Editing CUA: Vasectomy (2016)

'''See Original AUA Guideline'''

'''See Original CUA Guideline'''

'''See 2015 AUA Vasectomy Guideline Notes'''

'''See only 2016 CUA Vasectomy Guideline Notes'''

== Background ==

* Vasectomy is the 4th most commonly-used method of contraception (condoms most common followed by oral contraceptives for women, then tubal ligation)
* Vasectomy is simpler, faster, safer, less expensive, and equally effective as tubal ligation, another method of permanent contraception. It is among most the cost-effective of ALL methods of contraception, 1/4th cost of tubal ligation

== Pre-operative practice ==

* '''Obtain a preoperative consultation in person, preferably, or by telephone or electronic communication'''
** '''History'''
*** '''General medical history (particularly risk factors for bleeding (liver disease, bleeding diathesis, anti-coagulation medications, etc.)''' '''and reproductive history'''
*** '''Reproductive status of the patient's female partner;''' if the chance for pregnancy in the female partner is poor, the need for vasectomy may be less than the couple initially expected.
*** '''Determine if family planning is complete.''' If the female partner is pregnant at the time of the preoperative consultation, the couple may be advised to consider delaying the vasectomy until after delivery to avoid regret about vasectomy, which might occur if the pregnancy is lost unexpectedly. In the US, there is no requirement for spousal or partner involvement in preoperative consultation, but patients should be advised that partner or spousal involvement is desirable.
*** '''In Canada, there is no specific age of consent; any man with the legal capacity to provide informed consent may undergo a vasectomy'''. Consider offering young men more time to reflect on their decision prior to performing the surgery.
** '''Physical exam of genitalia'''
** '''Preoperative laboratory tests are not required''' unless indicated by the medical history (preoperative coagulation tests should be considered if the patient has risk factors for bleeding)
* '''Pre-operative counselling (3):'''
*# '''Vasectomy is intended to be a permanent form of contraception with a high probability of reversibility'''
*#* '''Alternative methods of contraception''' (permanent (tubal ligation) and non-permanent (barrier methods, oral or injectable contraceptive for partner)) '''are available'''
*#* '''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'''
*#** After vasectomy, impaired fertility due to anti-sperm antibodies is infrequent and that the presence of serum anti-sperm antibodies should not be considered a deterrent to vasectomy reversal
*#** Preoperative sperm-banking and post-operative vasectomy reversal and sperm retrieval (for subsequent in vitro fertilization) can be discussed if patients are concerned about the permanent nature of the procedure.
*# '''Vasectomy does not produce immediate sterility'''
*#* Time from vasectomy to azoospermia or '''rare non-motile sperm (RNMS)''' can vary from weeks to months
*#* '''Post-vasectomy semen analysis showing azoospermia or RNMS is necessary for the surgeon to be able to tell the patient if he can rely on his vasectomy for contraception'''.
*#* '''Men or their partners should use other contraceptive methods until vasectomy success is confirmed by post-vasectomy semen analysis.'''
*# '''Risk of complications (5)'''
*## '''Symptomatic hematoma and infection: 1-2%'''
*##* Rates vary with the surgeon’s experience and the criteria used to diagnose these conditions
*##* Rates of epididymitis are generally low
*## '''Chronic scrotal pain: 1-2%'''
*##* Associated with negative impact on quality of life
*##* 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'''
*## '''Failure''' (defined as failure to achieve azoopsermia or RNMS, or the occurrence of pregnancy)
*##* '''Early failure: defined as the presence of motile sperm in the ejaculate at 3-6 months post-vasectomy; 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
*##* '''Late failure: defined as the presence of motile sperm in the ejaculate after documented azoospermia in two post-vasectomy semen analyses; even after vas occlusion is confirmed, vasectomy is not 100% reliable in preventing pregnancy; the risk of pregnancy after vasectomy is ≈1/2000 for men who have post-vasectomy semen analysis showing azoospermia or rare non-motile sperm'''
*## '''Symptomatic nodule''' < 5%
*##* Presumed to be a sperm granuloma or a suture granuloma if a ligature was used to occlude the transected testicular end of the vas
*##* '''Acute pain spontaneously resolves in 2-3 months or less in most cases'''
*##* '''Treatment for a painful nodule at the vasectomy site is symptomatic therapy with anti-inflammatory agents and analgesics if needed'''
*##* '''Persistent pain at the vasectomy site is rare and may respond to excision and repeat vasectomy'''
*## '''Change in sexual function'''
*##* '''Increase in frequency or improvement in sexual satisfaction in half or more of patients and a decrease in frequency of intercourse and in sexual habits in only 5%'''
*##* No evidence that vasectomy increases the risk of erectile dysfunction, reduced or absent orgasmic sensation, decreased ejaculate volume, reduced sexual interest, decreased genital sensation and/or diminished sexual pleasure
*#* No evidence that vasectomy influences hormones (testosterone, FSH, LH), lipids, bone mineral density
*#* No evidence that vasectomy is associated with risk of prostate cancer, coronary heart disease, stroke, hypertension, dementia or testicular cancer

