CHAPTER 126 Vasectomy
Patient education handouts for this chapter are available online at www.expertconsult.com. Explicit patient instructions are imperative, especially in this procedure. The patient education handouts are highly recommended for this purpose.
As discussed later in the section on Technique Variations, vasectomy can be performed in many ways. In the mid-1980s, EngenderHealth (formerly AVSC International) helped popularize the no-scalpel vasectomy (NSV), a method devised in China by Dr. Li Shunqiang. China was at that time struggling against a 2:1 bias favoring tubal ligation over vasectomy. Dr. Li designed a vas fixation clamp and sharp dissecting forceps (SDF), which allowed him to perform vasectomy in a “refined” and less invasive manner. NSV became widely accepted by Chinese men. Whether NSV is, in practice, less invasive than the traditional methods depends entirely on the training, skill, and experience of the surgeon. Certainly it has been demonstrated in some hands to be a quick, virtually bloodless, and often painless procedure. It lends itself to a significant psychological advantage with the apprehensive patient.
Similarly, the “no-needle no-scalpel vasectomy,” or more simply, no-needle vasectomy (NNV) technique, devised by the author in 1999, replaces the previous skin wheal and vasal block anesthetic with a jet injection, and helps relieve patients’ fear of needle administration of anesthetic in this sensitive area (Wilson, 2001).
Anatomy
The epididymis is a soft, comma-shaped attachment on the testis that originates at the superior pole and wraps around the back down to the inferior pole, clinging to the smooth, firm surface of the testis, but separated by a sulcus. (See patient education worksheet online at www.expertconsult.com.)
The vas deferens originates as a convoluted, tenuous duct from the tail of the epididymis at the inferior pole of the testis. As it courses cephalad along the posteromedial aspect of the spermatic cord, it becomes straight and sturdy, with thick walls of smooth muscle tissue, which give it a dense, almost gritty texture to palpation. In a cross-section of the scrotum above the level of the testicles, the vas is a prominent tubular structure surrounded by tiny vasal nerves and supplied by its own small deferential artery (Fig. 126-1). It is deep within the scrotum, separated from the skin surface by nine tissue layers, the deepest of which is the internal spermatic fascia, which also contains the testicular artery, lymphatics, and nerves, and the pampiniform plexus. At that level it is usually distinctly palpable and firm, about 3 mm in thickness, like a hard-cooked spaghetti noodle or a ball-point pen refill. But anatomic variation accounts for vasa that may be as thin as 1.5 mm or as thick as 4.5 mm. Occasionally, the convoluted portion extends all the way to the inguinal canal. Some patients have congenital absence of the vas on one side, although they are rarely aware of it.
Indications
Contraindications
Relative
Preprocedure Patient Preparation
Patient education materials and handouts are widely used and are of great value in preparing the patient for vasectomy. The vasectomy questionnaire, patient education handouts, and patient consent forms help achieve fully informed consent. (See all of these forms online at www.expertconsult.com.)
Many now recognize the educational value of patient education videotapes/DVDs. The patient can review the material several times privately at home. A vasectomy counseling videotape is available from Creative Health Communications through The National Procedures Institute (see the Suppliers section). With portable DVD players, the patient can easily view the material in the office before seeing the physician.
The preprocedure counseling visit can be documented using the encounter form, which reviews the patient’s pertinent history, physical examination, and counseling points, and documents the follow-up semen specimen checks. The form can be found online at www.expertconsult.com.
Also helpful is the Patient Education Worksheet, which also is available online at www.expertconsult.com. This is a checklist of the counseling material to be reviewed with the patient. The original sheet is for the patient and a copy is made for the chart. Not only is it a good summary of all points covered, but it serves as a reminder for the patient of what to do just before and after the surgery. (For a more detailed description of the preprocedural counseling visit, see Pfenninger [1984b].)
Equipment and Supplies
The preparation for vasectomy includes gathering the necessary equipment and supplies and arranging the sterile items on a surgical tray (Fig. 126-2). Each setup depends on the surgical setting and the surgeon’s preferred technique and choice of available supplies. A checklist for the staff to use in preparing for the procedure is a good way to avoid omissions and oversights.
-inch, 27-gauge needle) with lidocaine (2%) without epinephrine (10 mL) was used. In the NNV anesthesia technique (see later discussion), an instrument called the MadaJet is used to administer the lidocaine. Only 0.1 mL of lidocaine is used per side with this instrument, but it requires at least 1 mL in the chamber to prime and function correctly.
