Evaluation:

• A medical history and physical examination are appropriate. The patient should be questioned regarding medications, drug allergies, and any history of bleeding disorders. Prior scrotal surgery, such as orchiopexy or hydrocelectomy, should be noted, because this may make the procedure more difficult. Any history of testicular or scrotal pain should also be clearly documented.
  
  
• Physical examination of the genitalia should be performed in a warm room to allow for relaxation of the scrotum and detection of any anatomic abnormalities or unusual tenderness. Since men who request vasectomy usually have no specific complaints, it is tempting to perform a cursory exam to simply document the presence of two vasa. This temptation must be resisted. Many men requesting vasectomy are in the age group for which the incidence of testicular cancer is the highest. Furthermore, hernias, hydroceles, or symptomatic varicoceles that need repair should be diagnosed, so that treatment can be offered" concurrently with the vasectomy.
  
  
• Any abnormalities on scrotal examination or unexplained testicular symptoms should be evaluated with a scrotal ultrasound. If one of the vasa is congenitally absent, an abdominal ultrasound should be obtained, because these patients have a high incidence of renal agenesis. A vas that is difficult to palpate may require performance of the vasectomy in the operating room. In our experience, this is fairly unusual. Penile or scrotal infections should be diagnosed and treated prior to the vasectomy. Routine laboratory testing is unnecessary in most cases, and should only be obtained for specific indications.

Counseling:

• The role of vasectomy as a permanent form of sterilization must be emphasized.
  
  
• It is important for the patient to understand how the procedure is done and all potential complications, both short-term and long-term.
  
  
• There is a slight risk of failure (recanalization, 1/500 short-term; 1/4500 long-term) , hematoma (1/1000) and infection (1/1000).
  
  
• Vasectomy does not change semen volume or appearance; only 3% of ejaculate contains all the sperm.
  
  
• Vasectomy does not effect erectile function, libido, or quality of orgasm.
  
  
• Patients should aware that vasectomy reversal is often successful, but success is not guaranteed and the procedure is costly, lengthy, and rarely covered by insurance.
  
  
• Semen can be cryopreserved prior to vasectomy. The cryopreservation of sperm is a service widely available in the New York metropolitan areas. However, men should not count on cryopreserved semen as a guarantee of future fertility.
  
  
• After vasectomy, the patient must provide semen for analysis until two consecutive samples show azoospermia (a zero sperm count); contraception is required until sperm are cleared.

No-Scalpel Vasectomy surgical technique

The ideal No-Scalpel Vasectomy results in minimal bleeding and almost no intra-operative pain. An easy No-Scalpel Vasectomy is facilitated by a warm antiseptic solution for the skin preparation and a warm operating room (20 ?C to 25 ?C), which allows relaxation of the scrotal dartos muscle, facilitating isolation and fixation of the vas deferens.

The patient is placed a supine position. Surgical preparation includes shaving of the skin of the upper scrotum and retraction of the penis with a rubber band onto the upper abdomen, keeping it out of the way. After scrubbing with a Betadine solution, the skin is washed off with a clear water based antiseptic solution.

1. Fixation and isolation of the vas deferens from the spermatic cord:

The procedure begins with fixation of the vas deferens using the three-finger technique, which is the key to local anesthetic technique of the vasal nerve block and the surgical approach to the vas. Starting on the patient's right side, the middle finger of the left of hand is placed beneath the scrotum and the spermatic cord structures are drawn from the mid-line laterally until the vas deferens is trapped between the middle finger the thumb and the index finger. The location of the thumb is just below the optimal site for the puncture wound. The middle finger elevates and isolates the vas. The index finger stabilizes the vas. Once the vas is firmly fixed using the three-finger technique, the vasal nerve block is performed.

2. The NSV Anesthesia Technique: (Li PS, Li S, Schlegel PN and Goldstein M.: External spermatic shealth injection for vassal nerve block. Urology, 39:173-176, 1992).

The No-Scalpel Vasectomy uses an advanced technique to anesthetize the scrotum more effectively. Good local anesthesia is fundamental to a stress-free vasectomy for the patient and the surgeon. The equipment used for the vasal nerve block technique includes a 10 ml syringe, 1% Lidocaine 1% or 2% without adrenaline, and a 1 1/2 inches 25G or 27 gauge needle. The innervation of scrotal skin is separate from that of the testis and epididymis.

