No scalpel vasectomy

No scalpel vasectomy

No scalpel vasectomy is a type of ‘minimally invasive’ vasectomy. For a no-scalpel vasectomy, the urologist feels for the vas deferens under the skin of your scrotum and holds it in place with a small clamp. A tiny hole is made in the skin and stretched open so the vas deferens can be gently lifted out. It is then cut, tied or seared, and put back in place. No scalpel vasectomy leaves a small 2-3mm hole at the front of the scrotum. No stitches are required and healing time is minimal. Lidocaine 1% with or without epinephrine can be used to anesthetize the scrotal skin puncture site. Alternatively, a no-needle anesthetic technique is increasing in popularity compared with the standard needle infiltrative technique and uses a jet-injector device to deliver a high-pressure anesthetic spray of 0.3 mL lidocaine 2% through the intact skin and into the vas deferens and surrounding vas deferens tissues 1). Minimal trauma to the tissue means that you can return to work and physical activities sooner. Traditional vasectomy requires incisions and stitches on both sides. No scalpel vasectomy procedure offers the advantages of lower expense, lower level of invasiveness (ie, does not require general anesthesia or hospitalization), and quicker recovery time.

The no-scalpel vasectomy was originally developed in China in 1974 and first introduced in the United States in 1984, is an innovative approach to exposing the vas deferens using 2 specialized surgical instruments 2). A recent Cochrane Review concluded that the no scalpel vasectomy, as compared to traditional incisional technique, resulted in less bleeding, hematoma, infection, and pain, and a shorter operative time 3). According to one study, 37.8% of physicians, including urologists, family practitioners, and general surgeons, were using the no scalpel vasectomy technique by 2002 4).

No scalpel vasectomy is indicated for any fully informed man who does not want to father any children (or any additional children) and who desires an inexpensive outpatient method of voluntary permanent surgical sterilization.

Can my partner tell if I have had a vasectomy?

Sperm adds very little to the semen volume, so you shouldn’t notice any change in your ejaculate after vasectomy. Your partner may sometimes be able to feel the vasectomy site. This is particularly true if you have developed a granuloma.

Will my sense of orgasm be changed by having a vasectomy?

Ejaculation and orgasm are usually not affected by vasectomy. The special case is the rare man who has developed post-vasectomy pain syndrome.

Can I become impotent after a vasectomy?

An uncomplicated vasectomy can’t cause impotence.

Can a vasectomy fail?

There is a small chance that a vasectomy may fail. This occurs when sperm leaking from one end of the cut vas deferens find a channel to the other cut end.

Can something happen to my testicles?

In rare cases, the testicular artery may be hurt during vasectomy. Other problems, such as a mass of blood (hematoma) or infection, may also affect the testicles.

Can I have children after my vasectomy?

Yes, but if you haven’t stored frozen sperm you’ll need an additional procedure. The vas deferens can be microsurgically reconnected in a procedure called vasectomy reversal. If you don’t want to have vasectomy reversal, sperm can be taken from the testicle or the epididymis and used for in vitro fertilization. These procedures are costly and may not be covered by your health plan. Also, they don’t always work. If you think you may want to have children one day, you should look into nonsurgical forms of birth control before deciding to have a vasectomy.

No scalpel vasectomy anatomy

To understand the no scalpel vasectomy procedure, it is important to understand the basic anatomy and physiology of the seminal tract. Sperm is produced and then released into the seminiferous tubules. The sperm transits through the rete testis, efferent ductules, and into the epididymal tubule. See figures 1 and 2.

Epididymis

The epididymis consists of a single, highly convoluted tubule that is covered with tunica vaginalis. By convention, the epididymis is divided into the following anatomic segments: (1) the caput (head), (2) the corpora (body), and (3) the cauda (tail).

The proximal epididymis is involved in sperm maturation, whereas the distal region is the area of sperm storage. Vasoepididymal anastomosis to the more proximal epididymal tubule results in lower pregnancy rates because this bypasses a region of vital importance for sperm development.

Vas deferens

At the terminal end of the epididymis, a thick muscle wall that forms the proximal end of the vas deferens surrounds the tubule. The vas deferens follows the spermatic cord, courses through the inguinal canal, and enters the pelvis via the internal inguinal ring. From the pelvis, the vas travels behind the bladder and joins with the ipsilateral seminal vesicle to form an ejaculatory duct, which enters the prostate posteriorly. Contraction of the muscular wall of the vas deferens serves to propel sperm from the epididymis into the prostatic urethra via the ejaculatory ducts.

Figure 1. Male reproductive organ anatomy

male reproductive system

No scalpel vasectomy contraindications

Contraindications to no-scalpel vasectomy include the following:

  • Anatomic abnormalities, such as the inability to palpate and mobilize both vas deferens or large hydroceles or varicoceles
  • Past trauma and scarring of the scrotum
  • Acute local scrotal skin infections

No scalpel vasectomy complications

Complications of no scalpel vasectomy can be divided into the 3 major categories of intraoperative, early postoperative, and late postoperative.

