No-Scalpel Vasectomy

Brian Elkins, MD, DABFM, FAAFP
Email

Send Email

Recipient(s) will receive an email with a link to 'No-Scalpel Vasectomy' and will have access to the topic for 7 days.

Subject: No-Scalpel Vasectomy

(Optional message may have a maximum of 1000 characters.)

×


Introduction

Vasectomy is a surgical procedure that accomplishes permanent sterilization for men. The procedure generally involves interrupting the flow of sperm through the vas deferens on each side. Semen production is unaffected (except for the absence of viable sperm) and sexual function does not change. Vasectomy may be performed in the office with anxiolysis and local anesthesia, making it a very cost-effective method of preventing pregnancy. Vasectomy is generally safer than permanent female sterilization via tubal ligation because it requires only local anesthesia and does not require entry into the peritoneal cavity. 
The procedure consists of three major portions: (a) accessing the vas, (b) disrupting the vas, and (c) closure. There are numerous variations of each portion of the procedure. Accessing the vas may be done through either one midline opening or two lateral openings, and may utilize either an open or a “no-scalpel” technique. The no-scalpel technique utilizes a specialized ring clamp to grasp the vas deferens percutaneously and a sharply pointed hemostat to create the opening and to dissect out and elevate the vas. The no-scalpel technique is somewhat more difficult to perform but has been shown to result in fewer complications, such as bleeding and infection. 
Disruption of the vas usually involves excision of a portion of the vas on each side and is often followed by some type of occlusion, such as luminal cautery, clips, or suture ligation. Luminal cautery is superior to suture ligation; the interposition of a layer of fascia between the prostatic and testicular ends of vas deferens on each side has been shown to increase the success rate. Leaving the testicular end open has been shown in some studies to decrease the incidence of chronic testicular pain. The method described here utilizes luminal cautery of the prostatic vas, leaving the testicular end open and performing fascial interposition. The scrotal entry wound utilized in no-scalpel vasectomy heals spontaneously and does not require closure. 
The excised portions of vas deferens can be sent for pathological examination if desired. Alternatively, they can be retained in formalin until sterilization is confirmed by semen analysis, at which time they can be discarded; or they can be sent for analysis at a later time if the procedure fails. 
Because sperm remain in the vasa deferentia and seminal vesicles proximal to the site of surgery, vasectomy is not effective immediately. Patients must be cautioned to rely on another form of contraception until cleared with a semen analysis. Semen analysis is delayed until 3 months after the procedure because azoospermia may normally take this length of time to occur. The semen analysis consists of a single unspun specimen viewed on a slide under low magnification. Although complete azoospermia has traditionally been used as the criteria for successful sterilization, the presence of rare nonmotile sperm may persist in up to one third of men postvasectomy and is rarely associated with pregnancy. 
Despite of the intent of the procedure to result in permanent sterilization, about 6% of men eventually seek a reversal. Unfortunately for these men, vasectomy reversal is difficult, expensive, and is not always successful. Change in marital status is the most commonly cited reason for seeking vasectomy reversal. Younger men should be counseled carefully regarding this risk, because age younger than 30 years at the time of the procedure has been shown to be a predictive desire for later reversal. Interestingly, patients with no children are less likely to seek later reversal. 
Patients should be instructed to clip the hair on the anterior scrotum below the penis short (but not to shave as this increases risk of infection). Patients should bring an athletic supporter with them to wear home after the procedure. Patients also need to have someone to drive them home. Some providers recommend diazepam 10 mg orally prior to the procedure for anxiolysis; make sure to obtain informed consent before the patient is under the influence of the drug. Intravenous sedation can also be used if available. 
The most common complication of vasectomy is bleeding or hematoma formation. In most cases, this can be managed conservatively with anti-inflammatory medications and will resolve spontaneously; rarely, surgical exploration may be required to locate and cauterize or ligate a bleeding vessel. Failure of the procedure may occur and has been divided into “early” versus “late” failure, depending on whether azoospermia was never achieved (“early failure”), or whether azoospermia was followed by a subsequent semen analysis demonstrating the presence of motile spermatozoa (“late failure,” usually discovered after a pregnancy occurs). The technique described here has a 0.3% reported failure rate. Infection may occur but is uncommon. Sperm granuloma may occur with open-ended techniques but may often be asymptomatic and usually can be managed with anti-inflammatory medications. Congestive epididymitis may also occur but is less frequent with open-ended techniques than with clipping or ligation of the vas. 

