This article is intended to familiarize the surgeon with all aspects of vasectomy including preoperative counseling, anesthetic techniques, surgical techniques, postoperative follow-up, and postvasectomy semen analysis. The latest literature regarding the complication rates and failure rates of various vas occlusion techniques is also discussed.
Key points
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Vasectomy is fast, safe, effective, and underutilized in comparison with tubal ligation.
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The preoperative visit is crucial for educating the patient on the risks and expectations of vasectomy, and especially that vasectomy is considered permanent.
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Minimally invasive vasectomy or no-scalpel vasectomy is preferable to conventional vasectomy.
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Fascial interposition decreases recanalization rates.
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Mucosal cautery appears to have the lowest vasectomy failure rates (<1%), although more high-quality comparative studies are needed.
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Patients must understand that an alternative birth-control method is necessary after the procedure until a postvasectomy semen analysis shows azoospermia.
Introduction
Vasectomy was first attempted on a canine in the 1800s, and has grown to be the most common operation performed by urologists today in the United States. More than 75% of vasectomies in the United States are performed by urologists. Vasectomy is a safe and effective form of contraception, yet it is underutilized today. Data collected in 2002 revealed that only 5.7% of United States men aged 15 to 44 years used vasectomy as a means of contraception. Couples more commonly used condoms, oral contraceptives, or tubal ligation. Vasectomy is one of the most cost-effective contraceptive methods overall, its cost being is similar to that of the Mirena Intrauterine System ($844), the ParaGard Intrauterine Device ($718), and the Implanon implant ($791). The cost of vasectomy is one-quarter that of tubal ligation ($707 vs $2833). Compared with tubal ligation, vasectomy is equally effective in preventing pregnancy; however, vasectomy is less invasive, simpler, safer, faster, and less expensive. The benefits of vasectomy over tubal ligation include faster recovery and return to work, local rather than general anesthesia, and ability to perform the procedure in the office rather than in the operating suite. Complications are rare for both procedures, but tend to be more serious for tubal ligation because it is more invasive.
Although the advantages of vasectomy over tubal ligation are evident, tubal ligation is 2 to 3 times more prevalent in the United States. This discrepancy is present worldwide, but there are at least 10 countries where the prevalence of vasectomy equals or exceeds tubal ligation: Canada, Bhutan, United Kingdom, New Zealand, Netherlands, Spain, Republic of Korea, Malta, Tajikistan, and Denmark. The patterns of prevalence among the two groups in the United States have been found to be different. Tubal ligation is more prevalent among those with lower income and education levels, and among minority groups, whereas vasectomy use is higher among those with higher education and income and among white men.
It is clear that vasectomy should be performed equally as or more frequently than tubal ligation, and couples should therefore be counseled about the pros and cons of various contraception options so that an informed decision can be made.
Introduction
Vasectomy was first attempted on a canine in the 1800s, and has grown to be the most common operation performed by urologists today in the United States. More than 75% of vasectomies in the United States are performed by urologists. Vasectomy is a safe and effective form of contraception, yet it is underutilized today. Data collected in 2002 revealed that only 5.7% of United States men aged 15 to 44 years used vasectomy as a means of contraception. Couples more commonly used condoms, oral contraceptives, or tubal ligation. Vasectomy is one of the most cost-effective contraceptive methods overall, its cost being is similar to that of the Mirena Intrauterine System ($844), the ParaGard Intrauterine Device ($718), and the Implanon implant ($791). The cost of vasectomy is one-quarter that of tubal ligation ($707 vs $2833). Compared with tubal ligation, vasectomy is equally effective in preventing pregnancy; however, vasectomy is less invasive, simpler, safer, faster, and less expensive. The benefits of vasectomy over tubal ligation include faster recovery and return to work, local rather than general anesthesia, and ability to perform the procedure in the office rather than in the operating suite. Complications are rare for both procedures, but tend to be more serious for tubal ligation because it is more invasive.
Although the advantages of vasectomy over tubal ligation are evident, tubal ligation is 2 to 3 times more prevalent in the United States. This discrepancy is present worldwide, but there are at least 10 countries where the prevalence of vasectomy equals or exceeds tubal ligation: Canada, Bhutan, United Kingdom, New Zealand, Netherlands, Spain, Republic of Korea, Malta, Tajikistan, and Denmark. The patterns of prevalence among the two groups in the United States have been found to be different. Tubal ligation is more prevalent among those with lower income and education levels, and among minority groups, whereas vasectomy use is higher among those with higher education and income and among white men.
It is clear that vasectomy should be performed equally as or more frequently than tubal ligation, and couples should therefore be counseled about the pros and cons of various contraception options so that an informed decision can be made.
