Atlas of Primary Care Procedures, 1st Edition

Gynecology and Urology

46

No-Scalpel Vasectomy

Vasectomy is an easy-to-perform and effective form of permanent contraception. About 500,000 vasectomies are performed annually in the United States. Unfortunately, many men have fears that prevent greater acceptance of the technique. The no-scalpel technique offers an alternative to standard procedures, providing shorter operating time, less pain and swelling, and faster recovery. Because there is no incision, this technique may decrease the fear of the procedure. About one third of all vasectomies performed in the United States use the no-scalpel technique.

The no-scalpel vasectomy technique uses a 2- to 3-mm midline puncture into the scrotum using a special sharp-tipped vasectomy dissecting forceps. The instrument has the appearance of a curved hemostat sharpened to a fine point and is used to elevate the vas through the skin. The three-finger isolation technique (i.e., thumb and index finger on top and middle finger beneath the scrotum) is used to manipulate the vas to just beneath the midline skin and throughout the procedure. After the vas is elevated from the skin, a second special instrument, the atraumatic vas clamp or ring clamp, is used to hold the vas. All other tissues are separated from the vas, and two partial incisions are made into the vas on both sides of the clamp. The tip of a battery cautery unit is inserted within the cut vas, and the ends that will remain within the body (not held in the clamp) are thermally sealed. The short piece of vas (¼ to ½ inch) held by the ring clamp can be removed. The cut ends of the vas are separated by pulling fascial tissue over one end and placing a small metal clip on the fascia (not the vas). The metal clip also limits or prevents bleeding from the vas artery. The tissues are then replaced within the scrotum, the other vas is swung under the midline puncture site, and these techniques repeated on the second side.

One of the complications of vasectomy is the formation of sperm granulomas. These granulomas are usually 0.5 to 2 cm, firm, sometimes exquisitely tender nodules that develop at the end of the cut vas. Although the granulomas often resolve over time, they can produce significant postoperative distress. The method of handling the cut ends of the vas influences the rate of formation of sperm granulomas. Metal clips placed directly on the vas or tying the vas with suture increases the rate of granuloma formation. Heat cautery (not electrosurgery) appears to produce the lowest rates of granulomas.

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Removal of a small piece of vas during the procedure allows for histologic confirmation that the vas was severed. Such reassurance is expensive, costing $150 to $200 in some settings. One alternative is to send the specimens home with the patient (i.e., avoiding specimen storage by the physician). The specimens, which are placed in formalin, are kept in a secure location until the postoperative semen checks are clear. If the semen analysis does not clear, the specimens can then be evaluated histologically. Some practitioners do not remove any vas but instead interpose fascial tissue between cut ends of the vas. However, there may be psychological benefit for patients to view removed segments of tube in a clear plastic container immediately after the procedure.

Adequate local anesthesia can produce pain-free procedures for most patients. After administration of anesthetic into the midline skin, the three-finger technique is used to slide the right vas below this site. External spermatic sheath injection is performed, infiltrating anesthetic around the vas and vasal nerves. The anesthesia needle is directed adjacent to vas toward the external inguinal ring (abdominal end) and 1 to 2 mL of 1% lidocaine infiltrated proximal to the surgical site. The left side is anesthetized similar to the right side. This technique provides superior results and is more popular with patients than older anesthetic techniques.

Preoperative counseling is essential to determine the appropriateness of a candidate (or couple) for a permanent procedure (Table 46-1). Studies have determined that up to 10% of couples may express regret after permanent sterilization and that 1% to 2% request reversal. Vasectomy reversal procedures are expensive and have relatively low success rates (20% to 60%) in facilitating pregnancy. Those who request reversal of the procedure tend to request vasectomy at a young age, are single or not in a stable, long-term relationship, or have few or no children at the time of the procedure. Patients should never be pressured into having a procedure. It is important to have both partners present for the counseling session; if either partner is not in agreement for a permanent procedure, this choice of contraception should be deferred.

TABLE 46-1. GOALS FOR THE PREOPERATIVE COUNSELING SESSION

 

·   Determine the appropriateness of patient (couple) for permanent and irreversible sterilization.

·   Diminish fears (e.g., procedure is not castration, patient will still enjoy sex).

·   Obtain informed consent (e.g., risks, benefits complications of the procedure).

·   Inform of the risk of early or late failure (<1% for the procedure described in this chapter).

·   Discuss alternate contraception and the need for contraception after procedure until the ejaculate is clear.

·   Inform the patient about the procedure technique and importance of following postoperative instructions.