Equipment

  • No-scalpel vasectomy ring clamp

  • Note: The Li forcep is the original no-scalpel vasectomy ring clamp. An alternative instrument, the Wilson forcep, is also available. The Wilson forcep is pictured in the procedure photographs in this chapter. The operator may choose either forcep depending on experience and preference.

  • No-scalpel vasectomy hemostat

  • Lidocaine 1%, 10 mL, with a 30-guage needle

  • Lidocaine 1%/bupivicaine 0.5% 1:1, 10 mL, with a 1 ¼′ 27-guage needle

  • Narrow-tipped thermal or electrical cautery

  • Single-tooth Adson forcep

  • Small hemostats (“mosquitoes”)

  • Iris scissor

  • Needle driver

  • 4-0 polyglycolic acid absorbable suture with an RB-1 tapered (atraumatic) needle

  • Antibiotic ointment

  • Nonadherent dressing

  • Large pack of 4 × 4 gauze pads “fluffed”

Indications

  • A desire for permanent male sterilization

Contraindications

  • Active local or nearby infection

  • Varicocele

  • Large inguinal hernia

  • Coagulopathy

  • Uncertainty about the procedure

  • Desire for possible later reversal

  • Current pregnancy (relative)

  • Recent major life event affecting the decision (relative)

The Procedure

Step 1

The patient’s penis can be taped so that it does not drape over the scrotum. The hair on the anterior scrotum is clipped short with clippers if not already done by the patient. The scrotum is prepped with chlorhexidine solution or other surgical prep and is draped with sterile drapes. Be sure to include the posterior scrotum and adjacent upper thighs in the prep. Some place a warmed bag of normal saline on the scrotum over a sterile towel for several minutes at this point to assist with relaxation of the cremasteric muscles. This is an ideal time to verify that the vas deferens can be palpated and easily isolated and elevated on both sides prior to the start of the procedure. 

Step 2

The skin of the anterior midline scrotum is infiltrated with 1% lidocaine. Alternatively, two separate lateral areas can be anesthetized if two lateral points will be used to access the vasa. Use the smallest amount possible, about 0.5 to 1 mL, to minimize distortion of the tissues. The anesthetized area can be circled with a surgical marking pen for later reference if needed. Perform a perivasal block on each side. First, grasp the vas with the three-point fixation technique: the thumb and forefinger stretch the vas on the anterior surface of the scrotum while the third finger is located posteriorly, pressing the vas forward between the thumb and forefinger. 

Step 3

Advance a long needle (1.25 inches) along the vas directed toward the ipsilateral inguinal ring. Aspirate to confirm nonintravascular placement of the needle and then inject 5 mL of anesthetic. Using a longer needle allows the anesthetic to be placed proximally so that tissue distortion in the surgical field is minimized. Lidocaine 1% can be used, but a combination of lidocaine 1% and bupivacaine 0.5% in 1:1 mixture will provide longer-lasting anesthesia. 

Step 4

Isolate, elevate, and grasp the vas deferens using the three-point fixation technique. The posterior finger presses the vas toward the anterior scrotum to assist with clamping the vas. Grasp the vas percutaneously with the no-scalpel ring clamp. Take care to ensure that the vas is actually fixed within the clamp and has not slipped behind the clamp. 

Step 5

Open the no-scalpel hemostat and pierce the skin with one tip. Press firmly until you feel a slight “pop” sensation indicating the tip has pierced the vas. 

Step 6

Remove the hemostat, close the tips, and insert both tips together in the hole created in step 5. Dissect to the vas by spreading the tips apart. You may need to reinsert the hemostat and spread several times until the vas is exposed. 

