This chapter provides a brief history of vasectomy, as well as recommendations for preoperative counseling, an overview of the modified no-scalpel vasectomy technique, and a brief description of the complications of vasectomy. Sir Ashley Cooper first described vasectomy in as a sterilization procedure first performed on canines in the United Kingdom 5. However, vasectomies did not enter clinical use until the late 19 th century, at which time vasectomies were felt to induce prostatic atrophy, and were widely performed as an alternative to castration to reduce symptoms of prostatic hypertrophy and improve micturition 6. This eventually fell out of favor by the early 20 th century as evidence accumulated that vasectomy had no such benefit for patients with symptoms of enlarged prostates. Around this same time, many promoted vasectomy for eugenic sterilization 7.
Vital Health Statistics. Given the relatively large number of patients evaluated, the consistently low failure rates and the low failure rate from the single high-quality study, the panel judged that Diagnosis vasectomy counseling without FI also is likely to be consistently effective. Diagnosis vasectomy counseling information is central to understand the extent to which the relative Diagnosis vasectomy counseling of vasectomy in the US is a function of lack of understanding of the procedure. Copyright Translational Andrology and Urology. J Clin Oncology ; Prostate cancer. Mucosal cautery MC is the technique of applying thermal or electrical cautery to the mucosa of the cut ends of the vas to destroy the vasal mucosa while avoiding or minimizing damage to muscle layers.
Ass free giris nude sweet. Vasectomy Guideline (2015)
Few of these men require additional surgery. The risks of intraoperative and early postoperative pain, bleeding and infection are related mainly to the method of vas isolation. One man had an apparent late recanalization; the other had not returned for a PVSA. Non-divisional vasectomy with extended electrocautery Fucking ass wallpaper Stopes technique. Occlusion of both vasal ends with ligatures and FI. Four methods of vas occlusion that appear to be consistently reliable with regard Diagnosis vasectomy counseling contraceptive and occlusive effectiveness were identified: 1 MC Diagnosis vasectomy counseling FI and Diagnosjs the use of ligatures or clips on the vas; 2 MC without FI and without the use of ligatures or clips on the counseliny 3 open ended vasectomy leaving the testicular end conuseling while using MC of the abdominal end of the vas with FI; and 4 the Marie Stopes International method of vasectomy with extended non-divisional electrocautery of the vas. Experience with the first cases. The Panel affirms this recommendation and believes that diabetes is also a risk factor for post-operative infection. Please note that this Guideline was edited in to include additional information related to vasectomy and the risk of prostate Vzsectomy. BMC Diagnosis vasectomy counseling ; 6: The VAS score differences for the initial injection were significantly different between local infiltration and local infiltration with cord block and between local infiltration and pneumatic injection, but there were no Consensus models for the VAS scores during the remainder of the procedure. Six studies reported failure rates between 1. Treating physicians must take into account variations in resources, and patient tolerances, needs, and preferences. The low rate Diiagnosis
The purpose of this clinical guideline is to provide guidance to clinicians who offer vasectomy services.
- Diagnosis Index entries containing back-references to Z
- The purpose of this clinical guideline is to provide guidance to clinicians who offer vasectomy services.
- Diagnosis Index entries containing back-references to Z
- The Diagnostic Related Groups DRGs are a patient classification scheme which provides a means of relating the type of patients a hospital treats.
Aka: Vasectomy Counseling. These images are a random sampling from a Bing search on the term "Vasectomy Counseling. Search Bing for all related images. Started in , this collection now contains interlinked topic pages divided into a tree of 31 specialty books and chapters. Content is updated monthly with systematic literature reviews and conferences. Although access to this website is not restricted, the information found here is intended for use by medical providers.
Patients should address specific medical concerns with their physicians. Toggle navigation. Surgery Chapter. Page Contents Indications All Vasectomy patients weeks before procedure. Risk factors: Regretting Vasectomy Age under 30 years Education: Describe procedure anatomically Using diagram to show normal sperm course Show Seminal Vessicle s produce ejaculate Show location of incision in Scrotum. Exam Scrotal and perianal skin Dermatitis Infection Testes Testicular Pain or tenderness to palpation Testicular nodularity Hydrocele Vas deferens Vas mobility ease of isolation Congenital absence of vas deferens single vas Associated with renal anomalies Accessory vas deferens or duplicated vas rare Miscellaneous Varicocele Inguinal Hernia.
Valium mg Patient has transportation if premedication is used Partner clips hairs on anterior Scrotum No Aspirin 2 weeks before procedure No NSAID or platelet inhibitor 4 days before procedure Wear athletic supporter jock strap to appointment Shower and clean Scrotum on surgery day. Images: Related links to external sites from Bing. Related Topics in Surgery. Urology Chapters. Urology - Surgery Pages. Back Links pages that link to this page. Search other sites for 'Vasectomy Counseling'.
Denniston GC: Vasectomy by electrocautery: outcomes in a series of 2, patients. Non-divisional vasectomy with extended electrocautery Marie Stopes technique. BMJ ; It takes about three months before it is effective. Information regarding the potential value and possible complications from the addition of folding back to any technique. Urology ; 4: Rates of epididymitis varied across studies.
Diagnosis vasectomy counseling. Encounter other general counseling and advice on contraception
The single study that reported on men with CHD risk factors e. Five comparative cohort studies evaluated the relationship between vasectomy and stroke.
There also was no relationship between time since vasectomy and risk of stroke. Primary progressive aphasia PPA and other forms of dementia. Only one small study has reported a potential link between vasectomy and dementia. This small case control study has uncertain significance.
The opinion of the Panel is that clinicians do not need to routinely discuss PPA or other forms of dementia in pre-vasectomy counseling of patients because there is no convincing evidence that such a relationship exists.
Four comparative cohort studies examined the relationship between vasectomy and hypertension. Prostate cancer. Fourteen papers reporting on ten comparative cohort studies were retrieved in the literature search. Twenty case-control studies were identified that evaluated the association of vasectomy and prostate cancer Cossack ; Cox ; Emard ; Ganesh ; Hayes ; Hennis ; Holt ; Honda ; Hsing ; John ; Lesko ; Mazdak ; Mettlin ; Patel ; Platz ; Rosenberg , ; Schwingle ; Stanford ; Zhu ; only four studies reported a statistically significant odds ratio for this relationship Emard ; one of three control groups reported by Hsing ; Mettlin ; Rosenberg A meta-analysis of 13 case-control studies that met inclusion criteria for pooling 98, , , , , , , indicated that vasectomy was not statistically significantly associated with prostate cancer pooled odds ratio — 1.
Of this group of 30 studies, fourteen reported an analysis that focused on whether age at vasectomy conferred differential risk of prostate cancer. Ten studies reported no relationship between age at vasectomy and prostate cancer Hayes ; Holt ; John ; Lesko ; Mettlin ; Rosenberg ; Schwingl ; Sidney , ; Stanford ; Zhu ; 92, 93, 98, , , , , , four reported at least one significant statistical test Patel ; Platz ; Lynge ; Rohrmann Thirteen studies concluded there was no relationship between years since vasectomy and prostate cancer; 89, 92, 93, 98, , , , , , five studies reported at least one statistically significant finding Emard ; Giovannucci Tosteson , ; Rohrmann ; Rosenberg ; Siddiqui Given the overwhelming majority of negative findings from these sub-analyses, however, the Panel interpreted these data to indicate that there is no association between age at vasectomy or years since vasectomy with differential prostate cancer risk, and that vasectomy does not predispose men to develop advanced or lethal prostate cancer.
