Vasectomy

Aka: Vasectomy, No-Scalpel Vasectomy

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II. Epidemiology

  1. Vasectomy Incidence in U.S.: 500,000 per year
  2. Family Physicians perform 15% of all U.S. vasectomies

III. Techniques

  1. Traditional Vasectomy with scrotal incision
  2. No-Scalpel Vasectomy
    1. Preferred technique due to less bleeding, pain, intraoperative time, and risk of post-operative infection
    2. Cook (2007) Cochrane Database Syst Rev (2): CD004112 [PubMed]

IV. Procedure: Step 1 - Procedure Preparation

  1. See Vasectomy Counseling
  2. Consider Sedation
    1. Valium 5 to 10 mg taken 30 minutes before procedure
  3. Establish relaxing environment
    1. Warm room relaxes Scrotum
    2. Soft music
  4. Position patient supine or dorsolithotomy
  5. Retract penis
    1. Tape glans penis to Abdomen
    2. Rubber band method
      1. Loop two Rubber bands together
      2. Loop one end around head of penis
      3. Loop other end through handle of hemostat
      4. Clamp hemostat to patient's gown
  6. Prep skin with warmed Betadine solution
  7. Apply surgical drape

V. Procedure: Step 2 - Vas Deferens (spermatic cord) Positioning

  1. Non-dominant hand locates vas deferens
    1. Vas is caliber of a pen's inner ink plastic holder
  2. Three finger technique traps vas deferens
    1. Middle finger placed behind vas deferens
    2. Thumb and index finger placed over vas (2 cm apart)
  3. 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

VI. Procedure: Step 3 - Injection of Local Anesthesia (Perivasal block)

  1. Preparation: Standard needle injection
    1. Anesthetic: Xylocaine 2% without Epinephrine
    2. Syringe: 10 cc
    3. Needle: 27 gauge, 1.5 inch needle
  2. 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
  3. 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]

VII. Procedure: Step 4 - Skin penetration for No-Scalpel Vasectomy

  1. Press open ring clamp perpendicular into skin over vas
  2. Vas trapped between clamp and underlying finger
  3. Ring clamp closed and locked around vas deferens
  4. 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
  5. 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
  6. Insert second ring clamp through hole and grasp vas
  7. Remove first ring clamp and reattach through hole

VIII. Procedure: Step 5 - Vas Deferens Isolation

  1. Peal perivasal sheath away from vas (pealing onion)
  2. 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
  3. Clear >1 cm vas of perivasal sheath
  4. Apply ring clamp at each end of cleared segment

IX. Procedure: Step 6 - Vas Deferens Occlusion

  1. Hemitransect proximal (prostatic) vas deferens
  2. Insert cautery tip 4 mm into prostatic vas lumen
    1. Apply current while withdrawing slowly
  3. Ligation of proximal (prostatic) vas segment
    1. Silk 3-0 (1 or 2 separate ties)
    2. Surgical clip (without vas deferens transection or fascial interposition)
      1. Similar efficacy to standard vasctomy with ligation, transection and fascial interposition (same failure rate)
      2. Cook (2007) Cochrane Database Syst Rev (2): CD003991 [PubMed]
  4. Complete transection of proximal vas deferens
  5. 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]
  6. Transect distal (testicular) vas deferens end
    1. Store vas deferens segment in formalin
  7. Consider avoiding distal vas deferens ligation
    1. May reduce post-operative pain (lower vasal pressure)
    2. Risk of sperm Granuloma if not ligated
  8. Observe for signs bleeding (esp. pampiniform plexus)

X. Procedure: Step 7 - Procedure Completion

  1. Repeat from Step 2 forward with opposite vas deferens
  2. Same hole in Scrotum may be used for entry
  3. Close skin with Suture (e.g. Vicryl)

XI. Education: Follow-up and Precautions

  1. See Vasectomy Postoperative Counseling

XII. Resources

  1. Choosing Vasectomy Movie (Requires Flash)
    1. VasectomyConsentSjm.htm
  2. Vasectomy Medical (Commerical Site)
    1. http://www.vasectomymedical.com

XIII. References

  1. Clenney (1999) Am Fam Physician 60(1):137-52 [PubMed]
  2. Rayala (2013) Am Fam Physician 88(11): 757-61 [PubMed]
  3. Stockton (1992) Am Fam Physician 46(4):1153-64 [PubMed]

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