Schematic model.

Operative animation, Vasectomy reversal

Vasectomy reversal: microsurgical vasovasostomy, with the vasoepididymostomy branch

Restoring the passage of sperm after a vasectomy, by joining the two ends of each vas under the operating microscope. Each vas is delivered through an incision on the upper median raphe, its scarred segment cut out, and the fluid from the testicular end examined on a slide.

Sperm in the fluid means a two-layer vasovasostomy; no sperm means the block is in the epididymis and the vas is joined to an epididymal tubule instead. The lesson is the decision made at the slide.

Advanced tier FRCS andrology, male infertility and obstructive azoospermia Interactive 3D
Schematic scene preview: Vasectomy reversal
Preparing the 3D anatomy…

UrOops3D · UroRef · © Nity G

How to use this module. Play through the nine steps, or use Back and Next. Watch the scarred segment come out, the slide decide the operation, and the two layers go in under the microscope. The triggers show the no-sperm branch (play on through it), a join that narrows a year later, and a haematoma.

Click me next Section 2 of 8 Anatomy The structures this operation works between, and the one it must not cross.

The structures in the scene

Vasectomy reversal: how the structures relateThe cut vas at the join, and what lies round it. Cut vas: mucosa, muscularis, sheath: the inner layer; joined edge to edge, never torn Vasal mucosa (danger). Cut vas: mucosa, muscularis, sheath: beside it in the cord; never in the clamps Testicular artery and veins (danger). Cut vas: mucosa, muscularis, sheath: runs in its sheath; kept with the ends Vasal artery in the sheath. Cut vas: mucosa, muscularis, sheath: cut back to healthy vas beyond it Scar and sperm granuloma. Cut vas: mucosa, muscularis, sheath: joined end to side when no sperm Epididymal tubule (danger). Cut vas: mucosa, muscularis, sheath: its sperm decide the operation Testicular vasal fluid.Cut vas: mucosa,muscularis, sheath!Vasal mucosa!Testicular arteryand veinsVasal artery in thesheathScar and spermgranuloma!Epididymal tubuleTesticular vasalfluidthe inner layer;joined edge toedge, never tornbeside it in thecord; never in theclampsruns in its sheath;kept with the endscut back to healthyvas beyond itjoined end to sidewhen no spermits sperm decidethe operationTargetDangerLandmarkContext
The cut vas at the join, and what lies round it. Schematic, not to scale; relationships only.
  • Seen from in front of the patient, each vas runs up from the tail of its epididymis behind the testis and enters the cord at the top of the scrotum, where the vasectomy was done.
  • There the two ends lie a short distance apart, the testicular end often capped by a granuloma, with the testicular artery and veins beside them in the cord.
  • Under the microscope the cut vas is three rings: the mucosa round the lumen, the thick muscularis, and the sheath with its own artery.
  • ›Vas deferens - firm, white and thick-walled, with a narrow lumen; after a vasectomy its two ends lie apart, joined by scar.
  • ›Vasal mucosa - the thin inner lining of the lumen; the inner layer of the join is mucosa to mucosa.
  • ›Vasal muscularis - the thick middle layer that gives the vas its feel; the second layer of the join.
  • ›Vasal sheath and vasal artery - the adventitial sheath round the vas carries its own artery; it is kept with the vas and closed over the join.
  • ›Sperm granuloma - a firm nodule of extravasated sperm, usually on the testicular end; it is excised with the scarred segment.
  • ›Testicular artery and pampiniform plexus - beside the vas in the cord; the testis depends on the artery.
  • ›Epididymis and its tubule - one long convoluted tubule packed under its tunica; in a vasoepididymostomy a single dilated loop is opened and joined to the vas.
  • ›Scrotal skin, dartos and median raphe - the incision lies on the upper raphe and reaches both cords.
Click me next Section 3 of 8 Steps The operation in order, with the landmark that guards each move.

