OPERATION DATE: 04/22/2019 ATTENDING SURGEON: Wayne Hellstrom, MD ASSISTANT SURGEONS: 1. Peter Tsambarlis, MD 2. Igor Voznesensky, MD (R) PREOPERATIVE DIAGNOSIS: Iatrogenic infertility. POSTOPERATIVE DIAGNOSIS: Iatrogenic infertility. PROCEDURES PERFORMED: 1. Bilateral vasovasostomy. 2. Testicular sperm extraction for cryopreservation. SPECIMENS: Testicular tissue for cryopreservation. DRAINS: None. IMPLANTS: None. ANESTHESIA: General. INDICATION: This is a 41-year-old male with a past medical history of vasectomy, who subsequently has a new partner and wanted to regain fertility. In doing so, he presented to clinic and we discussed his options, which included vasectomy reversal and due to his time since last vasectomy, his age, and his partner's age, he was deemed a good candidate to do so. He did understand that there was a possibility of failure of the procedure as well as the risks associated with surgery in general including but not limited to bleeding, infection or damage to nearby structures, which in this case focused on the structures of the spermatic cord with subsequent damage to the testicle. The patient elected to proceed. TECHNIQUE: The patient was brought to the operating room and placed in the supine position. SCDs were applied to his legs bilaterally and turned on. General anesthesia was induced by the anesthesia team. He was then prepped and draped in the usual sterile fashion. Dr. Hellstrom was present for a time-out. We initially made an incision in the midline along the median raphe approximately 4 cm in length and through the incision dissected down to both testicles separately in order to deliver them both out of the field. Once this was done, we carried our dissection upwards along the vas deferens until we could palpably feel a defect in the vas deferens. At this point, we placed vessel loops proximal and distal to the defect and dissected that out. A single 3-0 nylon suture was placed on each side in the adventitial tissue of the vas deferens proximally into the skin in order to secure the vas for the remainder of the case. Once we isolated the vas deferential defect, we cut through the healthy portion of the vas deferens and identified clear fluid bilaterally. Upon microscopic analysis of this fluid, both sides did have sperm, the right was more robust than the left; however, due to the presence of clear fluid with sperm, the decision was made to proceed with a vasovasostomy. Prior to doing so; however, we delivered the testicles and performed a testicular sperm extraction. We initially placed two 5-0 Monocryl sutures along the tunica albuginea on the testicle and then cut between those sutures. Upon doing so seminiferous tubules pouch out of that defect and using a no-touch technique and tenotomy scissors, we cut multiple segments of the testicular tissue out and passed them off for cryopreservation. A fourth very small tissue was sent on a slide in order to confirm the presence of sperm and sperm was present bilaterally. We then closed the defect using a running 5-0 Monocryl sutures and then tied the previously placed stay sutures over the top in an interrupted fashion. We turned our attention back to the vas deferens. We started on the patient's left side, which was the more difficult side and created a modified 2-layer anastomosis. We confirmed the patency of the proximal end by first placing a small lacrimal dilator into the lumen and then the back of a nylon suture significant distance into the vasal lumen. Once this was done, we used 9-0 Monocryl suture placed in out-to-in and in-to-out fashion in order to have the knot outside of the vasal lumen in the 4 quadrants. We then placed a second layer between those previous 4 sutures in the more adventitial position. Once this was done, 2 interrupted 5-0 Monocryl sutures were placed to reduce any tension on the anastomosis by grabbing the perivasal tissue. This procedure was repeated on the patient's right side. We navigated both testicles back intotheir anatomic locations, preserving a medial septum during the initial delivery of the testicles. We then ran the dartos tissue closed incorporating that septum into the running closure. The skin was closed with interrupted 4-0 Monocryl sutures placed in a vertical mattress fashion. This concluded the procedure, which the patient tolerated well. Dr. Hellstrom was present for the entire duration of the case. His dressing consisted of collodium, Xeroform gauze, and a mummy wrap. Disposition: Plan is for him to be discharged and he will get his first semen analysis in approximately 6 weeks to confirm the presence of sperm in his ejaculate.