The scrotal skin is supplied by fibers of the pudendal, inguinal, and ilioinguinal nerves. The internal spermatic artery (testicular) and veins are located within the internal spermatic fascia. The vas deferens runs between the internal and external spermatic fascias. The deferential artery, vein and nerves are closely related to the vas deferens. The three-finger technique of administering local anesthesia involves injection within the external spermatic fascia but outside of the internal spermatic fascia, thereby minimizing the risk of hematoma and injury to the blood supply of the testis.

After the vas is fixed and isolated from spermatic cord, a 1 cm diameter of superficial skin wheal is raised over the intended puncture site directly above the vas deferens ( A). The needle is then advanced alongside the vas deferens within the vasal sheath toward the external inguinal ring, gently aspirate to ascertain that the needle is not in a blood vessel, and then 3 to 5 ml of 1% or 2% Lidocaine are injected around the vas deferens at a location away from the vasectomy site (B). The left vas deferens is then fixed with the left hand using the three-finger technique and a vasal nerve block is performed in an identical fashion after shifting the previous puncture hole to the new injection site.

3. Surgical procedure:

1. Fixation of the vas deferens: The surgeon stands on the right side of the patient; the vas is separated from the internal spermatic vessels and manipulated to a superficial position just below the middle scrotal raphe using the three-finger technique.
   

   

2. Grasping the vas deferens: The right vas is trapped over the middle finger, held in place by the thumb and index fingers. The right vas deferens is fixed with the ringed forceps by first stretching the scrotal skin tightly over the underlying vas and applying firm pressure downward as the blades of the ring forceps are opened and the vas deferens encircled. The ring forceps are now locked and the scrotum palpated to ensure that the vas deferens is trapped within the ring forceps.
   

   

3. Puncturing the lumen of the vas deferens: Next, the scrotal skin and vas wall are pierced using one left blade of sharpened curved dissecting forceps introduced at a 45 degree angle, exactly in the middle-line of the vas and downward into the lumen. A quick, sharp and single movement should be used to make a clear puncture of the skin down into the vas lumen to a depth of 2 to 5 mm.
   

   

   The left blade is then withdrawn, the curved dissecting forceps are closed, and both blades are re-introduced into the same puncture hole at the same 45 degree angle, with the same depth of 2 to 5 mm into the lumen of the vas deferens.

4. Dissecting the Vas Deferens: The blades of the dissecting forceps are then gently opened to spread the tissue, and a "back-and-forth" stretching movement is used to create a skin opening twice the diameter of the vas. The skin and vas wall are spread, revealing the bare vas deferens and its lumen.

   

5. Delivering the Vas Deferens: Using the right blade of the dissecting forceps, the vas wall is skewered at a 45 degree angle and the dissecting clamp is rotated laterally 180 degrees At the same time that the ringed forceps are released allowing delivery of the vas deferens. The partial thickness of the elevated vas is then grasped with the tips of the ringed forceps to secure it firmly.

   

6. Stripping the Vasal Sheath and Vessels: The sheath and vasal vessels are then carefully stripped from the vas, using a longitudinal not a transverse motion, with the sharp curved dissecting forceps to yield a bare segment of vas approximately 1.5 to 2 cm in length. Be careful to avoid blood vessels.
   

   

7. Vasal Occlusion: After the vas is delivered out of the scrotum, the occlusion technique is applied using the physicians' preferred method. Our method is to use sharp scissors to hemi-transect the vas allowing introduction of the thermal cautery and clips for vasal occlusion. Both ends of vas deferens are cauterized with a battery powered thermal cautery for a length of 1 cm. The lumen is further secured with a medium titanium Weck hemo-clip placed in such a way that the clip form a " V " pointed downward allowing easy return of the occluded vasal ends into the scrotum. After the hemo-clips are placed, a 1 cm length segment of the vas is removed and after checking for bleeding, the ends of the vasa are allowed to return to the scrotum. An identical procedure is performed on the opposite vas through the same puncture hole. After the procedure, antibiotic ointment is placed on the puncture hole and sterile dressings are held in place with scrotal supporter. No sutures are necessary for closure of the puncture hole, which is almost invisible to the patient.
   

