The No-Scalpel Vasectomy uses an advanced technique to approach the vas deferens. Two special instruments are used for this procedure. A scalpel is not needed. These two instruments are (1) ring fixation forceps and (2) dissecting forceps.
The Ring Fixation Forceps:
The surgeon uses the ringed tip of this instrument to encircle and to grasp the vas. It has a special cantilevered design that prevents injury to the scrotal skin. When this ringed forceps is locked, the pressure on the scrotal skin is reduced preventing inadvertently puncturing the skin. The common ring size for European men is 3.5mm diameter and for Asian men is 3.0 mm diameter.
The Dissecting Forceps:
It is similar to a sharpened curved hemostat, except the tips are sharply pointed. It is used as a trocar to puncture and dilate the scrotal skin providing an opening through which the vas can be delivered. This instrument is also used to dissect and deliver the vas.
Additional instruments and supplies needed for No-Scalpel Vasectomy are those normally used in minor office surgery. A 10 ml syringe with a 1 1/2 inch, 25 or 27 gauge needle is used to introduce the local anesthetic into the skin and to affect the selective anesthetic blockade of the deferential nerves around the vas. A straight pair of scissors is used to cut the vas deferens. Depending on the surgeons preference, a hand-held battery powered thermal cautery or an electrical cautery, hemo-clips or ligature are used to occlusion the vas.
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- Prior to vasectomy, the patient should be counseled to consider vasectomy a permanent surgical contraception.
- It must be emphasized that although vasectomy reversal is often successful, it is costly, and not 100% effective in restoring fertility to the man who has undergone vasectomy. Although not required, involvement of the spouse or partner in the decision-making and in witnessing the consent is highly recommended.
- 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.
- 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
- 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.
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.
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.