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Vasectomy: Surgical Technique and Complications

Definition of Vasectomy

Vasectomy is a surgical procedure for sterilization of men, commonly used as a method of birth control.

Indications for Vasectomy

The patient has to be sure about his finished family planning. It is important to inform the patient about the possible irreversibility of the operation. Furthermore, the need for contraception until sterility is achieved and the low risk of spontaneous recanalization has to be mentioned.

Contraindications of Vasectomy

Elective indication: coagulation disorders, any disease with an increased risk for surgery. Vasectomy is not recommended as a short-term form of contraception and should not be offered to men who wish to have children later in their life.

Surgical Technique of Vasectomy

Preoperative Preparations:

• Supine position of the patient
• Lokal anesthesia is the rule, general anesthesia is an option for patients with phobia or contraindications to local anesthetics.
• Perioperative antibiotic prophylaxis, if risk factors for surgical site infections are present.

Technique of Local Anesthesia for Vasectomy:

Both vas deferens are palpated alternately in the midline of the scrotum below the penis. Infiltrate the scrotal raphe in the area of the planned incision. Both vas deferens are infiltrated in the direction of the external inguinal rings with local anesthetic, e.g., lidocaine 1% or ropivacaine 0.5% 5 ml per side. The exposure time should be at least 10 min. Another syringe with 5–10 ml local anesthetic should be ready during the procedure.

No-Scalpel Vasectomy Procedure:

The left spermatic cord is grasped with the left hand, the vas deferens is isolated from the surrounding tissues and vessels and fixed between the thumb, index finger and middle finger in the area of the infiltrated scrotal raphe. A special sharp hemostat is used to puncture and dilate the scrotal skin to about 7 mm. A small ring clamp is used to grasp and fix the vas deferens. If this step is painful, additional local anesthetic is infiltrated. Spread the layers of tissue over the vas deferens and deliver the vas deferens into the wound. Dissection continues until 3 cm of vas deferens are freed from vessels and nerves. The free segment is resected between clamps and the ends are coagulated and closed with sutures. The proximal end is first returned to the scrotum and the vasal sheath is closed with a suture. Now the distal end is repositioned into the scrotum. Surgery of the right side is done in the same way through the same wound opening. Skin suture is unnecessary after no-scalpel vasectomy, a simple dressing for a few days is sufficient.

Open-ended Vasectomy:

The distal (scrotal) end of the ductus deferens is not coagulated or ligated. Both ends are separated by fascial interposition described above. Open-ended vasectomy aims at avoiding epididymal back pressure effects and thus reducing post-vasectomy pain. Long-term studies concerning the pearl index are not available.

Follow-up after Vasectomy

Wound examination. Two separate semen analysis should confirm sterility before other methods of contraception are stopped.

Complications (Side Effects) after Vasectomy

• Bleeding and hematoma
• Wound infection
• Sperm granuloma
• Post-vasectomy pain syndrome (see below)
• Persisting or recurrent fertility by recanalization or double vas deferens

Post-Vasectomy Pain Syndrome

The post-vasectomy pain syndrome is a chronic pain syndrome which develops immediately or several years after vasectomy. Several causes have been proposed: nerve injury, sperm granuloma, congestion of the epididymis and chronic inflammation.

Treatment consists in medical treatment (see section chronic pain treatment), excision of sperm granuloma, denervation of the spermatic cord or vasovasostomy (vasectomy reversal). Long-term studies for treatment success are not available.

References

  Deutsche Version: Vasektomie