Operative steps

  1. Couple assessment, examination The couple are assessed together: the time since the vasectomy, the female partner's age and fertility, and whether sperm retrieval with ICSI would suit them better. Consent covers failure, a possible vasoepididymostomy and storing sperm. Each vasectomy site is felt for its gap and any granuloma.
    where it bites: a reversal that cannot help this couple, because of the partner's fertility, is the wrong operation done well.
  2. Incision on the median raphe Supine, antibiotics, general or regional anaesthesia, preparation, draping and a time-out. A vertical incision is made on the upper median raphe and taken down through the dartos. One incision reaches both vasa; the chapter also allows an incision on the anterior wall of each hemiscrotum.
    where it bites: the scrotal skin and dartos are vascular; bleeding in the edges is controlled before going deeper.
  3. Delivery of the vas and its vasectomy site The right vas is brought into the wound with its vasectomy site. Babcock clamps are placed on the vas above and below the obstructed segment. An avascular plane in the sheath round the vas is opened and a Penrose drain passed through it for traction.
    where it bites: the testicular artery and the pampiniform veins lie in the cord beside the vas; only the vas is taken in the clamps.
  4. Freeing the ends, square cuts The operating microscope is brought in. The vas is dissected free of the scar, its vasal artery preserved, and the abdominal end mobilised toward the ring. Each end is held in a slotted nerve clamp and cut cleanly at a right angle beyond the scar, and the scarred segment with its granuloma is removed.
    where it bites: stripping the vas bare devascularises the ends; the sheath and its vessels stay with it.
  5. Testicular fluid and abdominal patency Fluid from the testicular end is placed on a slide with a drop of solution and examined under the microscope in theatre. Sperm are present, so a vasovasostomy is done. The vasal vessels at the cut are ligated, and the abdominal lumen gently dilated, cannulated and irrigated with saline to confirm patency.
    where it bites: no sperm in the fluid means a secondary epididymal block: the decision here is between a vasovasostomy and a vasoepididymostomy.
  6. Anterior wall: mucosa, then muscularis The two ends are stabilised in an approximating clamp and the field isolated. Both cut faces are marked at the six mucosal stitch sites. Three mucosal stitches are placed inside out on the anterior wall, taking mucosa with superficial muscularis, and tied; then three deep muscular stitches are placed between them.
    where it bites: the mucosa is delicate; a torn edge or a stitch through the back wall closes the lumen.
  7. Half turn, posterior wall, sheath The vas is turned a half turn and its lumen irrigated. The posterior wall is joined the same way, mucosa first and then muscularis. The vasal sheath is approximated over the join with interrupted stitches, the repair is inspected to confirm that it lies without tension, and haemostasis is secured.
    where it bites: tension on the join is the commonest technical reason for it to scar and narrow later.
  8. The other side The identical procedure is carried out on the left: the vas delivered, freed and cut back on each side of the scar, the testicular fluid examined, the abdominal end shown to be patent, and a two-layer vasovasostomy completed. Each side is decided on its own fluid.
    where it bites: the two sides may need different operations; each side has its own slide.
  9. Closure and follow-up The dartos is closed with a running absorbable stitch and the skin with a subcuticular absorbable stitch, and a dressing, gauze and a scrotal support are applied. Semen analysis follows at intervals. Patency, sperm returning to the semen, and pregnancy are separate outcomes and are reported separately.
    where it bites: sperm that return and then disappear mean a late narrowing of the join; the semen tests continue after the first good result.
Click me next Section 4 of 8 Danger zones Where this operation bites, and why it bites there.
Critical relationship

Danger zones

The spatial relationships the animation is built to make automatic. Before you read each one, ask yourself: at this point in the operation, what is about to go wrong, and what is my first move? The save for each sits in the Complications tab.

  • RiskTesticular blood supply within the cord - the testicular artery and veins lie beside the vas; dissection and clamps take the vas alone.
  • RiskDelicate vasal mucosa - handled only at its cut edge, joined mucosa to mucosa with fine stitches that do not catch the back wall.
  • RiskEpididymal tubules during bypass - thin-walled and easily torn; the loop chosen is dilated and has motile sperm in its fluid.
  • RiskThe vasal artery and sheath - kept with the vas so the ends stay well perfused; the sheath closes over the join.
  • RiskThe slide - the testicular vasal fluid decides the operation on each side.
Practise it Take me into the scene Opens the animation at a danger moment and asks you to predict the mechanism and your first move before it reveals.
Click me next Section 5 of 8 Complications The save for each one: the first move, the escalation trigger, the op-note line.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

No sperm in the vasal fluid

  • the testicular vasal fluid has no sperm; the obstruction is in the epididymis, from the back-pressure after the vasectomy, and a vasovasostomy on that side would fail.
The save
  1. Stop before joining. Examine more fluid; if none is seen at first, the testicular end can be flushed to look for seminal fluid. first move
  2. Open the epididymal tunica and inspect from the tail toward the head for a dilated tubule; puncture it and confirm motile sperm in its fluid.
  3. Bring the abdominal vas alongside without tension, open the tubule lengthwise, and join its edge to the vasal mucosa with inside-out stitches, then the outer layer.
  4. If this side needs a vasoepididymostomy and the surgeon is not trained in it, close and refer to a surgeon who is; sperm can be retrieved and stored for ICSI. escalation trigger
  5. Op note: the fluid on each side, the level of the tubule used, the technique, and any sperm stored. document

