Vasectomy

DOUGLAS G. STEIN

As the most dependable method of contraception and one that requires virtually no compliance, vasectomy is an ideal choice for those men who have made a mature, informed decision to have no more children, and especially for men who have difficulty with compliance. As a result, 12% of the U.S. population relies on vasectomy as their primary method of birth control. National surveys of vasectomy providers indicate an incidence of vasectomy of 500,000 per year in the United States, but patient-based surveys would indicate an incidence of 175,000 to 300,000 (1). While it has been noted that vasectomy is the “most common procedure involved in malpractice claims against urologists” (2), vasectomy accounted for only 8 of 469 (1.7%) urology malpractice claims closed with indemnity payment between 1985 and 2004 (3). So, while urologists need not avoid vasectomy to decrease perceived high liability, they need to be thoroughly versed in the management of men seeking vasectomy. Vasectomy Guidelines were published by the American Urological Association (AUA) in 2012. From ˜2,000 titles and abstracts, the AUA Guidelines Committee reviewed 900 articles and selected 275 to formulate 15 guidelines, which will be incorporated into this chapter. These guidelines with full explanations and references are available on the website of the AUA at http://www.auanet.org/education/guidelines/vasectomy.cfm.

DIAGNOSIS

The consultation visit should accomplish two objectives: (a) The patient should learn all aspects of vasectomy that constitute informed consent, including pre- and postvasectomy instructions, the benefits, the risks, and the alternatives, and (b) the doctor should assess the patient’s social and medical histories and his genital anatomy to determine whether he is a good candidate for vasectomy and advise him accordingly. According to the AUA Guideline Statement 1 (expert opinion), this process may take place in person or through an electronic and telephone exchange of information, values, and opinions.

In-person consultations allow the vasectomist to examine the patient to determine whether there are features of the patient’s anatomy or personality, which either (a) make him a better candidate for general anesthesia than for the more commonly used local anesthesia with or without oral or intravenous sedation, or (b) warrant referral to a more experienced vasectomy provider if general anesthesia is not desired or practical. Such features include incomplete testicular descent (either untreated or status post orchiopexy); scarring due to prior scrotal surgery; a small tight scrotum; obesity with thick spermatic cords; very thin vasa; large hydrocele, spermatocele, or varicocele; or extreme scrotal hypersensitivity. Guidelines Statement 2 (expert opinion) lists 11 “minimum and necessary concepts” which should be conveyed, whereas Guidelines Statement 3 (standard) indicates that there is no need to discuss those conditions once considered risks of vasectomy that have been proven to have no connection with vasectomy. This author prefers an electronic exchange of information via his website, in which the patient and his partner can read about vasectomy and watch a counseling video at their own pace, at a convenient time, and as often as they would find necessary to achieve full understanding. Patients preregister to provide the physician’s office with (a) relevant medical and social information, which can be considered long in advance of the procedure, and (b) acknowledgment of understanding of all aspects of vasectomy including preparation and postoperative recommendations. Patients and doctor can opt for an in-person consultation if warranted by elements of the patient’s history; for example, a history of prior orchidopexy, vasectomy/reversal, or obesity. Young men (<30 years) with fewer than two children are interviewed by phone to determine their motives, to explain reversible alternatives, and to confirm full understanding of the long-term implications of vasectomy. They are encouraged to consider sperm storage. Men who have never caused a pregnancy are asked to return a specimen mailer before the vasectomy to rule out azoospermia (avoid an unnecessary vasectomy) and to know about oligospermia, if present, in the event that they ever consider vasectomy reversal. The last 143 such cases included 4 with azoospermia and 6 with severe oligospermia (<25 sperm per high-power field [HPF]). The latter were offered formal semen analysis to establish a baseline.

