No-Scalpel Vasectomy

The two currently available male methods of contraception are condom use and vasectomy. Vasectomy is the major male contraceptive method in the USA, New Zealand, Australia, Great Britain, Canada, The Netherlands, China, India and Korea. Over the past two decades, the number of American couples choosing vasectomy as their method of contraception has risen. Nearly 7% of all married couples choose vasectomy as their form of birth control making it the third most popular form of contraception after female sterilization and oral contraception. However, vasectomy is faster, safer and less expansive than tubal ligation. In 1995, an estimated 493,882 vasectomies were performed in USA. 29% of all procedures were "no-scalpel" vasectomies. NSV requires less operating time and is performed in the office.

No scalpel vasectomy (NSV) was developed in China in 1974 and introduced to United States by Dr. Marc Goldstein from Cornell Medical Center, New York, in 1985. The procedure performed under local anesthesia using two specialized instruments designed in China: an extracutaneous vas deferens fixation clamp and dissecting clamp. The primary difference between NSV and conventional incisional technique lies in the delivery of the vas deferens. In a traditional vasectomy, the surgeon makes one or two incisions to gain access to the vas deferens; in the no-scalpel method, a small puncture in size is all that required. The puncture hole is gently stretched to pull the vas deferens. Then the vas deferens is cut and both ends are cauterized and closed with titanium clips or tied. This method results in fewer complications and rarely requires sutures to close the surgical site. Recovery time is usually faster and less painful because the procedure itself is less traumatic.

Studies indicated that NSV has a lower incidence of infection and hematoma due to small puncture wound, no suture closure, minimal dissection and tissue trauma. A prospective, randomized study in Thailand comparing the side effects of 2 vasectomy techniques showed that of 523 men, 1.34% became infected and 1.72% developed hematoma or bleeding after traditional incisional procedure. Of 680 men who underwent NSV, 0.15% became infected and 0.3% developed hematoma or bleeding. Overall percentage of complications after NSV is 0.4% versus 3.1% for conventional vasectomy.

As any surgical procedure, both conventional and No-Scalpel Vasectomy have some risk. The rate of most of these complications strictly correlates with surgical experience. Complications of vasectomy are infrequent and may be divided into 2 categories:

1. General surgical complications
   1. Bleeding/Scrotal hematoma-the most common early complications of vasectomy and occurs in about 1% of cases. Large hematoma potentially requires surgical drainage and hospitalization
   2. Superficial or deep scrotal infection- rare and usually related to underlying hematoma
2. Specific Complication
   1. Temporary or chronic testicular pain ( Post vasectomy pain syndrome)-may be secondary to congestive process in the epididymis and testicular portion of the transected vas deferens. Epididymitis is reported in 0.3-6% of vasectomized men. Also it is rarely an infection, trial of antibiotics may be indicated. Conservative treatment includes sitz baths, scrotal support and anti-inflammatory medications. Spontaneous improvement occurs usually within 6-12 weeks but chronic testicular pain may occur in 1 of every 10.000 vasectomies.
   2. Open-ended vasectomy has been recommended to prevent epididymal problems although it is not widely accepted since it may increase chances of recanalization
   3. Testicular atrophy-extremely rare since testis has elaborate blood supply network. It may happen in patients with preoperatively compromised testicular blood flow (e.g. recent non-artery-sparing varicocelectomy)
   4. Sperm granuloma is found in up to 60% of vasectomized men at vasectomy reversal. It is a hard lump formed as a result of sperm leakage from the cut vas deferens. Sperm granuloma is not dangerous but may be painful in 3% of the procedures. Pain caused by granuloma usually responds to conservative treatment but excision of sperm granuloma may be performed occasionally.
   5. Vasectomy failure occurs in 0.1-0.3% of cases when fulguration and surgical clips used to occlude vas deferens. Most failures result from spontaneous recanalization, which can occur any time after vasectomy. The likelihood of recanalization increases when sperm granuloma is present at the vasectomy site. Multiple interconnected epithelialized channels from the testicular end of the vas join the lumen of the abdominal side of the vas deferens. The sperm count is usually low. If motile sperm are seen after 6 weeks postvasectomy, early recanalization should be suspected. Recanalization most commonly occurs within 12 weeks of the vasectomy. If azoospermia fails to occur after the vasectomy, the procedure should be repeated. Late recanalization may occur several years after vasectomy and usually detected only after pregnancy occurs.

