No scalpel vasectomy: 20 year outcomes utilizing combined cautery, clip and facial interposition

Abstract

Vasectomy failure is common (1-10%) and a major cause of malpractice suits. No-scalpel vasectomy (NSV) is a minimally invasive technique, but failure rates are dependent on occlusion techniques. In this report, a combination of 4 occlusion techniques were employed. Retrospective chart review. All men who underwent NSV by a single surgeon within the past 20 years were included. For NSV the vas was delivered through a single midline puncture hole under local anesthesia, excluding vasal vessels and nerves. The vas was hemi-transected in two places ½-1 cm apart using thermal cautery. Intraluminal cautery was performed on both ends for a distance of 1cm until smoke was observed and the wire tip then rotated for 10 seconds to ensure a 360o burn. A hemoclip was lightly placed on the testicular end to prevent sperm leakage until cautery causes a permanent seal. The abdominal end was completely transected and allowed to retract into the vasal sheath. The sides of the sheath were grasped with a hemostat and sealed over the abdominal end with a hemoclip, accomplishing fascial interposition. The intervening vas segment was excised and the ends were dabbed with Betadine before retraction into the scrotum. The contralateral vas was accessed through the same puncture hole and occluded identically. Post-vasectomy semen analysis (PVSA) is requested after 6 weeks or 15 ejaculations, and a PVSA after the same interval. 646 vasectomies were performed over 20 years. Mean patient age in years was 41.5±5.8 and partner 38.7±3.7. Median # of children was 3. 377/646 men (58%) of men had at least one PVSA performed a median of 55 days after NSV. 177/377 (47%) required a second PVSA, of which 138/177 (78%) complied. No pregnancies were reported. One patient had redo NSV for persistent non-motile sperm on PVSA. One abscess required I&D. Two hematomas (2-3 cm) were managed conservatively. No chronic (>6 months) post-vasectomy pain was reported. Vasectomy failure can be virtually eliminated utilizing a combination of 4 different occlusion techniques: 1) intraluminal cautery for 10 seconds; 2) testicular end clip occlusion; 3) facial interposition; and 4) resection of a ½ - 1 cm segment. This approach can be employed using the no-scalpel technique through a single midline puncture hole. Delivery of vas cleanly from its sheath, excluding vasal vessels and nerves may minimize the incidence of chronic post-vasectomy pain. This belt, suspenders, rope and wire approach to vasal occlusion minimizes failure and complications.