Sperm density after Pregnancy (natural)
Preoperative No. Sperm density after initial operation subsequent operation Initial
sperm density patients 0 < 20 million/mL > 20 million/mL 0 < 20 million/mL > 20 million/mL operation Overall
0 18 10 1 7 4 1 13 3 (2) 8 (5)*
< 5 million/mL 8 5 3 4 (3) 4 (3)**
> 5 million/mL 2 0 2 1 (1) 1 (1)
*Articial insemination of the mans sperm: one case; intracytoplasmic sperm injection using ejaculated sperm: two cases; **intra-
cytoplasmic sperm injection using ejaculated sperm: one case.
S38 Postgraduate Course: Operative Andrology
(Table 4): one by articial insemination, one after
seven ICSI procedures using ejaculated sperm and
three by natural intercourse. The overall impregnation
rate was 57% among married patients with sufcient
follow-up periods, with a natural impregnation rate of
36%. The surgical outcome of ten non-azoospermic
patients is shown in Table 3. Among eight patients
with severe oligozoospermia (sperm count < 5 million/
mL), three achieved natural impregnation.
Conclusion
Vas deferens obstruction is unexpectedly frequent in
patients with a history of childhood IH. Although
vasovasostomy after IH is technically more difcult
than vasectomy reversal, and epididymovasostomy is
required in a third of the patients, fertility can be
restored by microsurgical reanastomosis.
References
1 Silber SJ. Epididymal extravasation following vasec-
tomy as a cause for failure of vasectomy reversal.
Fertil. Steril. 1979; 31: 30915.
2 Matsuda T, Hiura Y, Muguruma K, Okuno H, Horii Y,
Yoshida O. Quantitative analysis of testicular histology
in patients with vas deferens obstruction caused by
childhood inguinal herniorrhaphy: Comparison to
vasectomized men. J. Urol. 1996; 155: 5647.
3 Matsuda T, Horii Y, Yoshida O. Unilateral obstruction
of the vas deferens caused by childhood inguinal
herniorrhaphy in male infertility patients. Fertil. Steril.
1992; 58: 60913.
4 Matsuda T, Muguruma K, Hiura Y, Okuno H, Shichiri
Y, Yoshida O. Seminal tract obstruction caused by
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5 Belker AM, Thomas Jr AJ, Fuchs EF, Konnak JW,
Sharlip ID. Results of 1469 microsurgical vasectomy
reversals by the Vasovasostomy Study Group. J. Urol.
1991; 145: 505511.
6 Buch JP, Woods T. Retroperitoneal mobilization of
the vas deferens in the complex vasovasostomy. Fertil.
Steril. 1990; 54: 9313.
7 Gilis J, Borovikov AM. Treatment of vas deferens large
defects. Int. Urol. Nephrol. 1989; 21: 62734.
8 Lizza EF, Marmar JL, Schmidt SS et al. Trans-septal
crossed vasovasostomy. J. Urol. 1985; 134: 11312.
9 Silber SJ. Microscopic technique for reversal of vasec-
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10 Silber SJ. Sperm granuloma and reversibility of vasec-
tomy. Lancet 1977; ii: 5889.
Table 4 Six patients who underwent epididymovasostomy following patent inguinal vasovasostomy
Patient Side Opposite side Obstruction Sperm density Sperm motility Pregnancy
number period (years) (million/mL) (%)
1 Left V-V failure 3 62.3 65 AIH
2 Left V-V failure 28 23.0 42 ICSI
3 Right Atresia 28 35.2 1
4 Bilateral 33 29.5 60 Natural
5 Right Atrophic testis 23 29.0 61 Natural
6 Right V-V failure 28 17 47 Natural
V-V, vasovasostomy; AIH, articial insemination of the mans sperm; ICSI, intracytoplasmic sperm injection using ejacu-
lated sperm.
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