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Who gets a vasectomy?

 

The following abstract of an article entitled “The American man who chooses vasectomy: a profile” appeared in AVSC News. 1988;26(1):3 (no authors were listed):

 

“Who is the typical American man choosing vasectomy?

 

The evidence from studies is clear.

 

He is most likely to be white.

 

He lives in the West.

 

He is better educated and has a higher income than the average.

 

He is in his mid- to late thirties and has at least 1 son.

 

 He has been actively involved in birth control and strongly dislikes other contraceptive methods.

 

Vasectomy, to him, is a matter of convenience.

 

He is more strongly motivated than his wife to end childbearing and is protective of his wife’s health.

 

He is secure, with lower than average need for social approval.

 

How does he arrive at a decision?

 

 

 

American men take a long time to make a decision about vasectomy. The process may last anywhere from 2 to 10 years. Stephen Mumford has outlined a 7-step decision making process.

 

  1. A man: becomes aware of vasectomy,
  2. talks to a vasectomized man,
  3. decides to have no more children,
  4. seriously considers vasectomy,
  5. decides temporary methods are no longer acceptable,
  6. decides vasectomy is the best method, has a pregnancy “scare”
  7. He then calls Dr. Kelly for the procedure...

 

 

 

American Urological Association (AUA) Guideline

VASECTOMY:

AUA GUIDELINE

Ira D. Sharlip, Arnold M. Belker, Stanton Honig, Michel Labrecque, Joel L. Marmar,

Lawrence S. Ross, Jay I. Sandlow, David C. Sokal


 

 

Approved by the AUA

Board of Directors May 2012

Authors’ disclosure of potential conflicts of interest and author/staff contributions appear at the end of the article.

© 2012 by the American Urological Association

 

 

 

 

 

 

 

The Panel would like to acknowledge Susan L. Norris M.D., M.P.H., M.S. and her team for their methodological contributions and to also thank  Martha Faraday, Ph.D. for her additional methodological input and

for her invaluable contributions to the drafting of the final report.

L_______a_____   a

 

Purpose:  The purpose of this Guideline is to provide guidance to clinicians who offer vasectomy services. This guidance covers pre-operative evaluation and consultation of prospective vasectomy patients; techniques for local anesthesia, isolation of the vas deferens and occlusion of the vas deferens during vasectomy; post-operative follow-up; post-vasectomy semen analysis (PVSA) and potential complications and consequences of vasectomy.  

 Methods:  A systematic review of the literature using the MEDLINE and POPLINE databases (search dates January 1949 to August 2011) was conducted to identify peer -reviewed publications relevant to vasectomy.  The search identified almost 2,000 titles and abstracts. Almost 900 articles were retrieved for full-text review.  These yielded an evidence base of 275  articles after application of inclusion and exclusion criteria.  These publications were used to create the evidence-based portion of the Guideline.  When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate) or C (low).   Additional information is provided as Clinical Principles and Expert Opinion when insufficient evidence existed.  

 Guideline Statements

  1. 1.      A preoperative interactive consultation should be conducted, preferably in person. If an in-person consultation is not possible, then preoperative consultation by telephone or electronic communication is an acceptable alternative.  Expert Opinion
  2. 2.      The minimum and necessary concepts that should be discussed in a preoperative vasectomy consultation include the following:  Expert Opinion
  • Vasectomy is intended to be a permanent form of contraception.
  • Vasectomy does not produce immediate sterility.  
  • Following vasectomy, another form of contraception is required until vas occlusion is confirmed by post- vasectomy semen analysis (PVSA).  
  • Even after vas occlusion is confirmed, vasectomy is not 100% reliable in preventing pregnancy. 
  • The risk of pregnancy after vasectomy is approximately 1 in 2,000 for men who have post-vasectomy azoospermia or PVSA showing rare non-motile sperm (RNMS).
  • Repeat vasectomy is necessary in ≤1% of vasectomies, provided that a technique for vas occlusion known to have a low occlusive failure rate has been used. 
  • Patients should refrain from ejaculation for approximately one week after vasectomy. 
  • Options for fertility after vasectomy include vasectomy reversal and sperm retrieval with in vitro fertilization.  These options are not always successful, and they may be expensive. 

Vasectomy

  • The rates of surgical complications such as symptomatic hematoma and infection are 1-2%.  These rates vary with the surgeon’s experience and the criteria used to diagnose these conditions. 
  • Chronic scrotal pain associated with negative impact on quality of life occurs after vasectomy in about 1-2% of men. Few of these men require additional surgery.  
  • Other permanent and non-permanent alternatives to vasectomy are available.

 

  1. 3.      Clinicians do not need to routinely discuss prostate cancer, coronary heart disease, stroke, hypertension, dementia or testicular cancer in pre-vasectomy counseling of patients because vasectomy is not a risk factor for these conditions.  Standard (Evidence Strength Grade B)
  2. 4.      Prophylactic antimicrobials are not indicated for routine vasectomy unless the patient presents a high risk of infection. Recommendation (Evidence Strength Grade C)
  3. 5.      Vasectomy should be performed with local anesthesia with or without oral sedation. If the patient declines local anesthesia or if the surgeon believes that local anesthesia with or without oral sedation will not be adequate for a particular patient, then vasectomy may be performed with intravenous sedation or general anesthesia. Expert Opinion
  4. 6.      Isolation of the vas should be performed using a minimally-invasive vasectomy (MIV) technique such as the noscalpel vasectomy (NSV) technique or other MIV technique. Standard (Evidence Strength Grade B)
  5. 7.      The ends of the vas should be occluded by one of three divisional methods: 

(1)  Mucosal cautery (MC) with fascial interposition (FI) and without ligatures or clips applied on 

the vas; 

