Vasectomy

Prevalence: 75% vasectomies are done by urologists, 90% urology practices do vasectomies
Contraceptives: people choose condoms (29.5%), OCPs (25.6%), tubal ligation (8.1%), vasectomy (5.7%)
Cost analysis: vasectomy costs 1/4 tubal ligation

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
Vasectomy anxiety: fear of pain (27%), fear of unknown (23%), finality of procedure (5%)
30% believe it is reversible

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

Intended as permanent contraception, other non-permanent (reversible) methods available
Sterility is not immediate - contraception required until sterility proven
Other contraceptive methods available
Does not affect urination, erections, libido, ejaculation volume
Vasectomy does not affect risk of prostate cancer, CHD, stroke, HTN, dementia, testicular cancer
Antibiotic prophylaxis not required unless high risk for infection
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

Failure: 1/2000 risk of pregnancy
Repeat vasectomy: required in < 1%
Vasectomy reversal: not always successful (~50%), can be expensive, can also consider IVF
Decisional regret: 1-2%, 4-7% if no children prior to vasectomy
Other risks: sperm granuloma (< 5%), superficial bleeding/infection (1-2%), epididymitis < 1%, chronic scrotal pain (1-2%), Fournier’s gangrene (rare), death (one reported case)

Check to make sure vas are palpable
Prep/drape patient
Isolate vas w/ middle finger behind w/ non-dominant hand
Inject local in skin and vas (create a superificial wheal with majority of local, rest inject superiorly up the cord)
Use dissector clamp to pop through skin (local wheal helps this), gently spread on either side of vas
Push ring clamp down onto vas, open and clamp w/ force to prevent vas “escape”
Use dissector to isolate vas from surrounding layers until able to push dissector clamp underneath vas
Use forceps to gently pull surrounding layers off vas until only vas is left (should be able to spread clamp open and create large window if no further layers remain)
Once vas isolated, partially clamp proximal and distal (don't clamp entire vas)
Excise portion of vas (do not need to send to pathology)
Insert cautery into vasal lumen and give quick cautery to close lumen
Drop body end of vas, put gentle tension on testicular end, and place fascial interposition 3-0 chromic stitch over body end to separate the ends
Assess for hemostasis, then return vas to scrotum
3-0 chromic horizontal mattress suture
Apply bacitracin, scrotal support

Skin incision made with 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

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

Do not ejaculate for one week, then ejaculate 20-30 times over following 3 months
Wear supportive underwear - decreases tension on spermatic cord
Ice is optional
Okay to shower day after surgery - avoid soaking incisions until completely closed
Okay to start non-physical work day after surgery
Watch for pain, bleeding, swelling, redness, fever
Hematospermia is normal in first 1-2 months, will self-resolve
Post vas sperm analysis after 3 months to confirm success

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
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

Sharlip, Ira D., et al. "Vasectomy: AUA guideline." The Journal of urology 188.6S (2012): 2482-2491.

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