PERCUTANEOUS VASECTOMY: A SIMPLE MODIFICATIONELIMINATES THE STEEP LEARNING CURVE OF NO-SCALPEL

VASECTOMY

J. STEPHEN JONES*From the Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio

ABSTRACT

Purpose: We report a simplified method to avoid the most difficult step of no-scalpel vasectomy,while maintaining its minimally invasive advantages.

Materials and Methods: Using the no-scalpel vasectomy instruments in percutaneous fashionwe perform vasectomy in the office setting without fixation of the vas to skin using the ringclamp. The sharp no-scalpel hemostat punctures the skin. The vas is then grasped with theringed instrument instead of piercing the vas and performing the supination maneuver, asdescribed for no-scalpel vasectomy.

Results: Percutaneous vasectomy was performed in 573 men by a single surgeon. In the 35consecutive cases recently reviewed average operative time was 9.3 minutes with an additional67 seconds added when a resident performed the procedure on 1 side in 15 cases. As determinedby the knuckle of vas pulled through a puncture, average incisional length was 8.4 mm. Patientsreported complete recovery in an average of 8.9 days. No major complications occurred. A singlecase of recanalization (0.17%) was successfully corrected by repeat percutaneous vasectomy.

Conclusions: Percutaneous vasectomy is a minimally invasive option for permanent malesterilization that avoids the difficult aspects of no-scalpel vasectomy.

KEY WORDS: testis, vasectomy, ambulatory surgical procedure

Vasectomy has been used for permanent male sterilizationsince the late 19th century. Yearly 500,000 American menundergo this procedure, which is traditionally performedthrough 1 or 2 standard scrotal incisions. Li et al from Chinapioneered no-scalpel vasectomy in the 1970s as an efficientway to meet the demand for mandatory sterilization in themost populous nation.1 The procedure is favored by 30% ofAmerican vasectomists.2

MATERIALS AND METHODS

Warming the previously shaved, prepared and draped scro-tum with a warm towel relaxes the dartos and cremastericmuscles, so that the vas is readily palpable. It should be aswarm as tolerated by the patient. If adequate relaxation is notnoted, repeating this step with a warmer towel is advisable.

The nondominant surgeon thumb is placed at the rapheand used to trap the contralateral vas between the first andsecond fingers in a tripod grasp (fig. 1). The vas is isolated bygently kneading all cord structures away, so the vas is iso-lated between the thumb and fingers. With vas held to skinusing the tripod grasp 1% plain lidocaine is injected througha 27 gauge 1⁄2-inch needle, while advancing through skin intothe vasal sheath. This maneuver dissects the vas sheath andother cord structures away from the vas. Multiple needlepasses are avoided.

Instead of fixing the vas to the skin with the ringed clamp, asdescribed for no-scalpel vasectomy, the ulnar (right side forright handed surgeon) prong of the sharp no-scalpel hemostat isplaced through the skin all the way to vas, while holding the vassecurely in the tripod grasp. This clamp is then closed, placedthrough the incision and spread to expose the vas (fig. 2).

Ringed no-scalpel forceps are placed through the incisionand rolled over the vas to confirm the location. The ring is

then opened beneath skin level and pressed firmly againstthe thumb to grasp the vas (fig. 3). Until the surgeon is surethat the vas is secured, the tripod grasp is maintained. Afterit is secured the ringed forceps are extracted to pull a knuckle ofvas through the incision. The exposed aspect of the vasal sheathis incised with a scalpel longitudinally. Cutting slightly into thevas wall ensures that the sheath is opened completely, so thatthe vas extrudes through the sheath. The vas is grasped againwith another ringed forceps and the sheath falls away to exposea 1 to 3 cm. mobile section of vas (fig. 3).

After vasal excision and occlusion by the surgeon methodof choice the procedure is repeated on the contralateral vasfrom the opposite side of the table through a second inci-sion. Ice packs are recommended for 24 hours. Most pa-tients return to work at that time. Sterilization is con-

Accepted for publication November 1, 2002.* Financial interest and/or other relationship with Cook, Pharma-

cia and Pfizer.

FIG. 1. Vas is secured to skin using tripod grasp

0022-5347/03/1694-1434/0 Vol. 169, 1434–1436, April 2003THE JOURNAL OF UROLOGY® Printed in U.S.A.Copyright © 2003 by AMERICAN UROLOGICAL ASSOCIATION DOI: 10.1097/01.ju.0000047366.58553.1c

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firmed by quantitative semen analysis showing absentsperm on 2 occasions.

