|
No-Needle No-Scalpel Vasectomy
No Needle Jet Anesthetic Technique for the No-Scalpel Vasectomy
Introduction:
Vasectomy is a safe and effective method of permanent male contraception. In the United States, it is employed by nearly 7% of all married couples and performed on approximately one-half million men per year, more than any other urological surgical procedure.
Historically, some men have shied away from vasectomy because they fear pain and the possible complications. In clinical practice, however, one of the commonest voiced concerns is that of ‘the needle’ for injection of local anesthetic into and through the scrotal skin. Efforts to enhance the popularity of vasectomy have led the Chinese to develop refined methods of no-scalpel vasectomy that minimize trauma, pain and complications. The introduction of ‘no-scalpel’ vasectomy has successfully allayed many men’s fears with regard to the scalpel, and the success of the Chinese in attaining these goals is evidenced by a complete reversal of the ratio of male to female sterilizations (now 3:1, respectively) in favor of vasectomy in the Sichuan province of China.
The option of receiving local anaesthesia without a needle is a particularly welcome one for many, which may have some significant advantages for popularity of vasectomy, especially in the developing world. Conventional vasal block needle anaesthesia in no-scalpel vasectomy involves the use of a 25 or 27 gauge 1 ½” needle used to raise a wheal at the median raphe at the junction of the upper 1/3 and lower 2/3rds of the scrotum; it is then advanced its full length toward the external inguinal ring on each side where further anaesthetic solution is deposited. (Li, PS., Li, SQ., Schlegel, PN., Goldstein, M.: External Spermatic Sheath injection for vasal nerve block. Urology; 1992,39:173-6)
Wilson in 2001 initially described no-needle jet injection as an anesthetic technique for the vasectomy. Weiss and Li modified and refined the jet injection technique for vasectomy, attaining a close to 100% efficacy rate with no need for supplemental anesthetic ( table 2). (J Urol 2005; 173:1677-1680).
A: Needle Injection Pattern: Anaesthetic is delivered by a 25 or 27 gauge 1 ½ needle along the vas and creates an anaesthetic pool around the vas to block the vasal nerve.
B: Jet Injection Pattern: A mist of lidocaine solution without epinephrine is delivered via high pressure injection beneath the skin and throughout the tissue around the vas, which results in quicker absorption and less pain.
The goal of this no-needle jet anesthesia approach is to simplify the surgical technique and to reduce men’s fear of vasectomy. No-needle anaesthesia delivers a rapid onset of profound local anaesthesia for NSV with great patient satisfaction. It is a simple and safe technique. The benefit of doing away with the needle is that it may reduce men’s fear of pain and enhance the popularity of vasectomy worldwide.
SURGICAL PREPARATION
General Preparation: A warm room temperature (20C˚ to 25C˚) is set up in advance to facilitate relaxation of the scrotal skin. A thin, relaxed scrotum will assist in both the administration of anaesthesia and the performance of the no-scalpel vasectomy. The scrotal skin is shaved, preferably in advance, and the penis is retracted by means of a rubber band placed around the glans and secured with a clamp to the patient’s shirt.
Jet Injector Preparation: The MadaJet® (MADA Medical Products, Carlstadt, NJ.) has been widely used in the fields of dermatology, cosmetic and plastic surgery, gynecology, dentistry and podiatry.
1. The Mada injector and its components are fully auto-clavable for the purpose of sterilization. Following sterilization, using sterile technique, a drop of lidocaine solution is placed over the seal on the injector head to promote a good seal with the filling chamber and the filling chamber is filled with approximately 4 cc of anaesthetic solution, 2% lidocaine without epinephrine.
2. The jet injector assembly is then attached to the filling chamber. The main injector assembly is pumped back and forth, then fired several times in order to “prime” the mechanism and to clear any potential debris or contaminants from the tip prior to first use after filling. When filled to capacity, the injector should have sufficient solution for about four cases using the technique described.
3. A grooved spacer/sheath, specially designed to accommodate the diameter of the vas, is fixed over the tip of the injector.
4. The skin over the median raphe only has to be swabbed with an alcohol pad prior to the administration of anesthesia. The scrotal skin is cleansed with alcohol and the right vas deferens is isolated using standard No-Scalpel Vasectomy 3 finger technique.
5. The first injection is made over the right vas deferens at the median raphe at the junction of the upper 1/3 and lower 2/3rds of the scrotum. Two more injections are made 3-5mm apart going distally from the first injection.
