II. Epidemiology
- 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
- Has decreased after 2000 in U.S.
- Only 4% of men age >18 years old have had a Vasectomy in the U.S. (underutilized)
III. Approach: Counseling
- Vasectomy Preoperative Counseling (includes benefits and risks)
- Vasectomy Postoperative Counseling
IV. Types
- Traditional Vasectomy with scrotal incision
- No-Scalpel Vasectomy (preferred)
- Described on this page (see below)
- Preferred technique due to less bleeding, pain, intraoperative time, and risk of post-operative infection
- Cook (2007) Cochrane Database Syst Rev (2): CD004112 [PubMed]
- Marie Stopes International Technique
- Approved as a valid technique by AUA, but variable efficacy depending on technique and operator
- Consider in under-resourced areas
- Technique is significantly faster (may lower cost, increase availability)
- Post-Vasectomy semenanalysis confirmation is critical (as with other techniques)
- Vas Deferens is isolated as typically performed in No-Scalpel Vasectomy
- However, unlike other techniques, only cautery of vas deferens is performed
- Both the distal and proximal vas deferens are both cauterized
- No ligation, segment excision or fascial interposition is performed
- Efficacy
- Associated with a 0.64% failure rate
- Irrigating the distal (prostatic) vas deferens before cautery, assists with earlier sperm clearance
- References
- Approved as a valid technique by AUA, but variable efficacy depending on technique and operator
V. Technique: Step 1 - Procedure Preparation
- See Vasectomy Counseling
- Consider Sedation
- Valium 5 to 10 mg taken 30 minutes before procedure
- Establish relaxing environment
- Warm room relaxes Scrotum
- Soft music
- Position patient supine or dorsolithotomy
- Retract penis
- Prep skin with warmed Betadine solution
- Apply surgical drape
VI. Technique: Step 2 - Vas Deferens (spermatic cord) Positioning
- Non-dominant hand locates vas deferens
- Vas is caliber of a pen's inner ink plastic holder
- Three finger technique traps vas deferens
- Middle finger placed behind vas deferens
- Thumb and index finger placed over vas (2 cm apart)
- Maneuver vas deferens to midline (under median raphe)
- Use Index finger to maneuver vas deferens
- Position vas one third down from top of Scrotum
VII. Technique: Step 3 - Injection of Local Anesthesia (Perivasal block)
- Preparation: Standard needle injection
- Anesthetic: Lidocaine 2% without Epinephrine
- Syringe: 10 ml
- Needle
- Standard: 27 gauge, 1.5 inch needle
- Mini-Needle: 30 gauge, 1 inch needle (2 cc injected per vas deferens)
- Similar efficacy to standard needle, with less pain)
- Technique: Standard needle injection
- Bending needle at base 15 degrees may help injection
- Inject midline skin overlying isolated vas
- Raise 1-2 cm wheal of Lidocaine
- Aspirate to confirm non-intravascular position
- Inject 2-3 ml into vas and along course proximally
- Technique: Alternative - High pressure jet injector
- High pressure device delivers Local Anesthetic into vas deferens
- Less initial pain from injection and similar intraoperative Anesthesia as compared with standard injection
- Risk of self-injection of surgeon's finger grasping vas deferens
- White (2007) Urology 70(6): 1187-9 [PubMed]
VIII. Technique: Step 4 - Skin penetration for No-Scalpel Vasectomy
- 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
- Tine pierces scrotal skin at 45 degree angle into vas
- Insert forceps tine 3-4 mm into vas deferens
- Withdraw forceps tine
- Insert closed forceps into hole made by single tine
- Insert tines to 3-4 mm depth
- 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
IX. Technique: Step 5 - Vas Deferens Isolation
- Peal perivasal sheath away from vas (pealing onion)
- Use dissecting forceps to remove perivasal sheeth
- Insert forcep tines into perivasal sheeth
- Spread tines to clear sheath away from vas
- Remove and reattach ring clamps inside sheath
- Clear >1 cm vas of perivasal sheath
- Apply ring clamp at each end of cleared segment
X. Technique: Step 6 - Vas Deferens Occlusion
- Hemitransect distal (prostatic) vas deferens
- Insert cautery tip 4 mm into prostatic vas lumen
- Apply current while withdrawing slowly
- Ligation of distal (prostatic) vas segment is NOT recommended by AUA
- Higher recanalization rates when ligation is performed
- High Vasectomy efficacy without ligation assumes other measures
- Fascial layer closure, removal of a 1-2 cm segment, distal vas cautery
- Prior Ligation methods
- Silk 3-0 (1 or 2 separate ties)
- Surgical clip (without vas deferens transection or fascial interposition)
- Similar efficacy/failure to standard Vasectomy with ligation, transection and fascial interposition
- 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)
- Absorbable Suture (e.g. Vicryl) purse-string or clip
- Fascial interposition dramatically lowers Vasectomy failure rate
- Transect proximal (testicular) vas deferens end
- Remove a vas deferens 1-2 cm long
- Store vas deferens segment in formalin (if required by institutional requirements)
- Routine histology of excised segment is not recommended by AUA
- Consider avoiding cautery of proximal (testicular) free end of vas deferens
- May reduce post-operative pain (lower vasal pressure)
- Risk of sperm Granuloma if not ligated
- Observe for signs bleeding (esp. pampiniform plexus)
XI. Technique: Step 7 - Procedure Completion
- 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)
- Not required in No-Scalpel Vasectomy (and Suture may cause local irritation)
- Post-operative Antibiotics
- Not required in most patients
- Consider in higher risk patients (e.g. Immunocompromised, chronic Corticosteroids, advanced age, smoking)
XII. Education: Follow-up and Precautions
XIII. Resources
- Choosing Vasectomy Movie (Requires Flash)
- Vasectomy Medical (Commerical Site)