Vasectomy

Vasectomy is the most common urologic procedure for permanent male contraception — safe, office-based under local anesthesia, and highly effective. The core of good practice is thorough counseling about permanence and the need for confirmed sterility, a reliable vas-occlusion technique, and post-vasectomy semen analysis before contraception is stopped.

Counseling

Epidemiology

• 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

Who Chooses Vasectomy?

• 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

Evaluation

• 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

Counseling Points

• 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

Risks and Complications

• 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)

Technique

Anesthesia and Vas Positioning

• Perform in a warm room so the scrotum relaxes and the vas is easily identified; offer a benzodiazepine 30 minutes to 1 hour before the procedure (or the OR for anatomic or anxiety reasons).
• Position the vas at the scrotal midline, about one-third of the way from the penoscrotal junction to the bottom of the scrotum, and secure it with the three-finger technique (middle finger behind the scrotum, thumb and index finger tenting the skin taut).
• Anesthetise with 2% lidocaine without epinephrine through a small (25–32 gauge) needle: raise a subcutaneous skin wheal, then advance the needle ~1–1.5 cm alongside the vas toward the inguinal canal and inject the perivasal tissue on both sides as the needle is withdrawn. A jet/pneumatic injector is an alternative, and a topical anesthetic cream may precede the injection.

Procedure Steps

1. Check to make sure vas are palpable
2. Prep/drape patient
3. Isolate vas w/ middle finger behind w/ non-dominant hand
4. Inject local in skin and vas (create a superficial wheal with majority of local, rest inject superiorly up the cord)
5. Use dissector clamp to pop through skin (local wheal helps this), gently spread on either side of vas
6. Push ring clamp down onto vas, open and clamp w/ force to prevent vas "escape"
7. Use dissector to isolate vas from surrounding layers until able to push dissector clamp underneath vas
8. 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)
9. Once vas isolated, partially clamp proximal and distal (don't clamp entire vas)
10. Clear the mesentery and vasal vessels, then excise a 1.5–2 cm segment of the vas (no need to send to pathology)
11. Insert cautery into vasal lumen and give quick cautery to close lumen
12. Drop body end of vas, put gentle tension on testicular end, and place a fascial-interposition 4-0 absorbable stitch over the body end to separate the ends
13. Assess for hemostasis, then return vas to scrotum
14. 3-0 chromic horizontal mattress suture
15. Apply bacitracin, scrotal support

Vas Isolation Tips

• 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
• Keep any skin opening ≤ 10 mm — no larger opening is needed (Belker); pressing the anesthetic wheal helps disperse the local and eases subsequent vas isolation

Conventional (Scalpel) Vasectomy

As an alternative to the no-scalpel approach, make a transverse or longitudinal scalpel incision over the anesthetised vas, secure the vas with an Allis clamp or towel clip, and divide the dartos tunic and vasal sheath with the scalpel to expose it. Delivery, segment excision, and occlusion are completed as above, and the contralateral vas is reached through the same midline incision before closing with absorbable suture.

Vas Occlusion Tips

• 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%
• Occlude the lumen by cautery, suture, or hemoclips (often in combination), and close the vasal sheath over one cut end with a 4-0 absorbable suture for fascial interposition. Cautery of both ends, or an open-ended technique (testicular end left unoccluded, abdominal end cauterised), is generally more dependable than ligatures or clips (except in experienced hands), and fascial interposition should always be used to minimise recanalisation.
• 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

Postoperative Care & Follow-up

Normal Expectations

• 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; apply cold compresses on the day of surgery and the following day, and manage discomfort with NSAIDs or oral narcotics
• Avoid heavy lifting, strenuous activity, and sexual activity for the first week
• 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

Post-Vasectomy Semen Analysis (PVSA)

• 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