This document provides guidance on performing vasectomies, including preoperative evaluation and counseling, the no-scalpel technique, managing the vas ends, follow-up care, and complications. It emphasizes the importance of thorough patient selection, counseling, and use of the minimally invasive no-scalpel method to reduce risks and optimize outcomes.

2. Overview
 Counseling patients
 Contraindications
 Procedure types
 Postoperative follow up
 Short and long term complications

3. Barriers to Vasectomy
 Cost
 Fears
 Pain of the procedure
 Complications
 Uncertainty about sterility
 Cultural or religious beliefs
 Access to providers

4. Vasectomy
 Providers
 79% Urologist
 13% Family physicians
 8% General surgeons
 Cost
 $350-$1000
 $385 for uninsured patients at SFMR(70%
discount)
 Jeffco $300

5. Vasectomy vs Tubal
Ligation
 Tubal ligation
 Vasectomy is more cost effective, shorter
recovery period, less invasive, less
anesthesia than BTL
 Vasectomy cost is one quarter that of tubal
 Incidence
○ 5.7% of men
○ 16.7% of women
 Higher discrepancy outside the US

6. Preoperative Evaluation
 A preoperative consultation should be
performed in person
 Phone consultation: less desirable
alternative
 We do an in office visit
 History: contraindications, number of children,
relationship status
 Discuss risks/benefits/alternatives
 Physical examination
○ Easily palpable vas deferens
○ Lack of anatomic abnormalities: mass, varicocele

7. Preoperative Counseling
 Permanent procedure
 Not considered sterile until post-vasectomy
semen analysis
 A backup method of birth control should be
used until sterility confirmed
 Risk of pregnancy is 1 in 2000 for men
after vasectomy with post vasectomy
azoospermia or a PVSA showing rare non-
motile sperm
 Need for repeat vasectomy <1%

8. Preoperative Counseling
 Vasectomy is not a risk factor for:
 Prostate cancer
 Testicular cancer
 Coronary artery disease
 Stroke
 Hypertension
 Dementia
 Immune dysfunction
 Best candidate is man over 30 in a
stable, committed relationship

9. Preoperative Counseling
 Relative contraindications
 Varicocele
 Hydrocele
 Cryptorchidism
 Scrotal mass
 Bleeding diathesis
 Absolute contraindications
 Scrotal hematoma
 Genitourinary/groin infection
 Avoid ASA/NSAIDs for 7 days prior
 Diazepam 10mg one hour prior to the procedure
 Relaxes patient
 Relaxes cremasteric muscles

10. Informed Consent
 Discussion with patient and partner is
recommended
 not required for consent
 Procedural consent and MED 178
 Complete at initial visit as you cannot
consent after the patient has taken
diazepam on the day of the procedure
 Medicaid: MED 178
 30 days prior to the procedure
 Complete last section on day of procedure

12. Preparation
 Warm the room to 70-80 degrees
 Relaxes cremasteric and dartos muscles
 Prep
 Betadine or chlorhexadine
 Sterile drape
 Equipment
 Thermal cautery or electrocautery with needle tip
 Anesthetic:
○ Skin: 1cc of 1% lidocaine, 30g needle
○ Vasal block: 5cc per side of 1% or2% lidocaine or ropivicaine without
epinephrine, 27g needle
 4-0 absorbable suture (chromic)
 Instruments
○ Vas clamp/towel clamps
○ Sharp hemostat
○ Scissors
○ Pickups
○ Needle holder

13. Anesthesia
 AUA: Vasectomy should be performed
with local anesthesia +/- oral sedation
 IV or general anesthesia can be
considered for certain patients
 Use of a jet injector (No needle
technique)
 Improved pain with administration of
anesthesia
 No difference in pain during procedure
 Risk of injecting own finger

14. Anesthesia
 0.5-1ml of lidocaine injected over median
raphe in the middle of the scrotum
 With or without epinephrine
 Vasal nerve block
 Vas deferens brought up under median raphe
 2-5ml of anesthetic injected along vas sheath
 Use smallest caliber needle possible
 Consider EMLA

15. Isolation of the Vas

16. Procedure Type
 Traditional vasectomy
 Bilateral skin incisions
 Vas separated, a portion removed and ends
closed with electrocautery, suture or clips
 No-scalpel technique
 Scrotal skin punctured and spread open with
a sharp hemostat <10mm
 Skin opened with vas grasped by vas clamp
 Minimal dissection with vas dissector
 Minimally Invasive Vasectomy

17. No Scalpel Vasectomy
 Benefits
 Reduces operative time
 Reduces operative complications (2014
Cochrane Review)
○ Bleeding
○ Hematoma
○ Postoperative pain
○ Postsurgical infection
 Hastens resumption of sexual activity
 AUA: The vas deferens should be isolated
using a minimally invasive technique such
as the no scalpel method

18. Anatomy
 Innervation
 Ilioinguinal and genitofemoral nerves

19. Isolation of the Vas
 Bring the vas immediately under the
anesthetized wheal and grasp it through
tightly stretched skin with the vas clamp or
towel clamp
 Sharp hemostat used to stab the skin over
vas and spread open
 Vas clamp then repositioned to grasp the
vas without the overlying skin
 The perivasal tissue is dissected free to
expose a loop of vas which is secured with
hemostats

20. Isolation of the Vas

21. Dividing the Vas
 The vas is divided
 A segment of 10-15mm may be excised
 Failure rate most related to method of
management of vas ends
 Histologic examination of limited value
 Irrigation of the prostatic end of no value

