Percutaneous No-Scalpel Vasectomy via One Puncture in China Liping Li,1,2 Jialiang Shao,1 Xiang Wang1 Corresponding Author: Xiang Wang, MD Department of Urology, Huashan Hospital of Fudan University, 12 Wulumuqi Middle Road, Shanghai 200040, China. Tel: +86 21 5288 7080 Fax: +86 21 5288 8279 E-mail: seanw@medmail.com.cn Received April 2013 Accepted December 2013 1 Department of Urology, Huashan Hospital of Fudan University, Shanghai 200040, China. 2 Department of Urology, Zhongshan Hospital of Fudan University, Shanghai, 200032, China. Purpose: To‎evaluate‎the‎efficacy‎and‎postoperative‎morbidity‎of‎percutaneous‎no-scalpel‎ vasectomy‎(NSV)‎via‎one‎puncture‎in‎China. Materials and Methods:‎A‎total‎of‎150‎men‎visiting‎outpatient‎clinic‎of‎the‎surgery‎depart- ment‎of‎urology,‎Huashan‎Hospital‎and‎its‎Baoshan‎branch‎of‎Fudan‎University,‎opted‎for‎ percutaneous‎NSV‎with‎local‎anesthesia.‎The‎clinical‎data‎of‎150‎who‎underwent‎modified‎ NSV‎(MNSV)‎were‎retrospectively‎compared‎with‎those‎of‎120‎patients‎who‎underwent‎ standard‎NSV‎(SNSV).‎The‎results‎and‎follow-up‎were‎recorded. Results:‎The‎reviewed‎average‎operative‎time‎was‎9.8‎min‎(range‎8‎to‎20‎min).‎Average‎inci- sional‎length‎was‎5‎mm‎(range‎4‎to‎8‎mm).‎Patients‎reported‎complete‎recovery‎in‎an‎average‎ of‎8.5‎days‎(range‎4‎to‎14‎days).‎The‎complication‎rates‎were‎extremely‎low‎with‎this‎modi- fied‎technique.‎Only‎one‎case‎of‎late‎healed‎incision‎was‎observed‎(0.67%).‎ Conclusion:‎Percutaneous‎NSV‎via‎one‎puncture‎was‎proved‎to‎be‎a‎painless‎and‎effective‎ form‎of‎permanent‎contraception‎with‎an‎extremely‎low‎complication‎rate. Keywords: vasectomy;‎adverse‎effects;‎methods;‎prospective‎studies;‎follow-up‎studies;‎sur- gical‎procedures;‎minimally‎invasive. 1452 | SEXUAL DYSFUNCTION AND INFERTILITY Sexual Dysfunction and Infertility 1453Vol. 11 | No. 02 | March- April 2014 |U R O LO G Y J O U R N A L No-Scalpel Vasectomy | Li et al INTRODUCTION Vasectomy‎is‎a‎simple‎and‎reliable‎method‎of‎male‎permanent‎contraception‎that‎has‎achieved‎wide-spread‎acceptance‎in‎the‎world.‎Various‎surgical‎ap- proaches‎to‎occlude‎the‎vas‎have‎been‎recommended‎over‎the‎ years,‎including‎the‎conventional‎incision‎vasectomy‎(CIV)‎ through‎a‎2‎to‎3‎cm‎incision‎and‎the‎standard‎no-scalpel‎va- sectomy‎(SNSV)‎made‎through‎a‎2‎to‎3‎mm‎puncture‎wound‎ on‎the‎scrotum,‎both‎of‎which‎were‎first‎introduced‎from‎Chi- na and used in other countries.(1,2)‎NSV‎has‎been‎proved‎to‎be‎ a‎minimally‎invasive‎approach,‎which‎reduces‎the‎incision‎ size,‎procedure‎time,‎pain,‎bleeding‎and‎postoperative‎com- plications‎compared‎with‎CIV.(3-8)‎Yearly‎16‎million‎Chinese‎ men‎undergo‎this‎procedure,‎which‎is‎traditionally‎performed‎ through 1 or 2 standard scrotal incisions.(9)‎Some‎surgeons‎ have‎complained‎that‎the‎SNSV‎technique‎is,‎in‎fact,‎more‎ difficult‎to‎perform‎than‎the‎CIV‎technique.(10)‎Therefore,‎in‎ this‎study,‎we‎reported‎a‎MNSV‎with‎only‎one‎tiny‎puncture‎ in‎scrotum. MATERIALS AND METHODS A‎total‎of‎150‎men‎who‎have‎been‎undergone‎MNSV‎in‎our‎ center‎ were‎ analyzed‎ retrospectively‎ compared‎ with‎ those‎ 120‎men‎who‎have‎had‎SNSV.‎There‎were‎no‎significant‎dif- ferences‎between‎these‎2‎groups‎in‎terms‎of‎age‎and‎mean‎ number‎of‎children‎(P >‎.05).