Testicular Cancer. Four case-control studies 98, and seven comparative observational studies 73, 77, 89, 90, 94, , investigated whether there is an association between vasectomy and testicular cancer. A meta-analysis conducted as part of the Panel's literature review for the case-control studies indicated no significant difference between groups in terms of the odds of being diagnosed with testicular cancer for vasectomized men compared with non-vasectomized men Odds ratio OR 1.
Outcomes reporting differences across comparative observational studies did not permit a pooled analysis, but all seven studies reported non-significant differences between vasectomized and non-vasectomized men, and in the three studies that reported incidence by group, 73, 90, 94 incidence rates ranged from 0.
There was no association between history of vasectomy and testicular cancer stratified by years since vasectomy. There is only one reported death, which was not in the United States, due to vasectomy. The AUA Best Practice Policy on Urologic Surgery Antimicrobial Prophylaxis [pdf] recommends that prophylactic antibiotics for open and laparoscopic surgery including genital surgery performed without entering the urinary tract are indicated only if risk factors are present.
Risk factors include advanced age, anatomic anomalies of the urinary tract, poor nutritional status, smoking, chronic corticosteroid use, immunodeficiency, distant co-existent infection and prolonged hospitalization.
The Panel affirms this recommendation and believes that diabetes is also a risk factor for post-operative infection. When operating on certain patients who present with comorbidities associated with a particularly high risk of infection, the surgeon should consider the use of prophylactic antimicrobials. The minimum age requirement for vasectomy is the legal age of consent in the prevailing legal jurisdiction in which the procedure is performed.
The prospective vasectomy patient must, at a minimum, be the legal age of consent according to relevant legal statutes. In addition, each surgeon should exercise clinical judgment to determine the appropriateness of performing a vasectomy on a particular patient. The patient's age, the number of children that the patient has and other factors that the surgeon's experience indicate may be associated with successful outcomes e.
In the US, there is no requirement for spousal or partner involvement in preoperative consultation, but patients should be advised that partner or spousal involvement is desirable.
Any consenting adult male may proceed with a vasectomy without consultation with his partner unless local laws stipulate otherwise. However, because the prospective vasectomy patient's decision affects the fertility options for both him and his partner or spouse, it is optimal that his partner should be included in the preoperative consultation and decision-making process.
Preoperative laboratory tests are not required for vasectomy patients unless the patient's medical history suggests that laboratory work may be necessary to assess the patient's suitability for the vasectomy procedure. In particular, preoperative coagulation tests should be considered if the patient has a history of liver disease, bleeding diatheses or is taking anticoagulants. Absence from work. A low-quality, limited amount of literature was available to address how much time men typically take off from work after vasectomy.
For men who reported no time out of work, it was generally unclear if scheduled time off following the procedure had been pre-arranged prior to the vasectomy.
Time lost from work varied considerably, and there may be cultural and financial reasons that explain the disparities. Insufficient information was provided to explore this hypothesis, however. Rates of epididymitis varied across studies. Some variability is likely the result of different definitions used for epididymitis.
Bacterial epididymitis is often confused with pain caused by distention of the epididymal tubule due to back pressure below the vasectomy site or by epididymal sperm granuloma.
Nevertheless, across the 36 available studies, rates of epididymitis were generally low. The lack of an unvasectomized control group does not allow for a true estimate of the rate of these complications among vasectomized men; the rates presented here may be over-estimations. Sperm granuloma. The true rate of nodule formation at the vasectomy site has not been identified. Treatment for a painful nodule at the vasectomy site is symptomatic therapy with anti-inflammatory agents and analgesics if needed.
Persistent pain at the vasectomy site is rare and may respond to excision and repeat vasectomy. Psychosocial outcomes. Relatively few studies examined psychological outcomes among vasectomized men.
There is a paucity of high-quality, comparative observational studies reporting outcomes measured with validated instruments. In particular, data with applicability to men in the US or in other developed countries are sparse. Outcomes may vary by year of the study, geographic location, measurement tools used, selection of the study population, length of follow-up and other variables. It is thus impossible to draw firm conclusions on the effect of vasectomy on psychological function. Sexual outcomes.
Although there is a large number of studies examining sexual outcomes after vasectomy, 45, 51, 53, 55, 59, 60, , , , , , , , there are few studies with a comparison group and few studies that report data before and after the procedure. Thus, it is difficult to attribute changes in sexual satisfaction or function to the vasectomy itself. Outcomes relating to sexual function were heterogeneous, often poorly defined, and were usually assessed with instruments that were not validated.
Despite the relatively weak study designs, the available data with regard to sexual outcomes of vasectomy were consistent. Men generally resumed intercourse within two weeks of vasectomy. A recent large population-based study confirmed the lack of sexual problems in men following vasectomy. Patients may be reassured that there is no evidence that any of these problems are caused by vasectomy. Dissatisfaction and regret. Endocrine outcomes. The literature review revealed no evidence of significant effects of vasectomy on testosterone, follicle-stimulating hormone FSH , luteinizing hormone LH , lipids e.
One low-quality study reported on urolithiasis rates of vasectomized compared to non-vasectomized men. The OR was highest in men zero to four years post- vasectomy, compared to men without vasectomy.
Immunologic outcomes. A limited literature was available on the incidence and relevance of anti-sperm antibodies ASAs post-vasectomy. Studies pertaining to the influence of antisperm antibodies on pregnancy rates after vasectomy reversal are rare.
The precise prevalence of impaired fertility due to anti-sperm antibodies is unknown. The opinion of the Panel is that, after vasectomy, impaired fertility due to anti-sperm antibodies is infrequent and that the presence of serum antisperm antibodies should not be considered a deterrent to vasectomy reversal. Testicular changes after vasectomy.
Data are sparse on the effect of vasectomy on testicular histology and on pathologic changes following vasectomy. The available studies suggest that there may be significant post-vasectomy pathological changes in testes. Death as a result of vasectomy.
The literature review found no reports of death as a result of vasectomy in contemporary American urological practice. There is one report of death after vasectomy due to Fournier's gangrene. This case occurred in Europe and was reported in Occasionally adjunctive oral or intravenous sedation may be optimal or necessary for the few patients who are unable to tolerate vasectomy under local anesthesia alone.
For the rare patient in whom preoperative examination suggests that vas isolation will be particularly difficult and in whom oral or intravenous sedation is unlikely to be sufficient for patient comfort, general anesthesia may be necessary. Direct topical application of anesthetic cream at the vasectomy site in addition to standard injection of local anesthesia also may be used.
Several small studies have shown that topical application of anesthetic cream before local injection of anesthetic may reduce pain associated with injection of local anesthetic agents.
The topical cream should be applied by a health care professional rather than by the patient to prevent excessive application and risk of toxicity. Practitioners are cautioned that topical anesthetic cream should not be the sole source of local anesthesia for the performance of vasectomy.
Infiltration of local anesthetic agent into the skin and perivasal tissue is always necessary prior to performance of a vasectomy, regardless of whether topical anesthetic cream is used. Needle size. In the opinion of the Panel, the smallest available needle should be used for the injection of local anesthesia because small gauge needles typically produce less pain than larger gauge needles. In the Panel's experience, the optimal range of needle sizes is 25 to 32 gauge.
