No Scalpel Vasectomy

Vasectomy is the most popular form of permanent surgical birth control for men. In 2002, an estimated 526,501 vasectomies were performed in the United States, which is a rate of 10.2/1,000 in men aged 25-49 years. American Urologic Association (AUA) guidelines concluded that vasectomy as a permanent contraceptive procedure should be considered more frequently than is current practice.[1]

The no-scalpel vasectomy (NSV), originally developed in China in 1974 and first introduced in the United States in 1984, is an innovative approach to exposing the vas deferens using 2 specialized surgical instruments.[2]  (See the image below.) A Cochrane Review concluded that the NSV, as compared to traditional incisional technique, resulted in less bleeding, hematoma, infection, and pain, and a shorter operative time.[3, 4] According to one study, 37.8% of physicians, including urologists, family practitioners, and general surgeons, were using the NSV technique by 2002.[5]

Rotation and extrication of vas.

Vasectomy is indicated for any fully informed man who does not want to father any children (or any additional children) and who desires an inexpensive outpatient method of voluntary permanent surgical sterilization. Although less popular than other forms of sterilization, such as tubal ligation for the man’s sexual partner, the procedure offers the advantages of lower expense, lower level of invasiveness (ie, does not require general anesthesia or hospitalization), and quicker recovery time. Also, future checks of fertility are possible at any time with semen analysis, unlike with women who have undergone tubal ligation.

Contraindications to no-scalpel vasectomy (NSV) include the following:

• Anatomic abnormalities, such as the inability to palpate and mobilize both vas deferens or large hydroceles or varicoceles

• Past trauma and scarring of the scrotum

• Acute local scrotal skin infections

Extreme care and consideration must be taken with patients who are taking anticoagulants or antiplatelet medications.

Provision and review of both written and verbal informed consent is paramount. Men and their spouses must understand that vasectomy should be considered a permanent sterilization procedure. Belief that reanastomosis microsurgery provides a good backup plan for fathering future children should be strongly discouraged.

Surgical complications, failure rates, alternative methods of birth control, and possible chronic postoperative pain should also be discussed, and all questions should be answered. Emotional instability or equivocal feelings about permanent sterilization are contraindications to vasectomy.

Compliance with postoperative follow-up and postprocedure semen analysis is of utmost importance.

Lidocaine 1% with or without epinephrine can be used to anesthetize the scrotal skin puncture site.

Use a tuberculin syringe with a 0.375-inch fine point needle to raise a blanched skin wheal. For more information, see Local Anesthetic Agents, Infiltrative Administration.

Raising the skin wheal.

Side view of the skin wheal.

A bilateral perivasal block is accomplished by injecting lidocaine 1% or bupivacaine 0.25% or 0.5% by tracking a 27-gauge 1.5-inch needle along the path of the vas toward the inguinal ring as shown.

Advancing the needle parallel to the vas within the external spermatic fascial sheath toward the inguinal ring.

Optionally, many practitioners have the patient take an oral sedative, such as 1-2 mg lorazepam, 30 minutes prior to the procedure. In this case, the practitioner must be assured the patient has arranged for someone to drive him home after the procedure. If the oral sedative is to be administered before the patient comes to the office, someone must drive him to the office, as well.

Alternatively, a no-needle anesthetic technique is increasing in popularity compared with the standard needle infiltrative technique and uses a jet-injector device to deliver a high-pressure anesthetic spray of 0.3 mL lidocaine 2% through the intact skin and into the vas and surrounding vas tissues (Medajet Medical Injector; MADA Medical Products; Carlstadt, NJ).[6]

Attempts to use a topical skin anesthetic agent (ie, EMLA) prior to local injection of lidocaine failed to offer any benefit in perceived pain as shown by a visual analog scale.[7]

The equipment used to perform a no-scalpel vasectomy is listed below:

• Vasectomy tray

  • Needle, 1.5 inch, 27 gauge, attached to syringe, 10 mL

  • MadajetXL modified jet no-needle device (optional)

  • Plain lidocaine, 2%, total of 10 mL

  • Large rubber band to retract penis

  • Towel clips, 2

  • Gauze pack, 4 x 4

  • Straight hemostat

  • Fine point Iris scissors

  • Allison forceps with teeth, 2

  • Hemoclip applicator and medium clips

  • Suture, 4-0 (eg, chromic or polyglycolic acid [Dexon]; optional; for fascial interposition)

  • Needle driver (optional; for fascial interposition)

• Specialized NSV instruments

  • Vas fixation ring forceps

    Vas fixation forceps.

