Vasectomy

Anatomy and Physiology

The majority of the pertinent anatomy encountered during a vasectomy is within the scrotum. Multiple layers of the scrotum must be entered to gain access to the vas deferens. The tissues that will be encountered, superficial to deep, include the skin, Scarpa’s fascia, dartos, external spermatic fascia (continuation of external oblique), cremaster muscle (continuation of internal oblique), internal oblique fascia (continuation of transversalis fascia), tunica vaginalis (derived from peritoneum), tunica albuginea, and the testicle. The epididymis is on the posterior aspect of the testicle with the head on the superior aspect and the tail on the inferior aspect of the testicle. The epididymal body is between the head and tail. The vas deferens or ductus deferens starts at the tail of the epididymis and runs superiorly and medially with the spermatic cord through the external inguinal ring and the inguinal canal, then into the peritoneum through the internal inguinal ring. The vas deferens enters the ejaculatory duct where it meets with the seminal vesicles. It then travels through the prostate and enters the urethra at the seminal colliculus and ejaculatory duct. It is covered by a vas sheath with its own arterial blood supplied by the artery of the vas deferens. Venous drainage is through the pampiniform plexus, with innervation by short adrenergic neurons. 

Indications

Vasectomy is an elective procedure for male sterilization and pregnancy prevention. Therefore, the performing physician must talk about the risks, benefits, and alternatives. The decision should not be made lightly or hastily. When discussing with patients, the permanency of the procedure needs to be stressed. Generally, the recommendation is that both the patient and partner should be involved in this decision, but ultimately, only the consent of the patient undergoing vasectomy is absolutely necessary. While a vasectomy can be reversed, this should not be used as an argument to have the vasectomy performed.  If a patient is considering a vasectomy and is not sure that this is an acceptable, permanent solution for him, then he should not have the procedure.  The most common reason for men requesting a vasectomy reversal is divorce and remarriage.

Contraindications

There are no absolute contraindications for a vasectomy. There are relative contraindications to an office vasectomy, but these can be mitigated by performing the vasectomy in the operating room. Contraindications to an office vasectomy include difficulty isolating the vas deferens during the scrotal exam at the initial evaluation, coagulopathy, previous scrotal surgery, chronic orchialgia, or testicular pathology such as a malignancy. Some patients may present an ethical dilemma to the physician (young age, no children, lack of agreement with the partner, current pregnancy, and possibility of fetal loss), which the physician will need to consider during a consultation. In most cases, we recommend that patients wait until after a successful delivery before doing a vasectomy if it is requested during a pregnancy. 

Equipment

• Antimicrobial prep 
• Fenestrated drape 
• Sterile gloves 
• Anesthetic: plain lidocaine with syringe and needle for injection or pneumatic injector 
• Sharp vasectomy dissecting forceps 
• Vas tenaculum or vas ring forceps 
• Cautery (pencil or bovie) 
• Forceps 
• Vas scissors 
• Clip applier or suture 
• Needle driver 
• Absorbable suture for closure of skin
• Suture scissors 
• Hemostats 
• Antibiotic ointment 
• Sterile gauze 
• Atheletic supporter
• Operating light (optional)
• Consideration of loupe magnification for the physician

Personnel

Generally, there are one or two medical professionals involved in performing a vasectomy: the performing physician and sometimes an assistant.

Preparation

It is imperative for the provider who will be performing the vasectomy to meet and discuss the vasectomy with the patient before the procedure. This consultation should begin with a complete medical, sexual and social history. The medical history should focus on genitourinary problems, scrotal pain, trauma to the genitals, surgery to genitals, sexual function and any testicular malignancy. Hematologic issues, including anticoagulation or medical coagulopathy, require discussion. Social history should include consideration of their partner and pregnancy potential, prior pregnancies, and previous difficulties with pregnancy.  

Next, a physical exam should follow, focusing on the genitalia. The scrotum gets evaluated with a focus on the tolerability of the exam, the vas deferens mobility, the presence of hernias, varicoceles, spermatoceles, testicular masses, or testicular tenderness. 