One study evaluated patient visual analog scale VAS scores in response to blinded forearm intradermal injection with 25 gauge vs. However, these data do indicate that the pain associated with needle diameters in this range is minor. These data are in agreement with the Panel's opinion that needles between 25 and 32 gauge should be utilized for local infiltration and spermatic cord block to minimize patient pain. Patients may be told that the anesthetic often takes effect within one to three seconds.
The majority of members of the panel feel that the use of 30 or 32 gauge needles for injection of the local anesthetic is associated with less pain than occurs with the use of larger needles. Pneumatic injector. A pneumatic injector, also known as a jet or no needle device, has been used to deliver anesthetic agent transcutaneously.
However, it is not clear that intra-operative pain is reduced by this technique compared to standard injection technique. In one study, the mean VAS score for initial pain after pneumatic injections was In a separate cohort study, the mean VAS scores were reported for three separate procedures: 33 mm for local infiltration, 22 mm for no-needle pneumatic injector and 17 mm for local infiltration and cord block.
The VAS score differences for the initial injection were significantly different between local infiltration and local infiltration with cord block and between local infiltration and pneumatic injection, but there were no differences for the VAS scores during the remainder of the procedure. Pneumatic injection may be especially suitable for needle-phobic men.
Addition of buffer, epinephrine or corticosteroids to the local anesthetic agent or a topical cutaneous spray. There are insufficient data to know whether addition of buffer, epinephrine or corticosteroids to the local anesthetic agent or topical cutaneous spray reduces pain during vasectomy or reduces postoperative inflammation. Therefore, the addition of these agents is not endorsed by the Panel. Buffers have been added to local anesthetic agents to reduce pain during intradermal injections of various types but not specifically for vasectomy.
In the absence of data obtained specifically for vasectomy, the Panel does not endorse the addition of these substances to anesthetic agents. Conventional Vasectomy CV : One midline or bilateral scrotal incisions are made with a scalpel. Incisions are usually 1. No special instruments are used. The vas usually is grasped with a towel clip or an Allis forceps.
The area of dissection around the vas usually is larger than occurs with MIV techniques. Alteration of any of the specific steps does not allow the surgical technique to be called NSV. The NSV incision is usually less than 10 mm, and no skin sutures are needed. Two special instruments vas ring clamp and vas dissector are essential to NSV.
The area of dissection around the vas is kept to a minimum. Vas Isolation Techniques. There are two key surgical steps in performing vasectomy: 1 isolation of the vas and 2 occlusion of the vas. The risks of intraoperative and early postoperative pain, bleeding and infection are related mainly to the method of vas isolation.
The success and failure rates of vasectomy are related to the method of vas occlusion see next section titled Vas Occlusion Techniques. For definitions, see Table 3 above. Conventional Vasectomy CV. CV is performed by making either one midline incision or bilateral scrotal incisions using a scalpel. Incisions are usually from 1. No special instruments are used during CV, and the vas usually is grasped with a towel clip or an Allis forceps.
The no-scalpel vasectomy technique was developed in in China by Dr. The NSV isolation technique was the first minimally-invasive technique for vasectomy and is described in detail in text and with diagrams by Li et al. Note that the NSV technique is a method of vas isolation and does not specify a method of vas occlusion.
Strictly speaking, to be called a Li no-scalpel vas isolation technique, all of the following surgical steps must be observed:. If all of these specific steps are not used, then the vasectomy should be called a minimally-invasive vasectomy MIV rather than a no-scalpel vas isolation technique. When difficulty in isolating the vas is encountered or anticipated, as may be expected with a history of surgery for testicular maldescent or perivasal scarring from a previous operative procedure, a larger incision similar to the incision typically used for CV may be needed.
The term "minimally invasive vasectomy" includes any vas isolation procedure, including the NSV technique, which incorporates two key surgical principles. Minimal dissection of the vas and perivasal tissues, which is facilitated by using a vas ring clamp and vas dissector or similar special instruments.
The three finger technique described in Appendix A for immobilizing the vas or for making the skin opening has been modified slightly by various surgeons using MIV techniques other than the strict NSV technique. These variations include the use of the thumb rather than the middle finger behind the scrotum and other modifications of finger placement, bilateral skin openings or scrotal skin opening s made before grasping the vas with the vas ring clamp.
MIV isolation techniques utilize either an open access approach or a closed access approach. In the open access approach, the skin opening s are made before the vas ring clamp or similar instrument is applied to the vas. In the closed access approach, the vas ring clamp or similar instrument is applied around the vas, perivasal tissue and overlying skin before the skin opening s is are made.
The vas ring clamp and vas dissector are not required to perform MIV but are always very helpful. Single midline or bilateral incisions. The use of one midline or bilateral scrotal skin openings should be based on the surgeon's preference. Fewer adverse events were reported with a single incision and the procedure time was reduced, but no statistical testing was performed. The choice between midline and bilateral incisions should be left to the clinical judgment of the surgeon performing vasectomy.
Site of incision s. For a midline approach, the scrotal skin opening should be made just below the penoscrotal junction or midway between the penoscrotal junction and the top of the testes. For a lateral approach, some experts recommend that the scrotal skin opening should be made at the level of the penoscrotal junction or higher. Scrotal skin openings for vasectomy should be positioned to provide access to the straight portion of the vas.
Higher openings allow better access to the straight portion of the vas, make it easier to perform mucosal cautery and create longer vas remnants on the testicular side of the vasectomy. In addition, occlusion of the vas in its straight portion may facilitate the performance of the anastomosis during vasovasostomy if reversal of the vasectomy is requested later.
Insuring that one vas is not occluded twice. For a single-incision vasectomy, the surgeon should ensure that the same vas is not isolated and occluded in two locations, leaving the other vas unoccluded.
A gentle tug on each vas during isolation will cause the ipsilateral testis to move. No-Scalpel Vas Isolation Technique. One large randomized controlled trial, 59 one comparative study, one observational study, and two systematic reviews , concluded that the NSV technique of vas isolation has fewer early postoperative complications than CV. The randomized trial was a multi-center study at eight sites and included 1, men. The comparative study included 1, vasectomies. One study found that the men who had the NSV technique had significantly fewer hematomas and infections, with an overall complication rate of 0.
Other MIV Techniques. Reports on other MIV techniques have proposed special instruments other than the vas ring clamp and vas dissector 39, , , or alternative ways to use the vas ring clamp and vas dissector. When any MIV technique is used, the skin opening may be closed with a suture or left open at the end of the procedure. The choice of suturing the skin or leaving it open should be based on individual operative conditions and the surgeon's experience. The body of evidence showing the superiority of MIV techniques reduced intraoperative discomfort and reduced postoperative complications compared to conventional vasectomy techniques is given Grade B for strength of evidence because it is comprised of a good quality RCT and several systematic reviews in addition to a body of observational studies.
Overall, the findings across reports were consistent. It is the strong opinion of the Panel members that isolation of the vas with an MIV technique is superior to CV isolation procedures. In the US, virtually all techniques of vasectomy use complete division of the vas with or without excision of a segment of the vas. There is only one technique of vas occlusion, non-divisional extended electrocautery or the Marie Stopes International technique see below , which does not use division of the vas.