6. It is important to wear a finger protector over the middle finger of the non-dominant hand behind the vas to prevent accidental injection of anesthesia through the scrotum into the practitioner’s finger.
7. Accurately spaced contiguous injections (3 sprays for each side) create virtual intersecting circles of anaesthesia providing the operator with sufficient area for piercing and grasping the vas painlessly. The same technique is used for the left vas except that three injections are applied to the right lateral aspect of the median raphe adjacent to the previous injections. This cross anesthesia along the median raphe ensures patient comfort throughout the skin puncture and tissue spreading during no-scalpel vasectomy.
The jet injection is very effective because the anesthesia solution is ejected from a small hole in the tip of the injector and disperses in an inverted cone-shaped distribution affecting all of the tissues to a depth of 4 to 4.5 mm from the skin surface (Figure 4). The anesthetic solution is quickly absorbed by the tissue around the vas with much less trauma and pain compared to the needle injection. No skin wheal or local edema is present at the injection site making no-scalpel vasectomy easier to perform. The sites of injection are recognized by small blanched discolorations of the skin.
8. Following sterile prep in standard surgical fashion, the vasectomy may proceed immediately.
9. At this time, the tip of the jet injector should be soaked in a disinfectant solution (MadaCide is recommended by MADA Medical Products) to adequately sterilize it prior to it use on the next patient.
10. After a standard sterile prep, the ring clamp is applied between the 2nd and 3rd pairs of pin-point injection marks and the surgeon begins to perform no-scalpel vasectomy.
Summary:
- Safe, simple, effective
- Reduce men’s fear of vasectomy
- Reduce the risk of needle-stick injury
- Limits syringe waste management
- Approximately 8000 NNSV performed in North America since 2000
- Excellent patient’s satisfaction and enhanced the popularity of vasectomy.
Conclusion
No-needle anaesthesia with jet injection is a new technique to deliver rapid onset of profound local anaesthesia to the vasectomy patient. It reduces the risk of needle-stick injury and limits syringe waste management. It is a safe, economical and virtually painless anaesthetic application. The benefit of this technique is that it may reduce men’s fear of pain and may enhance the popularity of vasectomy worldwide.
Acknowledgements:
We would like to give great thanks to Drs. Ronald Weiss (Ottawa, Canada), Doug Stein( Tampa, FL) and Phlip Li in pioneering the use and acceptance of no-needle no-scalpel vasectomy (NNSV) and also for sharing their experiences with us. Also, we thank Dr. Ronald Weiss and Philip Li for allowing us to using some of their images from their book of "No-Needle Anaesthesia for No-Scalpel Vasectomy: An Instructive Guide for Surgeons" and sharing with us some of their experience.
References:
- Weiss, R., Li, PS.: No-Needle Jet Anesthetic Technique for No-Scalpel Vasectomy. J Urol 2005; 173:1677-1680.
- Li, S., Goldstein, M., Zhu, J., Huber, D.: The No-Scalpel Vasectomy. J. Urol 1991; 145; 341-4.
- Li, PS., Li, S., Schlegel, PN., Goldstein, M.: External Spermatic Sheath injection for vasal nerve block. Urology; 199239:173-6.
- Nirapathpongporn, A., Huber, D. and Krieger, J.N.: No-Scalpel Vasectomy at the King's birthday vasectomy festival. Lancet. 1990; 335; 894.
- Viladoms, JM., Li, PS.: Vasectom¡a sin Bistur¡. Arch. Esp. de Urol. 1994; 47; 695-701.
- Kaza, RM., Singh, I., Singhal, S., and Kumaran, V.: An evaluation of the No-Scalpel Vasectomy technique. BJU Int (England), Feb 1999, 83(3):283-284.
- Goldstein, M., Young, GPH., and Einer-Jensen, N., Testicular artery damage due to infiltration with a fine gauge needle: Experimental evidence suggesting that blind cord block should be abandoned. Surgical Forum 24:653-656, 1983.
- Liu, X., Li, S.: Vasal sterilization in China. Contraception, 1993; 48(3): 255-65.
- Wilson, CL.: No-needle anesthetic for no-scalpel vasectomy. [Letter] American Family Physician. 63(7):1295, 2001 Apr 1.
- Ellis, GI., Owens, A.: The efficacy and acceptability of using a jet injector in performing digital blocks. Am J Emerg Med. 1993;11:648-650.
