VASECTOMY: PROCEDURE AND CASE SCENARIO
MR and Mrs Banda have been married for 17 years with five children. They once went to see the gynaecology doctor some months ago at UTH to discuss some of the contraceptive methods they can use.
However the doctor had discussed with the couple different methods and their side effects. They then went on and discussed with the doctor that they have enough children and they wouldn’t want to have one again, the couple decide to go home and think about the contraceptive methods they would prefer. Few weeks later the couple had decided to do a vasectomy.
I. What is vasectomy?
II. How is the procedure for vasectomy done?
III. What is the complication of a vasectomy?
IV. What are the indication and contraindication of a vasectomy?
Introduction
Vasectomy is a surgical procedure for male sterilisation or permanent contraception, during the procedure, the male vasa deferentia are cut and tied or sealed so as to prevent fertilisation of female through sexual intercourse.
The first recorded vasectomy was performed on a dog in 1823. A short time after that R Harrison of London performed the first human vasectomy. However, the surgery was done not for sterilisation purposes but to bring about atrophy of the prostate.
Then in 1954 vasectomy began to be regarded as a method of consensual birth control.
This paper will highlight the procedure of a vasectomy, its complication and also the indication and contraindication.
PREOPERATIVE EVALUATION
It is recommended that a faceto-face consultation take place with the patient before planning the vasectomy. It is beneficial for the patient’s partner to be present, although this is not required. An appropriate medical history should be taken, focusing on his reproductive history.
Patients should also be questioned about bleeding tendencies and anticoagulant use as per routine preoperative workup. If there is suspicion of coagulopathy, coagulation tests may be necessary; otherwise, preoperative blood work is not needed.
A physical examination of the scrotum should be performed, with emphasis on manually isolating the vas deferens, as well as looking for scrotal abnormality such as undescended testis or testis tumours.
If the patient is unable to tolerate this examination while isolating the vas deferens, he may not be a good candidate for local anaesthesia.
The following points should be addressed at the preoperative visit that is Alternatives to vasectomy, Risk of infection or hematoma (1 percent–2 percent) of patients, Risk of chronic scrotal pain (1 percent–3 percent) patient must be aware to refrain from ejaculation for a week after the procedure.
Vasectomy is considered a permanent procedure. It does not produce immediate sterility; another form of contraception is required after the procedure until vasectomy success is confirmed by semen analysis, patient must be aware of early vasectomy failure.
Procedures of a vasectomy
ANAESTHETIC TECHNIQUE
Vasectomy can be performed under any type of anaesthesia, but most are performed under local anaesthesia because it is well tolerated with minimal morbidity. Certain patients may require intravenous sedation or general anaesthesia if they cannot tolerate the procedure or if the vas is particularly difficult to isolate.
Oral sedation in the form of a benzodiazepine (eg, diazepam) is offered by some clinicians to decrease anxiety and help in relaxing the patient.
Lidocaine or bupivacaine without epinephrine are typically the local anaesthetic agent of choice, and are injected using a small needle (eg, 25 gauge or smaller) to reduce patient discomfort. Some clinicians apply an anaesthetic cream to the skin before the needle stick, although it is unclear whether this significantly decreases pain.
VAS ISOLATION
Vasectomy is performed in two distinct steps: delivering and exposing the vas deferens out of the scrotum (vas isolation) and occluding the vas.
Before the introduction of the no-scalpel technique, vas isolation was performed using the conventional technique, which used a larger incision and involved more dissection without special instruments. The no-scalpel vasectomy was first described in China in 1974. (Li S et al 1992).
The no-scalpel technique has been found to have shorter operative times and to decrease the rate of hematomas, infections, and pain during the procedure. Standard of care is to perform a no scalpel technique or a variation of such that remains minimally invasive.
According to Dr Li Shunqiang, he divided no-scalpel vasectomy into steps as follows
- first isolate the vas manually to a superficial position under the median raphe
- Create skin wheal with local anaesthetic and inject into perivasal sheath.
- Use vas ring clamp to firmly secure the vas through the skin
-With vas dissector at 45 angles to the vas, puncture the skin, vas sheath, and vas wall with the left tip of the vas dissector, then remove. Close the vas dissector and puncture the skin and vas sheath. Spread to make a small opening in the skin, exposing the bare anterior wall of the vas. Puncture the vas with one tip of the vas dissector.
- Use supination motion to deliver a loop of vas above the skin opening while simultaneously releasing the vas ring clamp with the other hand.
- Regrasp the vas with the vas ring clamp. Use vas dissector to gently strip the sheath and vasal vessels away from the vas, yielding a clean segment of vas
- Divide the vas, with or without excision of a vas segment, and occlude the lumen per physician’s preference
Via same puncture hole, fix opposite vas in ring clamp and repeat steps -Leave puncture hole unsutured except in rare cases requiring closure.