Intraoperative complications

Extraneous injection of the perivasal block results in damage to small vessels and hematoma formation. Usually, these hematomas are very small and can be managed without surgery by using rest, ice, and nonsteroidal anti-inflammatory drugs (NSAIDs).

Major surgical damage to spermatic vessels can result in testicular compromise and atrophy; this complication is often not realized until late in the postoperative course. This rare and unfortunate complication requires urologic consultation and may, ultimately, result in orchiectomy.

As with any surgical procedure, unrealized minor damage to the nerves can result in immediate postoperative pain or persistent chronic pain.

Early postoperative complications (during the first postprocedure week)

Small (1-2 cm) hematomas or wound infections can develop. Large hematomas are possible from severed perivasal vessels leaking into the easily expandability scrotal tissue. These hematomas are diagnosed by physical examination and, unless they are extremely large, can often be treated with ice, rest, and expectant management.

Because the no scalpel vasectomy technique involves pushing vessels around the puncture site and perivasal fascia rather than cutting them, the incidence of hematomas has been reduced. In China, where the no scalpel vasectomy technique originated, the literature on no scalpel vasectomy indicates a hematoma rate of 0.09%. A randomized controlled trial by Sokal et al 5) in 1999 found a hematoma rate of 0.3% in the no scalpel vasectomy group compared to 12.2% in the traditional incisional group. A Chinese series of over 150,000 operations revealed an infection rate of only 0.91% 6). Most recently, a Cochrane review concluded that no scalpel vasectomy resulted in less bleeding, hematoma, infection, and pain, as well as shorter operation times, than the incisional method 7).

Late postoperative complications

Epididymal congestion is noted by patients as swelling and tenderness surrounding the epididymis or testicle that is accentuated by movement or strenuous activities. On examination, the testicle is usually enlarged, tender, and with a slightly indurated epididymis; however, fever is not usually present. This condition is thought to be noninfectious and related to vascular and lymphatic congestion. The application of heat and use of NSAIDs (nonsteroidal anti-inflammatory drugs) usually resolves symptoms within a week. If fever, elevated white count, or accentuated redness or tenderness is found, local infection should be considered.

A sperm granuloma may develop. This typically occurs during the second or third postoperative week and involves up to 25% of patients. This complication should be considered if, on examination of the patient, a small, palpable, pea-sized nodule is found at the testicular end of the transected vas deferens. Once again, NSAIDs are used to resolve this problem, though persistent pain sometimes requires surgical removal of the nodule.

Development of a persistent pain syndrome affects a very small number of postvasectomy patients approximately 1 per 1000 patients 8). Even so, most of these patients state they do not regret having had the procedure. Patients often question whether undergoing a vasectomy will change their sexual potency or performance. In outside studies and in this author’s experience, the reduced fear of pregnancy and increased ease of spontaneous intercourse usually results in improved, rather than diminished, sexual function.

While conservative therapies are often effective for treating post-vasectomy pain syndrome, refractory cases may be treated with vasectomy reversal. In a recent series from Canada, 13 of 14 men who underwent vasovasostomies experienced an improvement in pain and quality of life 9). Half of the patients were rendered pain-free, signifying vasectomy reversal as an effective treatment for the post-vasectomy pain syndrome.

At one time, increased instance of heart disease or prostatic cancer in patients who underwent vasectomy had been considered. According to long-term follow-up studies of patients who have undergone vasectomy, such increased instances are not evident 10). A 2002 study by Cox et al 11) found no increased risk of prostate cancer in these patients even 25 years after the procedure.

No scalpel vasectomy recovery

You may be uncomfortable after your vasectomy. You may need mild pain medications to take care of any pain. Severe pain may suggest infection or other problems, and you should see your urologist. You may have mild pain like what you’d feel like several minutes after getting hit “down there.” A benign lump (granuloma) may form from sperm leaking from the cut end of the vas deferens into the scrotal tissues. It may be painful or sensitive to touch or pressure, but it isn’t harmful. This usually gets better with time.

Your urologist will give you instructions for care after a vasectomy.

You should go home right away after the procedure. You should avoid sex or activities that take a lot of strength. Swelling and pain can be treated with an ice pack on the scrotum and wearing a supportive undergarment, such as a jockstrap. Most men heal fully in less than a week. Many men are able to return to their job as early as the next day.

Sex can often be resumed within a week after the vasectomy. But it’s important to know that a vasectomy doesn’t work right away. After the vasectomy, new sperm won’t be able to get into the semen, but there will still be lots of sperm “in the pipeline” that takes time to clear. You will have to follow up with your urologist for semen analysis to check for sperm in your ejaculate. During this time, you should use other forms of birth control.

The time it takes for your ejaculate to be free of sperm can differ. Most urologists suggest waiting to check the semen for at least 3 months or 20 ejaculates, whichever comes first. One in 5 men will still have sperm in their ejaculate at that time, and will need to wait longer for the sperm to clear. You shouldn’t assume that your vasectomy is effective until a semen analysis proves it is.

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