  • Sharp dissecting forceps

    Sharp dissecting forceps.

• Instruments to occlude the vas

  • Handheld cautery with disposable tip and sterile holding sheath

  • Bovie cautery unit with disposable needle point

• Athletic supporter

• Ice pack

The patient is positioned on an examination table in a position comfortable enough that he can tolerate a procedure that lasts approximately 30 minutes.

An overhead surgical light is helpful, though some surgeons prefer to use a smaller portable headlight.

Loop the large rubber band over the glans of the penis and retract the penis upward, away from the operative field.

Secure the rubber band with a towel clip to the patient's shirt or gown.

Rubber band technique.

After positioning, the skin is prepared with any number of bacterial surgical scrubs; the preferable choice is chlorhexidine. Povidine-iodine solutions tend to become sticky when dry and make mobilization of the vas difficult, whereas chlorhexidine remains slippery. Gently warming the preparatory solution in a microwave for approximately 10 seconds before application helps to prevent cremasteric muscle contractions and scrotal shortening.

Drape the operative site with sterile surgical towels, leaving only the scrotum exposed. Palpation should then be performed to confirm the presence and mobility of both the right and left vas within the scrotum.

The 3-finger vas fixation technique of the NSV method is critical to proper application of the surgical instruments. The practitioner’s nondominant hand is first used to manipulate the first vas to an area below the median raphe of the scrotum. This area is located at the juncture of the superior and medial third of the scrotum, along the darkened strip of the median raphe.

In this area, a small wheal of 1% lidocaine with epinephrine should be raised to anesthetize the site of instrument application. The subsequent skin blanching from the epinephrine allows for easy identification of the anesthetized area. For more details, see Anesthesia.

After the wheal is raised, gauze should be used to gently pinch and massage out the excess lidocaine to assist in applying the ring forceps. Lidocaine with epinephrine should not be used for the deeper vas block technique, so as not to mask any later uncontrolled bleeding of constricted small vessels.

The vas is then tensed over the middle finger, using the 3-finger technique, and the vas block is accomplished by advancing a 1.5-inch, 27-gauge needle through the anesthetized skin wheal along the course of the vas and toward the inguinal ring while fixated with the 3 fingers. At the approximate depth of 1-2 inches, administer 2-3 mL of lidocaine 1-2% without epinephrine in the perivasal sheath.

The 3-finger technique and perivasal block.

Before the solution is injected, careful aspiration is important to prevent intravenous injection. After withdrawing the needle, reach across the table with the nondominant hand and bring the second vas underneath the anesthetized skin wheal in a similar fashion. Repeat the same vas block on the opposite vas.

After the anesthetic technique is accomplished, bring the first vas underneath the skin wheal using the 3-finger technique.

The open ring clamp is then pushed down at a 90° angle over the skin to trap the width of the vas between the ring forceps and the underlying surgeon’s finger. The ring clamp is then closed and locked in place.

If excess scrotal skin is palpated around the vas, it can gently be "milked" out by releasing the lock on the ring forceps 1-2 mm at a time without dropping the vas. Care should be taken to assure that the ring forceps are applied at a direct perpendicular angle and that an equal amount of vas can be palpated exiting both sides of the ring.

Perpendicular application of the ring forceps.

Following confirmation of securing the vas, the handles are then lowered and the fingers of the nondominant hand reapplied, using the index finger to stretch the scrotal skin over the arch of the entrapped vas.

The dissecting forceps are then opened with the surgeon’s dominant hand; the innermost blade should be used to pierce the scrotal skin directly over the vas.

The tine is then directed to a 45° angle to a depth of approximately 3-4 mm, preferably into the center of the vas lumen.

The single tine is then withdrawn and the dissecting tines are closed and placed back in the original puncture hole. Then the dissecting tines are forcibly opened to spread the outer scrotal skin and fascial layers down to and exposing the bare vas. Several openings and closings of the dissecting forceps are helpful to ensure all covering layers are stretched, free, and penetrated. Frequently, optimal exposure can be confirmed by a light grayish discoloration of the vas (compared to the surrounding fascial tissue). The stretching should also be approximately twice the width of the vas to allow for extricating of the vas once the ring forceps are released.

Insertion of sharp dissecting forceps.

After outward exposure of the vas, the outermost tine of the dissecting forceps is used to spear or secure the vas. The handles are then rotated 180°. As the rotation occurs, the ring clamp is gently released by the opposite hand, and the dissecting forceps are raised vertically to pull the vas free of the surrounding fascia and out of the scrotum.

