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No-Scalpel Vasectomy

No-Scalpel Vasectomy

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Trephination of Subungual Hematoma

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Vasectomy is a safe and effective form of sterilization that about half a million men in the United States undergo each year.1 Dr Li Shun-Quiang first introduced the no-scalpel technique of vasectomy in China in 1974. Use of the dissecting forceps allows entry through the skin without a scalpel, expedites the removal of the connective tissue around the vas deferens, and results in less trauma.

Here we review the basic steps of the no-scalpel vasectomy. While the fundamentals are universal, many variations of the procedure exist.

PREOPERATIVE COUNSELING

During the preoperative visit, determine whether the patient is fully informed and certain about his decision and assess the suitability of the anatomy for the procedure. Emphasize the permanent nature of a vasectomy, because reversal is only about 50% successful depending on the time frame (more successful if reversed within the first 3 years).2

Reproductive history. Include the number of children the patient fathered and his current relationship status. Ask the patient whether he may want to father more children in the future. Counseling should include discussion of sperm banking, because 6% of men who have had vasectomy ultimately request reversal.3 Including the spouse or partner in the discussion is helpful. Also inquire about any prior surgery or trauma to the scrotum.

Anatomy examination. Confirm the presence of vas deferens bilaterally. Note any old scars, inguinal hernias, hydroceles, varicoceles, spermatoceles, testicular pain, or signs of infection (orchitis or epididymitis). Make sure both vasa can be manipulated anteriorly to guarantee ease of grasping. If there is any obstructive pathology, or if the anatomy is unfavorable, we refer the patient to a specialist for further evaluation.

Review of procedure and complications. This is best accomplished using an anatomical drawing of the male reproductive tract. The main complications are bleeding, infection, and failure to accomplish sterility. The incidence of complications has been shown to depend on the experience of the physician but is probably well under 5%.1 Antibiotic prophylaxis is not routinely recommended. Bleeding risk partly depends on the patient’s level of physical activity after the procedure.

Advise patients that persistent pain from vasectomy is extremely rare. In addition, vasectomy does not affect the volume of semen produced or libido and does not lead to a dangerous “congestion of sperm” in the testes. The sperm are reabsorbed naturally into the body. Links between vasectomy and testicular or prostate cancer have not been substantiated.

Informed consent. After preoperative counseling, the patient should sign a sterilization consent form.

PATIENT INSTRUCTIONS AND PREPARATION

Have the patient shave the scrotum and thoroughly cleanse the area before arrival and bring a supportive undergarment, such as an athletic supporter. Shaving with hair clippers is prudent because use of a straight razor may increase the risk of postoperative infection. The patient should arrange for a ride home after the procedure.

Keep an electrocautery unit available to achieve hemostasis and for vas ligation. With the patient in a supine position, retract the penis cephalad. Apply an antiseptic to the scrotum and surrounding area and attach a fenestrated drape to the scrotum. Confirmation of anatomy should be done before initiating the procedure.

ANALGESIA AND ANESTHESIA

Strategies to Enhance the Effectiveness of the Vasal Nerve Block
•From the patient’s right side (if right-handed), inject 1% plain lidocaine to form a skin wheal at a point—roughly two-thirds the way up from the distal scrotum to the base of the penis (preferably on the median raphe if attempting only one puncture site).
•Mark the needle puncture site with a skin marker or by lightly nicking the skin several times with the tip of the needle.
•Manipulate the vas to the area of the skin wheal using both hands. Try to “walk the vas” underneath the skin, without releasing it with more than one hand at a time, to prevent it from slipping away.
•Sequester the vas, using the 3-finger grasp, and carefully insert the needle cephalad to a depth of 1 to 1.5 inches within the perivasal sheath (Figure).
•Inject 2 to 5 mL of lidocaine around the vas without moving the needle.
•Repeat the process on the opposite vas through the same midline skin wheal.
•Keep a lidocaine injection readily available in case additional anesthesia is needed.

Figure – A vasal nerve block is being administered to the patient’s left vas deferens; the right vas was previously anesthetized. This demonstrates the “back-handed” 3-finger grasp to sequester the vas on the side opposite from the physician.

Most patients tolerate the no-scalpel vasectomy well with only local anesthetic. Oral diazepam taken 1 hour before the procedure can help the patient relax. Strategies to maximize the effectiveness of the vasal nerve block are listed in the Box. Both vasa can be anesthetized through a single site on the median raphe. If the anatomy prohibits mobilization of the vas to the midline position, the procedure may be performed through both sides of the scrotal skin, as was done on the patient illustrated here.

An alternative way to administer anesthesia for vasectomy is a relatively new “no-needle” technique, which uses a high-pressure lidocaine spray delivery device. This method has been shown to decrease the pain of local anesthesia from a 2 to a 1 on a visual analog pain scale of 10. However, the clinical significance of this is debatable.4

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