This technique is rarely, if ever, used in the United States. Therefore, in this guideline, vas occlusion means that the vas has been completely divided with or without excision of a vas segment, unless otherwise noted. Vasectomy effectiveness can be defined as either contraceptive effectiveness , which is the absence of pregnancy, or occlusive effectiveness , which is demonstrated by the finding on PVSA of azoospermia or of RNMS, as defined in a subsequent section of this Guideline.
For definitions, see Table 4. Fascial interposition FI : Placing a layer of the vasal sheath internal spermatic fascia between the two severed ends of the vas in order to cover one end, but not the other end, with the vasal sheath. Folding back : A method of folding and suturing each divided vas end on itself to prevent the two cut ends from facing each other. This method utilizes electrocautery to destroy approximately 2. This method is rarely, if ever, used in the US. Fascial interposition FI is the technique of placing a layer of the internal spermatic fascia between the two divided ends of the vas.
The fascial layer may be placed over the testicular or the abdominal end. Typically it is combined with other techniques such as ligation and excision or mucosal cautery.
Folding back is the technique of folding and suturing each divided vas end on itself to prevent the two cut ends from facing each other. Mucosal cautery MC is the technique of applying thermal or electrical cautery to the mucosa of the cut ends of the vas to destroy the vasal mucosa while avoiding or minimizing damage to muscle layers.
The goal of MC is to create a plug of scar tissue which occludes the vas lumen. The length of the cauterized segment varies from a few mm to 1. MC may be combined with excision of a vas segment, folding back or FI. Cauterizing the mucosa while simultaneously limiting cautery damage to the muscular layer of the vas prevents sloughing of the cauterized portion of the vas, which could occur if its full thickness is destroyed by cautery.
Non-divisional extended electrocautery technique of vas occlusion Marie Stopes International technique consists of electrocoagulation of the full thickness of the anterior wall and a partial thickness of the posterior wall of the vas for a length of approximately 2. It uses monopolar electrocautery delivered by a Hyfrecator through a reusable needle. The technique was developed by Marie Stopes International in London United Kingdom as a vasectomy technique that could be easily disseminated, particularly in Third World conditions.
Open-ended vasectomy is the technique of leaving the testicular end of the divided vas unoccluded while occluding the abdominal end. The hypothetical aims of this technique are 1 to prevent or reduce post-vasectomy pain by decreasing back pressure in the epididymis 46 and 2 to allow the formation of a sperm granuloma at the transected testicular end of the vas, which some experts speculate might increase the chance of success of vasectomy reversal.
Challenges in Interpreting the Evidence. The Panel undertook review of the vas occlusion literature with the goal of identifying with a high level of certainty specific techniques that consistently produce occlusive effectiveness. However, the vas occlusion literature suffers from serious methodological flaws that reduce certainty regarding conclusions about the relative efficacy of various occlusion techniques. Two reports showed uncertain significance.
It is not clear from this report exactly how many couples were followed for pregnancy occurrence. In the absence of this information, it is not possible to conclude with certainty that the pregnancy failure rate is 6 in 14,; the pregnancy failure rate may be higher if pregnancy data were not available for all patients. The other study reported no cases of sperm persistence and no pregnancies in 6, vasectomy patients. Because the number of patients who were followed and the timing of follow-up are not detailed in this paper, it is not possible to know whether successful vasectomy occurred in 6, men or in some number less than 6, Methodologically strong studies of occlusion technique effectiveness that would result in a high level of certainty regarding findings are characterized by the following:.
None of the studies reviewed by the Panel met all of these criteria, and only three studies met a majority of these criteria. This resulted in assigning Grade C as the strength of evidence for the body of literature on the efficacy of vas occlusion. Given the limited certainty associated with the use of Grade C evidence, the Panel focused on identifying methods of vas occlusion that produce consistent findings, including acceptably low failure rates, across multiple studies with large numbers of patients.
Four methods of vas occlusion that appear to be consistently reliable with regard to contraceptive and occlusive effectiveness were identified: 1 MC with FI and without the use of ligatures or clips on the vas; 2 MC without FI and without the use of ligatures or clips on the vas; 3 open ended vasectomy leaving the testicular end unoccluded while using MC of the abdominal end of the vas with FI; and 4 the Marie Stopes International method of vasectomy with extended non-divisional electrocautery of the vas.
Based on this analysis of the literature, the Recommendations below were created. The Panel acknowledges that, in creating an evidence-based guideline, these Recommendations are necessarily based on the data that are available in the medical literature. OR by the non-divisional method of extended electrocautery. Reliable Techniques of Vas Occlusion.
Thirteen study arms evaluated MC of both vas ends and FI to occlude the vas in approximately 18, patients. Failure rates for this technique ranged from 0. Although the majority of these data were from non-randomized observational designs, one study arm was from a high-quality observational study that reported an occlusive failure rate of 0. Given the large number of patients evaluated, the overall consistently low failure rates and the low failure rate from the single high-quality study, the panel judged that this vas occlusion technique is likely to be consistently effective.
Six study arms Barone — 2 arms; Coffman ; O'Brien ; Philp ; Shapiro evaluated MC of both vas ends but without FI to occlude the vas in approximately 13, patients. Four of the six study arms were from non-randomized observational designs, but two arms were from Barone , the high-quality observational study; these two arms reported an overall failure rate of 1. All of the other study arms both divided the vas and excised a segment.
Given the relatively large number of patients evaluated, the consistently low failure rates and the low failure rate from the single high-quality study, the panel judged that MC without FI also is likely to be consistently effective. Four study arms 38, 41, , evaluated approximately 4, men with an open ended method in which the testicular end was left unoccluded, the abdominal end was occluded with MC and FI was performed.
Failure rates ranged from 0. One of the three study arms was from Barone , the high-quality observational study, and reported a failure rate of 0.
Because of the low failure rates, including the low failure rate from the high-quality study arm, the panel judged that this technique also is consistently effective. With regard to the same technique of open ended vasectomy with MC but without FI, only two study arms were found.
Both study arms were from the same study evaluated a total of patients and reported failure rates of 4. Therefore, the panel does not advocate the omission of FI in performing open ended vasectomy with MC. PVSAs were obtained on 41, patients and revealed early failures a failure rate of 0.
Given the consistency of low failure rates across many centers and many clinicians as well as the very large number of patients, the panel interpreted these data to indicate that non-divisional vasectomy with extended electrocautery of the vas also is consistently effective. The Panel is aware, however, that large numbers of surgeons in the US and elsewhere occlude the vas using ligatures or clips. This highly-variable literature is reviewed in the paragraphs below.
Thirty-one study arms evaluated occlusion by ligatures of both ends of the vas without FI. Specifically, twelve studies reported failure rates of 1. Six studies reported failure rates between 1. Thirteen studies reported rates higher than 2. Two of the three highest failure rates were reported in high-quality studies.
The only randomized trial reported a failure rate of Nine study arms evaluated the use of ligatures on both ends of the vas in combination with FI. Six study arms reported failure rates of less than 1. The remaining studies reported failure rates of 1. The high rate of 5. Seven study arms used clips on both ends of the vas without FI. Four studies reported failure rates less than 1.
The literature review identified only one study that combined clips with FI; 0. The opinion of the Panel, however, is that vas occlusion by clips and FI is unlikely to produce higher occlusive failure rates than vas occlusion by clips alone. Other Occlusive Techniques. Adjunctive Techniques for Vas Occlusion.