Rotation and extrication of vas.

The ring clamp can then be used to secure the exposed vas outside the scrotum.

While holding the ring clamp in the vertical position, a blunt cotton-tipped applicator can be used to separate out and push down surrounding fascia from the loop of exposed vas.

The sharp forceps can then be used to penetrate the tissue between the loop of vas and spread it downward to reveal a clean loop. Care must be taken not to stretch or rupture the very small but powerful blood vessels that surround the body of the vas. Light electric cautery can be used to seal any ruptured vessels at this time.

Stripping of fascia to expose loop of vas.

Numerous methods of occlusion of the vas can be instituted at this point in the procedure.

This author’s technique involves hemi-transecting the vas, threading an electric cautery needle 1 cm into the loop on the prostatic end of the vas, and slowly withdrawing it while applying current. A full-thickness burn injury is not optimal, as this can cause future necrosis and subsequent sloughing of the tip of the cut vas, which can result once again in a patent vas lumen. A progressive burn of the inner lumen of the vas is preferred, leaving the outer vas layer intact.

Intraluminal cautery.

Multiple studies have shown cautery to be a superior method of vas occlusion that results in a lower failure rate compared to simple suture or clip ligation[8] ; however, medical consultations for hematoma or infection were more frequent in the cautery group. The clinical significance of this finding should be balanced against the much higher effectiveness.[9]

After cautery, the prostatic vas is then completely transected and allowed to retract.

The Allison forceps are then used to pull the fascia over the end of the prostatic vas. The fascia is then secured with a single medium steel handle clip. Fascial interpositioning between the cut vas ends further reduces recannulization rates and sterilization failures.[10]

Fascial interpositioning with hemoclip.

This author prefers the open end vasectomy, in which the testicular end is not cauterized but is simply allowed to retract into the scrotum once bleeding is controlled. The theoretic benefit in this technique is that the open end method has fewer symptoms of epididymal congestion and low instance of sperm granuloma. The sterilization efficacy rate has proven to be very similar to that of vasectomy techniques in which both ends of the vas are occluded.[11]

Following confirmation of which testicle is attached, the vas ends are both released back into the scrotum. The second vas is then brought into position under the original puncture hole, again using the 3-finger technique. In the author’s experience, only a single puncture hole has been required well over 99% of the time, as the vasa are very freely moveable within the scrotum. The single puncture hole cuts down on the trauma to the scrotum considerably by stretching rather than cutting the skin, obviating the need for closing sutures.

After the second vas is positioned and secured with the ring forceps under the puncture hole, the procedure described above is carried out on the second vas.

After the second vas is released back into the scrotum, the small puncture hole usually contracts to only several millimeters and does not require suturing, stapling, or other closure. Antibiotic ointment is typically applied, as well as fluffed gauze for padding under an athletic supporter.

The patient should lie supine as much as possible during the first 24-48 hours after the procedure and apply ice to the underwear or athletic supporter covering the scrotum intermittently for the first 24 hours. The patient or his partner should call the doctor if excessive bleeding, swelling, pain, or discharge from the puncture site occurs. A prescription for a nonaspirin analgesic with or without a narcotic is provided. Follow-up instructions include emphasis of the necessity for adequate contraceptive use until a negative semen analysis is obtained, plus instructions for proper collection of the postprocedure sample.

Informed consent is critical. Include the patient’s partner in preoperative and postoperative instructions. The procedure must be seen as an attempt at permanent sterilization.

A calm and quiet surgical environment is helpful for patient relaxation. Consider recommending that patients bring a music player and headphones to wear during the procedure.

The 3-finger technique of securing the vas is essential to the correct application of the specialized instruments of NSV.

Be sure to take meticulous care to attain hemostasis, sealing even the smallest perivasal blood vessel to avoid hematomas.

Postoperative instructions include that the patient should go home, lie down, stay quiet for the remainder of the day, and avoid any strenuous lifting or exercise for the next few days.

Insist that couples remember to use adequate birth control until a negative semen analysis is obtained. Approximately 50-60% of patients don’t return for the postprocedure semen sample. Enlist the partner in reminding the patient to return for the sample.

Complications of NSV can be divided into the 3 major categories of intraoperative, early postoperative, and late postoperative.

Intraoperative complications

Extraneous injection of the perivasal block results in damage to small vessels and hematoma formation. Usually, these hematomas are very small and can be managed without surgery by using rest, ice, and nonsteroidal anti-inflammatory drugs (NSAIDs).

