Nomogram to Preoperatively Predict the Probability of Requiring
Epididymovasostomy During Vasectomy Reversal
David M. Fenig,* Michael W. Kattan, Jesse N. Mills,† Maria Gisbert, Changhong Yu
and Larry I. Lipshultz‡
From Cheseapeake Urology Associates (DMF), Baltimore, Maryland, Cleveland Clinic (MWK, CY), Cleveland, Ohio, The Urology Center of
Colorado (JNM), Denver, Colorado, and St. Luke’s Episcopal Hospital (MG) and Baylor College of Medicine (LIL), Houston, Texas
Up to 6% of men who undergo vasectomy may later undergo vasectomy
reversal. Most men require vasovasostomy but a smaller subset requires epidid-
ymovasostomy. Outcomes of epididymovasostomy depend highly on specialized
training in microsurgery and, if predicted preoperatively, might warrant referral
to a specialist in this ﬁeld. We created a nomogram based on preoperative patient
characteristics to better predict the need for epididymovasostomy.
Materials and Methods:
We evaluated patients who underwent primary vasec-
tomy reversal during a 5-year period. Preoperative and intraoperative patient data
were collected in a prospectively maintained database. We evaluated the ability of
age, years since vasectomy, vasectomy site, epididymal fullness and granuloma
presence or absence to preoperatively predict the need for epididymovasostomy in a
given patient. The step-down method was used to create a parsimonious model, on
which a nomogram was created and assessed for predictive accuracy.
Included in the study were 271 patients with a mean age of 42 years.
Patient age was not positively associated with epididymovasostomy. Mean time
from vasectomy to reversal was 9.7 years. Time to reversal and a sperm granu-
loma were selected as important predictors of epididymovasostomy in the ﬁnal
parsimonious model. The nomogram achieved a bias corrected concordance index
of 0.74 and it was well calibrated.
Epididymovasostomy can be preoperatively predicted based on
years since vasectomy and a granuloma on physical examination. Urologists can
use this nomogram to better inform patients of the potential need for epididymo-
vasostomy and whether specialist referral is needed.
testis, vasectomy, vasovasostomy, nomograms, granuloma
Submitted for publication May 21, 2011.
* Correspondence: Chesapeake Urology Asso-
ciates, 7625 Maple Lawn Blvd., Suite 210, Fulton,
Maryland 20759 (telephone: 443-471-5781; FAX:
† Financial interest and/or other relationship
with Auxilium and Eli Lilly.
‡ Financial interest and/or other relationship
with Allergan, Auxilium, AMS, Pﬁzer and Repros
500,000 vasectomies are
performed in the United States each
year, an incidence of approximately
10/1,000 men 25 to 49 years old. This
number remained consistent for the
1991, 1995 and 2002 estimates.
to 6% of men who undergo vasectomy
may undergo VR in their lifetime.
Most men require VV and a smaller
subset requires EV, which is a more
delicate, technically demanding pro-
In a study by Chawla et al 48% of
men had unrecognized epididymal ob-
struction as the etiology of VR fail-
This missed epididymal occlu-
sion is at least partly due to the lack
of comfort of some urologists with per-
forming EV. A survey of microsurgical
practice patterns showed that a small
minority of nonfellowship trained com-
munity urologists perform EV when
there is poor quality vasal ﬂuid.
mal EV outcomes depend highly on spe-
Vol. 187, 215-218, January 2012
THE JOURNAL OF UROLOGY
Printed in U.S.A.
© 2012 by A