The literature was also examined to determine whether adjunctive techniques for vas occlusion are associated with consistently lower failure rates. Insufficient evidence was found to draw conclusions with regard to the techniques of folding back, irrigation of the abdominal end of the divided vas, excision of different lengths of vas segments and FI over the abdominal end compared to FI over the testicular end.
With regard to folding back of the vas on itself as a method to separate the ends of the divided vas, the available studies used a variety of occlusive techniques in addition to folding back, making it unclear whether folding back affected failure rates. Similarly, it is not clear whether irrigation of the abdominal end of the vas with various solutions enhances sperm clearance rates. There also is insufficient evidence to establish the optimal length of vas which should be excised, if any.
In addition, based on the available evidence, there do not appear to be differences in effectiveness when FI is performed over the testicular vs. The panel agrees with the lack of value of histologic examination of resected vas deferens segments as a determinant of success of the vasectomy. At the discretion of the surgeon, it may be helpful to send excised tissues for histological evaluation for confirmation of vasal tissue.
PVSA is used to confirm the effectiveness of a vasectomy postoperatively for definitions, see Table 6. Vasectomy effectiveness can be defined as either contraceptive effectiveness or occlusive effectiveness. The standard definition of contraceptive effectiveness is the absence of pregnancy.
The standard definition of occlusive effectiveness is post-vasectomy azoospermia. However, some men fail to achieve azoospermia after vasectomy yet never father a pregnancy. For example, one study found sperm in the semen of 18 of 9. Vasectomy failure. Vasectomy failure is the occurrence of pregnancy or failure to achieve azoospermia or RNMS after a reasonable period of time following vasectomy. Vasectomy failure may be a technical failure resulting from a surgical error such as occluding one vas twice without occluding the other vas or failure to identify the very rare situation of vas duplication on one side.
Technical failure is characterized by persistently normal or nearly normal motile sperm counts and sperm motility after vasectomy. Vasectomy failure also may result from recanalization at the vasectomy site. Recanalization following vasectomy should be suspected if motile sperm or rising sperm concentrations are seen after a routine PVSA has shown azoospermia or RNMS. Pregnancy due to recanalization is estimated to occur after approximately 1 in vasectomies or less often.
Azoospermia : Absence of sperm during microscopic exam of at least 50 Hpfs in a single well mixed, uncentrifuged semen specimen. Recanalization : A histologic diagnosis that shows reconnection of the vas ends, either directly or by microcanaliculi, after vasectomy. PVSA Principles. Controversies in the timing, technique, reporting and significance of PVSA include the following:.
The aim of a PVSA is to confirm occlusive effectiveness and to advise a patient that he can safely rely on his vasectomy for contraceptive purposes. Practical principles relevant to PVSA are as follows:. Considering these principles, a vasectomy should be considered successful as soon as a PVSA confirms that the risk of pregnancy is sufficiently low to allow the patient to rely on the vasectomy alone for contraception.
Conversely, a vasectomy should be considered a failure — or not yet a success — when a man needs to use another contraceptive method or needs to repeat the surgical procedure before relying on his vasectomy. Sperm Clearance After Vasectomy. Sperm clearance after vasectomy is time dependent with both large inter-individual variations as well as variability across published reports, including those that used the same vas occlusion technique.
Inter-individual variation may result from differences in reproductive anatomy and possibly patient age. Sperm may persist in the ejaculate for many months after vasectomy.
Such persistence may be due to residual sperm in the seminal vesicles or ampullae of the vasa, recanalization, or, very rarely, a failure to have performed the vasectomy on one vas. The main reason for the presence of non-motile sperm is probably that residual sperm in the seminal vesicles or ampullae of the vasa are slowly released from the reproductive tract.
Nevertheless, some men have continued to have sperm or sperm parts in the semen which have been found for as long as 31 years post-vasectomy. With regard to age, several studies have suggested that sperm clearance may take longer in older men compared to younger men. The opinion of the Panel is that rates of azoospermia related to number of post-vasectomy ejaculations are too variable to be useful in determining when to do the first PVSA. Variability across published reports in sperm clearance rates may result from surgical technique used to occlude the vas; differences in criteria for vasectomy success e.
In addition, in many studies, although patients were instructed to report at specific intervals post-vasectomy, some report at later intervals. If the physician sends PVSA specimens to a commercial laboratory, the physician should request that the laboratory perform the PVSA without centrifugation because centrifugation may reduce or eliminate sperm motility see below.
The physician should also request the laboratory to report both the presence or absence of sperm and the presence or absence of sperm motility. If only non-motile sperm are present, the physician should request the laboratory to report the number of non-motile sperm per mL.
Clearance of motile sperm. Older studies suggest all motile sperm disappear within three weeks after vasectomy. However, it should be noted that many patients in these studies did not return for PVSAs or did not return for a second PVSA when requested, making the true rates of sperm reappearance both motile and non-motile unclear.
Laboratory techniques, especially centrifugation, influence the presence or absence of azoospermia observed in a PVSA. The 5th edition WHO laboratory manual for the examination and processing of human semen suggests relying on careful examination of an uncentrifuged specimen, similar to a recently PVSA protocol proposed by Korthorst Because centrifugation may interfere with sperm motility and clinically relevant numbers of sperm can be identified without centrifugation, a surgeon should request a clinical laboratory not to perform centrifugation for a PVSA.
Office examination of uncentrifuged post vasectomy semen samples. These regulations allow for semen analysis in a doctor's office, i. There is now interest in developing a method of estimating the number of sperm per mL of semen from the number of sperm per Hpf found in a PVSA.
In addition, it has been suggested that a home PVSA test might increase patient compliance with PVSA instructions, but improved patient compliance has not yet been studied or proven. To avoid potential legal problems, careful instruction is essential to ensure that the patient will use the test in a valid manner. The disclosures must include how to set up the test, how to read the final result and the relative risks of pregnancy.
Given this requirement and the lack of long-term follow-up data on patients who have used the test, the opinion of the Panel at this time is that, although this test may have potential value that may be proven in the future, there are insufficient data for the panel to come to a conclusion regarding its use in clinical practice. During the first few weeks after vasectomy, sperm that are left in the male reproductive system on the abdominal side of the vasectomy site may retain the ability to fertilize an ovum.
To evaluate sperm motility, a fresh uncentrifuged semen sample should be examined within two hours after ejaculation. WHO guidelines recommend that semen analysis to assess motility should be done within 60 minutes of ejaculation when the semen sample is provided in the laboratory facility. Semen samples should be transported at ambient temperatures, i.
Some clinicians recommend for convenience and compliance reasons, that PVSA specimens can be sent by mail following regulations regarding shipping biohazards. This approach is adequate to assess only the presence or absence of sperm. Both azoospermia and RNMS are acceptable criteria for vasectomy success. Absence of sperm motility appears to be a robust criterion to indicate occlusive effectiveness. One group reported routine testing of men at three to four weeks after vasectomy using MC and FI and provided clearance based on the absence of motile sperm.
One man had an apparent late recanalization; the other had not returned for a PVSA. This pregnancy rate is not significantly different from the risk of about 1 in 2, after documented azoospermia on two consecutive semen analyses, based on data from the Elliot Smith Clinic, from Marie Stopes International, 29 and from large case series reports. In a WHO study of a hormonal male contraceptive, 8. Philp et al. About 4, vasectomies were performed with ligation and excision between and , and about 12, vasectomies were performed with MC but not FI after However, the method of semen analysis at the Elliot Smith Clinic has not been reported, except for the information that patients provided semen samples by mail, which precludes an examination for motility.
