Clinical Conditions

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 2/3 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

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  2. Li, PS., Li, S., Schlegel, PN., Goldstein, M.: External Spermatic Sheath injection for vasal nerve block. Urology; 199239:173-6.
  3. Nirapathpongporn, 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. 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.
  6. 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.
  7. Liu, X., Li, S.: Vasal sterilization in China. Contraception, 1993; 48(3): 255-65.
  8. Wilson, CL.: No-needle anesthetic for no-scalpel vasectomy. [Letter] American Family Physician. 63(7):1295, 2001 Apr 1.
  9. 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.
  10. 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.
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