Various methods have been described for ligation of the vas.6 Here we illustrate the traditional suture ligation and excision technique, which is the most common method used worldwide.1 However, this method is associated with a higher failure rate that is thought to be caused by necrosis distal to the ligatures and subsequent recanalization of the exposed ends. Hemoclip ligation and excision, fascial interposition, and intraluminal cautery that extends at least 1 cm into 1 or both vasa are associated with less recanalization and higher success; however, these techniques may require additional equipment or cautery tips that are not readily available. We often incorporate interposition—the more cost-effective technique.
With the dissecting forceps, we create a loop through the perivasal tissue between the elevated proximal and distal segments of vas, then tie each end with an absorbable suture (leaving at least 1 cm between the knots) and remove the segment with scissors (Figures 9, 10, and 11). The excised segment can be sent for pathological examination to confirm that it is the vas deferens. Be sure to elevate the cut ends of vas and their connective tissue to ensure hemostasis on each side and cauterize areas of bleeding as needed. The vas can be allowed to slip back into the scrotum. We repeat the process on the opposite vas, ideally, through the same midline puncture. If we are unable to manipulate the opposite vas to the same hole, we anesthetize and puncture a second area of the scrotum to complete the procedure.
The skin of the scrotum, with its many folds, is very forgiving. We usually let the small puncture heal by secondary intention. If the hole is gaping, we may use interrupted or continuous percutaneous stitches; however, a simple subcuticular stitch with absorbable suture may suffice. The dressing, which consists of antibiotic ointment and a stack of gauze, is securely held in place by the patient’s supportive undergarment.
AFTERCARE AND FOLLOW-UP
Recommendations for postoperative care vary. We prescribe strict rest for 48 hours and no heavy exertion, exercise, or weight lifting for 1 to 2 weeks. Acetaminophen and cold compresses are usually sufficient for pain control. NSAIDs are not recommended for the first 2 days because of increased bleeding risk. A follow-up visit in 1 week may be prudent to ensure that the level of postoperative pain and tenderness is appropriate and to check for infection. Hematomas rarely occur if careful hemostasis is done at the end of the procedure. When present, they are usually managed conservatively.
Sterility is typically confirmed 3 months postoperatively, although an earlier sample may be obtained after 6 weeks and at least 15 ejaculations. Patients must use back-up contraception until sterility is confirmed. Persistent presence of motile sperm requires that the vasectomy be repeated. The finding of rare, nonmotile sperm after 3 months is associated with successful sterilization.1