·   Examine the patient to identify the vas bilaterally and exclude scrotal pathology.

·   Remind the patient to avoid aspirin preoperatively, bring an athletic supporter to the procedure, and clip (not shaving) hair on the anterior or lateral side of the scrotum the night before the procedure.

·   Provide sedation (e.g., diazepam prescription) for the procedure, if desired. Informed consent should be obtained before sedatives are administered.

 

Patients should clip the hair on the anterior and lateral sides of the scrotum the night before the procedure. Instruction should be given to avoid aspirin and aspirin-containing medications for 10 days before the vasectomy. The patient should bring an athletic supporter to the procedure. After the procedure, gauze is laid over both sides of the scrotum, and the supporter is placed to secure the gauze

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and to provide elevation and comfort to the scrotal tissues. Patients are instructed to limit strenuous activities for a week after the procedure. Sex may be attempted for the fist time 1 week after the procedure. After 25 ejaculations (usually 3 to 4 months after the procedure), the patient is instructed to bring a specimen to the office to ensure the absence of sperm. Repeat examinations of specimens usually is unnecessary, but they can be performed at the patient's request or if the first specimen is not completely clear of sperm.

INDICATIONS

  • Permanent sterilization

RELATIVE CONTRAINDICATIONS

  • Uncooperative patient
  • Poorly or noncounseled patient regarding procedure technique and permanent consequences
  • Young patient (<23 years old), single patient, childless patient, patient not in a well-established monogamous relationship
  • Coagulopathy or bleeding diathesis
  • Presence of scrotal tumors or masses
  • Unable to palpate either vas deferens at the preprocedure visit

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PROCEDURE

Instruct the patient about the proper location of the hair to be clipped (not shaved) the night before the procedure. Have the patient shower after the hair clipping.

 

(1) Instruct patient to clip hair on the anterior and lateral sides of the scrotum the night before the procedure.

PITFALL: Patients may incorrectly clip the entire hair over the symphysis pubis onto the abdomen. Give proper instruction to avoid unnecessary clipping.

PITFALL: Shaving traumatizes skin and increases surgical infection rates. Instruct patients to clip, not shave the hairs.

The instruments for the procedure are the atraumatic ring clamp (Figure 2A) and the vas dissecting forceps (Figure 2B).

 

(2) The ring clamp and vas dissecting forceps.

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The right vas is palpated; it feels like a firm, thin cord running from the testicle into the inguinal area. Although other structures can feel like vas, they usually flatten as the tissue is rolled between the fingers. The index finger and thumb grasp the vas above the scrotum, and the middle finger is placed beneath. Grab the vas at the junction of the middle and upper thirds of the scrotum.

 

(3) The three-finger technique.

PITFALL: Handle the vas gently. Rough manipulation, especially if traction is applied on the vas, will produce significant discomfort and unnecessary anxiety for the patient.

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Cross section of the spermatic cord structures is shown (Figure 4A). Nonsterile gloves can be used for this part of the procedure (Table 46-2). Raise a skin wheel in the midline skin above the vas (Figure 4B). Now slide the needle alongside the vas, directing the needle to about 1 inch above the planned surgical site (Figure 4C). The needle is directed toward the external inguinal ring (toward the abdomen). Administer 1 to 2 mL of anesthetic inside the external spermatic fascia, immediately adjacent to the vas. The needle is withdrawn, the left vas is swung to the midline, and the procedure repeated on the opposite side. A right-handed operator often finds it easier to face the patient's feet and to perform the isolation of the left vas with the left hand (Figure 4D).

 

(4) Anesthesia.

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PITFALL: Failure to achieve adequate anesthesia often results from failure to administer the anesthetic within the external spermatic fascia. Use the posterior middle finger to feel the needle as it slides immediately adjacent to the vas.

PITFALL: It is possible to direct the needle through the posterior scrotum and into the practitioner's middle finger. Slow and careful advancement of the needle should avoid this problem.