‎The‎characteristics‎of‎subjects‎ are‎shown‎in‎Table.‎Those‎who‎agreed‎for‎vasectomy‎must‎ sign‎ an‎ informed‎ consent‎ form‎ and‎ ensure‎ the‎ following:‎ should‎have‎had‎at‎least‎one‎or‎more‎children,‎should‎have‎re- alized‎the‎risk‎of‎the‎possible‎complications‎and‎should‎have‎ obtained‎the‎consent‎of‎their‎spouses‎to‎undergo‎the‎steriliza- tion‎method.‎The‎exclusion‎criteria‎were‎subjects‎with‎tes- ticular‎cancer,‎active‎scrotal‎skin‎infections,‎epididymitis,‎or- chitis,‎balanitis‎and‎some‎other‎surgical‎contraindication.‎All‎ vasectomies‎were‎performed‎by‎the‎responsible‎author‎and‎ his‎assistant.‎Main‎outcome‎measures‎were‎the‎patients’‎char- acteristics, hospital stay, incisional length, recurrence rate, complication‎rate,‎operating‎duration‎and‎complication‎rate.‎ The‎surgical‎procedure‎was‎similar‎to‎percutaneous‎SNSV‎ as‎reported‎by‎Li‎and‎colleagues.(1)‎The‎method‎for‎SNSV‎is‎ illustrated‎in‎Figures‎1-5.‎A‎few‎modifications‎were‎made‎as‎ the‎following:‎the‎point‎of‎puncture‎was‎single‎to‎complete‎ bilateral‎vasectomy‎and‎located‎on‎the‎scrotal‎surface‎at‎the‎ median‎raphe‎approaching‎the‎root‎segment‎of‎penis;‎after‎ puncturing‎through‎the‎scrotal‎skin,‎a‎dissecting‎forceps‎and‎ two‎no-scalpel‎hemostats‎were‎used‎to‎isolate‎the‎vas‎scrupu- lously‎and‎the‎wound‎was‎closed‎by‎medical‎adhesive.‎ RESULTS In‎the‎group‎of‎MNSV,‎the‎average‎operative‎time‎was‎9.2‎ min‎from‎sterilizing‎the‎skin‎to‎closing‎the‎skin.‎Average‎inci- sional‎length‎was‎5‎mm.‎Patients‎reported‎complete‎recovery‎ Figure 1. Fixing one vas to the scrotal surface at the median raphe using the three-finger technique to stabilize the vas. Per- forming a local vasal nerve block using a needle injection with 1-2% lidocaine without epinephrine. Figure 2. Sharpened no-scalpel hemostat pierces skin. 1454 | in‎an‎average‎of‎8.0‎days.‎The‎mean‎duration‎of‎follow-up‎was‎ 6.5‎months.‎Complete‎azoospermia‎was‎achieved‎in‎100%‎of‎ men‎3‎months‎postoperatively‎by‎at‎least‎two‎semen‎analyses.‎ Most‎of‎the‎men‎(92%)‎resumed‎work‎on‎the‎same‎day‎and‎all‎ (100%)‎resumed‎work‎within‎a‎week.‎The‎complication‎rates‎ were‎extremely‎low:‎there‎was‎one‎diabetic‎patient‎with‎late‎ healed‎incision‎without‎infection‎(0.67%).‎The‎wound‎did‎not‎ heal‎within‎ten‎days‎postoperatively.‎By‎controlling‎his‎blood‎ sugar‎with‎insulin,‎the‎wound‎healed‎later‎(Table).‎ DISCUSSION NSV‎were‎first‎introduced‎from‎China‎and‎then‎used‎in‎oth- er countries.(1,2)‎It‎has‎been‎demonstrated‎that‎it‎results‎in‎a‎ smaller‎wound‎and‎shorter‎operation‎time‎compared‎to‎the‎ CIV‎procedure,‎being‎the‎most‎reliable‎and‎the‎safest‎method‎ currently‎available‎for‎male‎contraception.(11)‎Because‎of‎its‎ minimally‎invasive‎nature‎more‎and‎more‎families‎in‎China‎ also‎select‎NSV‎for‎contraception‎recently. With‎twenty‎years‎passing‎away,‎there‎were‎numerous‎meth- ods‎ improving‎ NSV.‎ Owing‎ to‎ the‎ initial‎ needle‎ puncture‎ that‎is‎usually‎the‎commonest‎voiced‎concerns‎for‎the‎pa- tient,‎a‎revolution‎of‎application‎of‎novel‎and‎actually‎pain- less‎anesthesia‎has‎made‎the‎procedure‎more‎comfortable.‎It‎ was‎called‎no-needle‎jet‎injection‎or‎no-needle‎vasectomy.