   Post-vasectomy considerations

   Post-vasectomy Care:

   • The patient should be instructed to limited physical activity and lie supine as much as possible during the first 24 hours.
     
     
   • Intermittent application of an ice pack during the first 24 hours helps to decrease pain and swelling.
     
     
   • Patients may return to deskwork the next day, but heavy lifting, vigorous activity, and sexual intercourse should be avoided for one week.
     
     
   • Most patients require only over-the-counter medications (Tylenol) for pain control. Aspirin and Ibuprofen like medicines should be avoided pre and post-vasectomy to prevent potential bleeding problems.
     
     
   • Minor pain and bruising are to be expected and do not require medical attention. The patient should seek medical attention if he has fever, excessive pain, swelling, or bleeding from the puncture site(wound).
     
     
   • Patients must understand that other forms of contraception should be continued until two separate semen analyses document azoospermia. The disappearance of sperm from the ejaculate correlates more with the number of ejaculates than with the time interval after vasectomy. Approximately 90% of men will be azoospermic after 15 ejaculations. About 80% of men will be azoospermic 6 weeks after vasectomy, regardless of ejaculatory frequency. If early failure from recanalization occurs, it will usually do so within the first 12 weeks. Based on these observations, we recommend an initial semen analysis 6 weeks postoperatively followed by a confirmatory test 4-6 weeks later. Only after two consecutive centrifuged semen specimens document azoospermia can the patient be told it is safe to discontinue other forms of contraception. However, he also needs to understand that no procedure is 100% successful, including vasectomy.
     
     
   • If the first postoperative semen analysis shows sperm-especially if they are motile- we ask the patient to continue contraception and provide another specimen in 6-8 weeks. The presence of motile sperm persisting 3 months after the vasectomy is a clear sign of failure, and in these cases the procedure should be repeated. Some patients will have rare, non-motile sperm in their ejaculate for many months. Although the exact risk of pregnancy in this population cannot be determined, it is estimated to be below 1%. Couple should be counseled in this regard and be offered a repeat procedure if they desire.

   Complications:
   The chance of failure after No-Scalpel Vasectomy at Cornell is about 0.1%. The most frequent complaints after vasectomy are swelling of the scrotal tissue, bruising, and minor pain. While these symptoms generally disappear without treatment, ice packs and scrotal support provides relief. More serious complications of the No-Scalpel Vasectomy, such as hematomas and infection, are uncommon, less than 0.1% at Cornell.

   • Hematoma is the most common early complication of vasectomy, occurring in 0.1 to 3% of patients. The incidence of hematomas diminishes considerably as the urologists become more experienced. Hematomas can grow to a large size, potentially requiring surgical evacuation and hospitalization. Smaller hematomas can be managed with restricted activity, pain medication, and warm compresses. Patients should be instructed to avoid aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) for 10 days before and after the vasectomy to further reduce the chances of bleeding complications.
   • Sperm granulomas result from leakage of sperm at the testicular end of the vasectomy site. Sperm granulomas occur in 1-30% of patients, and can usually be managed conservatively, most are asymptomatic. However, urologists should be aware that sperm granulomas do predispose the patient to recanalization.
   • Wound infections and epididymitis are rare complications of vasectomy, occurring in 1-3 of every 500 cases. Local wound care and oral antibiotics should be administered as needed.

   Conclusions

   Vasectomy is a simple and effective method for providing permanent contraception. Newer techniques, such as the "no-scalpel" vasectomy, have decreased the incidence of local complications and have enhanced the popularity of vasectomy as a means of birth control. The benefits of NSV are:

   • Less Discomfort
   • Ten times fewer complications than conventional (scalpel) technique
   • No sutures needed
   • 40 to 50% quicker recovery than conventional vasectomy.

   Twenty (FAQ) frequently asked questions about No-Scalpel Vasectomy

   1. What is a Vasectomy?
      Vasectomy is the surgical interruption of the two tubes (vas deferens) that carry a man's sperm from his testicles to his ejaculatory ducts, where the sperm are stored before departure from his body during orgasm. Vasectomy prevents sperm from being added to the man's ejaculation fluid (semen); therefore, he can no longer make a woman pregnant. The sperm containing fluid that is blocked by vasectomy constitutes only 3% of a man's semen volume, therefore, a man will not notice any changes in his semen. Vasectomy is simply an effective, inexpensive, easy-to-perform method of contraception. Over 500,000 men in North America choose vasectomy each year.