Failed join, late obstruction

  • sperm return to the semen and then disappear, or never return: the join has narrowed with scar or the epididymis has become blocked.
The save
  1. Repeat the semen analysis to confirm it, and examine him for a granuloma or tenderness at the join. first move
  2. Review the operation note: the fluid found at the time and the type of join on each side.
  3. Offer a choice: a redo reconstruction, often a vasoepididymostomy, or sperm retrieval with ICSI, taking the partner's age into account; refer to a surgeon who does redo reversals. escalation trigger
  4. Record each semen result with its date, and that patency and pregnancy have been discussed as separate outcomes. document

Scrotal haematoma

  • that evening the left hemiscrotum is tense, swollen and bruised; bleeding is the first complication the chapter lists.
The save
  1. Examine him: a soft, stable swelling is managed with a support, ice and analgesia, and reviewed. first move
  2. Check the anticoagulant and antiplatelet history, and the testis for tenderness.
  3. A tense, expanding or very painful haematoma is a senior review now; it may need exploration, evacuation and haemostasis, with care for the joins. escalation trigger
  4. Record the size and progress of the swelling and the plan, and tell him what would bring him back. document
Click me next Section 6 of 8 Troubleshooting When the case turns: the problem, then the next move.

Intra-operative troubleshooting

When the case turns: the problem, then the next move.

  • ActionNo fluid at all from the testicular end - the chapter allows the testicular end to be flushed to look for seminal fluid; fluid with sperm in it still allows a vasovasostomy.
  • ActionThick, creamy fluid without sperm - the EAU guideline reads the absence of sperm, especially in thick fluid, as a secondary epididymal obstruction, and a vasoepididymostomy may be indicated.
  • ActionThe ends will not meet without tension - the chapter gains length by freeing the abdominal end toward the ring and the testicular end down to the junction with the epididymis.
  • ActionA small atrophic testis on one side - the chapter allows a crossed vasovasostomy, the good testis joined to the other side.
  • ActionNo microscope - the chapter allows magnifying loupes when a microscope is not available.
  • ActionAn older partner with limited ovarian reserve - the EAU guideline recommends sperm retrieval for ICSI rather than reconstruction when the partner's ovarian reserve is limited, or when the couple choose to go straight to ICSI.
Click me next Section 7 of 8 FRCS viva Say it out loud, then mark yourself against the model answer.

FRCS viva questions

The examiner stems this scene prepares you for. Try to answer out loud first, then reveal, and learn the discriminator, the detail that turns a pass into a strong pass.

QA man had a vasectomy eleven years ago. He and his new partner want a child. How do you counsel them?reveal answer
  • I would see them as a couple, because the outcome depends on both.
  • I would ask about the partner's age, her own fertility and any previous children, and his history since the vasectomy.
  • On examination I would feel the testes, the vasectomy sites and the epididymes.
  • I would explain the two routes: a microsurgical reversal, which aims for natural conception, and sperm retrieval with ICSI.
  • I would give the figures from the Vasovasostomy Study Group, 1,469 men at five institutions.
  • After a first reversal sperm returned in 86% and pregnancy followed in 52%.
  • The interval since the vasectomy matters: under 3 years, patency 97% and pregnancy 76%; 3 to 8 years, 88% and 53%; 9 to 14 years, 79% and 44%; 15 years or more, 71% and 30%.
  • At eleven years he falls in the 79% and 44% band.
  • I would warn him that a vasoepididymostomy may be needed on one or both sides, and offer to store sperm at the operation.
Strong pass

Say both

  • Quoting the interval bands with their source
  • Separating patency from pregnancy
Examiner note
Quoting the interval bands with their source, and separating patency from pregnancy.
QYou have cut the testicular end. How do you decide between a vasovasostomy and a vasoepididymostomy?reveal answer
  • The fluid decides it, on each side.
  • I put the testicular vasal fluid on a slide with a drop of solution and look at it under the microscope in theatre.
  • If there are sperm, even only parts of sperm, I do a vasovasostomy.
  • If the fluid is thick and creamy and has no sperm, the EAU guideline reads that as a secondary epididymal obstruction, and a vasoepididymostomy may be indicated.
  • If there is no fluid at all, I can flush the testicular end to look for seminal fluid.
  • The Vasovasostomy Study Group showed why this matters: when sperm were absent bilaterally and a vasovasostomy was done anyway, patency was 60% and pregnancy 31%.
  • For the vasoepididymostomy I open the epididymal tunica, find a dilated tubule, puncture it and confirm motile sperm, then join it to the vas in two layers.
  • I would only offer that if I am trained to do it; otherwise I would store sperm and refer.
Strong pass

Making the slide, side by side, the decision, and knowing the result of joining when there are no sperm.

