Editing CUA: Vasectomy (2016) (section)

== 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'''