   2. What is the No-Scalpel Vasectomy (NSV)?
      It is a safe minimally invasive procedure that reduces vasectomy's already low complication rate. The NSV was developed in China by Dr. Shunqiang Li in 1974 and introduced to the western world by AVSC International and Dr. Marc Goldstein of the New York-Presbyterian Hospital-Cornell Medical Center in 1985. Instead of cutting the scrotal skin, the skin is punctured and the vas id delivered with two special instruments. Over 15 millions men have undergone the NSV procedure worldwide since 1974. It is rapidly becoming the standard vasectomy technique in the United States.

      

   3. What are the benefits of No-Scalpel Vasectomy?
      The benefits of NSV are:
      1. Less discomfort.
      2. Ten times fewer complications than conventional (scalpel) technique.
      3. No sutures needed.
      4. 40 to 50% quicker recovery than conventional vasectomy.

   4. What is different about a No-Scalpel Vasectomy?
      No-Scalpel Vasectomy is different from a conventional vasectomy in the way the doctor approaches the vas deferens. In addition, an improved method of anesthesia helps make the procedure less painful.

      In a conventional vasectomy, after the scrotum has been numbed with a local anesthetic, the doctor makes one or two small cuts in the skin and lifts out each tube in turn, cutting and blocking them so the sperm cannot reach the semen. Then the doctor stitches the cuts closed.

      In a No-Scalpel Vasectomy, the doctor feels for the vas deferens under the skin and holds them in place with a small clamp. Instead of making two incisions, the doctor makes one tiny puncture with a special instrument. The same instrument is used to gently stretch the opening so the tubes can be reached. The vas deferens is then blocked using the same methods as conventional vasectomy. There is very little bleeding with the no-scalpel technique. No stitches are needed to close the tiny opening, which heals quickly, with no scar.

   5. Is No-Scalpel Vasectomy safe?
      Vasectomy in general is safe and simple. Vasectomy is an operation, and all surgery has some risks, such as bleeding, bruising, and infection. However, serious problems rarely happen.

   6. Is No-Scalpel Vasectomy painful?
      No. Since we use a special nerve block anesthetic technique, the No-Scalpel Vasectomy is an almost painless procedure. Before the vasectomy, the doctor may give you a mild sedative to relax you. You may experience mild discomfort when the local anesthesia is administered. However, once it takes effect you should feel no pain. Some men feel a slight "tugging" sensation as the vasa are manipulated.

   7. Will it hurt after No-Scalpel Vasectomy?
      No. Before the vasectomy, the doctor may give you a mild sedative to relax you. After surgery you may be a little sore for a few days. Generally, two or three day's rest is enough time for recovery before men can return to work and most normal, non-strenuous physical activity. Sex can usually be resumed 7 days after the procedure. Afterwards, you will be sore for a couple of days, and you might want to take a mild painkiller. But the discomfort is usually less with the no-scalpel technique, because there is less injury to the tissues. Your doctor or nurse will provide you with complete instructions about what to do after surgery.

   8. How long will a No-Scalpel Vasectomy take?
      It depends upon the doctor, but on average, about 7 to 15 minutes. Most vasectomies are done right in the doctor's office, or in a clinic.

   9. How can I be sure I need a vasectomy?
      Well, first, you must be absolutely sure that you don't want to father a child under any circumstances. Then, talk to your partner; it's a good idea to make the decision together. Consider other kinds of birth control. Talk to a friend or relative who has had a vasectomy. Think about how you would feel if your partner had an unplanned pregnancy. Talk with a doctor, nurse, or family planning counselor.

      A vasectomy might not be right for you if you are very young, your current relationship is not stable, you are having the vasectomy just to please your partner, you are under a lot of stress, or you are counting on being able to reverse the procedure later.