Figure 126-3 No-scalpel instruments. A, Wilson vasectomy forceps. B and C, Sharp dissecting forceps.
(B and C, From Li SQ, Goldstein M, Zhu J, Huber D: The no-scalpel vasectomy. J Urol 145:341–344, 1991.)
No-Needle Vasectomy Anesthesia Technique
In the NNV technique, the traditional vasal block method is replaced by the no-needle technique. This is accomplished using a piston-like instrument (MadaJet 401UR; Mada Medical, Inc., Carlstadt, NJ; Fig. 126-5A), which uses the force of fluid under pressure to “push” the anesthetic into the tissues. The jet injection is a fine stream (about 0.006 inch in diameter) that instantly penetrates about 4 mm through the skin and vas deferens, producing an almost immediate and complete anesthetic effect (Fig. 126-5B).
The vas should be isolated as described later in step 3 of the No-Scalpel Vasectomy Procedure section. However, now both the index and middle fingers are placed behind the scrotum with the thumb in front. The straight segment of vas spans a small “safe” space between the index and middle fingers. The MadaJet is cocked and the tip is then placed firmly over the vas next to the thumb, directed into the “safe” space, and actuated by pushing the button. Each injection will be 0.1 mL of lidocaine. When beginning, it may help to mark the intended site of the scrotum with a marking pen and then isolate the vas to this spot for anesthesia. The marked spot will make it easier to bring the other vas to the same location. It also identifies where the opening should be made. A second application can be made over each vas to ensure a good block if desired. The total amount of anesthetic will then be 0.2 to 0.4 mL.
Technique Variations
Occlusion Methods
A number of occlusion techniques have been used, with varying degrees of success, but existing evidence is insufficient to recommend one specific technique (Sokal and Labrecque, 2009).
Interposing fascia between the cut and cauterized ends results in very low failure rates of 0.1% to 0.5%. The fascia can be closed with absorbable suture or with hemoclips. The latter are quicker and avoid the bleeding seen occasionally when placing a suture. (For an excellent discussion of various techniques, see Lipshultz and Benson [1980]. Although it is a dated article, the material remains an excellent review.)
Excision of a vas segment greater than 4 cm is 100% successful, but causes excess morbidity and leaves little possibility of reversal. Labrecque and colleagues (2002) found that excising a longer (15 mm) segment of vas did not improve recanalization rates over shorter excisions. In some settings, specimens for pathologic examination may be required by policy; however, there is little or no benefit, and substantial added cost, in having histologic confirmation. The optimal length of excised segment is thought to be 1 to 2 cm. Experienced surgeons may not remove any tissue once they are able to identify the vas in vivo with certainty, and are certain of their cautery and fascial interposition techniques. The American Urology Association has stated that sending vas segments for histologic confirmation is not necessary. Instead of sending the segments for histologic examination, some clinicians give the 1-cm vas segments in formalin to the patient and instruct him to keep the segments in a medicine cabinet, away from children, until he has had two negative semen checks. The patient can then dispose of the segments once sterility is confirmed. Considering that 500,000 vasectomies are performed each year in the United States, that each pathology specimen costs between $150 and $200 to process, and that some physicians put each side in separate bottles, clinicians can save the health care system $75 million to $150 million per year by not sending the vas segments to the laboratory! If the patient keeps the specimens, and if the vasectomy should fail (which is rare), the patient can then submit the tissue to the laboratory for evaluation, if desired.
Open-Ended versus Closed-Ended
The “open-ended” technique uses cautery only on the prostatic end of the cut vas, along with closing the fascia over that end. It differs from other techniques in that the testicular end of the vas remains unoccluded, or “open.” The open-ended technique was first recommended and used more than 50 years ago. Errey and Edwards (1986) reported an improvement in postoperative complaints. The technique is assumed to minimize back-pressure on the testicle, which could be associated with long-term pain in the occasional patient (i.e., postvasectomy pain syndrome). The trade-off is that symptomatic sperm granulomas and vasectomy failure could be increased because of the open pathway from the testicle. Careful attention to proper technique of cautery and fascial interposition helps prevent failure; however, most surgeons still routinely cauterize both the prostatic and testicular ends in the belief that this “closed-ended” method is the best assurance against failure. Some surgeons use the open-ended technique only for men younger than 30 years of age on the basis that they may be more likely to request reversal, which would then be theoretically easier, while routinely using the closed-ended technique in those older than 30 years.
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