decision to include case series, primarily to illustrate the
ciencies in the available data. This decision did not
cantly affect the pooled OR as evidenced by our
sensitivity analysis in which these studies were excluded.
Although the current literature-based meta-analysis has
provided the most comprehensive assessment, yet, of
vasal sperm and postoperative patency, it has relied on
aggregated published data rather than on individual pa-
tient data, which would be preferred. Undoubtedly, there
is also publication bias in reporting only good outcomes
after VR, despite the fact that this bias was not obviously
detected in our statistical analyses. We were also unable
to control for surgical technique, although this may also
be construed as a strength, as an analysis using a large
number of surgeons may imply reproducibility. However,
it must be noted that the number of men who had VV
performed when sperm were absent in the vasal
much smaller than the comparison group of men who had
sperm present. Many men with intravasal azoospermia
likely would have undergone EV, which would bias our
analysis. Nonetheless, despite the limitations of the data,
we believe our study is robust in critically evaluating the
published literature on the presence of sperm in vasal
uid during VV.
Our meta-analysis emphasizes the need for more pro-
spective studies of VR outcomes with standardized
reporting measures if we are to truly de
ne measures of
surgical success. We recommend that future studies
include data on age (both patient and partner), length of
obstructive interval, gross intravasal
uid appearance (ie,
clear, cloudy, creamy, or pasty), presence of intravasal
whole sperm and/or sperm parts (ie, sperm heads or tails
alone), length of testicular vas remnant, presence of
granuloma, and achievement of patency and pregnancy.
Larger prospective studies involving concomitant mea-
surement and reporting of these variables are needed
in particular to address the important question of whether
the presence of vasal sperm constitutes a useful indepen-
dent clinical factor for intraoperative decision making.
We have performed a systematic review and meta-analysis
of VV outcomes in the current era. The OR of post-
operative patency was approximately 4 times higher given
the presence of intravasal sperm or sperm parts as opposed
to their absence at the time of VR. There was marked
variability in outcomes and factors reported. Our review
highlights the poor methodological quality of existing
evidence and underscores the need for more thorough
follow-up and higher standards of reporting in the future.
Eisenberg ML, Lipshultz LI. Estimating the number of vasectomies
performed annually in the United States: data from the National
Survey of Family Growth.
Sandlow JI, Nagler HM. Vasectomy and vasectomy reversal:
important issues. Preface.
Urol Clin North Am
Belker AM, Thomas AJ Jr, Fuchs EF, et al. Results of 1,469
microsurgical vasectomy reversals by the Vasovasostomy Study
Lipshultz LI, Rumohr JA, Bennett RC. Techniques for vasectomy
Urol Clin North Am
Goldstein M, Li PS, Matthews GJ. Microsurgical vasovasostomy:
the microdot technique of precision suture placement.
Kolettis PN, Burns JR, Nangia AK, et al. Outcomes for vaso-
vasostomy performed when only sperm parts are present in the vasal
Herrel L, Hsiao W. Microsurgical vasovasostomy.
Asian J Androl
Elzanaty S, Dohle GR. Vasovasostomy and predictors of vasal
patency: a systematic review.
Scand J Urol Nephrol
Silber SJ, Galle J, Friend D. Microscopic vasovasostomy and sper-
Haldane JB. The estimation and signi
cance of the logarithm of a
ratio of frequencies.
Ann Hum Genet
Cochran WG. The combination of estimates from different exper-
Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-
Egger M, Davey Smith G, Schneider M, et al. Bias in meta-analysis
detected by a simple, graphical test.
Sheynkin YR, Chen ME, Goldstein M. Intravasal azoospermia: a
Sigman M. The relationship between intravasal sperm quality and
patency rates after vasovasostomy.
Smith RP, Kovac JR, Badhiwala N, et al. The signi
cance of sperm
heads and tails within the vasal
uid during vasectomy reversal.
Indian J Urol
Bolduc S, Fischer MA, Deceuninck G, et al. Factors predicting
overall success: a review of 747 microsurgical vasovasostomies.
Urol Assoc J
Ratana-olarn K, Gojaseni P, Muangman V, et al. Vasectomy
reversal: experience in Ramathibodi Hospital, Thailand.
Patel SR, Sigman M. Comparison of outcomes of vasovasostomy
performed in the convoluted and straight vas deferens.
Chiang HS. Clinical study of vasectomy reversal: results of 60
single-surgeon cases in Taiwan.
J Formos Med Assoc
Silber SJ, Grotjan HE. Microscopic vasectomy reversal 30 years
later: a summary of 4010 cases by the same surgeon.
Kolettis PN, D
Amico AM, Box L, et al. Outcomes for vaso-
vasostomy with bilateral intravasal azoospermia.
Kolettis PN, Sabanegh ES, D
Amico AM, et al. Outcomes for va-
sectomy reversal performed after obstructive intervals of at least 10
Kolettis PN, Woo L, Sandlow JI. Outcomes of vasectomy reversal
performed for men with the same female partners.
Kolettis PN, Sabanegh ES, Nalesnik JG, et al. Pregnancy outcomes
after vasectomy reversal for female partners 35 years old or older.
Supplementary data associated with this article can be found,
in the online version, at
UROLOGY 85 (4), 2015