== Procedure ==

* '''Pre-operative antibiotics: not indicated for routine vasectomy unless the patient presents a high risk of infection'''
** The AUA Best Practice Policy on Urologic Surgery Antimicrobial Prophylaxis recommends that '''prophylactic antibiotics''' for open and laparoscopic surgery (including genital surgery) without entering the urinary tract '''are indicated only if risk factors are present'''.
*** Risk factors include advanced age, anatomic anomalies of the urinary tract, poor nutritional status, diabetes, smoking, chronic corticosteroid use, immunodeficiency, distant co-existent infection and prolonged hospitalization
*** However, even the presence of ≥ 1 of these risk factors does not necessarily require the use of antimicrobial prophylaxis.
* '''Anesthesia'''
** '''Vasectomy should be performed with local anesthesia, with or without oral sedation.'''
*** Can be done with IV sedation or general anesthesia 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
*** Infiltrate local anesthetic agent into skin and perivasal tissue. The smallest available needle (25-32G) should be used for the injection of local anesthesia There are insufficient data to know whether addition of buffer, epinephrine or corticosteroids to the local anesthetic agent or topical cutaneous spray reduces pain during vasectomy or reduces postoperative inflammation. Therefore, the addition of these agents is not endorsed
*** Topical anesthetic cream: uncertainty regarding application reliably reduces pain'''; can be used in addition to local anesthetic, topical should not be the sole source of local anesthesia for the performance of vasectomy'''
* '''Surgery'''
** '''Key surgical steps in performing vasectomy (2):'''
**# '''Isolation of the vas'''
**# '''Occlusion of the vas'''
*** '''The risks of intraoperative and early postoperative pain, bleeding and infection are related mainly to the method of vas isolation'''
*** '''The success and failure rates of vasectomy are related to the method of vas occlusion'''
*** '''Vas isolation methods (3):'''
***# '''Conventional'''
***#* One midline or bilateral scrotal incisions are made with a scalpel. Incisions are usually 1.5-3.0 cm long.
***#* No special instruments are used. The vas usually is grasped with a towel clip or an Allis forceps.
***#* The area of dissection around the vas usually is larger than occurs with minimally-invasive techniques.
***# '''No-scalpel vasectomy (NSV)'''
***#* A minimally invasive method that uses specific instruments and sequential specific steps. '''Alteration of any of the specific steps does not allow the surgical technique to be called NSV and is instead called a minimally-invasive vasectomy.'''
***#* The NSV incision is usually <10 mm, and no skin sutures are needed.
***#* Two special instruments (vas ring clamp and vas dissector) are essential to NSV.
***#* The area of dissection around the vas is kept to a minimum
***#* '''Associated with a significantly lower risk of postoperative complications (hematoma, pain, infection) than conventional incisional vasectomy'''
***# '''Other minimally-invasive technique'''
**** '''Recommended methods of vas isolation (2):'''
****# '''NSV technique'''
****# '''Oother minimally-invasive vasectomy technique'''
***** '''Should not do conventional vasectomy'''
**** The choice between midline and bilateral incisions should be left to the clinical judgment
*** '''Vas occlusion methods (6)'''
***# '''Mucosal cautery'''
***# '''Fascial interposition'''
***#* Placing a layer of the internal spermatic fascia between the two divided ends of the vas. The fascial layer may be placed over the testicular or the abdominal end.
***#* May increase the complication rate
***#* Typically combined with other techniques such as ligation and excision or mucosal cautery
***# '''Division and ligation (suture, clips)'''
***#* No consistent evidence indicating that division with excision of a short vas segment (< 4 cm) is preferable to division without excision
***# '''Folding back'''
***#* Folding and suturing each divided vas end on itself to prevent the two cut ends from facing each other
***# '''Open-ended vasectomy:''' '''leaving the testicular end of the divided vas unoccluded while occluding the abdominal end'''
***#* Hypothetical aims of this technique are 1) to prevent or reduce post-vasectomy pain by decreasing back pressure in the epididymis and 2) to allow the formation of a sperm granuloma at the transected testicular end of the vas, which some experts speculate might increase the chance of success of vasectomy reversal. When open-ended vasectomy is performed, fascial interposition is used to prevent recanalization.
***# '''Non-divisional extended electrocautery technique of vas occlusion (Marie Stopes International technique)'''
***#* Electrocoagulation of the full thickness of the anterior wall and a partial thickness of the posterior wall of the vas for a length of approximately 2.5 to 3 cm without dividing the vas
***#* Developed by Marie Stopes International in London (United Kingdom) as a vasectomy technique that could be easily disseminated, particularly in Third World conditions.
***#* '''Only technique which does not completely divide the vas (all other techniques are divisional)'''
**** '''Recommended methods of vas occlusion (3):'''
****# '''Mucosal cautery +/- fascial interposition'''
****# '''Open ended vasectomy leaving the testicular end of the vas unoccluded, using mucosal cautery on the abdominal end, with fascial interposition'''
****# '''Non-divisional method of extended electrocautery''' (Marie Stopes technique)
***** Division and ligation, with or without fascial interposition and with or without excision of a short segment of the vas, is justified in individual surgeons who have the training and/or experience that produce consistently satisfactory failure rates of ≤1% when using these techniques
**** '''Not recommended methods of vas occlusion (3):'''
***** '''Folding-back'''
***** '''Division and ligation''' (unless surgeon experience enables, see above)
***** '''Fascial interposition alone'''
*** '''Routine histologic examination of the excised vas segments is not required'''
*** '''Special concern is warranted in men that have undergone or may undergo an ipsilateral varicocelectomy. After varicocelectomy, the deferential veins may be the sole source of testicular venous return''' [in proper varicocelectomy, all spermatic cord veins are ligated except the deferential vein] and it is also possible to damage the testicular artery(ies), leaving the deferential artery as the principal arterial supply to the testis. Thus, '''when a vasectomy is performed in men who have undergone or may undergo varicocelectomy in the future, it is strongly advisable to isolate the vas deferens carefully at the time of vasectomy and completely exclude the associated deferential arteries and veins so as to avoid potential injury to the deferential vasculature and minimize the risk of ipsilateral testicular injury'''

