In a State-of-the-Art Lecture Sunday morning, Jesse Mills, MD, discussed the advantages and disadvantages of scalpel versus no scalpel and cautery versus no cautery when performing vasectomies.
Dr. Mills said there are really no data that indicate that either the scalpel method or the no-scalpel approach is significantly superior, so the choice usually depends on training.
“For the most part, the advantages versus disadvantages of scalpel versus not using a scalpel come down to patient satisfaction rates,” said Dr. Mills, Associate Clinical Professor of Urology at the David Geffen School of Medicine and Director of The Men’s Clinic at the University of California, Los Angeles. “There certainly have been a number of trials showing that there’s less bleeding with a no-scalpel vasectomy and lower hematoma formation, which makes sense because there’s a little less tissue dissection.”
Other advantages of a no-scalpel vasectomy include shorter surgical time, less pain and faster resumption of intercourse.
“Among the disadvantages of the no- scalpel approach is that it requires specialized instrumentation. One of the things I found in my practice is those super-sharp Jacobson forceps don’t stay super-sharp through multiple vasectomies, so there’s a little bit of a replacement cost,” Dr. Mills said. “But other than that, there’s nothing that tells us that one way is better when it comes to success rates.”
Dr. Mills said cautery versus no cautery ultimately hinges on the choice of occlusion method.
“There are multiple ways to do occlusion and this is where we get into some important nuances,” Dr. Mills said. “Vasal ligation, for example, probably has the highest failure rate possible. If you’re just going in and tying a suture across the vasectomy, it’s quick and it’s easy but has very high failure rates. It’s probably an unacceptable way to do the procedure if all you’re doing is ligating the vas deferens.”
No matter what occlusion method is used, Dr. Mills said combining it with fascial interposition can bring the failure rate down to almost zero.
“However you want to occlude your vas deferens, combining with fascial interposition and adding in some thermal cautery of some kind is going to give you the highest success rates, with potentially less tissue destruction and segmental removal,” he said. “The only disadvantage is that it takes more time.”
Dr. Mills also noted that a new, experimental vasectomy procedure, reversible inhibition of sperm under guidance, shows some promise.
“It involves putting a polymer of styrene maleic anhydride into the vas, where it forms essentially a barrier to sperm motility so that every time a man ejaculates the sperm into the vas deferens it’s killed on contact,” Dr. Mills said. “It’s not even close to being ready for prime time, but it is something interesting on the horizon.”