   10. Will a vasectomy change me sexually?
       The only thing that will change is that you will not be able to make your partner pregnant. Your body will continue to produce the hormones that make you a man. You will have the same amount of semen. Vasectomy won't change your beard, your muscles, your sex drive, your erections, or your climaxes. Some men say that without the worry of accidental pregnancy and the bother of other birth control methods, sex is more relaxed and enjoyable than before.

   11. How will vasectomy affect me?
       Vasectomy only interrupts the vas deferens that carry sperm from the testes to where they are added to your semen. It does not alter a man's sensation of orgasm and pleasure. Your penis and your testes are not altered in any way. The operation has no noticeable impact on the man's ability to perform sexually, nor does it affect the balance of male hormones, male sex characteristics, or sex drive. As always, testosterone continues to be produced in the testes and delivered into the blood stream. Your body still produces semen, and erections and ejaculations occur normally. As before, the body naturally absorbs unused sperm. The patient will not feel any different physically from the way he felt before. Vasectomy is simply a sterilization procedure; once it has been performed, a man's semen will no longer contain sperm and he can no longer father a child.

   12. Will I be sterile right away?
       No. After a vasectomy, there are always some active sperm left in your system. It takes about at least 25 ejaculations to clear them. You and your partner should use some other form of birth control until your doctor tests your semen and tells you it is free of sperm.

   13. Can I discontinue other birth control methods right away?
       No! Sperm can remain in the vas deferens above the operation site for weeks or even months after vasectomy. You will not be considered sterile until two post-vasectomy semen analyses show that no sperm remain in your ejaculate. Until then, you must continue to use other birth control methods to prevent pregnancy.

   14. How soon can I go back to work?
       You should not do heavy physical labor for at least 48 hours after your vasectomy. If your job doesn't involve this kind of work, you can go back sooner. Many men have their vasectomies on Friday so they can take it easy over the weekend and go back to work on Monday.

   15. When can I start having sex again?
       Sex can usually be resumed 7 days after the procedure, but remember to use some other kind of birth control until the doctor says you are sterile.

   16. Are there potential complications associated with vasectomy?
       Yes. All contraceptive methods carry some risks as well as benefits. Vasectomy is a very low risk procedure, but complications are possible.
       • Bleeding (hematoma) and infections are the most common (although rare) complications of vasectomy. These occur in 3.1% of men undergoing a conventional vasectomy and less than 0.4% of men undergoing a No-Scalpel Vasectomy. The no-scalpel method we describe is associated with a much lower rate of hematoma because the skin and vas sheath are punctured and the opening is then dilated, so blood vessels are more likely to be pushed aside rather than cut. The risk of a severe complication occurring, one that would require admission to the hospital is less than one in a thousand (0.01%).

       • Failure of the procedure. Vasectomy is not guaranteed to be 100% effective. Even when the procedure is performed perfectly, recanalization, sperm finding their way across the blocked ends of the vas deferens, can occur. Although this is very rare (less than 0.2% of the time), it can occur months or even years later. This demonstrates the necessity of performing semen analyses some 6-8 weeks post-vasectomy to verify that the patient's semen contains no sperm. Recanalization usually occurs in the first 2-3 months after vasectomy (incidence 1/500), but has been known, in extremely rare cases, to occur even years later (incidence 1/4500).

       • Sperm granuloma, a hard, sometimes painful lump, about the size of a pea, may form as a result of sperm leaking from the cut vas deferens. The lump is not dangerous and is almost always resolved by the body in time. Scrotal support and mild pain relievers are usually all that are required to alleviate the symptoms, although the doctor may suggest other treatments.

       • Congestion, a sense of fullness or pressure caused by sperm in the testes, epididymis, and lower vas deferens, may cause discomfort some 2 to 12 weeks after vasectomy. Like granuloma, congestion is not serious and usually resolves itself in time.

   17. Are there long-term health risks?
       Since most men live for a long period of time after a vasectomy, it has been possible to investigate thoroughly, the possibility of long-term health risks associated with vasectomy. Over 10 studies have evaluated more than 20,000 men who have had vasectomies, documenting their progress for up to 25 years after the procedure. The data indicates that men having a vasectomy are no more likely to develop cancer, heart disease or other health problems. In 1993, a panel assembled by the National Institutes of Health, the Association for Voluntary Surgical Contraception (AVSC International), and the National Cancer Institute reaffirmed the conclusion of most medical experts, that vasectomy is a safe and effective means of permanent birth control.