Preoperative evaluation
It is recommended that a face-to-face consult take place with the patient before planning the vasectomy. It is beneficial for the patient’s partner to be present, although this is not required. An appropriate medical history should be taken, focusing on his reproductive history. Patients should also be questioned about bleeding tendencies and anticoagulant use as per routine preoperative workup. If there is suspicion of coagulopathy, coagulation tests may be necessary; otherwise, preoperative blood work is not needed. A physical examination of the scrotum should be performed, with emphasis on manually isolating the vas deferens, as well looking for scrotal abnormality such as undescended testis or testis tumors. If the patient is unable to tolerate this examination while isolating the vas deferens, he may not be a good candidate for local anesthesia. The preoperative examination may also alert the physician to patients whose vasa are difficult to locate or isolate; this allows planning of oral sedation or general anesthesia at the time of procedure if necessary.
Preoperative counseling of the patient is extremely important, and may prevent postoperative patient dissatisfaction or even litigation in the case of complications or vasectomy failure. Most patients have decided on vasectomy as their choice of permanent contraception before meeting with the physician, but a discussion of the risks, benefits, alternatives, and expectations should be conducted at the initial consultation. Patients should be counseled that vasectomy is considered irreversible and permanent. If the patient indicates any uncertainty regarding the desire for future fertility (eg, asking about sperm cryopreservation), vasectomy should not be performed and other contraceptive methods should be discussed. Likewise, if the patient seems too young and has not had children, it is reasonable to encourage other contraceptive options that are less permanent. The other benefit of the preoperative consult is to give the patient a “cool-down” period while waiting for the procedure date, thus allowing time for patients to change their mind if an impetuous decision for vasectomy has been made initially.
The following points should be addressed at the preoperative visit, many of which are addressed in more detail in this article.
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Alternatives to vasectomy
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Risk of infection or hematoma (1%–2%)
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Risk of chronic scrotal pain (1%–3%)
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Refrain from ejaculation for 1 week after the procedure
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Vasectomy is considered permanent
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Vasectomy does not produce immediate sterility; another form of contraception is required after the procedure until vasectomy success is confirmed by semen analysis
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Early vasectomy failure: risk of needing repeat vasectomy (<1%)
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Late vasectomy failure: after vasectomy success is confirmed by semen analysis, there is still a small chance of pregnancy (approximately 1 in 2000)
Anesthetic technique
Vasectomy can be performed under any type of anesthesia, but most are performed under local anesthesia because it is well tolerated with minimal morbidity. Certain patients may require intravenous sedation or general anesthesia if they cannot tolerate the procedure or if the vas is particularly difficult to isolate. Oral sedation in the form of a benzodiazepine (eg, diazepam) is offered by some clinicians to decrease anxiety and aid in relaxing the patient. Lidocaine or bupivacaine without epinephrine are typically the local anesthetic agent of choice, and are injected using a small needle (eg, 25 gauge or smaller) to reduce patient discomfort. Some clinicians apply an anesthetic cream to the skin before the needle stick, although it is unclear whether this significantly decreases pain.
Vas isolation
Vasectomy is performed in 2 distinct steps: delivering and exposing the vas deferens out of the scrotum (vas isolation), and occluding the vas. Before the introduction of the no-scalpel technique, vas isolation was performed using the conventional technique, which used a larger incision and involved more dissection without special instruments. The no-scalpel vasectomy was first described in China in 1974. The no-scalpel technique has been found to have shorter operative times and to decrease the rate of hematomas, infections, and pain during the procedure. Today the standard of care is to perform a no-scalpel technique or a variation of such that remains minimally invasive.
In this article the term “minimally invasive vasectomy” is used to describe any vasectomy performed using a variation of the true no-scalpel vasectomy originally described by Li Shunqiang, as long as it maintains a small skin opening and limits the amount of dissection around the vas with specialized vasectomy instruments. Box 1 lists the exact steps of the original no-scalpel vasectomy. A more detailed description of the no-scalpel technique can be found in EngenderHealth’s illustrated guide for surgeons. Note that the no-scalpel technique refers to vas isolation only and does not denote a method of vas occlusion. Two instruments were designed for this procedure: the vas deferens fixation ring clamp ( Fig. 1 ), used to grasp the vas, and the vas dissector ( Fig. 2 ), which is a sharp, curved mosquito hemostat without serrations. These instruments are widely used today for minimally invasive vasectomies.
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Isolate the vas manually to a superficial position under the median raphe
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Create skin wheal with local anesthetic and inject into perivasal sheath
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Use vas ring clamp to firmly secure the vas through the skin
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With vas dissector at 45° angle to the vas, puncture the skin, vas sheath, and vas wall with the left tip of the vas dissector, then remove
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Close the vas dissector and puncture the skin and vas sheath. Spread to make small opening in the skin, exposing the bare anterior wall of the vas
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Puncture the vas with one tip of the vas dissector
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Use supination motion to deliver a loop of vas above the skin opening while simultaneously releasing the vas ring clamp with the other hand
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Regrasp the vas with the vas ring clamp. Use vas dissector to gently strip the sheath and vasal vessels away from the vas, yielding a clean segment of vas
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Divide the vas, with or without excision of a vas segment, and occlude the lumen per physician’s preference
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Via same puncture hole, fix opposite vas in ring clamp and repeat steps
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Leave puncture hole unsutured except in rare cases requiring closure
Routine preoperative antibiotics are not necessary when performing minimally invasive vasectomy with the sterile technique. Scrotal skin should be shaved, and the patient prepped with antimicrobial solution and draped in a standard sterile fashion. The procedure may be noticeably easier if the Dartos smooth muscle is relaxed, so using warm preparation solution and avoiding cold room temperatures may be beneficial.
