Section: Urology Curriculum: Curriculum, page 7

Patient Counselling

Other contraception options and alternatives including permanence of vasectomy
Social hx including family, partner knowledge, future family intent
Need interim contraception for 3 months and azoospermia on semenalysis before assuming sterility
Still 1 in 2000 risk of pregnancy
Needs condoms to protect against STI’s

Preoperative Assessment

Full medical hx and O/E - sexual developmental hx, genital injury or surgeries
Confirm single vas and testicle each side and absence of anatomical abnormalities
Presence of other scrotal pathologies - varicocoele etc
Refer solitary testicle, extensive genital surgery and non-palpable vas to UROLOGY
Varicocoele, hydrocoele, scrotal mass, cryptorchidism → UROLOGY

Innervation - ilioinguinal N and genital br of GF N supply anterior scrotum skin and spermatic cord → LA here is sufficient
Scrotal layers - scrotal skin → dartos fascia and muscle → external spermatic fascia → cremasteric fascia and muscle → internal spermatic fascia which covers cord and contains VAS and neurovasculature
Vasculature - artery to vas and pampiniform plexus are within the cord
Varicocoele makes vas isolation difficult

3 approved vasectomy isolation methods:
- Conventional vasectomy
- No-scalpel technique
- Minimally invasive
Vas occluded by one of three divisional techniques:
- Mucosal cautery (MC) with fascial interposition (FI) without clips or ties placed on vas
- MC without FI and without clips or ties on vas
- Open ended vasectomy leaving testicular end of vas unoccluded, using MC on the abdominal end and FI
- OR by the non-divisional method of extended electrocautery
Vasectomy failure rates based on semen analysis are highest with simple excision and ligation of vas and lowest with occlusion techniques combining cautery and fascial interposition

I perform under GA
Supine. Shave area in operating room. Time out. Sterile prep and drape
Grasp vas at the neck of scrotum and work it towards the skin.
Hold the vas close to the skin using non-dominant hand
Place two Allis forceps either side of a 1cm segment of vas to be excised.
Make a vertical incision of the skin between the Allis forceps.
Divide through the coverings layer by layer using the scalpel in the line of wound until the glistening white muscular coat of the Vas is seen.
Use another Allis to grasp the Vas and free it to deliver a segment about 3cm in length and deliver into wound.
Both ends of the vas are clamped with artery forceps and the vas cut between the ties and a short segment sent for histology. Each end is tied with 2/0 Vicryl and then stump of vas doubled over and tied again to form a loop.
I push the lower end back into the scrotum.
I close the incision with 2/0 Vicryl interrupted sutures.
I incorporate the upper end into the subcutaneous tissues to keep the ends widely separated.
I perform the same on the opposite side and apply a scrotal support.

Supportive underwear/scrotal support
Ice pack
Simple analgesia
Avoid sex for 1/52 with alternate contraception until confirmational semenalysis 3/12 post-procedure
Clearance - 3/12, 20 ejaculations and azoospermia (non motile sperm is less reliable and warrants repeat test as could indicate an old test
Timing of test
- Should be performed 12 weeks post procedure.
- Patient should have had 20 ejaculates to ensure clearance of residual sperm.
- Sperm presence
  - Azospermia - complete absence of sperm indicates vasectomy success
  - Persistent motile sperm - suggests recanalisation of the vas deferens.
- If sperm (motile of non-motile) is present on the 12 weeks test, additional semen analysis is required 4-6 weeks later.

Haematoma - pampiniform plexus
Infection
Epididymitis - congestive, leave testicular side of vas open to prevent pressure
Sperm granuloma - sperm leakage from testicular end of vas, 2-3/52 post surgery is sore, rarely require surgery
Post vasectomy pain syndrome - usually due to congestive epididymitis, rarely surgery needed - reversal or epididymectomy completion
Failure - technical errors, recanalization, UPSI prior to azoospermia