‎ This‎technique‎used‎a‎special‎instrument‎that‎delivered‎via‎ high‎pressure‎injector‎through‎tiny‎head‎to‎beneath‎skin‎and‎ throughout‎tissue‎around‎vas‎achieving‎complete‎anesthetic‎ block‎of‎the‎vas.(12)‎As‎a‎result‎of‎economy‎and‎technique‎ aspect‎in‎China,‎this‎advanced‎and‎great‎anesthetic‎method‎ has‎not‎been‎used‎in‎our‎study.‎At‎the‎aspect‎of‎surgical‎pro- cedure,‎there‎were‎also‎some‎modifications‎of‎NSV.‎ Chen‎divided‎NSV‎into‎instrument-dependent‎no-scalpel‎va- sectomy‎(IDNSV)‎which‎is‎publicly‎known‎and‎instrument- independent‎ no-scalpel‎ vasectomy‎ (IINSV).(13)‎ The‎ main‎ difference‎between‎them‎is‎two‎specialized‎instruments‎(an‎ extracutaneous‎fixation-ring‎clamp‎and‎a‎dissecting‎clamp)‎ which‎are‎required‎in‎the‎former.‎The‎IINSV‎technique‎offers‎ an‎alternative‎option‎for‎vasectomists‎whenever‎the‎specific‎ instruments‎of‎standard‎NSV‎are‎unavailable.‎Jones‎suggested‎ a‎percutaneous‎vasectomy,‎which‎to‎avoid‎the‎most‎difficult‎ step‎which‎is‎fixation‎of‎the‎vas‎to‎skin‎using‎the‎ring‎clamp. (10)‎The‎steep‎learning‎curve‎of‎NSV‎is‎well‎known.‎It‎was‎ stated‎that‎15‎to‎20‎cases‎are‎required‎to‎develop‎proficiency‎ Figure 3. Spreading scrotal wall to expose vas. Figure 4. Ringed clamp is placed into incision to isolate and extract vas. Figure 5. An 1 cm piece of vas is excised and the occlusion is accomplished by ligation and cautery of the lumen of both vasal ends. Sexual Dysfunction and Infertility 1455Vol. 11 | No. 02 | March- April 2014 |U R O LO G Y J O U R N A L No-Scalpel Vasectomy | Li et al with‎the‎procedure‎even‎for‎experienced‎vasectomists.(1)‎This‎ described‎simple‎modification‎maneuvers‎are‎mastered‎even‎ by‎most‎junior‎residents‎within‎fewer‎than‎10‎cases.‎Numer- ous‎techniques‎for‎vasal‎occlusion‎have‎been‎developed‎and‎ were‎used‎all‎over‎the‎world.‎These‎consisted‎of‎excision‎of‎ a‎segment‎of‎vas‎of‎various‎lengths,‎ligation‎of‎the‎vas‎with‎ either‎suture‎or‎clips,‎folding‎back‎the‎end‎of‎the‎vas‎onto‎ itself,‎fascial‎interposition‎between‎the‎cut‎ends‎of‎the‎vas,‎ and‎cautery‎of‎the‎lumen‎of‎the‎vas‎(electric‎or‎thermal).(8) Because‎of‎the‎heterogeneity‎of‎study‎designs,‎surgical‎tech- nique‎used,‎and‎assessment‎of‎results,‎there‎was‎no‎evidence‎ that‎some‎occlusion‎method‎was‎more‎effective‎in‎terms‎of‎ contraception‎and‎associated‎with‎a‎lower‎risk‎of‎complica- tions‎compared‎with‎any‎other‎occlusion‎method.(8) As a re- sult,‎percutaneous‎IDNSV‎with‎some‎modification‎was‎used‎ in our study. The‎complication‎rates‎were‎low‎with‎NSV.‎The‎most‎com- mon‎complications‎were‎infection‎and‎hematoma.‎Infection‎ was‎very‎rare‎when‎NSV‎was‎performed‎under‎sterile‎condi- tions‎and‎was‎usually‎coexistent‎with‎an‎underlying‎hema- toma.(3)‎It‎was‎well‎documented‎that‎incidence‎of‎complica- tions‎was‎closely‎related‎to‎the‎experience‎of‎the‎physician. (4)‎The‎mean‎incidence‎of‎hematoma‎is‎less‎than‎0.5%.(3,14) In‎our‎study‎there‎was‎one‎(0.67%)‎diabetic‎patient‎with‎a‎late‎ healed‎incision.‎This‎patient‎had‎poor‎diabetes‎mellitus‎con- trol.‎Fasting‎blood‎sugar‎was‎9‎mmol/L.‎In‎order‎to‎control‎ the‎glycemia,‎insulin‎was‎administered.‎The‎late‎healed‎inci- sion‎was‎fully‎recovered‎later.‎In‎brief,‎diabetes‎mellitus‎and‎ uncontrolled‎glycemia‎were‎the‎main‎reason‎for‎these‎compli- cations.