After the provider evaluation, a frank discussion regarding the risks, benefits, and alternatives to vasectomy should be performed, allowing informed consent. The following are key concepts that require consideration:[4][5]

• Vasectomy is considered permanent
• The patient is not considered sterile until a semen analysis shows azoospermia or rare non-motile sperm
• Risk of pregnancy with a negative semen analysis is 1 in 2000
• 0.24% of men require repeat vasectomy
• Risks of the procedure as well as the alternatives

The risk of hematoma and infection is about 1% to 2%, with very rare cases of Fournier gangrene.[6][7] The risk of chronic scrotal pain is believed to be about 1% requiring further management, and the risk of epididymitis is also approximately 1%.[5][8] Sperm granulomas occur less than 5% of the time, and even fewer are symptomatic.[9] Men require instruction that they will continue to ejaculate and produce semen but it will be devoid of sperm and that generally, no difference is noted in the ejaculate volume as sperm only make up about 10% or less of the semen.[10] Testosterone and libido following vasectomy has been studied and has been shown to be unaffected.[11][12]

Alternative types of vasectomies include: operating room, no-scalpel technique, laparoscopic, and open (which are typically associated with another abdominal surgery). Alternatives forms of pregnancy prevention include abstinence, withdrawal, condoms, spermicidal solutions, diaphragm, cervical cup, IUD, OCP, implants, depot injections, lactation amenorrhea method, emergency contraception, and tubal ligation. 

Our policy is to ask the patient to take a shower the night before and again the morning of the procedure to get the scrotal area as clean as possible.  We also suggest that they shave the scrotum themselves the night before and give them detailed written instructions or refer them to a YouTube video that explains exactly how to do the shaving. 

Technique or Treatment

Prepping and Draping

Typically, the patient shaves the scrotum before or has it shaved at the time of the procedure. Then, the scrotum is washed and prepped with an antimicrobial solution, and the surgical field is isolated with a fenestrated drape. The scrotum is exposed through the opening of the drape, with the penis isolated underneath. We generally ask the patient if they would like a narration of the procedure. Some men prefer narration, but others prefer silence. Music is often a distraction technique. 

Procedure

Note: There are numerous ways to perform vasectomies – the two basic requirements are the isolation of the vas deferens and occlusion of the vas lumen. This procedure description is very general and represents just one of many ways to perform a vasectomy, and any method is acceptable, as long as it accomplishes isolation and occlusion.[13]

The vas is identified manually and held with the thumb of the left hand underneath and stabilized between the first two fingers of the left hand.  This makes the vas close to the anterior surface of the scrotum.  A local anesthetic is then injected into the skin and optionally into the peri-vasal space.

The skin is opened either with a scalpal or the tip of a sharp dissector. Our preference is to use a scalpel, then use the local anesthetic again to infiltrate the area around and immediately underneath the vas.  If using a direct puncture technique, then the infiltration of the per-vasal tissues is recommended before incising the skin.

A small hemostat or the tips of the dissector may be used to open the skin incision and create space around the vas.  The vas deferens is then grasped with the vas tenaculum or a sharp towel clip. An additional anesthetic may be added as needed at this point.  

The vas deferens and peri-vasalar tissue are grasped with the vas tenaculum to provide traction as the sharp dissector is used to remove the peri-vasal tissue; this is done by again spreading the tips of the sharp dissector while within the peri-vasal tissue. There are times when the vas tenaculum is used to regrasp the vas deferens because as more tissue has been released, the vas deferens becomes more isolated. Generally, a length of about 2 cm of vas deferens is exposed through the puncture wound. At this point, the vas deferens has been ISOLATED from the peri-vasal tissue.

The vas sheath can now be opened. This is done by using the scalpel longitudinally along the exposed vas sheath. A small hemostat can then be used to separate the vas from the sheath.  Once this is done, the vas can easily be pulled to give more length. Our preferred technique is to place the hemostat under the vas for traction and then to place clips.  We prefer clips because sutures may cut through or slip off more often.  We place two clips on either side, then a hemostat on one of the clips on either side as a precaution.  At this point, a portion of the vas can be removed; typically abou 1 cm in length. The ends or tips may cauterized but the hemostats remain in place to control both ends. 

One end is allowed to retract while the other end is maintained using forceps or the hemostat which allows for a fascial interposition, if desired. The vas sheath may be reapproximated with either a clip or suture but we usually just leave it alone. Hemostasis requires review and possible cautery; especially to the vasal artery which runs in the sheath.  After a careful evaluation, the vas is allowed to retract into the scrotum by removal of the tenaculum first, then the remaining hemostat.

The surgeon then performs the same procedure on the opposite side. The dartos and skin are reapproximated with electrocautery, suture, or nothing if small enough and hemostatic. The wound gets covered with antibiotic ointment or possibly some Dermabond, and gauze is placed over the ointment to prevent the fouling of undergarments. We usually prefer to use a small bunch of gauze pads and a scrotal support to provide mild compression to the surgical site immediately after the procedure. 