Normal sperm count after vasectomy usually results from failure to cut both vasa deferentia, rare presence of the accessory vas or insufficient number of ejaculation to clear out remaining sperm from the seminal vesicles.

Most surgeons suggest that vasectomy has to be repeated if sperm present after 2 consecutive semen analysis performed at 6 and 12 weeks postvasectomy. Persistence of o nonmotile sperm after vasectomy is a known phenomenon. Studies reported the occurrence of nonmotile sperm 12 weeks after vasectomy in 33-42% of patients. The proposed explanation of the persistence of nonmotile sperm is the residual sperm in the seminal vesicles. In the study of De Kniff et al (1997) 96% of these patients become azoospermic. Reappearance of nonmotile sperm after azoospermia is rare and was found in 0.6-8% of patients after vasectomy. Among these patients no pregnancies were found after 22 months follow-up.

It is suggested that men with small amount (<1,000,000) of nonmotile sperm have very small risk of causing pregnancy. Nevertheless, this risk cannot be disregarded. The informed and individualized decision regarding reoperation or follow-up should be made by physician and patient together.

Thorough counseling before vasectomy is very important. It permits couple to ask questions, express any concerns and to become sure of their decision. Counseling is scheduled to give patient full detail on the benefits and possible drawbacks of vasectomy.

A patient undergoing vasectomy should be interested in permanent surgical contraception. He should be aware regarding other nonpermanent contraception methods available. Vasectomy reversal may be discussed as an option, but emphasized that it is not 100% effective. Couple should also be informed about available sperm banking before procedure. The some vasectomy regret factors may include age under 30, childless marriage, unstable relationship, pressure by partner to perform vasectomy, partner is unaware about vasectomy.

Thorough history has to be obtained and detailed physical exam performed. Possible medical contraindications for vasectomy include blood dyscrasias, current UTI, anatomic abnormalities where vas cannot be palpated. Additionally, vasectomy is better performed in the operating room in patients with previous scrotal surgical procedures. Relative contraindications include marriage problems, unresolved psychological or psychosocial conflict. It is beneficial if both patient and his wife are present for counseling and sign consent for vasectomy together. Procedure is discussed in details. Written preoperative and postoperative instructions make patient's preparation for the procedure easier.

The disappearance of sperm from ejaculate correlates with the number of ejaculation and occurs after 12-15 ejaculations in 80-90% of the patients. We routinely check semen analysis 8 and 16 weeks after vasectomy. If the final examination shows azoospermia, patient is given clearance to have unprotected intercourse. Ideally, semen analysis has to be performed at doctor's office or at least at the same lab. Some physicians also recommend yearly semen analysis. Patient has to be aware that vasectomy is not a 100% guaranteed procedure to achieve sterility. Because failure of vasectomy may result in pregnancy, it is of utmost importance to follow closely instruction for determining sterility. Unfortunately, 34-36% of patients never return vasectomy for many reasons e.g. change of geographic area, change of the physician, misunderstanding the instructions, divorce or separation with current partner etc.

It is not always possible to control these patients but it is imperative for surgeon to spent significant time with the patient to explain procedure and the importance of postvasectomy follow-up for determining sterility. Special consent form is very helpful.

Recent data indicate that vasectomy is not associated with any serious, long-term adverse systemic effects. Current studies did not confirm vasectomy to be associated with the increased risk of the development of atherosclerosis-related diseases, prostate or testicular cancer.

No-Scalpel Vasectomy Program at Stony Brook University Hospital provides personal consultation before the procedure. The session includes:

• Explanation of the procedure by using diagrams
• History and detailed physical exam.
• Explanation of possible complications, risks and failures.
• Explanation of the need for postoperative serial semen analyses with required schedule and the need of contraception before clearance for unprotected intercourse.
• Answering questions.
• Discussing relevant data of the systemic effects of the vasectomy.
• Providing written pre-and postoperative instructions.
• Signing written consent by patient and his wife.
• Scheduling the procedure at the convenient time.

If you still have any questions or concerns, telephone consultation is available before vasectomy.