‎It‎warned‎that‎despite‎of‎a‎small‎incision,‎those‎who‎ are‎in‎poor‎health‎condition‎could‎be‎aware‎of‎them.‎Some‎ measures‎should‎be‎taken‎to‎improve‎it.‎Compared‎with‎other‎ studies,‎the‎effectiveness‎and‎main‎outcome‎were‎accordant‎ and‎seemed‎even‎better‎(Table).‎ In‎our‎opinion,‎this‎result‎was‎profited‎from‎some‎modifica- tions‎of‎percutaneous‎NSV.‎A‎single‎puncture‎in‎scrotum‎to‎ complete‎bilateral‎vasectomy‎can‎reduce‎the‎total‎incisional‎ length.‎The‎point‎of‎puncture‎chosen‎on‎the‎scrotal‎surface‎ at‎the‎median‎raphe‎approaching‎the‎root‎segment‎of‎penis‎ can‎reserve‎a‎longer‎vas‎next‎ to‎the‎epididymal‎end.‎This‎ improvement‎can‎decrease‎ tension‎of‎ the‎epididymis‎after‎ ligation.‎ It‎ can‎ increase‎ the‎ contraception‎ rate‎ and‎ relieve‎ postoperative‎pain.‎A‎dissecting‎forceps‎and‎two‎no-scalpel‎ hemostats‎were‎used‎to‎isolate‎the‎vas‎scrupulously.‎It‎can‎ isolate‎the‎vas‎precisely‎without‎injuring‎the‎vessels‎of‎the‎vas‎ and‎reduce‎the‎incidence‎of‎hematoma‎formation.‎The‎wound‎ was‎ closed‎ by‎ medical‎ adhesive‎ to‎ prevent‎ contamination‎ with‎water‎and‎microorganisms.‎It‎helped‎to‎protect‎the‎inci- Table. Outcome measures of studies comparing our study with others. Effectiveness Complications no. (%) Study Sample Size Opera- tion Time (min) Incisional Length (mm) Post-vasectomy Se- men Analysis Hema- toma Infec- tion Others Total Timing Failure Rate No. (%) Kumar et al. 1999(7) 4253 9.5 Not reported 3 months Not reported 2 (0.047) 3 (0.07) 3 painful nodules (0.07) 2 vasal fistulae (0.047) 10 (0.2) Labrecque et al. 2002(8) 3761 Not reported Not reported 112 days 104 (2.8) 24 (0.64) 7 (0.19) 90 Vasitis/orchi- epididymitis (2.4) 20 granuloma (0.53) 2 other unspecified (0.05) 143 (3.8) Jones, 2003(13) 573 9.3 8.4 2 to 4 weeks 1 (0.17) Not re- ported Not re- ported Not reported Not reported Chen, 2004(12) 215 15.2 7.8 Not reported 1 (0.4) 6 (2.4) 1 (0.4) 4 granuloma (1.6) 11 (5) Our study 150 9.2 5.0 3 months 0 (0.00) 0 (0.00) 0 (0.00) 1 late healed incision (0.67) 1 (0.67) 1456 | sion‎against‎infection.‎Patients‎can‎even‎take‎shower‎on‎the‎ day‎of‎operation. CONCLUSION We‎concluded‎that‎percutaneous‎NSV‎via‎one‎puncture‎is‎a‎ virtually‎painless‎and‎extremely‎effective‎form‎of‎permanent‎ contraception‎with‎an‎extremely‎low‎complication‎rate. REFERENCES 1. Li SQ, Goldstein M, Zhu J, Huber D. The no-scalpel vasectomy. J Urol. 1991;145:341-4. 2. Huber D. No-scalpel vasectomy: the transfer of a refined surgi- cal technique from China to other countries. Adv Contracept. 1989;5:217-8. 3. Schlegel PN AGM. Vasectomy. In: M G, M G.M Gs. Surgery of Male Infertility: New York, WB Saunders; 1995. p. 35-45. 4. Goldstein M. Surgical management of male infertility and other scrotal disorders. In: Walsh PC RAVE, Walsh PC RAVE. Walsh PC RAVEs. Campbell’s Urology. 8thed: New York, WB Saunders; 2002. p. 1541-7. 5. Viladoms JM, Li PS. Vasectomia sin Bisturi. Arch Esp Urol. 1994;47:695-701. 6. Skriver M, Skovsgaard F, Miskowiak J. Conventional or Li vasectomy: a questionnaire study. Br J Urol. 1997;79:596-8. 7. Kumar V, Kaza RM, Singh I, Singhal S, Kumaran V. 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