Step 7

Once the vas is exposed, open the hemostat and insert one tip into the vas. Rotate your wrist to bring the tip upward. This should elevate a small portion of the vas essentially free of surrounding connective tissue. 

Step 8

With the vas still elevated, using your other hand grasp through the vas with the ring clamp. 

Step 9

Use the hemostat to strip an approximately 1 cm segment of vas free of fascia. Use “mosquito” hemostats to fix the perivas tissue at the prostatic (proximal) and testicular (distal) ends of the exposed vas. Bleeding from the vasal artery sometimes occurs at this step and may require clamping the vessel with a hemostat. 

Step 10

Using the ring clamp still clamped through the vas, elevate the vas and partially incise the prostatic end of the vas, exposing the lumen but leaving a portion of the wall intact for traction. 
Step 10
Step 10

Step 11

Cauterize the lumen of the prostatic end of vas. Insert the cautery tip well into the vas and cauterize the lumen. Cauterizing the lumen will cause the vas to scar closed. Try to avoid causing full-thickness cautery of the vas which may cause sloughing of the cauterized tip resulting in an open vas. 
Step 11
Step 11

Step 12

Excise a 1 cm segment of vas deferens by completing the partial incision of the prostatic end and by cutting through the testicular end of vas. The segment is placed into formalin in a labeled specimen container. 
Step 12
Step 12

Step 13

Place a purse string suture in the perivas fascia over the testicular end of vas using the 4-0 absorbable suture and tapered needle. (This can also be placed over the prostatic end of vas if desired. In some cases, the fascia is easier to bring up on one or the other side for the purse string suture.) When the purse string suture is tied, a layer of fascia should interpose between the two free ends of vas. Check the area for hemostasis, and when satisfactory, allow the fascia and remaining free end of vas to drop back into the scrotum. Repeat steps 4 through 13 for the opposite side. The entry wound can usually be left open. Apply antibiotic ointment and cover first with a small nonadherent gauze pad followed by several 4 × 4 gauze pads “fluffed” to provide cushioning. Assist the patient in putting on the athletic supporter so that the dressing remains in place. 
Step 13
Step 13

Complications

  • Hematoma

  • Pain, infection, and bleeding

  • Congestive epididymitis

  • Sperm granuloma

  • Failure (about 0.3%)

Postprocedure Instructions

Patients are instructed to rest and to intermittently place an ice pack on the groin on the day of the procedure. On the second day, the patient may ambulate to a limited degree. Activity may return to normal by the third day for most patients, although some prefer to avoid heavy lifting for 1 week. Patients should wear the athletic supporter for about 1 week for comfort. 
Patients should be carefully counseled to obtain a semen analysis 3 months after the procedure to verify sterilization and to use another form of contraception until then. 

Coding Information

The following code may be reported for either bilateral vasectomy or for unilateral vasectomy (e.g., in the case of a patient who previously had an orchiectomy). 

Bibliography

Alderman PM. Complications in a series of 1224 vasectomies. J Fam Pract.  1991;33:579–584. [View Abstract]
Chawla A, Bowles B, Zini A. Vasectomy follow-up: clinical significance of rare nonmotile sperm in postoperative semen analysis. Urology.  2004;64:1212–1215. [View Abstract]
Clenney TL, Higgins JC. Vasectomy techniques. Am Fam Physician.  1999;60:137–152. [View Abstract]
Dassow P, Bennett JM. Vasectomy: an update. Am Fam Physician.  2006;74:2069–2074, 2076.
Labrecque M, Nazerali H, Mondor M, et al. Effectiveness and complications associated with 2 vasectomy occlusion techniques. J Urol.  2002;168:2495–2498. [View Abstract]
Li SQ, Goldstein M, Zhu J, et al. No-scalpel vasectomy. J Urol.  1991;145:341–344. [View Abstract]
Potts JM, Pasqualotto FF, Nelson D, et al. Patient characteristics associated with vasectomy reversal. J Urol.  1999;161:1835–1839. [View Abstract]
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
×