- Bennett, J., Nichols, F., Rosenblum, M., Condry, J.: Subcutaneous administration of midazolam: a comparison of the Bioject jet injector with the conventional syringe and needle. J Oral Maxillofac Surg. 1998;56:1249-1254.
- Munshi, AK., Hegde, A., Bashir, N.: Clinical evaluation of the efficacy of anesthesia and patient preference using the needle-less jet syringe in a pediatric dental practice. J Clin Pediatr Dent. 2001;25:131-136.
- Zsigmond, EK., Darby, P., Koenig, HM., Goll, EF.: Painless intravenous catheterization by intradermal jet injection of lidocaine: a randomized trial. J Clin Anesth. 1999;11:87-94.
- Cooper, JA., Bromley, LM., Baranowski, AP., Barker, SG.: Evaluation of a needle-free injection system for local anaesthesia prior to venous cannulation. Anesthesia. 2000;55:247-250.
[ back to top ]
Advances in Vasectomy - No Needle, No Scalpel...No Problems?
(Lead Story, Physician's Weekly March 6, 2006)
|
A no needle technique that delivers local anesthesia in patients undergoing vasectomy appears to be a simple and safe approach that yields high patient satisfaction. The hope is that eliminating needles will decrease the fear of needles in men electing for a vasectomy.
|
Vasectomy is the one of the safest and most dependable methods of permanent contraception available to men. It is estimated that about 500,000 vasectomies are performed each year in the United States. With the traditional technique for vasectomy, surgeons usually require 20 to 30 minutes to complete the procedure. Patients can return to work fairly quickly, but they do have some pain. Moreover, research has indicated that 1% of traditional procedures have complications, which include bleeding, hematoma, and infection.
In 1975, Li Shunqiang, MD, developed the no scalpel vasectomy in China. Since that time, the procedure has been adopted in the United States and about 15 million Americans have undergone a no scalpel vasectomy. In addition to being an effective contraceptive, clinical studies have shown that it is associated with a 10-fold reduction in complications when compared vasectomy.
Reducing Pain & Complications With a New Approach
A no needle, no scalpel vasectomy is a unique and nearly painless technique for anesthetizing the scrotal skin and the vas deferens. An anesthetic solution is sprayed through the skin and around the vas deferens using a high pressure jet injector (Table 1). According to Marc Goldstein, MD, FACS, patients describe the sensation of the no needle, no scalpel procedure as "a gentle snap of a rubber band against the scrotal skin." He says "the technique delivers local anesthesia for vasectomy with less pain, which is important because most men are afraid of the needle puncture involved in traditional vasectomy. After the procedure, patients often return to their daily routine within just a few days because there is little or no pain and because no stitching is involved."
Additionally, the no needle, no scalpel vasectomy takes an average of about seven minutes to complete for an experienced surgeon, according to Dr. Goldstein. "Another key advantage is that it requires the use of less lidocaine. Only 0.6 cc of an anesthetic are required because it’s more directly targeted to the treatment area [Table 2]. A cone-shaped distribution of the anesthetic is administered and provides effective anesthesia. In turn, the patient experiences much less postoperative swelling."
Learn the No Scalpel Approach First
According to Dr. Goldstein, mastering the no scalpel procedure is necessary before surgeons can begin to learn the no needle, no scalpel vasectomy. "The traditional vasectomy is simple in that we can find the vas deferens more easily when a large incision is made. But the no scalpel approach is all based on feeling the vas deferens and trapping it between the fingers using the three-finger fixation technique. It’s a learning curve that requires much experience."
Accurate placement of the high pressure jet injector is important when learning the no needle, no scalpel vasectomy, according to Dr. Goldstein. "Surgeons can actually inject themselves in the finger with the anesthetic if they fail to place the injector in exactly the right place. However, surgeons can minimize this risk as they become more experienced using the technology."
Can All Patients Receive No Needle, No Scalpel Vasectomy?
According to Dr. Goldstein, most patients seeking a vasectomy can undergo the no scalpel approach. "The only patients who would be excluded from having this procedure would be those who have had extensive prior scrotal surgery. Previous surgery can make it difficult for surgeons to totally visualize the vas deferens. Also, there may be a contraindication if the patient exhibits prior scarring from scrotal surgery or if they have cryptochidism. In the 20 years that I have been performing no scalpel vasectomy, I have had just two patients who have been unable to have the procedure."
