Sunday-November 19, 2017 
    
      Home | Procedures | Pre-Surgery Form | Registration | Search | About Us  
 
FORBES magazine names YourSurgery.Com as one of it's "Best of the Web"
 
Vasectomy
Male sterilization

Vasectomy is an operation performed on men to achieve permanent sterility. Vasectomy is not castration and does not alter a man's sex drive or sensation of orgasm. Furthermore, it does not alter the male sex hormones or the male sex characteristics. Approximately 500,000 vasectomies are performed in the U.S.A. every year. The operation is easily and most commonly performed in an out-patient office setting and is inexpensive. Patients have the procedure, then leave shortly thereafter, either driving themselves or being driven home.

Anatomy and Physiology

In men, the testicles (testes) produce the sperm which unites with the egg in a woman to produce a fetus.

  • The structures that make up the male sexual apparatus are (Figure 1)
Figure 1 - Normal male reproductive anatomy
    1. Testicles (testes) are the two small egg shaped structures that are in the scrotum, the bag-like structure behind and beneath the penis
    2. Epididymis is C-shaped structure that sits above the testicle. It is composed of 18 -20 feet of a very thin coiled tube
    3. Vas deferens (sometimes called the ductus deferens) is a heavier tubular structure that passes out of the scrotum towards the seminal vesicle and prostate gland. It is accompanied by the testicular artery, vein and nerve, which together form the spermatic cord
    4. Seminal vesicles are club shaped structures about two inches in length and ¾ inch in diameter that lie on the back of the bladder
    5. Prostate gland is a walnut shaped structure that surrounds the urethra as it exits the bladder
    6. Urethra is a tubular channel that extends from the bladder to the tip of the penis
    7. Penis is the male sexual organ. It encloses the urethra
  • The sperm from a testicle (testis) travels through the epididymis, then through the vas deferens and enters into the seminal vesicles where the sperm mixes with a fluid called seminal plasma
  • The seminal plasma also contains fluid from the prostate gland. The sperm mixes with the seminal plasma and, during the act of intercourse with ejaculation, the seminal plasma containing the sperm is passed through the urethra in the penis into the vagina of the partner

History and Examination

  • During the initial history and physical examination the doctor usually asks questions regarding
    1. marital status
    2. number of children
    3. methods of birth control used and the effectiveness of the methods
    4. general health of the patient
    5. any urologic problem (such as an urinary tract infection)
  • The physical examination is centered primarily on evaluation of the genitalia, particularly the testicles and spermatic cords. The vas deferens is a hard, rubbery tubular structure that can easily be felt through the scrotum. If the surgeon cannot feel the vas deferens or cannot isolate it against the scrotal skin, consideration may be given to doing the vasectomy in the operating room where the scrotum can be explored with a larger incision

Indications/Contraindications

There are no absolute contraindications to vasectomy

  • The only indication for a vasectomy is a desire for permanent sterility and it is with this purpose in mind that the operation should be undertaken. If it is in the mind of the patient that at some future point the vasectomy can be reversed, so that sterility can be changed into fertility, the vasectomy should probably be postponed
    1. Roughly one out of every 100 men who have vasectomies, at some time consider having the vasectomy reversed. In the U.S. approximately 5,000 vasectomy reversals are performed yearly
    2. Again, the strong advice is that if there is any hesitation or uncertainty regarding the desired permanent state of sterility, the vasectomy should be postponed
    3. Vasectomy reversal has a low success rate of achieving pregnancy and is often not a covered benefit of insurance plans
    4. Some men have had sperm frozen just in case a child is desired later. Because a man who considers this probably still has doubts, it is probably best he does not undergo a vasectomy
  • This surgery is purely voluntary and sufficiently simple so that there are virtually no contraindications though there are situations in which the man may regret the choice
    1. Single or recently married
    2. Wife is opposed to sterilization
    3. Having been pressured into having the procedure
    4. No children
    5. Being under the age of thirty
    6. Decision made immediately after childbirth
    7. When there are few alternative methods available

Surgical Procedure

During intercourse following a vasectomy, the seminal plasma is eliminated from the body in the usual fashion, it just does not contain sperm and, therefore, can not cause pregnancy. On the day of surgery, patients are usually advised to shower in the morning and bring an athletic supporter to the doctor's office to wear on the way home. The patient may be advised to have his wife or a friend come with him to drive him home

  • Standard vasectomy (Figure 2)

Figure 2A - The skin of the scrotum is opened and the vas deferens is brought out with an instrument

Figure 2B - The vas is cut and the cut ends coagulated. (The ends may also be tied or clipped.)

