Vasectomy remains a safe and effective method of contraception for men. Many variations in surgical technique currently are used by surgeons in the United States, each with its own benefits and drawbacks. Regardless of the surgical method used, the most important factor for successful vasectomy remains the experience and skill of the surgeon. The amount of evidence-based literature on the rationale for the different techniques for vasectomy remains limited. Careful study and innovation of vasectomy techniques will ensure that the most commonly performed urologic surgical procedure remain an excellent form of contraception in the future.
Vasectomy is the most commonly performed urologic surgical procedure performed in the United States. An estimated 500,000 men undergo the procedure each year in the United States, equivalent to 11% of all married couples relying on vasectomy for contraception. The widespread use of vasectomy is mirrored by wide variations in surgical techniques, follow-up protocols, and procedural costs. This article discusses key aspects of surgical anatomy, preoperative considerations, commonly used surgical techniques, and postoperative care.
Patient counseling
As with any surgical procedure, vasectomy should be performed only after thorough patient counseling is performed. It is ideal if both partners participate in the counseling session. As suggested by Schwingl and Guess, alternative methods of contraception, the intended irreversible nature of vasectomy, and risk for failure should be discussed with each patient. Other risks, including the incidence of chronic pain, should be discussed. A surgeon may be confronted with unique ethical issues, such as unilateral decision making (ie, only the male partner making the decision without his partner involved), young age of the patient, and so forth. These possible scenarios underscore the need for a detailed conversation with each individual patient. Fully informed consent should be obtained only after discussing the risks for the procedure and alternative forms of therapy.
Despite the intended irreversibility of the procedure, up to 6% of men who undergo vasectomy request vasectomy reversal. The most common reasons cited by patients seeking vasectomy reversal include divorce and remarriage. Several investigators have shown that men younger than age 30 at the time of vasectomy are 12 times more likely to seek vasectomy reversal in the future than those who underwent vasectomy after age 30. Should a patient inquire about the possibility of reversal to regain fertility in the future, a surgeon should carefully discuss the risks and variable success rates of the procedure and its possible cost. Prevasectomy sperm cryopreservation remains an option, although its cost-effectiveness is debatable and may suggest a patient’s indecision about permanent contraception. This should be discussed with patients if they request.
Surgical anatomy
A proper understanding of surgical anatomy lies at the foundation of any successful surgical procedure. The different layers of the scrotum and the course of the vas as it ascends from the scrotum are key points for physicians performing a vasectomy.
Scrotal Tissue Layers
The scrotum contains the testes, epididymis, and portions of the vas deferens. It is divided into halves by the scrotal septum, which is denoted by the median raphe on the scrotal skin. The skin of the scrotum itself is hirsute and contains many sebaceous glands. The scrotal skin is firmly attached to the underlying superficial fascial layer, known as dartos fascia. Deep to the dartos fascia is the external spermatic fascia, which is a continuation of the external muscle fascia of the abdominal wall. The external spermatic fascia is continuous over the penis as Buck’s fascia. The internal oblique muscle of the abdominal wall gives rise to the cremasteric muscle and fascia. Deep to the cremaster lays the internal spermatic fascia, which is derived from the transversalis fascia. The vas deferens is reached once the internal spermatic fascia is opened. The relationship of scrotal tissue layers in relation to the vas is demonstrated in Fig. 1 .
Anatomic variations of scrotal anatomy also must be considered when performing vasectomy. In the majority of patients, vasectomy is performed outside of the tunica vaginalis. Autopsy studies show, however, that approximately 12% of men have high insertions of the tunica vaginalis (bell-clapper deformity). In these patients, the tunica vaginalis completely encircles the testis, epididymis, and distal spermatic cord (including the vas). Vasectomy performed in patients who have this variant is, therefore, inside the tunica vaginalis and potentially leads to the development of a hydrocele in some cases.
Vasal Anatomy
Spanning a length of approximately 45 cm, the vas deferens (ductus deferens) connects the testicle to the seminal vesicles, which coalesces with the vasal ampulla to become the ejaculatory ducts. The vas begins at the epididymal tail (globus minor) as the convoluted vas. It is a thick-walled tube consisting of mucosal and submucosal layers surrounded by an outer longitudinal and inner circular smooth muscle. As the vas begins its ascent within the scrotum, it travels medially to the epididymis and then posteriorly as it enters the spermatic cord. It is in this region of the scrotum where the vas can be palpated as a firm cord close to the pampiniform plexus. Once above the testicle, the vas becomes straight as it ascends within the spermatic cord posterior to the cord vessels. Occasionally it can be palpated anteriorly. After the vas passes through the inguinal canal, it emerges in the pelvis lateral to the inferior epigastric vessels. It then passes medially to the other pelvic side wall structures and enters the prostatic base posteriorly. At the terminal end of the vas is the ampulla—a tortuous and dilated segment that is able to store spermatozoa.