The AUA Guidelines Committee includes the usual risks in the “minimum and necessary concepts” to be considered in the consultation exchange, namely, bleeding, infection, failure, and chronic pain. The guidelines also recommend that patients be “reassured” that there is no evidence of a cause-and-effect relationship between vasectomy and a change in sexual function. But through two large surveys of more than 100 respondents each, this author has learned that a small percentage of patients blame vasectomy for a diminution of libido, erectile function, or climax intensity. So this author includes those possibilities in his informed consent to avoid future legal problems.

INDICATIONS FOR SURGERY

While no strict criteria exist for determining which patient should be offered vasectomy, the Electronic Code of Federal Regulations for sterilization of persons in federally assisted family planning projects (Title 42 CFR Part 50 subpart B) specifies that the individual be at least 21 years of age and mentally competent when consent is obtained and that 30 days pass between the date of consent and the date of vasectomy.

FIGURE 51.1 A and B: The vas deferens is lifted into position beneath the midline and anesthetic injected into the skin directly over it. C: Through the anesthetized skin, anesthetic is injected directly alongside the vas.

ALTERNATIVE THERAPY

Especially because vasectomy should always be presented as a permanent form of contraception, a full disclosure of alternative contraceptive methods must be a part of informed consent. While condoms are the only other alternative available to males, men should have a thorough understanding of the options available to women, even though these provide less control for the male. When features of the male anatomy (obesity, tight scrotum, thin vasa, or scarring from prior scrotal surgery) would make vasectomy difficult for the vasectomist at his or her skill level, couples considering permanent contraception should be asked to consult with a more experienced vasectomist, as complications rates are lower for vasectomies performed by more experienced vasectomists (4). Although not guaranteed successful, patients should be counseled regarding sperm cryopreservation and storage as an insurance policy that may enable paternity after vasectomy without need for vasectomy reversal.

SURGICAL TECHNIQUE

Nearly all surgical procedures involve three steps: (a) anesthesia, to allow the procedure to proceed without pain, (b) access, or how the surgeon gets to the target organ, and (c) technique, how one manages the target organ, the actual occlusion of the vas deferens. Except for patients with comorbidities associated with a high risk of infection (e.g., diabetes, immunodeficiency, coexistent infection), the AUA Guideline Statement 4 recommends no preoperative antibiotics.

Anesthesia

AUA Guideline Statement 5 is an expert opinion that “vasectomy should be performed with local anesthesia with or without oral sedation … if the surgeon believes that local anesthesia with or without oral sedation will not be adequate for a particular patient, then vasectomy may be performed with intravenous sedation or general anesthesia.”

Despite the growing popularity of no-needle anesthesia since 2002 (5), especially appealing to men who “just hate needles,” administration of anesthesia with a needle is the most common and traditional technique, with a 2010 article (6) promoting a “mini-needle” technique. Using a three-finger no-scalpel vasectomy (NSV) technique to hold the vas beneath the median raphe, a 1-inch 30-gauge needle and 3 mL syringe are used to deliver 0.5 mL of 2% lidocaine to create a midline skin wheal through which an additional 0.50 to 0.75 mL is injected as close as possible and even into each vas in turn (Fig. 51.1). Vasectomy is started immediately on the first side injected.