Major surgical damage to spermatic vessels can result in testicular compromise and atrophy; this complication is often not realized until late in the postoperative course. This rare and unfortunate complication requires urologic consultation and may, ultimately, result in orchiectomy.

As with any surgical procedure, unrealized minor damage to the nerves can result in immediate postoperative pain or persistent chronic pain.

Early postoperative complications (during the first postprocedure week)

Small (1-2 cm) hematomas or wound infections can develop. Large hematomas are possible from severed perivasal vessels leaking into the easily expandability scrotal tissue. These hematomas are diagnosed by physical examination and, unless they are extremely large, can often be treated with ice, rest, and expectant management.

Because the NSV technique involves pushing vessels around the puncture site and perivasal fascia rather than cutting them, the incidence of hematomas has been reduced. In China, where the NSV technique originated, the literature on NSV indicates a hematoma rate of 0.09%. A randomized controlled trial by Sokal et al found a hematoma rate of 0.3% in the NSV group compared to 12.2% in the traditional incisional group.[12]  A Chinese series of over 150,000 operations revealed an infection rate of only 0.91%.[13]  Most recently, a Cochrane review concluded that NSV resulted in less bleeding, hematoma, infection, and pain, as well as shorter operation times, than the incisional method.[14]

Late postoperative complications

Epididymal congestion is noted by patients as swelling and tenderness surrounding the epididymis or testicle that is accentuated by movement or strenuous activities. On examination, the testicle is usually enlarged, tender, and with a slightly indurated epididymis; however, fever is not usually present. This condition is thought to be noninfectious and related to vascular and lymphatic congestion. The application of heat and use of NSAIDs usually resolves symptoms within a week. If fever, elevated white blood cell count, or accentuated redness or tenderness is found, local infection should be considered.

A sperm granuloma may develop. This typically occurs during the second or third postoperative week and involves up to 25% of patients. This complication should be considered if, on examination of the patient, a small, palpable, pea-sized nodule is found at the testicular end of the transected vas. Once again, NSAIDs are used to resolve this problem, though persistent pain sometimes requires surgical removal of the nodule.

Development of a persistent pain syndrome affects a very small number of postvasectomy patients (approximately 1 per 1000 patients, according to McConaghy[15] ). Even so, most of these patients state they do not regret having had the procedure. Patients often question whether undergoing a vasectomy will change their sexual potency or performance. In outside studies and in this author’s experience, the reduced fear of pregnancy and increased ease of spontaneous intercourse usually results in improved, rather than diminished, sexual function.

While conservative therapies are often effective for treating post-vasectomy pain syndrome, refractory cases may be treated with vasectomy reversal. In a series from Canada, 13 of 14 men who underwent vasovasostomies experienced an improvement in pain and quality of life. Half of the patients were rendered pain-free, signifying vasectomy reversal as an effective treatment for the post-vasectomy pain syndrome.[16]

At one time, increased instances of heart disease or prostatic cancer in patients who underwent vasectomy had been considered. According to long-term follow-up studies of patients who have undergone vasectomy, such increased instances are not evident.[17] A 2002 study by Cox et al found no increased risk of prostate cancer in these patients even 25 years after the procedure.[18]  A more recent systematic review and meta-analysis that included 53 studies found no association between vasectomy and high-grade, advanced-stage, or fatal prostate cancer.[19]  Another meta-analysis found no link between vasectomy and the development of testicular cancer.[20]

Failure rates with vasectomy using intraluminal cauterization and fascial interpositioning as described are approximately 1%.

Sterility is not instantaneous. Postvasectomy semen analysis to assure azoospermia is critical before releasing patients to stop using other forms of birth control.

Unfortunately, studies show that less than half (42%) of men return with a sample.[17]

The median time to loss of sperm motility is 3 weeks postprocedure; the time to azoospermia is 10 weeks. The absence of any sperm after 12 weeks is thought to reliably predict long-term sterility.

Many surgeons require that 2 negative semen samples 4-6 weeks apart be obtained to determine sterility. A paper from the Cleveland Clinic suggested considering a single azoospermic sample at 3 months postprocedure to be an adequate determination of sterility.[21]

Although infrequently utilized, distal vasal flushing with 30 mL of sterile water may shorten the time to azoospermia for between 20% and 30% of vasectomy patients. This modification may be an option for those who would like to shorten the time to azoospermia.[22]