Lara C. Pullen, PhD

Source: Medscape Medical News

Oct 25, 2012

 

The American Urological Association (AUA) has published new guidelines for physicians who offer vasectomy services, recommending that vasectomy be considered more often as a permanent contraception option.

A supplement to the December issue of the Journal of Urology contains new clinical guidelines for multiple treatments including guidelines for vasectomy. The vasectomy guidelines cover perioperative practice, anesthesia, vas isolation, vas occlusion, and postoperative practice.

Pravin Rao, MD, director of reproductive medicine and surgery, Brady Urological Institute, Johns Hopkins University, Baltimore, Maryland, spoke with Medscape Medical News about the new guidelines. Dr. Rao, who did not participate in their development, explained that, “there really has not been a set of well-delineated guidelines for physicians up to this point.”

The AUA recommends an in-person preoperative interactive consultation, which should cover the permanent nature of the surgery, the fact that vasectomy does not produce immediate sterility, and the need for additional contraception until vas occlusion is confirmed. The preoperative consultation does not need to include routine discussion of prostate cancer, coronary heart disease, stroke, hypertension, dementia, or testicular cancer because post vasectomy patients are not at higher risk for these conditions. Prophylactic antimicrobials are not indicated unless the patient is at high risk for infection.

The guidelines indicate that local anesthesia should be used for the vasectomy, with oral sedation being optional. Vas isolation should be performed using a minimally invasive vasectomy technique such as the no-scalpel technique.

Vas occlusion can be accomplished by extended electrocautery or by 1 of 3 divisional methods:

• mucosal cautery with fascial interposition and without ligatures or clips applied on the vas,
• mucosal cautery without fascial interposition and without ligatures or clips applied on the vas, or
• open-ended vasectomy leaving the testicular end of the vas unoccluded, using mucosal cautery on the abdominal end and fascial interposition.

Surgeons who are able to consistently achieve results by occlusion of the vas with ligatures or clips may use this approach.

According to the guidelines, there is no need for routine histologic examination of the removed vas segments.

Other contraceptive methods should be used until the vasectomy is confirmed successful by post vasectomy semen analysis (PVSA) approximately 8 to 16 weeks after vasectomy. The analysis should be performed on semen within 2 hours after ejaculation. Other contraception may be stopped when the semen sample exhibits a zoospermia, rare non-motile sperm, or 100,000 or fewer non-motile sperm/mL.

If motile sperm are seen on PVSA at 6 months post vasectomy, the vasectomy should be considered a failure. A repeat vasectomy can be performed. Persistence of more than 100,000 non-motile sperm/mL at 6 months post vasectomy should trigger serial PVSAs and clinical judgment to determine whether or not the vasectomy was a failure.

Funding for the committee members was provided by the American Urological Association. Dr. Rao has disclosed no relevant financial relationships. Full conflict-of-interest information is available on the journal’s Web site.