The patient is slowly cleaned up and prepared to discharge. We generally have patients stay for a short time following to ensure they are not feeling faint or experiencing any significant bleeding or scrotal swelling.  

Post Vasectomy Semen Analysis (PVSA)

A semen analysis is generally performed 8 to 16 weeks following vasectomy. PVSA is necessary within 2 hours of ejaculation. The sample should be moved at room temperature and kept undiluted and uncentrifuged. Microscopic evaluation hopes to reveal azoospermia or rare non-motile sperm. Rare non-motile sperm has been defined as fewer than 100000 per ml,[14] more practically if 2 or more sperm per high-powered field (100x) in 20 fields or if motile sperm are present, this represents failure.[15] If over 100000 per ml non-motile sperm or motile sperm are visible, a repeat semen analysis will be required at 6 months post-vasectomy as 30 to 50% will achieve azoospermia within 6 months.[16] If sperm are again present, this is a failure, and the patient will require repeat vasectomy.  

Post-procedure

Post-procedure care will require discussion and written instructions. Following the procedure, patients will experience some pain. Pain should be controlled in a multimodal way, utilizing ice, supportive undergarments, acetaminophen, ibuprofen, and possible narcotics. Patients may have some blood from the wound and local erythema, but after 2 days, this should improve. The recommendation is to limit activity and aggressive sexual activity for approximately 3 to 5 days. Showering can resume post-procedure, day 0, but the patient should delay submerging incision with bathing or swimming for 5 to 7 days. Generally, no follow up is required except for the semen analysis or if complications or patient concerns arise.

Many practices will require a post-vasectomy semen analysis or sperm count before they will certify that the vasectomy is working.  We typically will request this at about 3 months post-vasectomy and then call the patient with the results. 

Complications

Procedure

Common patient experiences during the vasectomy include pain at the surgical site and pain and pressure within the abdomen. Select patients can become nauseous and experience lightheadedness. The proceduralist can encounter bleeding or difficulty isolating the vas deferens.  

Post-procedure

Early: Hematospermia is infrequent and resolves without intervention.[17] The risk of hematoma and infection is about 1%  to 2%, with very rare reported cases of Fournier's gangrene.[7][6] The risk of epididymitis is approximately 1%.[5]

Late: The risk of chronic scrotal pain is believed to be about 1% requiring further management.[8] Sperm granulomas occur less than 5% of the time, and even fewer are symptomatic.[9] With azoospermia or under 100,000 per ml of non-motile sperm, the risk of pregnancy is around 1 in 2000.[4] There is also a 0.24% possibility of failure of vasectomy, requiring a repeat procedure.[5]

Clinical Significance

Vasectomy is the fourth most common contraceptive method behind condoms, oral contraceptives, and tubal ligation, in descending order.[18] Vasectomy is faster, equally effective, and one-fourth the cost of tubal ligation.  However, if a patient is uncertain about the permanent aspect of the vasectomy, an alternative method should be chosen, such as a tubal ligation. 

Enhancing Healthcare Team Outcomes

Vasectomy can take place in a variety of clinical settings with many technique variations possible. The two main requirements of a vasectomy are isolation and occlusion. A thorough history and physical exam needs to be performed, and the patient needs clear instructions as to the risks, benefits, alternatives, and expectations of vasectomies. Patients who are considering a possible vasectomy reversal at a future time should probably be advised to obtain an alternative contraceptive procedure. 

Vasectomy is generally an office procedure requiring a trained clinician but may also need an assistant. Pain is typically minimal but can cause patients to become faint during the procedure. The role of the nurse is instrumental in the monitoring of the patient during the surgery and providing post-operative care. Patients require education about the postoperative course, pain control, wound care, diet, sexual activity, showering, and physical activity; the surgeon or the nurse can provide this counsel.

Best outcomes occur when patients are adequately informed about vasectomy. A vasectomy is an excellent form of birth control, but before intercourse, post-vasectomy patients require PVSA to ensure azoospermia or rare non-motile sperm.[13] 

Nursing, Allied Health, and Interprofessional Team Interventions

Nursing generally assists with the procedure; they do this by presenting instruments, calming the patient, and assisting with teaching the patient. They also are the initial individuals that patients contact with questions or concerns. 

Nursing, Allied Health, and Interprofessional Team Monitoring

Nurses monitor the patient following the procedure to ensure they are safe to discharge. They also typically are the first individuals to receive phone calls from patients with questions or complications from the procedure.