Sexual Function/Infertility

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

Purpose:

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.

Results:

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.

Conclusions:

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.

Key Words:

testis, vasectomy, vasovasostomy, nomograms, granuloma

Abbreviations

and Acronyms

CI

±

concordance index

EV

±

epididymovasostomy

VR

±

vasectomy reversal

VV

±

vasovasostomy

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:

410-715-1864).

† Financial interest and/or other relationship

with Auxilium and Eli Lilly.

‡ Financial interest and/or other relationship

with Allergan, Auxilium, AMS, Pfizer and Repros

Therapeutics.

A

PPROXIMATELY

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.

Up

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-

cedure.

In a study by Chawla et al 48% of

men had unrecognized epididymal ob-

struction as the etiology of VR fail-

ure.

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.

Opti-

mal EV outcomes depend highly on spe-

0022-5347/12/1871-0215/0

Vol. 187, 215-218, January 2012

THE JOURNAL OF UROLOGY

Printed in U.S.A.

© 2012 by A

MERICAN

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ROLOGICAL

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DOI:10.1016/j.juro.2011.09.026

www.jurology.com

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