VAS DIVISION
Once a loop of bare vas deferens is outside of the wound, it is then divided with scissors. With a traditional vasectomy, a segment of vas is then excised. The optimal length of vas to excise, if any, should be left up to the surgeon.
Excising a long (>2 cm) segment of vas may decrease the chance of recanalisation, (Edwards IS at al 2002) but will also require more dissection along the spermatic cord, increase complications, and make vasectomy reversal more challenging and less successful. According to Practice Committee of the American Society, the author believe that if a segment of vas is excised, it should not exceed 1 to 2 cm in length.
According to Matthew
Det al 2013. If a segment of vas is excised, sending the excised segments for histologic examination is not necessary. The measure of vasectomy success is determined by the results of the post vasectomy semen analysis (PVSA) rather than confirming vasal tissue on histologic evaluation.
Despite this, some surgeons continue this practice because they find it useful to confirm vasal excision, and also out of fear of litigation in the case of a postvasectomy pregnancy.
VAS OCCLUSION
According to Matthew Det al 2013 Vasectomy success can be measured by either azoospermia on PVSA or absence of pregnancy after vasectomy.
In terms of achieving vasectomy success, the most important step comes after division of the vas and occlusion of the vas. There are several vasocclusion techniques, including intraluminal cautery of one or both ends, ligation with suture, occlusion with clips, fascial interposition, and any combination of these.
Review of the literature reveals many studies examining each of these techniques, yet it is difficult to conclude which occlusion method is superior, owing to study flaws and lack of uniformity in terms of patient follow-up and measurement of success. Several methods of vas occlusion have been identified. (Matthew Det al 2013)
Intr aluminal cautery, or mucosal cautery, is performed by applying thermal cautery or low-voltage electrical cautery with a needle tip within the lumen of the vas. It is unclear as to what length of cauterized mucosa is required to create occlusion, but most surgeons cauterize between 5 and 15 mm of vas lumen.
The goal is to destroy only the mucosal layer, which then scars to create a plug in the lumen. Avoiding thermal injury to the muscular layer prevents complete sloughing of the cauterized vas segment, which could potentially allow recanalization. to (Matthew Det al 2013) When mucosal cautery is applied to both the abdominal and testicular ends of the divided vas deferens without using less than 1 percent.18–20 Fascial interposition has become a commonly used technique, because when used with other methods of occlusion it decreases vasectomy failure rates.(Sokal D et al 2004).
The goal is to separate the two newly divided ends of the vas to reduce the chance of recanalization. To do so, a layer of vas sheath is placed between the two ends of the vas as a tissue barrier with the help of one or two absorbable sutures The fascial layer can be placed over the abdominal or the testicular end. When fascial interposition is combined with mucosal cautery of both ends of the divided vas, failure rates are less than one percent.
COMPLICATIONS
Complications of infection and hematoma are uncommon using minimally invasive vas isolation, with the rate somewhere on the order of one to two percent.
As discussed earlier, the risk of these complications is less with the minimally invasive techniques than with conventional open vasectomy.
There are rare reports of Fournier gangrene occurring postoperatively, one case of which resulted in death. (Kendrick JS et al 1987)
Debilitating chronic scrotal pain may occur in men immediately or years following their vasectomy and is sometimes referred to as post vasectomy pain syndrome.
In some cases, the pain may be severe enough to adversely affect the quality of life. (Matthew Det al 2013)
According to McMahon AJ et al, Patients should be warned of this risk before proceeding with surgery. Various studies differ in the reported rate of post vasectomy pain.
The only comparative study showed that six percent of a group of 101 vasectomised men had pain severe enough to seek medical attention, compared with two percent of no vasectomised men.
Leslie and colleagues found in a prospective audit that among 593 vasectomised men, 0.9 percent described a pain that affected their quality of life at seven months postoperatively.
Two questionnaire-based retrospective studies with followup over four years revealed pain affecting quality of life in 2.2 percent of men in one study, and five percent in the other.
Therefore, during the informed consent process each patient should be aware of the small risk of chronic scrotal pain, which appears to be around one to three percent.
Contraindication of vasectomy
Anatomical abnormality such as the inability to palpate and mobilise both vas deferens or large hydroceles or varicoceles, post Trauma and scarring of the scrotum and also acute local scrotal skin infection.
Indication of Vasectomy Vasectomy is indicated for any fully informed man who does not want to father any children or any additional children and who desire an inexpensive outpatient method of voluntary permanent surgical sterilisation.
Conclusion
Vasectomy has proved to be a safe and effective form of sterilisation. It is underutilised in comparison with tubal ligation, even though vasectomy is simpler, faster, safer, and less expensive.
The preoperative visit prior to vasectomy is important for discussion of expectations and risks, including the less than one percent risk of vasectomy failure and the need for contraception after the procedure until the PVSA shows successful vas occlusion.
The no-scalpel vasectomy technique of vas isolation and its minimally invasive variations have decreased the complication rates for vasectomy. The vas occlusion technique determines the chance of vasectomy success