   18. Will it protect me from getting or passing on STDs or AIDS?
       No. It will only prevent you from making your partner pregnant. If you or your partner have a sexual disease, or have more than one sexual partner, the best way to protect yourself and your partner is to use a latex condom.

   19. How much will it cost?
       Costs will include the doctor's fee, medication, counseling, clinic fees, and a follow-up visit to check your semen. Amounts will vary. The doctor or clinic should tell you in advance how much it would be. Your insurance company may pay for sterilization.

   20. Can a vasectomy be reversed?
       An estimated 2% to 6% of men undergoing vasectomy may request a reversal at a later date. In many cases, the cut ends of the vas deferens can be surgically reattached. However, this operation, a microsurgical vasovasostomy, is expensive ($5,000-$10,000) and, for a variety of reasons, does not guarantee a return to fertility. Vasectomy reversal appears to be more successful if performed within 10 years of the vasectomy, but again, there is no guarantee that fertility will be restored. Vasectomy should therefore be considered a permanent procedure. Before you choose to have a vasectomy, make quite sure that you and your partner do not want any more children. If you are thinking about a reversal now, perhaps you should take more time to decide whether vasectomy is right for you. For more information, please visit the section "Microsurgical Vasovasostomy" and "Microsurgical Vasoepididymostomy" in this website.

   References

   1. Li S., Goldstein M., Zhu J., et al: The No-Scalpel Vasectomy. J. Urol 1991; 145; 341-4.
   2. Huber D.: No-Scalpel Vasectomy: The transfer of a refined surgical technique from China to other countries. Advances in Contraception. 1989; 5; 217-220
   3. Nirathpongporn, A., Huber, D. and Krieger, J.N.: No-Scalpel Vasectomy at the King's birthday vasectomy festival. Lancet. 1990; 335; 894.
   4. Viladoms, JM., Li, PS.: Vasectom?a sin Bistur?. Arch. Esp. de Urol. 1994; 47; 695-701
   5. Gonzales B, Maston-Ainley S, Vansintejam G, Li PS: No-Scalpel Vasectomy-An Illustrated Guide for Surgeons. 1992 AVSC International
   6. Liu X, Li S: Vasal sterilization in China. Contraception, 1993; 48(3): 255-65
   7. V; 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
   8. Schlegel PN, Goldstein M. Vasectomy. 1992;AUA Update Series, lesson 13, XI: 98
   9. Li P.S., Li S., Schlegel P.N. et al: External Spermatic Sheath injection for vasal nerve block. Urology; 199239:173-6
   10. Farley TM, Meririk O, Mehta S and Waites GM: The safety of vasectomy. Bull WHO (Switzerland), 1993;71(3-4): 41309
   11. Marquett CM, Koonin LM, Antarsh L, Gargiullo PM, Smith JC: Vasectomy in the United States, 1991. Am J Public Health, 1995; 85(5):644-9
   12. Haw Jm, Feigin J: Vasectomy counseling. Am Far Physician, 1995;52(5): 1395-9
   13. Kendrick JS, Gonzales B, Huber DH, Grubb GS, Rubin GL: Complications of vasectomy in the United States. J Fam Pract. 1987; 25:245-48
   14. Schmidt SS, Minckler, TM: The vas after vasectomy: comparison of cauterization method. Urol 1992; 40:468-70
   15. Genniston GC. Vasectomy by electrocautery: Outcomes in a series of 2.500 patients. J Fam Pract. 1985; 21:35-37
   16. Giovannucci E, Ashcherio A, Rimm EB et al: A prospective cohort study of vasectomy and prostate cancer in US men. JAMA 1993; 269; 873-877
   17. Giovannucci E, Tosteson TD, Speizer FE et al: A retrospective cohort study of vasectomy and prostate cancer in US men. JAMA, 1993; 2-269:878
   18. Howards SS, Peterson HB. Vasectomy and prostate cancer. Chance, bias or a casual relationship? JAMA.1993; 269:914
   19. Harper PB: Experts Advise No Change in Vasectomy Practice: Prostate Cancer Link Doubtful. Association for Voluntary Surgical Contraception News. 1993:31:1-2