22. Methods of Vasal Occlusion
 AUA recommended methods
 Mucosal cautery with facial interposition without
ligature or clip placement
 Mucosal cautery without facial interposition, ligature
or clip placement
 Open ended vasectomy, testicular end open,
abdominal end cauterized with facial interposition
 Non-divisional extended electrocautery
 Clips or ligatures with or without excision of a
segment may be used by surgeons whose training
and experience allow for success with this method.
 Acceptable failure rate threshold <1%

23. Managing the Vas ends
 Fascial interposition without ligation and with
1-1.5cm of intraluminal fulguration of the
prostatic end: ??? most effective method
 Facial interposition significantly reduces risk of
recanalization at 34 weeks
 Ligation of both ends has a failure rate of 1-6%
 Ischemic sloughing of ends leads to recanalization
 Open ended vasectomy
 Leave testicular end open
 Lower rate of congestive epididymitis

24. Methods of Vasal Occlusion

25. Other Methods of Managing
Vas Ends
 Folding back and suturing
 Placement of clips
 Marie Stopes International (MSI)
 Non-divisional extended electrocautery
 Destroy 2.5-3cm of vas without dividing

26. Completing the procedure
 Observe for bleeding and control with
direct pressure and/or cautery
 Return vas to scrotal cavity
 Leave wound open to heal unless
incisional approach used
 Dress with antibiotic ointment and a
sterile dressing with scrotal support

27. Complications
 Most common
 Hemorrhage
 Infection
 Hematoma
 Chronic pain
 Lowest incidence of complications in
providers performing more than 50
procedures/year
 1-2% have hematoma or infection
 1-2% have chronic scrotal pain

28. Sperm Granuloma
 Immunologic reaction to extravasation of
sperm
 Thought to be protective
 May play a role in post vasectomy pain
syndrome
 May play a role in recanalization

29. Post-vasectomy Pain
Syndrome
 Persistent scrotal pain months to years after the
procedure
 Chronic dull pain, worse with ejaculation
 Incidence 1-6%
 Up to 15% report some bothersome pain chronically
 Possible causes:
 Epididymal congestion
 Nerve entrapment
 Treatment
 Mild: NSAIDS, warm baths
 Nerve blocks/steroid injections
 Granuloma excision
 Vasectomy reversal
 Epididymectomy

30. Post Vasectomy Semen
Analysis
 A fresh, uncentrifuged semen specimen should be examined within 1-2
hours of ejaculation
 <100,000 non-motile sperm per ml
 8-16 weeks post procedure is the ideal time
 WHO: One semen specimen analyzed 3 months and 20 ejaculations
after procedure
 Obtain after abstinence for 2-7 days
 Keep at body temperature
 Transport within 60 minutes/Examine within 4 hours
 Protocol more important when confirmation of motility desired
 19% fail to provide a semen sample for analysis
 Repeat specimen in 1-2 months when sperm seen on 3 month
specimen
 CLIA requires that provider performed microscopy be qualitative
 Cannot quantitate sperm concentration, only presence and motility
 Home PVSA kit
 Sensitive to <250,000/ml
 Does not detect motility

31. Vasectomy Failure
 Definition (AUA): presence of motile sperm 6
months post procedure
 Causes
 Recanalization: presence of sperm after a sample
previously showing azoospermia
 Aberrant anatomy: third vas deferens
 Technical error ligation of the same side twice
 Presence of motile sperm on the 3 month
sample likely represents vasectomy failure
 Presence of non-motile sperm should be
followed with monthly semen analyses until
azoospermia achieved

32. Vasectomy Reversal
 Most likely to succeed if done <15 years
after the procedure
 Pregnancy rates post procedure: (patency)
○ <3 years: 76% (97%)
○ 3-8 years: 53% (88%)
○ 9-14 years: 44% (79%)
○ >15 years: 30% (71%)
 Vasovastomy
 Pregnancy rate 45-70%
 Vasoepididymostomy
 Done in cases of epididymal obstruction
 Pregnancy rate 10-50%

33. Vasectomy Reversal
 Cost: $16,000-$30,000
 Factors associated with an increased
risk of desiring reversal
 Age: 12.5% increased risk in 20’s
 Change in marital status
 Men with children
 Alternative: sperm retrieval with IVF

34. Postoperative Counseling
 Refrain from ejaculation for one week
 No prophylactic antibiotics
 No protection against STI’s
 Use another method of contraception
until azoospermia confirmed
 Ice and scrotal support for 48 hours
 NSAIDs/Hydrocodone for pain control

35. Postoperative Counseling
 Normal
 Mild pain, swelling, bruising for 2-3 days
 Blood in the ejaculate
 Observe for
 Increasing pain
 Swelling
 Drainage
 Fevers
 Bleeding
 Return to work
 Light duty in 2-3 days
 No heavy lifting for 7 days
 Need someone to drive patient home
 Keep the area dry for 24 hours, then may shower and
wash gently

36. Alternative Procedures
 Vasal occlusion
 Injected plugs
○ Medical-grade polyurethane or silicone rubber
○ Intra-vas device: polyurethane or silicone plug
 ? Better chance at reversal
 Longer time to sterility
 Percutaneous injection
 Temporary: polymer
 Permanent: sclerosing agent

37. Summary
 Patient selection and counseling
 Proper equipment
 No scalpel vasectomy is preferred
 Follow up PVSA to ensure sterility

38. Questions?