== Post-operative care ==

* Men should be told to remain in the clinic for 15‒20 minutes after the vasectomy
* Verbal and/or written instructions regarding post-operative care should be provided
* Patients should wear supportive undergarments immediately after the procedure to reduce pain caused by tension on the spermatic cord. This support should be continued until the patient is comfortable without it
* Mild swelling and pain are common for a few days. The patient should take oral pain medication.
* In general, the patient should keep the surgical site clean and dry, but showers may be permitted the day after the surgery including gentle washing of the surgical site with soap and water. Swimming or bathing in a tub of water should be avoided for 3-5 days.
* '''Patients should refrain from ejaculation for approximately 1 week after vasectomy'''
* Patients who notice hematospermia during the first month or two after vasectomy may be reassured that this will resolve spontaneously and has no clinical significance
* Men generally resume intercourse within 2 weeks of vasectomy
* In the absence of bothersome discomfort, patients may return to non-physical work on the day of or the day after vasectomy

== Post-vasectomy semen analysis ==

* '''See Figure 1 from Original CUA Guideline'''
* '''Timing'''
** '''AUA: 2-4 months after vasectomy'''
** '''CUA guidelines: 3 months''' '''after vasectomy'''
*** AUA: the choice of time to do the first post-vasectomy semen analysis should be left to the judgment of the surgeon. The longer the time period before the first post-vasectomy semen analysis, the better the chance that the post-vasectomy semen analysis will show azoospermia or rare non-motile sperm but the longer the time that the patient must use another method of contraception.
*** One study demonstrated that the fastest motile sperm clearance rates occurred when mucosal cautery was combined with fascial interposition, and the slowest rates occurred when ligation was used. The method of vas occlusion may be considered regarding timing of the first post-vasectomy semen analysis.
** '''Men or their partners should use other contraceptive methods until vasectomy success is confirmed by post-vasectomy semen analysis'''
* '''Vasectomy success (can abandon contraception):'''
** '''AUA: 1 sample that shows azoospermia OR only rare non-motile sperm (≤ 100,000 non-motile sperm/mL)'''
** '''CUA: 1 sample that shows azoospermia OR 2 samples that show only rare non-motile sperm'''
*** '''Patients should be told that semen samples should be collected after an abstinence period of 2-7 days, how to collect the semen sample, maintaining the sample at body temperature, and submitting the sample within 30‒60 minutes after production.'''
*** '''To properly evaluate sperm motility, a fresh uncentrifuged semen sample should be examined by direct microscopy within 2 hours after ejaculation. Centrifugation may interfere with sperm motility'''. '''If no sperm are seen, the centrifuged sample should be examined for the presence of motile and immotile sperm.'''
*** CUA: The evaluation of 2 post-operative semen samples is a better predictor of success than the evaluation of a single semen sample
*** Couples should be reminded about the risk of late failure despite azoospermia or rare immotile sperm on initial testing. In most cases, late failure is first identified as a pregnancy and later confirmed by semen analysis documenting presence of motile sperm.
**** The reappearance of sperm (mostly immotile) after documented azoospermia in 2 post-vasectomy semen samples may occur in up to 10% of patients. '''The reappearance (or persistence) of immotile sperm years after vasectomy has not been associated with documented pregnancies'''.
