Vasectomy

Family Physicians perform 13-15% of all U.S. vasectomies
Most common in age >30 years
Vasectomy Incidence in U.S.: 500,000 per year
1. Has decreased after 2000 in U.S.
2. Only 4% of men age >18 years old have had a Vasectomy in the U.S. (underutilized)

Traditional Vasectomy with scrotal incision
No-Scalpel Vasectomy (preferred)
1. Described on this page (see below)
2. Preferred technique due to less bleeding, pain, intraoperative time, and risk of post-operative infection
3. Cook (2007) Cochrane Database Syst Rev (2): CD004112 [PubMed]
Marie Stopes International Technique
1. Approved as a valid technique by AUA, but variable efficacy depending on technique and operator
  1. Consider in under-resourced areas
  2. Technique is significantly faster (may lower cost, increase availability)
  3. Post-Vasectomy semenanalysis confirmation is critical (as with other techniques)
2. Vas Deferens is isolated as typically performed in No-Scalpel Vasectomy
  1. However, unlike other techniques, only cautery of vas deferens is performed
  2. Both the distal and proximal vas deferens are both cauterized
  3. No ligation, segment excision or fascial interposition is performed
3. Efficacy
  1. Associated with a 0.64% failure rate
  2. Irrigating the distal (prostatic) vas deferens before cautery, assists with earlier sperm clearance
4. References
  1. Black (2002) J Fam Plann Reprod Health Care 28(3):137-8 +PMID: 16259831 [PubMed]

Non-dominant hand locates vas deferens
1. Vas is caliber of a pen's inner ink plastic holder
Three finger technique traps vas deferens
1. Middle finger placed behind vas deferens
2. Thumb and index finger placed over vas (2 cm apart)
Maneuver vas deferens to midline (under median raphe)
1. Use Index finger to maneuver vas deferens
2. Position vas one third down from top of Scrotum

Preparation: Standard needle injection
1. Anesthetic: Lidocaine 2% without Epinephrine
2. Syringe: 10 ml
3. Needle
  1. Standard: 27 gauge, 1.5 inch needle
  2. Mini-Needle: 30 gauge, 1 inch needle (2 cc injected per vas deferens)
    1. Similar efficacy to standard needle, with less pain)
Technique: Standard needle injection
1. Bending needle at base 15 degrees may help injection
2. Inject midline skin overlying isolated vas
3. Raise 1-2 cm wheal of Lidocaine
4. Aspirate to confirm non-intravascular position
5. Inject 2-3 ml into vas and along course proximally
Technique: Alternative - High pressure jet injector
1. High pressure device delivers Local Anesthetic into vas deferens
2. Less initial pain from injection and similar intraoperative Anesthesia as compared with standard injection
3. Risk of self-injection of surgeon's finger grasping vas deferens
4. White (2007) Urology 70(6): 1187-9 [PubMed]

Press open ring clamp perpendicular into skin over vas
Vas trapped between clamp and underlying finger
Ring clamp closed and locked around vas deferens
Use single tine of open Sharp dissecting forceps
1. Tine pierces scrotal skin at 45 degree angle into vas
2. Insert forceps tine 3-4 mm into vas deferens
3. Withdraw forceps tine
Insert closed forceps into hole made by single tine
1. Insert tines to 3-4 mm depth
2. Spread dissecting forceps to stretch skin and fascia
Insert second ring clamp through hole and grasp vas
Remove first ring clamp and reattach through hole

Peal perivasal sheath away from vas (pealing onion)
Use dissecting forceps to remove perivasal sheeth
1. Insert forcep tines into perivasal sheeth
2. Spread tines to clear sheath away from vas
3. Remove and reattach ring clamps inside sheath
Clear >1 cm vas of perivasal sheath
Apply ring clamp at each end of cleared segment

Hemitransect distal (prostatic) vas deferens
Insert cautery tip 4 mm into prostatic vas lumen
1. Apply current while withdrawing slowly
Ligation of distal (prostatic) vas segment is NOT recommended by AUA
1. Higher recanalization rates when ligation is performed
2. High Vasectomy efficacy without ligation assumes other measures
  1. Fascial layer closure, removal of a 1-2 cm segment, distal vas cautery
3. Prior Ligation methods
  1. Silk 3-0 (1 or 2 separate ties)
  2. Surgical clip (without vas deferens transection or fascial interposition)
    1. Similar efficacy/failure to standard Vasectomy with ligation, transection and fascial interposition
    2. Cook (2007) Cochrane Database Syst Rev (2): CD003991 [PubMed]
Complete transection of distal vas deferens
Close overlying fascia layer (fascial interposition between vas deferens ends)
1. Absorbable Suture (e.g. Vicryl) purse-string or clip
2. Fascial interposition dramatically lowers Vasectomy failure rate
  1. Labrecque (2002) J Urol 168:2495-8 [PubMed]
Transect proximal (testicular) vas deferens end
1. Remove a vas deferens 1-2 cm long
2. Store vas deferens segment in formalin (if required by institutional requirements)
  1. Routine histology of excised segment is not recommended by AUA
Consider avoiding cautery of proximal (testicular) free end of vas deferens
1. May reduce post-operative pain (lower vasal pressure)
2. Risk of sperm Granuloma if not ligated
Observe for signs bleeding (esp. pampiniform plexus)

Repeat from Step 2 forward with opposite vas deferens
Same hole in Scrotum may be used for entry
Consider closing skin with Absorbable Suture (e.g. Vicryl)
1. Not required in No-Scalpel Vasectomy (and Suture may cause local irritation)
Post-operative Antibiotics
1. Not required in most patients
2. Consider in higher risk patients (e.g. Immunocompromised, chronic Corticosteroids, advanced age, smoking)