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 untill sterility is achieved and the low risk of spontaneous recanalization has to be mentioned.
Contraindications of Vasectomy
- Untreated coagulation disorders
Surgical Technique of Vasectomy
- Supine position of the patient
- Vasectomy is usually done in local anesthesia. Some patients may prefer spinal or general anesthesia.
- Perioperative antibiotic prophylaxis, if risk factors for a wound infection are present.
Technique of Local Anesthesia for Vasectomy:
The spermatic cord is infiltrated with each 8–10 ml lidocaine 1% on both sides at the level of the external inguinal ring. Wait for at least 10 minutes before proceeding! The maximum dose of lidocaine should not exceed 300 mg for an adult, so another 10–14 ml lidocaine 1% is left for local anesthesia of the vasectomy site (5–7 ml per side). Caution: respect the contraindications for lidocaine or any other local anesthetic.
Vasectomy Procedure (Standard Technique):
The left hand grasps the spermatic cord, the vas deferens is isolated from the surrounding tissue and vessels and is fixed between the thumb and index finger. If necessary, the skin and vas deferens is infiltrated with some more local anesthetic. The vas deferens is fixed to the skin with a sharp ring clamp. This step may still be painful, local anesthesia can now be injected liberately, if the vas is secured with the clamp.
A skin incision is done (about 1 cm length) to expose the vas deferens. Spread the subcutaneous tissue with a curved mosquito clamp. Incise the surrounding tissue layers of the vas deferens untill the wall of the vas is reached. Once again, the vas is grabbed with a ring clamp, care is taken to avoid surrounding tissue layers. With traction on the ring clamp, the vas can be separated from the surrounding tissue (3 cm duct should be mobilized). Dissect the vas and resect about 1–2 cm from the vas deferens. The distal and proximal ends are coagulated and ligated. A subcutaneous suture may separate the the two ends of vas deferens (fascial interposition). Skin suture.
On the contralateral side, the procedure is done the same way.
Technical Modifications of the Vasectomy Procedure
A skin incision is avoided. With the help of special clamps, the skin is perforated and stretched. The vas is isolated with special hooks and they are coagulated and ligated as described above. The complication rate is lower [Cook 2007].
The distal end of the vas deferens is not ligated or coagulated, the ends of the vas are separated with fascial interposition. Open-ended vasectomy aims at reducing post-vasectomy pain syndrome by preventing congestion of the epididymis.
Follow-up after Vasectomy
- Control of wound healing
- After three month, two separate semen analysis have to confirm sterility.
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.
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- Cook, L. A. u. a.
- Scalpel versus no-scalpel incision for vasectomy. In: Cochrane Database Syst Rev (2007), S. CD004112.