AUA Guidelines of 2015 on Vasectomy, abstracted by Dr. Harold M. Reed, senior member of the American Urological Association
AUA Guideline Statements
1. A preoperative interactive consultation should be conducted, preferably in person. If not as an in-person, then preoperative consultation by telephone.
2. The minimum and necessary concepts that should be discussed in a preoperative vasectomy consultation include the following:
- 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 vitrofertilization> They are not always successful, and may be expensive.
- The rates of surgical complications such as symptomatic hematoma and infection are 1-2%.
- Chronic scrotal pain associated with negative impact on quality of life occurs after vasectomy in about 1-2% of men.
3. Vasectomy is not a risk factor for prostate cancer, coronary heart disease, stroke, hypertension, dementia or testicular cancer.
4. Prophylactic antimicrobials are generally not indicated for routine vasectomy.
5. Vasectomy should be performed with local anesthesia with or without oral sedation.unless the patient declines local anethesia.
6. Isolation of the vas should be performed using a minimally-invasive technique.
7. The ends of the vas should be occluded by one of three divisional methods:
- Mucosal cautery (MC) with fascial interposition (FI) and without ligatures or clips applied on the vas;
- MC without FI and without ligatures or clips applied on the vas;
- Open ended vasectomy leaving the testicular end of the vas unoccluded, using MC on the abdominal end and FI;
8. The divided vas may be occluded by ligatures or clips applied to the ends of the vas.
9. Routine histologic examination of the excised vas segments is not required.
10. Men or their partners should use other contraceptive methods until vasectomy success is confirmed by PVSA.
11. To evaluate sperm motility, a fresh, uncentrifuged semen sample should be examined within two hours after ejaculation.
12. Patients may stop using other methods of contraception when examination of one well-mixed, uncentrifuged, semen specimen
shows azoospermia (no sperm) or only rare non-motile sperm.
13. Eight to sixteen weeks after vasectomy is the appropriate time range for the first seminal analysis.
14. Vasectomy should be considered a failure if any motile sperm are seen on PVSA at six months after vasectomy.
15. If > 100,000 non-motile sperm/mL persist beyond six months after vasectomy, then folowup analyses and clinical judgment should be used to decide whether the vasectomy is a failure.
Chronic scrotal pain. Rarely, some men complain of persistent unilateral or bilateral scrotal pain after vasectomy. The medical literature on post-vasectomy pain is comprised of poor-quality studies characterized by small sample sizes, failure to report inclusion criteria, failure to use validated pain measures, high non-response rates, poorly-specified definitions of outcomes, highly variable rates and lack of clarity regarding whether active or passive surveillance was used to determine chronic pain rates. The opinion of the Panel is that the most important information for patient counseling is the risk of chronic scrotal pain which is severe enough to cause the patient to seek medical attention and/or to interfere with quality of life. The most robust study of this indicates a 0.9% rate of such a pain seven months after the surgery. Only three studies reported follow-up of three years or more regarding severe chronic scrotal pain after vasectomy. One group reported in a single-group retrospective study that at 4.8 years of follow-up, 2.2% of vasectomized men reported chronic scrotal pain sufficient to exert an adverse impact on quality of life. An additional group reported in a prospective single-cohort design with four years of follow-up that 5% of vasectomized men sought medical attention because of testicular pain. In the sole comparative study, at 3.9 years of follow-up 6.0% of vasectomized men reported pain severe enough to motivate the seeking of medical care compared to 2.0% of non-vasectomized men. The opinion of the Panel is that chronic scrotal pain severe enough to interfere with quality of life occurs in 1-2% of men after vasectomy. Medical or surgical therapy is usually, but not always, effective in improving this chronic pain. Few men require surgical treatment for chronic scrotal pain that may occur after vasectomy.
Symptomatic hematoma and infection rates. Many studies with sample sizes >500 patients reported rates of immediate post-operative local complications;
rates of hematoma and infection were 1 to 2% in most series. There is some evidence that rates are lowest among urologists compared to family physicians and
general surgeons. It is important to note that in this group of studies the method of vas isolation and occlusion often was not reported, making it unclear if surgical
technique was related to complication rate. Although these studies were consistent in their findings, they were observational and largely retrospective, and,
therefore, present an unknown risk of under-reporting. In addition to these reports of post-operative hematoma and infection in studies with sample sizes
> 500 patients, there are very rare case reports of Fournier’s gangrene after vasectomy including one patient in Europe who died.he opinion of the Panel is that
patients should be counseled that the risk of hematoma and wound infection after vasectomy is approximately 1-2%
Minimally-Invasive Vasectomy (MIV). The term “minimally invasive vasectomy” includes any vas isolation procedure, including the no scalpel, which incorporates two key surgical principles.
1.Small ( 10 mm) openings in the scrotal skin, either as a single midline opening or as bilateral openings
2. Minimal dissection of the vas and perivasal tissues, which is facilitated by using a vas ring clamp and vas dissector or similar special instruments
The three finger technique described in Appendix A for immobilizing the vas or for making the skin opening has been modified slightly by various surgeons using MIV techniques other than the strict NSV technique. These variations include the use of the thumb rather than the middle finger behind the scrotum and other modifications of finger placement, bilateral skin openings or scrotal skin opening(s) made before grasping the vas with the vas ring clamp.
THE PRACTICE OF VASECTOMY
Section 1: The Importance of Vasectomy
Vasectomy is the most common non-diagnostic operation performed by urologists in the United States (US). Estimates of the number of vasectomies performed annually in the US vary depending on survey type. Data from the National Study of Family Growth in which only married couples were polled indicate a range from 175,000 to 354,000. In a physician survey, an estimated 526,501 vasectomies were performed in the US in 2002. This number seems to have been approximately stable for the previous decade. More than 75% of vasectomies in the US are done by urologists, and about 90% of urology practices in the US perform vasectomy. The potential complications of vasectomy are less serious than those of tubal ligation.
In 2002, data collected in the US show that vasectomy was used by 5.7% of men ages 15-44 and that this represents the fourth most commonly-used contraceptive method.
The first three were condoms, used by 29.5% of men, oral contraceptives for women used by 25.6% of couples and tubal ligation used by 8.1% of couples Compared to tubal ligation , which is also a method of permanent contraception, vasectomy is equally effective in preventing pregnancy; however, vasectomy is simpler, faster,
safer and less expensive. Vasectomy is one of the most cost-effective of all methods of contraception; its cost is about one-fourth of the cost of tubal ligation.
Vasectomy requires less time off work, requires only local rather than general anesthesia and is usually performed in a doctor’s office or clinic. as isolation and does not specify a method of vas occlusion. For a detailed description of the NSV technique, see Appendix A.