*** A self-post-vasectomy semen analysis home test has been approved by the FDA and is available for clinical use. This test is sensitive to sperm counts >250,000/ml, but the test does not assess for sperm motility. If two tests are performed and both are negative, then the negative predictive value of a sperm count >250,000 sperm/mL is 99.9%. However, the 250,000 sperm/mL cut-off is significantly higher than the cut-off most commonly used to declare a man sterile after vasectomy. The most commonly used cut-off in the literature and the definition of vasectomy success used in this guideline is ≤100,000 non-motile sperm/mL.
* '''Vasectomy failure'''
** '''May be due to'''
**# '''Technical failure resulting from a surgical error''' (such as occluding one vas twice without occluding the other vas)'''; characterized by persistently normal or nearly normal motile sperm counts and sperm motility after vasectomy'''
**# '''Failure to identify vas duplication on one side (very rare situation)'''
**# '''Recanalization at the vasectomy site;''' should be suspected if motile sperm or rising sperm concentrations are seen after a routine post-vasectomy semen analysis has shown azoospermia or rare non-motile sperm. Recanalization can be either transient or persistent based on the results of serial post-vasectomy semen analysis.
** '''AUA'''
*** '''If a post-vasectomy semen analysis demonstrates ANY motile sperm prior to 6 months, additional post-vasectomy semen analysis should be performed at intervals of 4-6 weeks for up to 6 months after vasectomy for further evaluation'''
**** ≈30-50% of men with recanalization eventually achieve azoospermia or rare non-motile sperm over a period of 6 months after vasectomy due to fibrosis of the vas and occlusion of the recanalization. Therefore, the decision to repeat the vasectomy should not rely on a single semen analysis showing motile sperm within 6 months after vasectomy.
**** '''Repeat vasectomy should be done if the number of motile sperm increases in subsequent semen analyses or if motile sperm persist for >6 months after vasectomy.'''
*** '''If > 100,000 non-motile sperm/mL persist beyond 6 months after vasectomy, trends of serial post-vasectomy semen analysis and clinical judgment should be used to decide whether the vasectomy is a failure and whether repeat vasectomy should be considered (CUA Guidelines consider this failure and recommend repeat vasectomy)'''
**** The decision to consider vasectomy a failure if >100,000 non-motile sperm/mL persist should be based on clinical judgment that includes the trend of sperm counts, the patient’s preferences and the patient’s tolerance for the risk of pregnancy.
** '''CUA'''
*** '''If a post-vasectomy semen analysis demonstrates ANY motile sperm OR >100,000 non-motile sperm''', '''patients must continue the use of other contraceptive measures and repeat semen analysis in 4-8 weeks'''
**** '''If repeat testing shows'''
***** '''Azoospermia or <100,000 non-motile sperm, contraception can be abandoned'''
***** '''Persistence of motile or > 100,000 non-motile sperm at 6 months after the initial procedure, a repeat vasectomy is indicated'''
** If a man reports that his wife has become pregnant and his semen analysis reveals azoospermia, the physician should inform him that the pregnancy could have been due to a transient recanalization despite the semen analysis results

== Questions ==

# What are important aspects of pre-vasectomy patient counselling?
# What are the potential risks of vasectomy?
# What are the different methods of vas isolation? Which are recommended?
# What are the different methods of vas occlusion? Which are recommended?
# When should the first semen analysis be performed post-vasectomy as per AUA and CUA Guidelines?
# What is considered vasectomy success as per the AUA and CUA Guidelines?

== Answers ==