Figure 2C - The cut ends are then pushed back into the scrotum

    1. The procedure is a minor operation which takes about one-half hour. In most cases the vasectomy procedure is carried out as an outpatient, frequently in the surgeons office
    2. The skin of the scrotum overlying the vas deferens is injected with local anesthetic
    3. The vas is then grasped with a special clamp to hold it up against the skin
    4. A small incision is made in the scrotum with a scalpel following which a small piece of the vas is taken out of the scrotum and a piece of the vas removed
    5. One or both ends of the cut vas may be sealed with clips, cautery or suture
    6. The cut ends are then returned to the scrotal sac
    7. The scrotum is then closed with a few sutures
  • Without incision
    1. This procedure, which was developed in China in the 1970's, does not require a scalpel and is used by many surgeons in their offices
    2. The skin of the scrotum overlying the vas deferens is injected with local anesthetic and the vas grasped with the special clamp to hold it up against the skin
    3. Using a special instrument, a small puncture hole is made in the skin, the opening stretched and the vas teased out of the scrotum
    4. The same methods of blocking the vas are used as in the standard procedure
    5. The vas is then pushed back into the scrotum. Usually no sutures are necessary to close the puncture wound
  • These two procedures are, in fact, essentially the same

Complications

Complications are uncommon and can be classified into minor and major.

  • Minor complications
    1. Bruising, even extensive bruising is something that resolves on its own
    2. Swelling, even up to golf ball-size on each side will usually resolve without any difficulty
    3. Some pus and crusting at the incision site usually disappears disappears over the course of several days as the sutures in the skin dissolve and fall away
    4. Sperm granuloma is occasionally produced when sperm leaks from the cut vas deferens or from a rupture of the epididymis. The sperm act like foreign material and the body sets up an inflammatory reaction that can lead to firm balls of tissue. These balls rarely cause a problem
  • Major complications
    1. Delayed bleeding can occur where a vessel that was under control and not bleeding at the time of operation breaks loose to form a blood clot in the scrotum and may need to be removed surgically
    2. Infections of either the epididymis and/or the testicle may occur requiring antibiotics. Severe cases may require hospitalization to receive intravenous antibiotics
    3. The most severe complication, which is rare, is that the patient may lose a testicle because of bleeding or infection
    4. Rarely pain that lasts over 3-4 months and occasionally is severe
  • Recently articles have appeared in the medical literature suggesting vasectomy may predispose to prostate cancer. The American Urologic Association has taken a look at these statistics and the current feeling is that vasectomy is not a risk factor in the development of prostate cancer. All patients should at an appropriate age have regular rectal examinations for prostate cancer and PSA blood study. The current recommendation is that all African-American men over the age of 40 and all other American men over the age of 40 who have a family history of prostate cancer be evaluated yearly from age 40 on. For non-African Americans, yearly rectal exam and PSA should start between the ages of 45 and 50
  • Some studies have suggested that men who have a vasectomy under the age of 40 may have twice the risk for kidney stones

Failure of the procedure

There are two reasons why vasectomy may fail to achieve sterilization.

  • It takes approximately three to four months for the average healthy male to have enough ejaculations to clear the seminal vesicles of sperm. A patient is not considered sterile until two consecutive semen specimens show no evidence of sperm dead or alive. The number one reason for vasectomy to fail is early unprotected intercourse
  • The second cause is called recanalization. The vas does not actually grow back together, but the cells that line the inside of the vas grows through the scar tissue to hook up with the other side. Fortunately, this is rare and most urologists do the vasectomy by not just cutting the vas, but also taking out tissue to leave a gap between the cut ends

Care After Surgery

  • After surgery the man should go home, get off his feet and relax using ice packs to cool down the scrotum and help prevent swelling and inflammation
  • Full activity usually resumes one to three days after surgery
  • Most doctors recommend that vasectomy patients abstain from sexual activity for approximately one week, then the more frequent the activity occurs using birth control methods, the faster the body clears itself of live sperm
  • Vasovasostomy (Vasectomy Reversal)
    1. Approximately 1% of men who undergo a vasectomy request reversal of the procedure. The most common reasons being death of a child, remarriage and the desire for another child when finances improve. In comparison to the relatively simple vasectomy procedure, reversal is a major procedure.
    2. The procedure is carried out in the hospital, usually with the patient asleep
    3. An incision is made in the scrotum
    4. The cut ends of the vas are dissected free and then cut back from the scar tissue until normal vas is seen. This is usually done with the aid of an operating microscope that magnifies the small opening in the vas so that it can be more readily handled
    5. Fine sutures are then used to sew the two ends together
    6. Occasionally, the vas must be sutured to the very fine coiled tubing of the epididymis. If this is the case the chance for success is much lower
    7. Success of reversal varies considerably being as low as 20% to as high as 60-7