QDescribe the two-layer microsurgical vasovasostomy.reveal answer
  • Under the microscope I free the vas from the scar, keeping its sheath and vasal artery.
  • I hold each end in a slotted nerve clamp and cut it cleanly at a right angle on healthy vas, so that all three layers can be seen and the mucosa bleeds healthily.
  • I check the testicular fluid and the patency of the abdominal end.
  • I put both ends into an approximating clamp and mark the six mucosal stitch sites on each face.
  • On the anterior wall I place three mucosal stitches inside out, taking the mucosa with superficial muscularis, and tie them; then three deep muscular stitches between them.
  • I turn the vas a half turn, irrigate the lumen and do the posterior wall the same way.
  • Finally I approximate the sheath over the join and check that there is no tension.
  • The Vasovasostomy Study Group found no better patency or pregnancy after the two-layer join than after a modified one-layer join, so precision matters more than the number of layers.
Strong pass

Say both

  • Mucosa to mucosa without catching the back wall
  • A join without tension
Examiner note
Mucosa to mucosa without catching the back wall, and a join without tension.
QWhy not just go straight to sperm retrieval and ICSI?reveal answer
  • For some couples that is the right answer.
  • The EAU guideline recommends microsurgical vasovasostomy or epididymovasostomy for azoospermia caused by vasal or epididymal obstruction in men whose partners have good ovarian reserve.
  • It recommends sperm retrieval, such as microsurgical epididymal sperm aspiration or testicular sperm extraction, as an adjunct to reconstruction, when reconstruction is not possible, when the partner's ovarian reserve is limited, or when the couple prefer to go straight to ICSI.
  • I would explain that a reversal, if it works, allows natural conception and more than one child, and that ICSI needs the partner to go through ovarian stimulation and egg collection with every cycle.
  • The guideline also says that sperm can be retrieved at the reversal and stored for ICSI, which covers a join that fails.
Strong pass

Letting the partner's ovarian reserve and the couple's preference choose the route.

QSix months after a reversal, sperm returned at the first test but the latest sample has none. What has happened?reveal answer
  • The likely cause is a late narrowing of the join with scar, or a secondary epididymal block that has developed.
  • I would repeat the analysis to confirm it and examine him for a granuloma or tenderness at the join, and I would read the operation note for the fluid found on each side.
  • The EAU guideline gives late failure after a vasectomy reversal as uncommon, 0 to 12%, and after a vasoepididymostomy as varying between 1 and 50%.
  • The options are a redo reversal, often a vasoepididymostomy, or sperm retrieval with ICSI.
  • In the Vasovasostomy Study Group repeat reversals were less successful than first ones: patency 75% and pregnancy 43%.
  • If sperm were stored at the first operation, ICSI can start at once.
Strong pass

Say both

  • Following the semen beyond the first good result
  • Knowing that a redo does less well
Examiner note
Following the semen beyond the first good result, and knowing that a redo does less well.
Click me next Section 8 of 8 Evidence The guidance each of these answers is built on.