Nonetheless, subsequent reports from this clinic have confirmed a lack of pregnancies among men with only rare sperm. Korthorst et al. It is desirable to select a time for the first PVSA that will minimize the number of PVSAs needed to establish that azoospermia or RNMS has been achieved but still allow men to abandon other forms of contraception as soon as possible after vasectomy.
Motile sperm disappear within a few weeks after successful vasectomy. While rates of sperm clearance vary across studies, including studies that used the same vas occlusion technique, the available literature indicates that, in general, the proportion of men who achieve azoospermia or RNMS after vasectomy increases with time. Eleven study arms from nine studies reported rates of azoospermia at eight weeks post-vasectomy.
Sixteen study arms reported azoospermia rates at 12 weeks post-vasectomy. The lowest rate of Thirteen study arms reported azoospermia rates at six months post-vasectomy. The low rate of Given the potential confounders to interpretation discussed in the Vas Occlusion section of this Guideline, it is not clear if vas occlusion technique affects the rate of achieving azoospermia.
It is worth noting, however, that the methodologically strongest study in this group the Sokal RCT reported relatively low rates of Similarly, of the eight study arms reporting azoospermia rates of Additional useful information regarding the potential influence of vas occlusion technique is provided by Labrecque et al. This study provides additional information that may be considered by the surgeon in the decision regarding when to request the first PVSA.
When the vas is successfully occluded, motile sperm disappear by a few weeks after vasectomy. However, vasectomy should not be repeated immediately if motile sperm are found on PVSA prior to six months after vasectomy.
Additional PVSAs should be performed at intervals of four to six weeks for up to six months after vasectomy for further evaluation. Motile sperm may represent a risk of pregnancy and indicate the need for continued use of another contraceptive method, further PVSA testing and, if persistent, repeat vasectomy. There are no data to suggest that delayed occlusive success occurs in men who still have any motile sperm in a PVSA at six months after vasectomy.
If azoospermia is not achieved by six months after vasectomy, then a PVSA should be performed in a laboratory approved for high complexity semen testing. After completion of a vasectomy, physicians should consider giving men a specific appointment for the first PVSA to improve compliance with follow-up. The number of tests requested one or two and the time at which samples were requested one to two months vs. When the second test was requested at three to four months post vasectomy, rates of full compliance were decreased somewhat compared to protocols where two tests were ordered within two months.
One randomized controlled trial including men evaluated the effectiveness of scheduling an appointment for the first PVSA versus simply asking men to return at two months post-vasectomy. A postoperative visit with the surgeon specifically for physical examination of the scrotum is not routinely necessary. At this time, patients should be informed that there is always a remote risk of pregnancy even if azoospermia has been achieved.
Each patient should know that if his partner becomes pregnant, he may have experienced a rare vasectomy failure and should return to his surgeon for a semen analysis.
Even if a PVSA at such a time reveals azoospermia, a transient recanalization may have occurred with the subsequent disappearance of sperm from the semen, as shown by DNA studies on parents and the child in such situations. A number of case reports have confirmed paternity based on genetic testing even though the men previously had multiple semen analyses showing azoospermia, i.
One benefit of a systematic review is to illuminate deficits in the scientific knowledge base, the amelioration of which would move the field forward and allow for advances in clinical care. The Panel identified the following areas for future research efforts.
Panel members were selected by the chair and co-chair. Membership of the panel included urologists, family medicine physicians, and other clinicians with specific expertise on vasectomy techniques.
The mission of the committee was to develop recommendations that are evidence-based or consensus-based, depending on Panel processes and available data, for optimal clinical practices in the surgical technique of vasectomy. Funding of the committee was provided by the AUA; committee members received no remuneration for their work.
Each member of the committee provides an ongoing conflict of interest disclosure to the AUA. While these guidelines do not necessarily establish the standard of care, AUA seeks to recommend and to encourage compliance by practitioners with current best practices related to the condition being treated.
As medical knowledge expands and technology advances, the guidelines will change. Today, these evidence based guideline statements represent not absolute mandates but provisional proposals for treatment under the specific conditions described in each document. For all these reasons, the guidelines do not pre-empt physician judgment in individual cases.
Treating physicians must take into account variations in resources, and patient tolerances, needs, and preferences. Conformance with any clinical guideline does not guarantee a successful outcome. These guidelines are not intended to provide legal advice about vasectomy. Although guidelines are intended to encourage best practices and potentially encompass available technologies with sufficient data as of close of the literature review, they are necessarily time-limited. Guidelines cannot include evaluation of all data on emerging technologies or management, including those that are FDA-approved, which may immediately come to represent accepted clinical practices.
Note to the Reader: Please note that this Guideline was edited in to include additional information related to vasectomy and the risk of prostate cancer.
Purpose The purpose of this Guideline is to provide guidance to clinicians who offer vasectomy services. Guideline Statements 1. Expert Opinion 2. The minimum and necessary concepts that should be discussed in a preoperative vasectomy consultation include the following: Expert Opinion Vasectomy is intended to be a permanent form of contraception.
Following vasectomy, another form of contraception is required until vas occlusion is confirmed by post- vasectomy semen analysis PVSA. The risk of pregnancy after vasectomy is approximately 1 in 2, for men who have post-vasectomy azoospermia or PVSA showing rare non-motile sperm RNMS. Options for fertility after vasectomy include vasectomy reversal and sperm retrieval with in vitro fertilization.
These options are not always successful, and they may be expensive. These rates vary with the surgeon's experience and the criteria used to diagnose these conditions. Few of these men require additional surgery.
Other permanent and non-permanent alternatives to vasectomy are available. Standard Evidence Strength Grade B 4. Recommendation Evidence Strength Grade C 5. Expert Opinion 6.
Standard Evidence Strength Grade B 7. The ends of the vas should be occluded by one of three divisional methods: Mucosal cautery MC with fascial interposition FI and without ligatures or clips applied on the vas; MC without FI and without ligatures or clips applied on the vas; Open ended vasectomy leaving the testicular end of the vas unoccluded, using MC on the abdominal end and FI; OR by the non-divisional method of extended electrocautery.
Recommendation Evidence Strength Grade C 8. Expert Opinion Clinical Principle Recommendation Evidence Strength Grade C Option Evidence Strength Grade C Methodology Process for Literature Selection.
Additional Points for Preoperative Practice The minimum age requirement for vasectomy is the legal age of consent in the prevailing legal jurisdiction in which the procedure is performed. Minimal dissection of the vas and perivasal tissues, which is facilitated by using a vas ring clamp and vas dissector or similar special instruments The three finger technique described in Appendix A for immobilizing the vas or for making the skin opening has been modified slightly by various surgeons using MIV techniques other than the strict NSV technique.
Other Important Points of Surgical Technique. Background Information about Vas Occlusion In the US, virtually all techniques of vasectomy use complete division of the vas with or without excision of a segment of the vas.
Vasectomy effectiveness : Contraceptive or occlusive effectiveness. Methodologically strong studies of occlusion technique effectiveness that would result in a high level of certainty regarding findings are characterized by the following: Randomized controlled trial procedures Enrollment of consecutive patients Clearly described technique of vas occlusion Standardized PVSA protocol Clearly described criteria for PVSA failure PVSA data on all patients for a minimum of six months post-vasectomy Follow-up regarding pregnancy for a minimum of one year after vasectomy Studies with sufficient sample size to allow precise estimation of effects None of the studies reviewed by the Panel met all of these criteria, and only three studies met a majority of these criteria.