Begin by isolating the straight portion of the vas with one hand using the 3-finger technique. Separate the vas from the spermatic-cord contents, and trap the vas over the middle finger and under the index finger and thumb ( Fig. 3 ). There is no clear advantage of using one midline incision rather than bilateral incisions, and this should be decided upon based on surgeon preference and comfort. The bilateral incision approach may decrease the chance of cutting the same vas twice, although pulling on each vas should raise the testis on that side, which should eliminate this risk. Once the vas is isolated just underneath the skin between the fingers, local anesthetic is injected superficially to create a skin wheal. Injection into the vasal sheath can also facilitate anesthesia for the patient.
The next step of a minimally invasive vasectomy depends on whether an open-access or closed-access technique is performed. The closed-access technique, first described with the no-scalpel vasectomy, is performed by grasping the vas and the skin together with the ring clamp. As outlined in Box 1 , an opening is then made in the skin using the vas dissector to expose the vas. The vas is then skewered with one tip of the vas dissector and rotated to bring a vas loop out of the skin opening, and the bare vas is regrasped with the vas clamp. The vas dissector is spread apart to strip the vas ( Fig. 4 ). Bleeding is often encountered at this step, which should be addressed immediately with cautery. Once an adequate loop of bare vas is outside the scrotum, it is then divided and occluded.
When using the open-access technique, the skin opening is made with the vas dissector first, allowing the vas clamp through the opening to grasp the vas, which is brought out of the skin opening. Further dissection of the perivasal tissues to expose the bare vas is performed with the vas dissector. To facilitate this, a longitudinal incision with a scalpel can be made through the vasal sheath along the vas, allowing the sheath to be separated from the vas more easily. Once a loop of bare vas is created, the remainder of the procedure is identical. The open-access technique was found in one study have a shorter operative time than the standard no-scalpel vasectomy, with no difference in length of incision.
Vas division
Once a loop of bare vas deferens is outside of the wound, it is then divided with scissors. With a traditional vasectomy, a segment of vas is then excised. Questions of how much vas to remove and whether excision is even necessary remain unanswered. The optimal length of vas to excise, if any, should be left up to the surgeon. Excising a long (>2 cm) segment of vas may decrease the chance of recanalization, but will also require more dissection along the spermatic cord, increase complications, and make vasectomy reversal more challenging and less successful. The authors believe that if a segment of vas is excised, it should not exceed 1 to 2 cm in length. As discussed later, the method of occlusion of the vas is more important for vasectomy success than is excision of a long vasal segment.
If a segment of vas is excised, sending the excised segments for histologic examination is not necessary. The measure of vasectomy success is determined by the results of the postvasectomy semen analysis (PVSA) rather than confirming vasal tissue on histologic evaluation. Despite this, some surgeons continue this practice because they find it useful to confirm vasal excision, and also out of fear of litigation in the case of a postvasectomy pregnancy.
Vas occlusion
Vasectomy success can be measured by either azoospermia on PVSA or absence of pregnancy after vasectomy. In terms of achieving vasectomy success, the most important step comes after division of the vas and occlusion of the vas. There are several vas-occlusion techniques, including intraluminal cautery of one or both ends, ligation with suture, occlusion with clips, fascial interposition, and any combination of these. Review of the literature reveals many studies examining each of these techniques, yet it is difficult to conclude which occlusion method is superior, owing to study flaws and lack of uniformity in terms of patient follow-up and measurement of success. Several methods of vas occlusion are presented here, and their efficacy discussed.
Intraluminal cautery, or mucosal cautery, is performed by applying thermal cautery or low-voltage electrical cautery with a needle tip within the lumen of the vas. It is unclear as to what length of cauterized mucosa is required to create occlusion, but most surgeons cauterize between 5 and 15 mm of vas lumen. The goal is to destroy only the mucosal layer, which then scars to create a plug in the lumen. Avoiding thermal injury to the muscular layer prevents complete sloughing of the cauterized vas segment, which could potentially allow recanalization. When mucosal cautery is applied to both the abdominal and testicular ends of the divided vas deferens without using fascial interposition, vasectomy failure rates are less than 1%.
Fascial interposition has become a commonly used technique, because when used with other methods of occlusion it decreases vasectomy failure rates. The goal is to separate the two newly divided ends of the vas to reduce the chance of recanalization. To do so, a layer of vas sheath is placed between the two ends of the vas as a tissue barrier with the help of 1 or 2 absorbable sutures ( Fig. 5 ). The fascial layer can be placed over the abdominal or the testicular end. When fascial interposition is combined with mucosal cautery of both ends of the divided vas, failure rates are less than 1%.
