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Vasectomy

Epidemiology

• 75% vasectomies are done by urologists
• 90% urology practices do vasectomies
• Contraceptives - condoms (29.5%), OCPs (25.6%), tubal ligation (8.1%), vasectomy (5.7%)
• Vasectomy costs ¼ tubal ligation

Who chooses vasectomy?

• More common if more kids, higher education, Caucasian, older age, longer marriage
• Less common (tubal ligation) if IUD or coitus interruptus
• If wife’s friends satisfied w/ vasectomy or tubal, more likely to choose that option
• Anxiety about vasectomy - pain (27%), fear of unknown (23%), finality of procedure (5%)
• 30% believe it is reversible

Evaluation

• Discuss vasectomy in-person if possible
• Assess bleeding risk
• Perform genital exam - assess for genital pathologies, increased scrotal sensitivity, level of anxiety/discomfort, poorly palpable vas

Counseling

• Intended as permanent contraception, other non-permanent (reversible) methods available
• Sterility is not immediate - contraception required until sterility proven
• Other contraceptive methods available
• Vasectomy does not affect prostate cancer, CHD, stroke, HTN, dementia, testicular cancer
• Antibiotic prophylaxis not required unless high risk for infectio
• Patient must be old enough to provide consent
• Spouse/partner involvement is recommended but not required
• No labs required, consider coags if patient has prior high risk of bleeding

Risks/complications

• Not 100% successful - 1/2000 risk of pregnancy
• Repeat vasectomy required in < 1%
• Fertility after vasectomy requires vasectomy reversal or sperm retrieval (IVF, ICSI) - not always successful (~50%), can be expensive
• Bleeding/infection risk 1-2%
• Rare Fournier’s gangrene, one case of death
• Epididymitis < 1%
• Chronic scrotal pain 1-2%
• Sperm granuloma < 5%
• Dissatisfaction 1-2%

Anesthesia

• Use local anesthesia w/ or w/o oral sedation
• Can consider topical anesthesia cream prior to local anesthesia injection
• Use small (25-32 gauge) needle
• Consider pneumatic anesthesia injector

Procedure Steps

1. Check to make sure vas are palpable
2. Prep/drape patient
3. Isolate vas w/ middle finger behind w/ non-dominant hand
4. Inject local in skin and vas
5. Make scalpel incision over vas, can be transverse or longitudinal
6. Dissect layers down onto vas
7. Push ring clamp down onto vas, open and clamp w/ force to prevent vas “escape”
8. Once vas obtained, can inject local proximal/distal
9. Use dissector to isolate vas from surrounding layers, can also cut off with scalpel
10. Once vas isolated, clamp proximal and distal
11. Excise portion of vas, send to pathology
12. Perform mucosal cautery
13. Ligature each end w/ 2-0 silk tie, can stitch through vas
14. Keep tails long
15. Assess for hemostasis, then return vas to scrotum
16. 3-0 chromic horizontal mattress suture
17. Apply bacitracin, scrotal support

Vas isolation tips

• Skin incision made w/ scalpel or vas dissector (sharp instrument)
• If full steps of Li no-scalpel vasectomy are not followed, then it is MIS vasectomy
• Can grasp vas w/ clamp before or after skin incision
• No difference in 1 vs 2 skin incisions
• Perform incision at higher portion of vas (straight portion as opposed to convoluted)
• Tug on vas to confirm movement in ipsilateral testicle - prevents performing vasectomy x2 on only one side
• Place middle finger behind, thumb and index on top

Vas occlusion tips

• Perform one of three - mucosal cautery w/ fascial interposition but w/o clips or ligatures, mucosal cautery w/o fascial interposition clips or ligatures, or open ended testicular end w/ mucosal cautery and fascial interposition of abdominal end
• Occlusive failure rates < 1%
• Complete occlusion w/ or w/o excision of a segment
• Fascial interposition - placing internal spermatic fascia between two divided ends
• Ligation - ligature at occluded ends
• Clips - can clip one or both ends, one or multiple clips
• Folding back - suturing end to itself to prevent ends from opposing
• Mucosal cautery - cauterizing mucosa to create scar tissue, do not cauterize full wall otherwise entire segment will slough and vas may be patent
• Marie Stopes technique - cautery of full anterior wall and partial posterior wall for 2.5-3cm w/o vas division, performed in UK
• Pathologic confirmation not required

Normal expectations

• Discharge w/ cephalexin 500mg BID x3 days, short course pain meds + stool softeners
• Post vas sperm analysis after 3mo
• Do not ejaculate for one week
• Hematospermia is normal in first 1-2 months, will self-resolve
• Wear supportive underwear - decreases tension on spermatic cord
• Ice is optional
• Okay to shower day after surgery - avoid bath for 3-5 days
• Okay to start non-physical work day after surgery
• Watch for pain, bleeding, swelling, redness, fever

Post-Vasectomy Semen Analysis (PVSA)

• Contraceptive effectiveness - absence of pregnancy
• Occlusive effectiveness - post-vas azoospermia or rare non-motile sperm (< 100K nonmotile sperm/mL)
• Failure - recanalization, technical failure (vas not occluded)
• Suspect recanalization if sperm recurs after azoospermia
• Ejaculate at least 20 times prior to PVSA
• Sperm usually absent by 5-6 weeks (< 1% have motile sperm present)
• Use contraception until PVSA
• Check fresh uncentrifuged sample w/in 2hrs after ejaculation, store at room temp
• Okay to stop contraception if PVSA shows azoospermia or RNMS
• Perform PVSA between 8-16 weeks after vasectomy, specific date is up to surgeon
• Vasectomy failed if motile sperm seen on PVSA 6mo after vasectomy
• Repeat PVSA every 4-6 weeks after initial if motile sperm still present
• If >100K non-motile sperm present at 6mo, discuss further PVSA or repeat vasectomy