Prospective analysis of 35 consecutive cases was recentlyperformed to quantify representative results. Measurementswere made of incisional length, operative time and the im-pact of having a resident complete 1 side. Patients reported avisual analog pain scale immediately after the procedure.Each patient was contacted by a research nurse 2 to 4 weekslater and asked about return to work and self-defined return“to completely normal.”

RESULTS

Percutaneous vasectomy was performed on 573 men in theoffice setting. In the group of 35 patients prospectively eval-uated average operative time was 9.3 minutes (range 4 to 21)for the attending urologist when operating alone. When aresident performed the procedure on 1 side in 15 cases, av-erage operative time was an additional 67 seconds. No oralanalgesics or sedatives were used. Average incisional lengthwas 8.4 mm. (range 5 to 14). This length was determined bythe knuckle of vas pulled through the skin, which stretchedthe skin to the necessary incisional size.

No patient reported any concern other than discomfortusing visual analog scale pain scores (mean 2.5 of 10, range0 to 7). Any patient reporting significant discomfort wasfurther questioned. All responded that pain was due to injec-tion of local anesthesia into the scrotum and spermatic cord.

Patients returned to work an average of 2.5 days postop-eratively. This time was largely based on undergoing theprocedure immediately before a weekend off (by definition 3days to return to work) or vacation. Patients judged them-selves completely recovered in an average of 8.9 days. Asingle case of recanalization (0.17%) was identified at initialsemen analysis 2 months postoperatively. This patient un-derwent successful repeat percutaneous vasectomy withoutdifficulty.

During the last year 9 residents (PG-Y 2, 3 and 5) rotatedthrough the outpatient service. Each was subjectively judgedby the attending surgeon to be capable of performing theprocedure unsupervised in fewer than 10 cases. In the 36cases prospectively reviewed the operative time of only 1resident could be assessed through the learning curve. Withthis resident performing percutaneous vasectomy on 1 of the2 sides average operative time in the first 5 cases was 12.2minutes (range 10 to 16) compared with 7.8 minutes (range 7to 10) in the last 5 cases. These results are not statisticallysignificant but consistent with the trends observed as theother residents adopted the procedure.

DISCUSSION

No-scalpel vasectomy is more rapid and less painful than,and equally effective as the traditional approach.3, 4 Somephysicians, including the author, may have a difficult timemastering the supination maneuver of no-scalpel vasectomy.The curved sharp hemostat is designed to spear the vas andlift it through the wound by rotating the wrist. Percutaneousvasectomy avoids this step.

The steep learning curve of no-scalpel vasectomy is wellknown. The original report recommended hands-on training,stating that 15 to 20 cases are required to develop proficiencywith the procedure even for experience vasectomists.1

Whereas that scenario is not feasible or desirable for busyphysicians, the maneuvers described are mastered even bymost junior residents within fewer than 10 cases.

Patient acceptance is high. No patient reported unaccept-able pain and only 1 with a previously unoperated scrotumhad difficult vasal isolation. Judging patient recovery is sub-jective since almost all patients intentionally underwent theprocedure immediately before a weekend, which dependingon work schedules was not always Saturday and Sunday.Several patients also underwent the procedure during vaca-tion, and so they resumed normal activity well before return-ing to employment. For example, 1 physician was exercising2 days after the procedure but completed a week of vacationbefore returning to work. Therefore, this value probably over-estimates the time required before most patients could re-turn to work.

CONCLUSIONS

Percutaneous vasectomy represents a modification ofno-scalpel vasectomy that avoids the most difficult step. It

FIG. 2. Sharpened no-scalpel hemostat pierces skin (inset) andspreads scrotal wall to expose vas.

FIG. 3. Ringed clamp is placed into incision to isolate and extractvas (inset) and procedure is repeated on contralateral vas, usuallythrough second incision made from other side of table.

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combines the minimally invasive nature of no-scalpel va-sectomy with the simplicity of classic vasectomy. We haveobserved that this the technique is easier to teach to res-idents.

REFERENCES

1. Li, S., Goldstein, M., Zhu, J. and Huber, D.: The no-scalpelvasectomy. J Urol, 145: 341, 1991

2. Haws, J. M., Morgan, G. T., Pollack, A. E., Koonin, L. M.,Magnani, R. J. and Gargiullo, P. M.: Clinical aspects of vasec-tomies performed in the United States in 1995. Urology, 52:685, 1998

3. Morrison, G. E. C. and Alderman, P. M.: Re: a comparative studyof the no scalpel and standard incision approaches to vasec-tomy in 5 countries (letter to the editor). J Urol, 163: 1892,2000

4. Holt, B. A. and Higgins, A. F.: Minimally invasive vasectomy.Br J Urol, 77: 585, 1996

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