With regard to the no needle, no scalpel vasectomy, Dr. Goldstein says that patients are eager to undergo this less invasive procedure. "However, only about two or three institutions in the United States currently have the capability to perform the no needle, no scalpel vasectomy. It may take some time before the procedure becomes more widely available because physicians must acquire the instrumentation and learn the proper technique. The instruments must also be maintained perfectly in order to be utilized safely and effectively. It’s a good practice to have at least two high pressure jet injectors so that an alternative is available should one fail during the procedure."
Review original article (PDF)
[PDF Help]
READINGS AND RESOURCES
- Weiss RS, Li PS. No-needle jet anesthetic technique for no-scalpel vasectomy. J Urol. 2005;173:1677-1680.
- Li S, Goldstein M, Zhu J, Huber D. The no-scalpel vasectomy. J. Urol. 1991;145:341-344.
- Jow WW, Goldstein M. No-scalpel vasectomy offers minimal invasiveness. Contem. Obstet Gynecol. 1996;60:112-121.
- Goldstein M, Li PS, Matthews GJ. Microsurgical vasovasostomy: The microdot technique of precision suture placement. J. Urol. 1998;159:188-190.
- Boorjian S, Lipkin M, Goldstein M. Robotic microsurgical vasovasostomy and Vasoepididymostomy: A prospective randomized study in a rat model. J. Urol. 2004;171:304-306.
- Chan PT, Goldstein M. Superior outcomes of microsurgical vasectomy reversal in men with the same female partners. Fertil Steril. 2004;81:1371-1374.
- Nath NC. No-scalpel vasectomy at a glance. J Indian Med Assoc. 2005;103:273-274, 276-277, 288.
- Nemani PK. No-scalpel vasectomy--hope for future: Historical aspects. J Indian Med Assoc. 2005;103:270, 272.
- Chen KC, Peng CC, Hsieh HM, Chiang HS. Simply modified no-scalpel vasectomy (percutaneous vasectomy)--a comparative study against the standard no-scalpel vasectomy. Contraception. 2005;71:153-156.
[ back to top ]
New No-Needle, No-Scalpel Vasectomy Technique Safe and Effective, Study Shows
From the Weill-Cornell Medical Center
|
NewYork-Presbyterian/Weill Cornell Is First & Only Site in Northeast to Offer New Anesthetic Technique
|
NEW YORK (October 26, 2005) — A new anesthetic technique for vasectomy that does not involve the use of needles has been shown to be safe and effective, according to a recent study presented by Dr. Marc Goldstein of NewYork-Presbyterian Hospital/Weill Cornell Medical Center's Department of Urology. NewYork-Presbyterian/Weill Cornell is the first and only site in the Northeast to offer the new technique.
Among the 1,391 patients anesthetized using the no-needle technique, the average visual analogue scale (VAS) pain score for the injection was 1.65 of a maximum 10. The average VAS score during the surgical procedure was 0.67. No adverse effects were associated with the technique, reported the study, which was authored by Dr. Ronald Weiss of the University of Ottawa School of Medicine, along with NewYork-Presbyterian/Weill Cornell's Dr. Goldstein and Dr. Philip Shihua Li.
"One straightforward benefit of eliminating needles is that people don't like needles," says Dr. Goldstein, who performed the first no-needle case in the Northeast in October, 2004. "In conjunction with no-scalpel vasectomy, developed in China and introduced by me in the U.S. in 1985, no-needle vasectomy helps reduce men's fear of the procedure and represents the next step in the evolution of minimally invasive vasectomy techniques."
Dr. Goldstein is Surgeon-in-Chief of Male Reproductive Medicine and Surgery at NewYork-Presbyterian/Weill Cornell, and Professor of Urology and Reproductive Medicine at Weill Medical College of Cornell University. Dr. Li is Assistant Research Professor of Urology and Reproductive Medicine, and Director of Microsurgical Training and Research at Weill Cornell.
No-scalpel vasectomy — unlike conventional vasectomy, which involves two scrotal incisions — involves one tiny puncture, resulting in fewer complications and quicker recovery time.
The MadaJet non-needle anesthetic, manufactured by MADA Medical Products, Inc., of Carlstadt, NJ, has been widely used in many surgical fields such as dermatology, cosmetic surgery, dentistry and podiatry, as well as for immunization. The FDA-approved device employs a high-pressure spray of anesthetic solution that is delivered through the scrotal skin and into the tissue around the vas.