(2)  MC without FI and without ligatures or clips applied on the vas; 

(3)  Open ended vasectomy leaving the testicular end of the vas unoccluded, using MC on the abdominal end and FI; 

      OR by the non-divisional method of extended electrocautery.  Recommendation (Evidence Strength Grade C)

  1. 8.      The divided vas may be occluded by ligatures or clips applied to the ends of the vas, with or without FI and with or without excision of a short segment of the vas, by surgeons whose personal training and/or experience enable them to consistently obtain satisfactory results with such methods.  Option   (Evidence Strength Grade C)
  2. 9.      Routine histologic examination of the excised vas segments is not required. Expert Opinion
  3. 10.   Men or their partners should use other contraceptive methods until vasectomy success is confirmed by PVSA.  Clinical Principle
  4. 11.   To evaluate sperm motility, a fresh, uncentrifuged semen sample should be examined within two hours after ejaculation.  Expert Opinion  
  5. 12.   Patients may stop using other methods of contraception when examination of one well-mixed, uncentrifuged, fresh post-vasectomy semen specimen shows azoospermia or only rare non-motile sperm (RNMS or ≤ 100,000 non-motile sperm/mL). Recommendation (Evidence Strength Grade C) 
  6. 13.   Eight to sixteen weeks after vasectomy is the appropriate time range for the first PVSA. The choice of time to do the first PVSA should be left to the judgment of the surgeon. Option (Evidence Strength Grade C)  
  7. 14.   Vasectomy should be considered a failure if any motile sperm are seen on PVSA at six months after vasectomy, in which case repeat vasectomy should be considered. Expert Opinion
  8. 15.   If > 100,000 non-motile sperm/mL persist beyond six months after vasectomy, then trends of serial PVSAs and clinical judgment should be used to decide whether the vasectomy is a failure and whether repeat vasectomy should be considered. Expert Opinion  

 

 

 

 

 

 


 

 

 

European vasectomy guidelines

 

JonathanCarganMD
Louis R.KavoussiMD, MBA, Editior

Summary

While vasectomy is a highly effective procedure, challenges may arise concerning preoperative information provided to patients, the procedure itself, and in postoperative follow-up. Requests for reversal, a procedure that may be associated with reduced semen quality, may be more common among younger men and those who are childless at the time of the procedure. The European Association of Urology issued guidelines for vasectomy in January 2012. This update will provide highlights of these guidelines. However,clinicians should review the full guidelines available through this link before implementing recommendations in patient care(http://www.europeanurology.com/article/S0302-2838(11)01101-8/fulltext). The level of evidence for each of the recommendations varies.

The authors of the guidelines used a search of Medline and EMBASE covering the years 1980 to 2010. Their search focused on indications for the procedure, information provided preoperatively, vasectomy techniques and associated complications and failure rates, as well as postoperative follow-up. The Cochrane database was also searched. The authors attempted to focus on high-quality clinic trials and identified 113 candidate publications for review. Non-English language publications, abstracts, and reports from meetings were excluded.

Indications for vasectomy:

  1. The decision by the patient to proceed with the procedure must be made in a considered fashion and not under stressful conditions

  2. There are no absolute contraindications to vasectomy

  3. Relative contraindications include:

    1. Age < 30 years

    2. Severe Illness

    3. Lack of current relationship

    4. Scrotal pain

 

Preoperative information for patients:

  1. Patients should be informed of the following prior to vasectomy:

    1. It should be considered irreversible

    2. It carries a low complication rate and a low, but not zero, failure rate (e.g. chance of early/late recanalization)

    3. Contraceptive measures must continue until sterility is confirmed through postoperative semen analysis

    4. Based on data, the procedure is safe

    5. The technique to be used

    6. Relative contraindications

    7. Alternatives to surgery, as well as complications of the procedure

 

Note: Many patients are not aware of the risk of failure. Patients should be counseled concerning failure risk. All counseling should be strictly documented.

Technique:

  1. Regardless of technique, vasectomy:

    1. Can usually be performed on an outpatient basis with local anesthesia

    2. Both deferential ducts are exposed

    3. The no-scalpel technique of isolation carries fewer early complications

  2. Discontinuity of the deferential ducts can be achieved through:

    1. Excision of a piece of the vas deferens, with suture or clip ligation

    2. Prevention of recanalization through interposition of tissue

    3. Cautery performed on the luminal side

 

The authors note that no technique has been shown to be definitely superiority in achieving sterility.

Operative technique should be clearly documented.

The vas does not require routine pathologic examination.

Postoperative management:

Patients usually are asked to refrain from exertion for a given period, the length of which is at the discretion of the physician. Eighty percent of patients are usually back to normal activity within 1 week.

Postoperative semen analysis is usually performed 3 months following vasectomy and after 20 ejaculations. Eighty percent of men will have no spermatozoa by this time point.

  1. Men without spermatozoa can be cleared for sexual activity without additional contraception

  2. Men with low numbers of nonmotile spermatozoa can be given clearance if nonmotile spermatozoa occur at <100,000/mL.

  3. In men with motile spermatozoa or >100,000 spermatozoa/mL of semen, reexamination should be performed at 6-week intervals until no spermatozoa are found or count is <100,000 nonmotile spermatozoa/mL.

 

Men with persistent motile spermatozoa at 6 months of follow-up should have a repeat procedure.

Complications:

Complication Frequency
Postoperative bleeding and hematoma 4-22%
Infection 0.2-1.5%
Chronic scrotal pain 1-14%
Early recanalization 0.2-5.3%
Late recanalization 0.03-1.2%

References

  • 1GR Dohle Diemer Kopa , et al.European Association of Urology guidelines on vasectomy. Eur Urol. 61 (1):159-163 2012; Epub 2011 Oct 19 22033172


 

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