Evidence and guidance

Operative Dictations in Urologic Surgery
Armenakas NA, Fracchia JA, Golan R. Vasovasostomy, chapter 48, and Vasoepididymostomy, chapter 47. Wiley, 2019
Followed for the indications, the essential steps and both template dictations. From chapter 48: a superior scrotal or inguinal incision, here a vertical one on the upper median raphe; Babcock clamps above and below the obstruction and a Penrose drain through an avascular plane in the sheath; the microscope; the vas freed from scar and mobilised. Each end is held in a slotted nerve clamp and cut cleanly at a right angle; the testicular fluid is examined for sperm; the vasal vessels are ligated; the abdominal end is dilated, cannulated and irrigated to show patency. Then the approximating clamp, microdots at six mucosal sites, three mucosal stitches inside out on the anterior wall, three deep muscular stitches, a half turn, the posterior wall the same way, the sheath approximated, and the same on the other side. Its variations (loupes, flushing the testicular end, length gained by mobilising, a crossed vasovasostomy) are in the troubleshooting. From chapter 47 for the branch: the epididymal tunica opened and inspected from the tail toward the head, a dilated tubule punctured and its fluid checked for motile sperm, and the vas brought alongside and its adventitia secured. The tubule is opened lengthwise, its edge joined to the vasal mucosa end to side with inside-out stitches, and the vasal sheath and adventitia secured to the tunica. Complications from both chapters: bleeding, infection, testicular atrophy, persistent azoospermia and infertility. General practice, not from the chapters: the right side first, the single midline incision with the testis left in the scrotum, and every first, escalate and document step.
Open guideline
The Journal of Urology
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 1991;145:505-511
Abstract read 19 October 2026 (PubMed 1997700). 1,469 men at 5 institutions over 9 years. First-time procedures: sperm in the semen in 865 of 1,012 (86%), pregnancy in 421 of 810 couples (52%). By interval from vasectomy: under 3 years patency 97% and pregnancy 76%; 3 to 8 years 88% and 53%; 9 to 14 years 79% and 44%; 15 years or more 71% and 30%. Two-layer no better than modified one-layer. Sperm absent from the vasal fluid bilaterally with bilateral vasovasostomy: patency 50 of 83 (60%), pregnancy 20 of 65 (31%). Granuloma and type of anaesthesia did not affect results. Repeat reversals: patency 150 of 199 (75%), pregnancy 52 of 120 (43%).
Open guideline
EAU Guidelines
European Association of Urology. Guidelines on Sexual and Reproductive Health, 2026, chapter 11 Male infertility, section 11.6.1, obstructive azoospermia. Read 19 October 2026
Vasal obstruction after vasectomy requires microsurgical vasectomy reversal; weighted mean patency 90 to 97% and pregnancy 52 to 73%; time to patency 1.7 to 4.3 months; late failure uncommon, 0 to 12%. No sperm in the intra-operative vasal fluid, especially thick fluid, suggests a secondary epididymal obstruction, and epididymovasostomy may be indicated. For epididymovasostomy: patency 63 to 85%, cumulative natural pregnancy 21 to 45%, late failure 1 to 50%, recanalisation 3 to 18 months; sperm retrieved and stored at the operation. Recommendations (strong): microsurgical vasovasostomy or epididymovasostomy for vasal or epididymal obstruction when the partner has good ovarian reserve; sperm retrieval as an adjunct, when reconstruction is not possible, when ovarian reserve is limited, or when the couple prefer ICSI.
Open guideline

Curriculum. Supports learning relevant to the ISCP Urology Curriculum syllabus topic Andrology. Not a workplace-based assessment and not evidence of competence.

Two minutes

Close the lap: recall it before you leave.

Say it aloud, then reveal. Reading is not remembering.

  1. 01 The relationship Say the critical spatial relationship out loud, then reveal. reveal
    Memory frame

    Seen from in front of the patient, each vas runs up from the tail of its epididymis behind the testis and enters the cord at the top of the scrotum, where the vasectomy was done.

    Why?
    There the two ends lie a short distance apart, the testicular end often capped by a granuloma, with the testicular artery and veins beside them in the cord. Under the microscope the cut vas is three rings: the mucosa round the lumen, the thick muscularis, and the sheath with its own artery.
  2. 02 The first move No sperm in the vasal fluid. Your first move? reveal
    First move

    Stop before joining.

    More detail
    Examine more fluid; if none is seen at first, the testicular end can be flushed to look for seminal fluid.
  3. 03 The escalation trigger No sperm in the vasal fluid. What makes you call for help? reveal
    Escalate when

    If this side needs a vasoepididymostomy and the surgeon is not trained in it, close and refer to a surgeon who is; sperm can be retrieved and stored for ICSI.

  4. 04 The discriminator What turns a pass into a strong pass? reveal
    Strong pass

    Say both

    • Quoting the interval bands with their source
    • Separating patency from pregnancy
    Examiner note
    Quoting the interval bands with their source, and separating patency from pregnancy.
  5. 05 The pitfall Where does this operation bite first? reveal
    Pitfall

    Testicular blood supply within the cord

    Why?
    the testicular artery and veins lie beside the vas; dissection and clamps take the vas alone.

Revision practice with self-marked answers, not an assessment of clinical competence. Kept in this browser only; it does not sync between devices.