Source: Weill Cornell Medical College website -
http://news.med.cornell.edu/wcmc/wcmc_2005/10_26_05.shtml
[ back to top ]
No-needle Anesthetic Appeals to Needle-Phobic Vasectomy Patients
by
Theodore V. Benderev, M.D.
(Inside Urology News, vol. 2, no. 2)
Every urologist recognizes that most men are moderately apprehensive about a vasectomy procedure. And while over 500,000 men decide to have this simple, safe procedure each year, many more men think about the idea, but steer away from a vasectomy for various reasons - some real and some imagined. In the United States, of the 1.5 million surgical permanent sterilization procedures, two-thirds are tubal ligation and only one-third are vasectomies. This is even more remarkable when one considers that in Canada the ratios are reversed.
There is a new technique that could dramatically increase vasectomies in the United States over the current favorite alternative of tubal ligation. This relatively simple technique is catching the attention of both patients and doctors, answering one of the classic objections about the vasectomy procedure - the needle. This new anesthetic delivery method removes what many men consider to be the most painful part of the vasectomy: the two needle sticks for delivery of the lidocaine. The availability of a no-needle anesthetic technique may decrease the fear of pain in men and enhance the popularity of vasectomy worldwide.
Jet Spray Device
Five thousand patients in the United States and Canada have already received a jet injection spray instead of the traditional needle to deliver anesthetic to the skin and underlying vasa. In 2001, Charles L. Wilson, M.D. initially described this technique for vasectomy in a letter of communication.
Although relatively new to vasectomy procedures, similar no-needle techniques are commonly used for anesthesia in dentistry and many other areas of medicine with wide acceptance by doctors and patients. According to physician experts, this technique lowers patient fears, reduces pain, and simplifies procedures.
Research Study Reported
The findings of a study of 465 patients titled "No-Needle Jet Anesthetic Technique for No-Scalpel Vasectomy" was presented at the American Urology Association Annual Meeting this year in San Antonio, and was published in the Journal of Urology in May 2005. The paper describes a jetinjector device that produces almost instant anesthesia with an average total lidocaine dosage of only .6cc. The average visual analog scale score for the pain of the jet injection itself was 1.71 of 10. The average visual analog scale score for the pain of subsequent vasectomy during the surgical procedure was 0.66 of 10 (median 0.2). No patients experienced hematomas.
Doctors who described the technique and published their findings - Ronald S. Weiss, M.D. and Philip S. Li, M.D.- conclude this to be a "simple and safe approach with high patient satisfaction, as reflected in low pain scores."
Virtually Painless Option
My own skepticism about how a topical application can achieve such deeper anesthesia was dispelled following observation of the technique. Now, after use in more than 200 patients, the no-needle vasectomy has become the standard technique in my practice. The following patient comment is typical of the experience: “For me, it was completely painless. No-needle vasectomy was even better than what I expected.” The learning curve for jet anesthesia is relatively short, though it is important that the surgeon be skilled in some form of minimally invasive vasectomy, such as the no-scalpel vasectomy. Also, precautions outlined in the manual must be taken to avoid self-injury from the device.
Anesthesia without a needle has been welcomed by many men. Dr. Marc Goldstein, an international authority on vasectomy at Cornell University, reported, “My patients have responded exceptionally well to the no-needle approach for vasectomy.”
Where Will the Public Find Out About This New Technique?
Experience tells us that as more is written about new techniques such as the no-needle vasectomy in the traditional media, men and their families will search for information from the Internet. There are two Web sites available online for information about vasectomy and no-needle vasectomy. These sites are vasectomy.com, established in 1996 and currently the leading site for vasectomy and related information, and noneedlevasectomy.com, with a special focus on this technique.
Public interest and acceptance of the procedure is expected to grow as this technique becomes more widely available - answering the significant objection of many prospective patients. With tubal ligations out-numbering vasectomies in the U.S. by two to one, this technique may finally help more men decide to have a vasectomy rather than a couple opting for female sterilization. And, as public knowledge and response increases, marketing-aware practices will recognize how to change their patient mix to better serve the needs of the public as well as bolster their overall revenues.
Theodore V. Benderev, M.D., is a board-certified urologist and medical director of the multispecialty Incontinence and Pelvic Support Institute in Mission Viejo, CA.
Review original article (PDF)
[PDF Help]
|
