41.2.2 Examination

Examine the patient carefully before deciding to proceed, it is difficult to do a vasectomy under local anaesthetic in a frightened man with a tight scrotum or when there has been previous scrotal or inguinal surgery, or if the vas is impalpable or absent.

41.2.3 Shaving

Let the patient shave his own scrotum before the procedure to minimise infection; it is much more comfortable for him if he does it in the bath at leisure.

41.2.4 Anaesthesia

Local infiltration with a local anaesthetic provides excellent anaesthesia, which is usually sufficient in the relaxed cooperative patient.

41.2.5 Choice of Incision

The operation may be done through a single transverse, vertical scrotal incision, or through two incisions, one over each vas (Figure 41.5).

41.2.6 Operative Technique

There are many techniques for performing vasectomy. However, the most effective is when the lumen is cauterised and fascia interpositioned between the two ends [6].

The essential steps are that the vas deferens is located by its characteristic feel, like a hard cord (Figure 41.6). The sheath of the vas is incised longitudinally taking care to avoid the artery and veins of the vas. The vas is lifted up out of the sheath. Care is taken not to pull on the vas because this can cause vagal stimulation, bradycardia, fainting, and even cardiac arrest.

The vas is doubly clamped and divided and a small segment of vas from each side resected, carefully labelled in formalin as medico‐legal proof that the right organ was removed, should questions arise afterwards. Coagulate the lumen of the vas with diathermy and interpositioning tissue while closing is essential. Another way is to ligate the testicular end of the vas with fine (4–0) suture, curl the end back on itself into a loop, and tie it again (Figure 41.6). The other end is ligated and dropped back into the sheath of the vas, which is then closed with a stitch. The looped‐back end is left outside the sheath. It is the intention that the fascia of the sheath will prevent the ends coming together again.

Many urologists now advocate a ‘no‐scalpel’ vasectomy where a sharp haemostat is used to puncture the scrotal skin. The incision usually does not require a suture and may decrease the incidence of haematoma and infection rates.

41.2.7 Complications

Every large series of vasectomies records complications, few are severe, but all of them are notoriously apt to generate resentment and litigation [8–15]:

41.2.7.1 Early Complications

• Haematoma is common after vasectomy (average 2%), usually starts about 30 minutes after the end of the operation and is generally thought to be due to arterial or venous spasm, caused by handling the vas, and relaxing spontaneously later on.
  

  When reactionary haemorrhage occurs and leads to a haematoma, it is usual to return the patient to the operating theatre and evacuate the clot under anaesthesia. In practice, it is rare that a single bleeding vessel can be identified, and the blood is usually found between the tissues of the scrotum. After evacuation of the haematoma, the swelling may take several weeks to resolve completely. It is common for the patient to complain of pain in the scrotum for some time afterwards.

  
  
• Wound infection, urinary tract infection, and epididymitis can occur on average in 3.4% of patients. Infections can be severe enough to cause Fournier gangrene, albeit rare.
  
• Injury to surrounding structures can occur in less than 5%.

41.2.7.2 Later Complications

• Sperm granuloma can occur in 10–33% of patients, leading to a painful swelling which can develop either at the site of the divided vasa or in the epididymis. In most cases, it resolves spontaneously, but in others it persists, and the patient demands treatment. However, removal of the epididymis may, but does not always, relieve the pain. Histologically, there is a sperm granuloma, a chronic inflammatory response to extravasated sperm, which can lead to recanalization of the vas (Figure 41.7).
  
• Chronic testicular or scrotal pain can occur as a result of the sperm granuloma or from congestive epididymitis in 12–52% of patients. However, the majority usually have tolerable and transient, with about 2.2–15% affecting quality of life and seek further treatments.
  
• Failure, due to inadequate occlusion of one of both vasa which can lead to recanalization (Figure 41.7). Recanalization can occur either early (0–2%; 1 in 200) or even late in <1% (1 in 2000 men). Early recanalization is detected by regular semen analysis, the sperms would never completely disappear. Late recanalization is diagnosed once the wife gets pregnant, often years after the vasectomy.
  

  The mechanism of spontaneous recanalization seems to be that sprouts of the epithelium lining the vas burrow into the granulation tissue filling the gap between the divided ends of the vasa. If the sprouts meet each other, continuity is re‐established. It is believed that this recanalization took place in the first few months after vasectomy, when the granuloma was new before scar tissue had contracted to form an impenetrable barrier.

  
  

  Very occasional cases were reported where the vasa would reunite years later; they were regarded as an extreme rarity. However, whenever spontaneous reunion of the vas results in an unwanted pregnancy, the surgeon is likely to be accused of negligence; hence, the intense medico‐legal interest in the issue of ‘late’ recanalization (i.e. after the semen had been shown to be entirely free from spermatozoa in at least two consecutive specimens).

  
  
• Anti‐sperm antibodies develop in more than 60% of patients, but they do not have any long‐term sequelae.
  
• Vasectomy‐related death occurs in 1 per 1 000 000 in the developed world; however, i can be as high as 190 per 1 000 000 in the developing world. The main cause is infections.

Few surgeons would think it necessary to warn of complications so rare, but vasectomy is an exception because of the suspicions and ill feeling that are aroused by an unexpected pregnancy years after vasectomy. It is therefore a wise precaution to warn the patient and his wife that this, however rare, can happen.

Increased risk of prostate cancer or systemic illnesses, like atherosclerosis or cardiovascular disease has not been proven after vasectomy [6].

41.2.8 Postoperative Semen Analysis

After vasectomy, two consecutive semen samples (12 and 16 weeks) must show no sperm to be considered a success. Azoospermia is achieved in 80% of patients after 12 weeks and 20 ejaculations; however it is recommended that only after 16 weeks and 24 ejaculations that initial assessment for sperm motility be carried out and when examination of a well‐mixed, uncentrifuged, fresh postvasectomy sample shows azoospermia or only rare nonmotile sperm (<100 000 nonmotile sperm/ml) can other contraceptive precautions be stopped [15–17].

Clearance to stop contraception can be given to some patients who have very few nonmotile sperm (<10 000 nonmotile sperm/ml) found in a fresh specimen examined at least seven months after vasectomy [6, 12]. However, be cautious; paternity has been proven when not a single sperm can be found [18].

41.2.9 Vasectomy Reversal

Nearly 6% of patients that undergo vasectomy, undergo a reversal [19]. Vasovasostomy and vasoepidiymostomy are vasectomy reversal techniques used. Both require patience, time, and adequate anaesthesia. Surgeons should use loupes or the operating microscope and smaller suture material [20]. The divided ends of the vasa are exposed and sectioned until the lumen is revealed (Figure 41.8). The ends are anastomosed, either an end‐to‐end method, or end‐to‐side method can be used (Figure 41.9).

The results of reversal of vasectomy are disappointing. Although sperms reappear in the ejaculate in 90%, the pregnancy rate decreases with the increase in the interval from the vasectomy to reversal (Table 41.1) [6, 21]. There are several explanations. First the couples are older and biologically less likely to conceive. Second, while the sperms are retained in the epididymis, they may leak into the tissues and provoke an immunological reaction which will result in death or immobilisation of the sperms.