No-needle local anesthesia for vasectomy involves the use of a jet injector (or “spray applicator,” as this surgeon prefers to call it), the most popular of which is the MadaJet (MADA, Inc, Carlstadt, New Jersey). The spring-loaded MadaJet (Fig. 51.2) emits an extremely thin 0.1 to 0.2 mL stream of anesthetic (2% lidocaine, 0.5% bupivacaine or a mixture, depending on the duration of anesthesia desired) strong enough to penetrate the skin and underlying tissue to a depth of 2 to 5 mm, depending on the factory setting of the particular MadaJet. The vas is lifted into position beneath the skin at the preferred access site (anterior midline for
NSV or lateral scrotal wall for traditional approach), the overlying skin is prepped with alcohol, the fluted spacer of the MadaJet is pressed over the vas (Fig. 51.3), and the release button is pressed to discharge the anesthetic through the skin and around the vas. The procedure may be repeated along the path of the vas at a 4- to 5-mm interval, but one application per vas is often adequate. Medication entry sites are barely visible as minute dots, surrounding which are 6- to 10-mm diameter areas of anesthetized skin. If the right vas is lifted to the midline and injected 2 mm to the left of the median raphe, and if the left vas is then lifted to the midline and injected 2 mm to the right of the median raphe, the patient develops an area of anesthetized skin about 5 mm on each side centered on the midline, and the scrotal septum receives all doses of the anesthetic. Through the anesthetized area, a minimally invasive vasectomy (MIV) is performed. (If anesthesia of the skin or vas is not adequate to perform a vasectomy without pain, supplemental anesthesia with a needle can be applied.) Because only the spacer touches the patient, it can be soaked in an antibacterial/antiviral antiseptic solution between cases, or a freshly autoclaved spacer can be used for each case.

FIGURE 51.2 Cocking the MadaJet: The lever is depressed until the release button at the top pops up.

FIGURE 51.3 Fluted tip of MadaJet being lowered onto the right vas, held beneath the median raphe with a three-finger technique.

Access

AUA Guideline Statement 6 states that an MIV technique (skin opening <10 mm and minimal dissection of the vas and perivasal tissues) should be used. Because this is a standard based on grade B evidence, the conventional vasectomy will not be described here. The guidelines specify that the classic Li NSV technique is one form of MIV. Any deviation from nine steps in the description of the Li NSV technique warrants that the method be described as an MIV. As long as the access technique, whether performed on the lateral scrotal walls or in the midline, uses a skin opening <10 mm and minimal dissection of the vas and perivasal tissues (with the Li NSV vas dissector and ring clamp or similar instruments), it can be considered an MIV.

FIGURE 51.4 The three-finger technique for isolating the (A) right and (B) left vas deferens.

The Li NSV technique (7) uses the vas dissector and ring clamp and a three-finger technique (Fig. 51.4) to access both vasa in turn via a single small opening in the anterior midline of the scrotal wall (anesthetized with needle- or spray-applicatorapplied lidocaine). After the scrotum is formally prepped with povidone-iodine or chlorhexidine/alcohol and draped, needle anesthesia is used (see previously) or the pinpoint marks in the skin made by the spray applicator are located. In the Li technique, the vas, most commonly located on the posterior aspect of the spermatic cord, is swept medially and lifted into position beneath the median raphe (the site already anesthetized if the spray applicator was used) using a three-finger technique. The vas and overlying skin are grasped with the ring clamp (Fig. 51.5A), its tips applied at the left and right MadaJet application sites. If this is difficult, because the skin is thick or the vas thin, the surgeon may find it easier to puncture and spread the skin with the vas dissector then grasp the vas with the ring clamp through the opening thus created (Fig. 51.5B), still an MIV, but no longer a Li NSV, strictly speaking. MadaJet injection application sites can be difficult to locate, especially in dark-skinned men, so this step and the remainder of the vasectomy may be much easier with the magnification provided by 2.5× optical loupes. One tip of the vas dissector is introduced into the lumen of the vas and removed (Fig. 51.6). Both tips are introduced at the same spot and spread to twice the width of the vas (Fig. 51.7), splitting the vas open longitudinally and spreading all overlying layers. One tip of the vas dissector is then used to “hook” the vas (Fig. 51.8) and lift it from its sheath as the ring clamp is removed. The ring clamp is then used to grasp one wall of the vas and deliver a 1- to 2-cm loop of it from its sheath (Fig. 51.9).

FIGURE 51.5 A: Held using the three-finger technique, the right vas is grasped with the NSV ring clamp, incorporating the skin. B: In some cases (e.g., thick skin or thin vas), it may be easier to grasp the vas through a skin opening made with the NSV dissecting clamp.