Blood Supply
The vas receives it blood from the deferential artery—a branch of the inferior vesical artery. Anastomoses between the testicular artery and deferential artery provide collateral circulation to the structures. The cremasteric artery (branch of the inferior epigastric artery) also often participates in the collateral circulation.
Surgical anatomy
A proper understanding of surgical anatomy lies at the foundation of any successful surgical procedure. The different layers of the scrotum and the course of the vas as it ascends from the scrotum are key points for physicians performing a vasectomy.
Scrotal Tissue Layers
The scrotum contains the testes, epididymis, and portions of the vas deferens. It is divided into halves by the scrotal septum, which is denoted by the median raphe on the scrotal skin. The skin of the scrotum itself is hirsute and contains many sebaceous glands. The scrotal skin is firmly attached to the underlying superficial fascial layer, known as dartos fascia. Deep to the dartos fascia is the external spermatic fascia, which is a continuation of the external muscle fascia of the abdominal wall. The external spermatic fascia is continuous over the penis as Buck’s fascia. The internal oblique muscle of the abdominal wall gives rise to the cremasteric muscle and fascia. Deep to the cremaster lays the internal spermatic fascia, which is derived from the transversalis fascia. The vas deferens is reached once the internal spermatic fascia is opened. The relationship of scrotal tissue layers in relation to the vas is demonstrated in Fig. 1 .
Anatomic variations of scrotal anatomy also must be considered when performing vasectomy. In the majority of patients, vasectomy is performed outside of the tunica vaginalis. Autopsy studies show, however, that approximately 12% of men have high insertions of the tunica vaginalis (bell-clapper deformity). In these patients, the tunica vaginalis completely encircles the testis, epididymis, and distal spermatic cord (including the vas). Vasectomy performed in patients who have this variant is, therefore, inside the tunica vaginalis and potentially leads to the development of a hydrocele in some cases.
Vasal Anatomy
Spanning a length of approximately 45 cm, the vas deferens (ductus deferens) connects the testicle to the seminal vesicles, which coalesces with the vasal ampulla to become the ejaculatory ducts. The vas begins at the epididymal tail (globus minor) as the convoluted vas. It is a thick-walled tube consisting of mucosal and submucosal layers surrounded by an outer longitudinal and inner circular smooth muscle. As the vas begins its ascent within the scrotum, it travels medially to the epididymis and then posteriorly as it enters the spermatic cord. It is in this region of the scrotum where the vas can be palpated as a firm cord close to the pampiniform plexus. Once above the testicle, the vas becomes straight as it ascends within the spermatic cord posterior to the cord vessels. Occasionally it can be palpated anteriorly. After the vas passes through the inguinal canal, it emerges in the pelvis lateral to the inferior epigastric vessels. It then passes medially to the other pelvic side wall structures and enters the prostatic base posteriorly. At the terminal end of the vas is the ampulla—a tortuous and dilated segment that is able to store spermatozoa.
Blood Supply
The vas receives it blood from the deferential artery—a branch of the inferior vesical artery. Anastomoses between the testicular artery and deferential artery provide collateral circulation to the structures. The cremasteric artery (branch of the inferior epigastric artery) also often participates in the collateral circulation.
Operative considerations
Antimicrobial Prophylaxis
The scrotum generally is classified as clean-contaminated because of its close proximity to the perineum. Despite the proximity to the perineum, the incidence of surgical site infection (SSI) after conventional incisional vasectomy or the no-scapel vasectomy (NSV) is low, ranging from 1.5% to 9%. For this reason, prophylactic antimicrobials typically are not used when performing vasectomy, especially when performed in the clinic setting. Additionally, the use of prophylactic antibiotics for the prevention of bacterial endocarditis no longer is recommended during urologic procedures. A recent advisory council, however, has recommended the use of prophylactic antibiotic use in select patients who have total joint replacements. These patients include those who have had joint replacements within the past 2 years, are immunocompromised or -suppressed, or who have additional comorbidities, such as HIV, diabetes, malignancy, or prior joint replacement infections.
There are no randomized controlled studies on the use of prophylactic antibiotics with vasectomies but many reports on infectious complications from vasectomy. Many high-volume practices do not use antibiotics but if surgeons prefer the use of prophylactic antibiotics, they should be aimed at preventing infection from common pathogens of the genitourinary tract ( Escherichia coli , Proteus sp, Klepsiella sp, and enterococcus) and skin ( Staphylococcus aureus , coagulase-negative Staphylococcus sp, and group A streptococci sp ) . Common choices for SSI prophylaxis during scrotal surgery include a first-generation cephalosporin (eg, cephalexin), fluoroquinolone (eg, levofloxacin), or aminoglycoside (eg, gentamicin). These medications have appropriately long half-lives, are inexpensive when used as a single dose, and rarely are associated with allergic reactions. Fluoroquinolones or aminoglycosides may be used when patients have a β-lactam allergy. Timing of administration is key; antibiotic should begin within 1 to 2 hours of incision.