TABLE 46-2. NONSTERILE TRAY FOR ANESTHESIA AND POSTOPERATIVE CARE

 

Nonsterile gloves

Povidone-iodine solution soaked into 4 × 4 gauze (in a sterile basin)

10-mL syringe filled with 1% lidocaine

25- or 27-gauge 1¼ inch needle

½ inch of antibiotic ointment on gauze

2 inches of nonsterile 4 × 4 gauze

Patient-supplied athletic supporter

1 postoperative semen collection container (with patient's name) in a brown paper bag

Formalin container for excised portions of the vas deferens

Basin with sterile water poured onto 1 inch of 4 × 4 gauze (for cleaning scrotum after procedure)

 

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Prep the skin with povidone-iodine, place a sterile drape, and use sterile gloves (Table 46-3). Bring the right vas to immediately below the midline with the three-finger technique. Hold the clamp in the right hand (palm up), slightly open the tips of the clamp, and grasp the vas and skin inside the clamp (Figure 5A). Lower the handles of the ring clamp (Figure 5B). Place the middle finger of the left hand under the clamp, and the index finger is placed above the clamp to stretch the skin over the vas (Figure 5C).

 

(5) Hold the clamp in the right hand (palm up), slightly open the tips of the clamp, and grasp the vas and skin inside the clamp.

TABLE 46-3. STERILE PROCEDURE TRAY

 

Sterile gloves

Sterile fenestrated drape

Vas dissecting hemostat (forceps)

Atraumatic ring clamp

Disposable battery cautery unit placed inside a sterile glove

2 inches of 4 × 4 gauze

2 pairs of straight hemostats

1 curved hemostat

Surgical clip (Hemoclip) applicator

1 container (clip) of medium metal surgical clips (Hemoclips)

Iris scissors

 

Adapted from: Zuber TJ. Office procedures forms: The AAFP collection—quick reference guides for family physicians. Baltimore: Williams & Wilkins, 1999:110.

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The vas dissecting forceps are grasped in the right hand with the tips pointed down toward the scrotum. A puncture is made into the vas using one blade of the forceps (Figure 6A). Both tips are used to spread the skin immediately over the vas (Figure 6B). The lateral blade of the forceps pierces the wall of the vas (Figure 6C), and the palm is rotated to lift the vas outside the scrotum (Figure 6D).

 

(6) The vas dissecting forceps are grasped in the right hand with the tips pointed down to the scrotum.

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Some physicians have trouble elevating the vas from the scrotum using a single blade of the forceps. After puncturing and stretching the skin, the forceps can be used to laterally swing under the vas (Figure 7A) and lift the vas from the scrotal skin (Figure 7B).

 

(7) The forceps can be used to laterally swing under the vas and lift the vas from the scrotal skin.

Remove the ring clamp while the vas is held above the scrotum with the dissecting forceps. Grab the center of the vas with the ring clamp (Figure 8A), and use the vas dissecting forceps to separate the vasal fascia and artery (Figure 8B) from the vas (Figure 8C). The vas should be completely isolated (Figure 8D).

 

(8) Remove the ring clamp while the vas is held above the scrotum with the dissecting forceps, and grab the center of the vas with the ring clamp.

PITFALL: When dissecting the vas free, the vasal artery may bleed. A small hemostat can be placed on the bleeding artery, if needed.

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Make two partial incisions (i.e., hemitransection) into the vas using the straight iris scissors. The cut is made low (near the fascia) on the testicular side and high up (near the clamp) on the abdominal side (Figure 9A). The tip of the battery cautery unit is placed in both ends beneath the hemitransections (the portions that will remain within the body) (Figure 9B). Activate the cautery for just a few seconds; withdraw the tip after it begins to heat the tissue. Proper cautery results in minimal white formation in the end of the tissue, and the tip of the cautery unit tends to “stick” to the vas as it is withdrawn.

 

(9) Make two partial incisions into the vas using the straight iris scissors.

PITFALL: Do not cut more than halfway across the vas. If a full wall incision is made, the cut vas will retract back into the scrotum before it can be cauterized.

PITFALL: If both cuts are made high near the clamp, it will be difficult to interpose fascia over one end.

PITFALL: Do not create a full-thickness burn in the wall of the vas. A full-thickness burn will result in necrosis, the end of the vas will be resorbed, and the result will be an untreated free end of vas.

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Complete the partial cut on the vas on the testicular end only (Figure 10A). The testicular vas often retracts back into the scrotum. Lift up the fascia, and pull it over the testicular end of vas. A small metal clip is used to seal the fascia over the testicular end (Figure 10B). The clip must extend across to the abdominal end of the vas but should not clamp onto the vas. Bleeding complications can be reduced if the vasal artery is occluded in the fascia clip immediately adjacent to the vas (Figure 10C). After the metal clip is placed, inspect to ensure a bloodless field. Complete the cut on the abdominal vas, and remove the specimen in the clamp (Figure 10D). The right side is returned to the scrotum, and the left side slid medially with the same technique performed on the left. After the left side is completed, wash the povidone-iodine off the skin, place antibiotic ointment and gauze over the site, and apply the athletic supporter.