Mucosal cautery without fascial interposition. Open ended method leaving the testicular end unoccluded with mucosal cautery of the abdominal end and FI. Non-divisional vasectomy with extended electrocautery Marie Stopes technique. Occlusion of both vasal ends with ligatures without FI. Occlusion of both vasal ends with ligatures and FI. Occlusion of both vasal ends with clips without FI. The PVSA should allow for confirmation of occlusive effectiveness as soon as possible after vasectomy while simultaneously minimizing the number of PVSAs required to document occlusive effectiveness.
The PVSA protocol should confirm occlusive effectiveness with the highest possible level of certainty. Patients should be informed that post-vasectomy pregnancies are rare but have been documented even after multiple serial PVSAs reveal azoospermia. Additional Important Points of Postoperative Practice. One recent study addressed the value of a patient decision aid before and after the procedure and concluded that it was helpful in both a comprehensive and an abridged version.
This information is central to understand the extent to which the relative under-utilization of vasectomy in the US is a function of lack of understanding of the procedure.
Do men and partners of men considering vasectomy believe that vasectomy is a family or an individual decision? Anesthesia Pain levels measured with visual analog scales associated with the use of smaller gauge vs. Whether or not topical anesthetic cream application before injection of local anesthetic reduces the amount of pain measured by a visual analog score. If the pain of local anesthetic injection is reduced, the extent to which topical anesthetic cream before local anesthetic injection reduces the pain of injection as well as the pain of the vasectomy.
Pain level during local anesthesia administration as opposed to during the vasectomy procedure itself. Whether or not application of a topical cutaneous spray such as ethyl chloride, cocaine or other products prior to injection of local anesthetic reduces the pain of injection.
Intraoperative and post-operative pain levels and surgical complications e. The incidence of failed vasectomy with use of a single midline incision compared to bilateral incisions. Information regarding how the technical skills required to perform NSV are learned and translated into practice and to what extent practitioners reporting that they perform NSV are adhering to each of the requirements of the technique.
The incidence of early post-vasectomy scrotal hematoma and abscess formation according to the method of vas isolation. Vas Occlusion Methodologically robust e. Evaluation of the effectiveness of thermal cautery vs. RCTs to evaluate the occlusive effectiveness and complication rates associated with cautery and FI vs. Reliable techniques for applying cautery to the vasal mucosa and avoid damage to the vasal muscularis.
Information regarding the potential value and possible complications from the addition of folding back to any technique. The development of percutaneous occlusion techniques. Study of why some men have RNMS for substantial intervals post-vasectomy e.
Information about the prevalence of paternity at various post-vasectomy time intervals as long as 5 to 10 years. Whether the PVSA thresholds of commercially available home test kits are sufficient to ensure contraceptive effectiveness. Patient preferences for the timing of PVSA with regard to achieving earlier clearance vs. Investigations of post-vasectomy testicular changes i. Complications Methodologically rigorous studies to provide accurate rates of early post-vasectomy hematoma, wound infection and scrotal abscess formation.
Studies that distinguish between post-vasectomy pain due to epididymal congestion or epididymal sperm granuloma resulting from rupture of the epididymal tubule caused by back pressure below the level of the vasectomy vs. Studies of various imaging modalities that allow the accurate diagnosis of the cause of post-vasectomy epididymal pain. Incidence of chronic post-vasectomy pain according to standardized scales starting at three to six months and continuing until up to three to five years post-vasectomy.
British Journal of Urology- International ; The Journal of urology ; J Urol ; Vasectomy is a type of surgery that prevents a man from being able to get a woman pregnant. It is a permanent form of birth control. A vasectomy works by cutting the tubes that carry the sperm out of the testicles.
Having a vasectomy does not affect your sex life. It takes about three months before it is effective. Your doctor will test your semen to make sure that there are no sperm in it. Vasectomies can sometimes be reversed, but not always. Men who have had a vasectomy should still practice safe sex to avoid STDs. The GEMs are the raw material from which providers, health information vendors and payers can derive specific applied mappings to meet their needs.
Previous Code: Z Related Codes. Next Code: Z ICD Z Y Diagnosis was present at time of inpatient admission. YES N Diagnosis was not present at time of inpatient admission. NO U Documentation insufficient to determine if the condition was present at the time of inpatient admission. NO W Clinically undetermined - unable to clinically determine whether the condition was present at the time of inpatient admission. Information for Patients Tubal Ligation Tubal ligation getting your "tubes tied" is a type of surgery.
This chapter provides a brief history of vasectomy, as well as recommendations for preoperative counseling, an overview of the modified no-scalpel vasectomy technique, and a brief description of the complications of vasectomy. Sir Ashley Cooper first described vasectomy in as a sterilization procedure first performed on canines in the United Kingdom 5.
However, vasectomies did not enter clinical use until the late 19 th century, at which time vasectomies were felt to induce prostatic atrophy, and were widely performed as an alternative to castration to reduce symptoms of prostatic hypertrophy and improve micturition 6. This eventually fell out of favor by the early 20 th century as evidence accumulated that vasectomy had no such benefit for patients with symptoms of enlarged prostates.
Around this same time, many promoted vasectomy for eugenic sterilization 7. This remained a popular means of eugenic sterilization during the first half of the 20 th century.
As the popularity for eugenics declined mid-century, the practice of involuntary sterilization gradually declined, and has been prohibited since the s.
Voluntary sterilization by vasectomy surprisingly took much longer to gain widespread popularity. Between and , only 40, vasectomies were performed annually in the United States As opinion on self-sterilization improved, vasectomy became increasingly popular, and by , the number of vasectomies performed annually in the US increased to , However, even today vasectomy is underutilized.
In the United States, nearly 3 times as many couples choose to have tubal ligation compared to vasectomy 12 as their form of contraception, despite the increased risk and higher cost associated with female sterilization. Preoperative consultation is important with any surgical procedure to ensure patients are fully prepared for the potential risks, benefits and alternatives prior to committing to a procedure. For this reason, AUA guidelines recommend preoperative consultation should always be performed, and preferably performed in person The time from vasectomy to azoospermia or rare non-motile sperm RNMS can vary from weeks to months, depending on frequency of ejaculation, patient age and anatomical variation Post-vasectomy semen analyses are necessary to demonstrate success of the procedure.
Patients who fail to achieve azoospermia or RNMS may require repeat vasectomy. However, in a subset of patients with either elevated anxiety or anatomy making mobilization of vas difficult or painful, moderate sedation can be utilized. In our practice, when moderate sedation is required we only perform vasectomies with anesthesiology monitoring. Therefore, preoperative consultation should involve an examination of the scrotal contents, including mobilization of vas, to identify whether a patient may require sedation during vasectomy.
Once pre-operative consultation has been completed and patient arrives for vasectomy, low dose anxiolytic can be provided to patient if requested by patient , after which he is placed in a supine position and skin prepped using sterile technique, and draped.
Several methods of mobilizing and isolating the vas have been described, including the no scalpel technique as first developed by Li et al.