Although preoperative antibiotics typically are not used in vasectomy, proper preoperative skin preparation is essential in reducing the risk for SSI. Hair removal often is necessary owing to the hirsute nature of the scrotal skin. Once appropriate hair removal is completed, antiseptic solutions are applied to the surgical site. Typically, chlorhexidine-based antiseptics or povidone-iodine are used.
Anesthesia
The majority of vasectomies performed in the United States are done under local anesthesia in a clinic setting. Local anesthesia is safer than general anesthesia and more cost effective. The initial puncture of the scrotal skin with the needle to inject anesthetic agents, however, often is the greatest source of anxiety for patients. The use of eutectic mixture of local anesthetics (EMLA) cream for topical anesthetic to minimize discomfort of the needle puncture has been advocated. The efficacy of this practice, however, recently has come under scrutiny. An oral sedative, such as diazepam, often is given 1 hour before the procedure to relax patients. This in turn aids in relaxing scrotal musculature and facilitates the procedure.
To perform needle injection, the vas is brought to the scrotal surface using a three-finger technique, as described by Li and colleagues It is essential to isolate the vas away from the vessels of the spermatic cord and the base of the penis. Local vasal nerve block is achieved with 1% to 2% lidocaine without epinephrine in a 1.5-in, 25-gauge needle. An alternative solution can be used with a 1:1 ratio of 1% lidocaine and 0.5% bupivicaine. The authors use a mixture of chloroprocaine and bupivicaine in a 1:1 ratio. Chloroprocaine has a rapid onset of action (quicker than lidocaine) and has no burning effect on injection but has a short half-life of 30 minutes. A subcutaneous wheal is raised at the scrotal skin surface. The needle is advanced within the perivasal sheath and approximately 2 to 3 mL of anesthetic is injected around the vas ( Fig. 2 ). It is essential to avoid excessive needle movement or multiple punctures as this increases the risk for hematoma formation and can impair vas exposure due to edema.
The recent innovation of no-needle vasectomy, as described by Weiss and Li and Monoski and colleagues, uses a jet injection technique to establish local anesthesia. A jet injection instrument generates a high-pressure spray, which is forced through the skin, vas, and perivasal tissues. Reported advantages of this method of local anesthesia include decreased tissue trauma, faster onset of action, and decreased volume of solution required for local anesthesia.
Approaching the vas
Access to the vas and its delivery from the scrotum is the first component of vasectomy, regardless of the method of vasal occlusion used. This often is the most difficult aspect of the procedure for less-experienced surgeons. Before any incision or percutaneous entry of the scrotum is performed, the vas first must be isolated from other spermatic cord structures. Ideally, the vas should be isolated away from the base of the penis and in the midscrotal vas region to prevent possible testicular or inguinal pain during or after the procedure. This is made easier if the scrotum is relaxed (relaxed patient in a warm environment). The three-finger technique, also known as the tripod-grasp, is a common method for isolating the vas. The nondominant thumb is placed on the median raphe at the midpoint between the base of the penis and the superior margin of the testis. The left middle finger then is used to probe the scrotum posterior to the testis to locate the vas. Once the vas is isolated, it is brought anterior to the testis and trapped between the thumb and middle finger. Gently rolling or kneading the vas between the fingers helps ensure that other vessels of the spermatic cord are not trapped along with the vas. Next, the nondominant index finger is swept gently over the scrotal skin overlying the trapped segment of vas to minimize the tissue from the scrotal surface to the vas itself. Once the segment is isolated, the dominant hand is used to administer a local vasal nerve block or apply the jet injection technique. After sufficient anesthesia is induced, the operating surgeon may proceed to penetrate the overlying scrotal skin through a conventional incision or via the no-scalpel technique.
Vasectomy techniques
Conventional Incision Technique
In the conventional technique, bilateral 1-cm transverse incisions are made in the scrotal skin using a no. 15 blade scalpel. The incisions are carried down through the vasal sheath until the vas is reached. The vas then is delivered from the surrounding sheath while the deferential artery and nerves are isolated and swept away. The vas is transected and a length of vas is excised. This segment may range from 0 to 4 cm in length. The ends of the vas are occluded by one of several possible methods. These options for occlusion of the vas are discussed later. Once the vasectomy is completed, the scrotal skin typically is closed with absorbable sutures. Topical antibiotic ointment often is applied to the incision site and fluffed gauze dressings are applied.
No-scalpel Vasectomy
The NSV technique was first described by Li and colleagues in 1974. NSV eliminates the need for scrotal skin incision, which may contribute to its lower incidence of scrotal hematomas and infections.
In the NSV technique, a vasal nerve block is performed (described previously). Once the vas is isolated using the nondominant hand, a ring-tipped fixation clamp is opened and pressed downward into the scrotal skin. By opening the tips of the fixation clamp as it is pressed into the scrotal skin, the skin is overlying the vas stretched tightly around the vas as it is secured in the ring ( Fig. 3 ). A sharp-tip curved mosquito hemostat then punctures the scrotal skin through the same puncture hole created by the needle used for local anesthesia ( Fig. 4 ). The ringed fixation clamp is advanced into the opening and the vas is grasped and delivered.