 

(10) Complete the partial cut on the vas on the testicular end only.

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CODING INFORMATION

 

CPT® Code

Description

2002 Average 50th Percentile Fee

 

55250

Vasectomy, including postoperative semen examination

$550

 

CPT® is a trademark of the American Medical Association.

INSTRUMENT AND MATERIALS ORDERING

A patient counseling video (introduction can be personalized for a particular practice) can be ordered from Plainly Creative Works, Inc., 809 Elm Street, Essexville, MI 48732 (phone: 989-892-7614).

A training package (including more than 60 slides about technique, $100), illustrated guide to the technique, WHO video, and scrotal model for practicing the technique can be ordered from EngenderHealth (http://www.engenderhealth.org). An illustrated, step-by-step guide ($35), training video ($35), patient education guide ($90), patient education brochures, marketing brochures, scrotal training model, and anatomy diagrams can be ordered from Advanced Meditech International (http://www.ameditech.com).

Surgical clips can be ordered from Weck Closure Systems, 2917 Weck Drive, P.O. Box 12600, Research Triangle Park, NC 27709 (phone: 800-234-9325; http://www.weckclosure.comhttp://www.pillingweck.com). Ringed forceps, surgical hemostat (dissecting clamp or forceps), fine-tipped thermal cautery, and surgical clips can be ordered from Advanced Meditech International (http://www.ameditech.com). A ring clamp and vasectomy hemostat ($150 to $170 per set) can be ordered from Miltex (http://www.steeles.com).

BIBLIOGRAPHY

Alderman PM. Complications in a series of 1224 vasectomies. J Fam Pract 1991;33:579–584.

Badrakumar C, Gogoi NK, Sundaram SK. Semen analysis after vasectomy: when and how many? BJU Int 2000;86:479–481.

Clenney TL, Higgins JC. Vasectomy techniques. Am Fam Physician 1999;60:137–152.

Cox B, Sneyd MJ, Paul C, et al. Vasectomy and risk of prostate cancer. JAMA 2002;287:3110–3115.

Davis LE, Stockton MD. Office procedures. No-scalpel vasectomy. Prim Care 1997;24:433–461.

Esho J, Cass AS. Recanalization rate following method of vasectomy using interposition of fascial sheath of vas deferens. J Urol1978;120:178–179.

Goldstein M. No-scalpel vasectomy: a kinder, gentler approach. Patient Care 1994;28:55–73.

Gonzales B, Marston-Ainley S, Vansintejan G, et al. No-scalpel vasectomy: an illustrated guide for surgeons. New York: Association for Voluntary Surgical Contraception, 1992.

Lesko SM, Louik C, Vezina R, et al. Vasectomy and prostate cancer. J Urol 1999;161:1848–1852.

Li PS, Li SQ, Schlegel PN, et al. External spermatic sheath injection for vasal nerve block. Urology 1992;39:173–176.

Li SQ, Goldstein M, Zhu J, et al. No-scalpel vasectomy. J Urol 1991;145:341–344.

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Manson JE, Ridker PM, Spelsberg A, et al. Vasectomy and subsequent cardiovascular disease in U.S. physicians. Contraception1999;59:181–186.

Mason RG, Dodds L, Swami SK. Sterile water irrigation of the distal vas deferens at vasectomy: does it accelerate clearance of sperm? A prospective randomized trial. Urology 2002;59:424–427.

Miller WB, Shain RN, Pasta DJ. The pre- and post-sterilization regret in husbands and wives. J Nerv Ment Dis 1991;179:602–608.

Nangia AK, Myles JL, Thomas AJ. Vasectomy reversal for the post-vasectomy pain syndrome: a clinical and histological evaluation. J Urol2000;164:1939–1942.

Potts JM. Patient characteristics associated with vasectomy reversal. J Urol 1999;161:1835–1839.

Schmidt SS, Minckler TM. The vas after vasectomy: comparison of cauterization methods. Urology 1992;40:468–470.

Sivardeen KA. Post vasectomy analysis: call for a uniform evidence-based protocol. Ann R Coll Surg Engl 2001;83:177–179.

Stockton MD, Davis LE, Bolton KM. No-scalpel vasectomy: a technique for family physicians. Am Fam Physician 1992;46:1153–1164.

Zuber TJ. Office procedures. The AAFP collection-quick reference guides for family physicians. Baltimore: Williams & Wilkins, 1999:139–148.