The original no-scalpel technique involves applying a vas ring clamp directly around the vas, peri-vasal tissue and overlying skin after local anesthesia is administered. A conventional vasectomy utilizing scalpel incisions has fallen out of favor with many urologists, as comparative studies have shown the no-scalpel approach to result in less bleeding, hematoma, infection and pain compared to the conventional incision technique As utilized in our practice, we will review the steps of the modified no-scalpel technique, which has also been referred to as the minimally-invasive vasectomy.
With patient in comfortable supine position, the vas is grasped between index finger and thumb. The skin and vas are then mobilized to the lateral or anterior position of the scrotum, or for those who wish to utilize just one puncture site, near the penoscrotal junction, ensuring the straight segment of the vas is isolated. Local anesthetic is injected into subcutaneous and peri-vasal tissues using either traditional intradermal needle 27 or 30 G or no-needle jet injector.
The vas dissector is then used to pierce the anesthetized skin. Utilizing the vas ring clamp, the vas is grasped and delivered through the wound. The vas dissector is then one again used to pierce directly into the lumen of the vas, and the overlying peri-vasal fascia is spread to expose the anterior wall of the vas. The ring clamp is then adjusted to encompass only vas, and the peri-vasal fascia and vascular bundle swept away from posterior wall with a raytec sponge.
In the US, virtually all techniques of vasectomy use complete division of the vas with or without excision of the vas 3. However, once divided, there are multiple additional measures that can be taken to ensure permanent occlusion of the vas.
Based on this body of literature, the AUA Guidelines recommend the ends of the vas be occluded by one of three methods; mucosal cautery with fascial interposition, mucosal cautery alone, or open ended vasectomy with fascial interposition leaving the testicular end of vas un-occluded while using cautery on the abdominal end Other techniques not described previously have been found to have wide range of vasectomy failure rates, some as high as Based on these findings and recommendations, we have adopted excision, mucosal cautery and fascial interposition into our practice.
Fascial interposition is then performed by grasping peri-vasal fascia and placing a small hemoclip over the tissue, thus burying the abdominal end of vas, and effectively separating the two ligated ends. The vasectomy puncture site is then closed by grasping dartos underneath skin, and cauterizing with Bovie, effectively welding shut the puncture deep to the skin.
Skin is left to close secondarily. The identical procedure is performed on the contralateral side through a new puncture site, although some providers prefer one midline opening. A clear watertight dressing or bandages can be applied prior to placement of scrotal support. Postoperative care is similar to other scrotal surgery, and include limiting physical activity and utilizing non-steroidal anti-inflammatory drugs, as well as mild narcotics if necessary for pain management.
Every patient is provided an athletic supporter at time of his vasectomy. We have found that the incidence of prolonged testicular discomfort is greatly reduced by having the patient wear this for 1—2 weeks. Additionally, men are encouraged to use ice on scrotum intermittently for 24—48 hours, and minimize physical activity for 1 week. We do not require patients to return for postoperative wound evaluation, unless patient is experiencing unexpected pain or other concerns.
A PVSA is obtained at 8—12 weeks after the vasectomy to confirm technical success. However, a small portion will continue to have non-motile sperm in the ejaculate post vasectomy. These studies, having followed the men prospectively for several years, have reported zero pregnancies despite persistence of non-motile sperm in the ejaculate 18 , The presence of motile sperm at the time of the first PVSA, however, may not represent early recanalization and not all of these men require repeat vasectomy.
Several studies evaluating men with motile sperm on PVSA have reported the complete disappearance of spermatozoa over subsequent semen analyses 23 , According to one series following men with motile sperm on first post vasectomy semen analysis, However, if motile sperm are identified on semen analysis 6 months after vasectomy, these men should be offered repeat vasectomy for persistent recanalization.
As described previously, the minimally invasive or no-scalpel techniques are associated with decreased risk for both hematoma and infections 3. Fortunately, the majority of patients with acute pain and swelling after vasectomy can be managed conservatively and pain typically resolves without further intervention. Chronic pain has no association with immediate postoperative complications such as infection, or hematoma Chronic scrotal pain, also known as post vasectomy pain syndrome, can persist for months to years, and is defined as constant or intermittent testicular pain for 3 months or longer with a severity that interferes with daily activities prompting the patient to seek medical attention The pathophysiology leading to post vasectomy pain is unclear, and felt to be potentially related to inflammation resulting in damage and fibrosis of spermatic cord nerves The majority of men with post vasectomy scrotal pain can be managed conservatively However, men with pain refractory to conservative measures may potentially benefit from surgical intervention.
When pain is localized to the site of a sperm granuloma, excision of the granuloma can relieve pain and prevent recurrence In patients with chronic pain not clearly confined to epididymis or granuloma, microsurgical spermatic cord denervation can be considered.
Men who experience continued pain despite surgical measures may be best managed with referral to pain clinic for additional pain management instruction.
Lastly, in men with chronic pain who fail to respond to surgical and medical intervention, inguinal orchiectomy may be required. Therefore, we have found it useful to have patients wear scrotal support or compression shorts for 1—2 weeks following the procedure in order to minimize pulling of the spermatic cord. This appears to have lessened the number of calls and postoperative visits. We have also stressed the need for no heavy lifting for the first 5—7 days in order to reduce the likelihood of scrotal hematoma.
A preoperative consultation should be conducted prior to vasectomy, and examination performed at that time to identify patients who may require sedation or have other abnormalities that need to be addressed;. Isolation of the vas should be performed using a minimally invasive vasectomy technique;. The ends of the divided vas should be occluded by one of three methods: mucosal cautery with fascial interposition, mucosal cautery without interposition, or fascial interposition with mucosal cautery on only the abdominal end of the vas;.
Men or their partners should use other contraceptive methods until vasectomy success is confirmed on post vasectomy semen analysis;. These patients with this finding can stop using other methods of contraception;. Vasectomy should be considered a failure if any motile sperm are seen on their 6-month PVSA. Conflicts of Interest : The authors have no conflicts of interest to declare. National Center for Biotechnology Information , U.
Journal List Transl Androl Urol v. Transl Androl Urol. Dane Johnson and Jay I. Author information Article notes Copyright and License information Disclaimer. Corresponding author.
Correspondence to: Jay I. Email: ude. Received Apr 15; Accepted Jun Copyright Translational Andrology and Urology. All rights reserved. This article has been cited by other articles in PMC. Historical perspective Sir Ashley Cooper first described vasectomy in as a sterilization procedure first performed on canines in the United Kingdom 5.
Preoperative counseling Preoperative consultation is important with any surgical procedure to ensure patients are fully prepared for the potential risks, benefits and alternatives prior to committing to a procedure. Vas isolation Once pre-operative consultation has been completed and patient arrives for vasectomy, low dose anxiolytic can be provided to patient if requested by patient , after which he is placed in a supine position and skin prepped using sterile technique, and draped.
Vas occlusion In the US, virtually all techniques of vasectomy use complete division of the vas with or without excision of the vas 3. Completion of procedure and postoperative care The vasectomy puncture site is then closed by grasping dartos underneath skin, and cauterizing with Bovie, effectively welding shut the puncture deep to the skin. Post vasectomy follow up A PVSA is obtained at 8—12 weeks after the vasectomy to confirm technical success. These patients with this finding can stop using other methods of contraception; Vasectomy should be considered a failure if any motile sperm are seen on their 6-month PVSA.
Acknowledgements None. Footnotes Conflicts of Interest : The authors have no conflicts of interest to declare. References 1. Estimating the number of vasectomies performed annually in the United States: data from the National Survey of Family Growth. J Urol ;