No Scalpel Vasectomy

NO SCALPEL VASECTOMY
OPEN-ENDED: THE GOLD STANDARD

THE LINGO

All is revealed in The Video

Think of No Scalpel Vasectomy (NSV) as simply a way of ‘getting to’ the tubes via a single small hole in the middle.

The Tubes

The Vas Deferens, or simply ‘The Vas.’ Sperm swim from the testicle up through The Vas to the base of the bladder.

Upper End & Lower End

Each of the two tubes is divided, leaving two ends.

The upper end is the end nearest the groin, referred to as the abdominal end. The lower end is the end nearest the testicle, referred to as the testicular end.

The Fascia

Fascia, sounding like ‘Fasha,’ is the strong thin layer of connective tissue that lies just outside of the tubes.

Fascial Interposition

The fascia covers the stump of one end whilst the other end is left outside the fascia.

Open Ended Vasectomy

The lower end is left open. The end result of fascial interposition to the upper end.

VASECTOMY WHITEBOARD

OPEN ENDED NO SCALPEL VASECTOMY EXPLAINED

WHAT IS NO SCALPEL VASECTOMY?

No Scalpel Vasectomy (NSV) is a type of ‘minimally invasive’ vasectomy – the vasectomy version of keyhole surgery. Traditional vasectomy requires incisions and stitches on both sides of the sac. NSV leaves a small 2-3mm hole at the front of the scrotum. No stitches are required, so you don’t have to come back for stitch removal. Minimal trauma to the tissue means that you can return to work and physical activities sooner.

Do we really need guidelines to confirm that vasectomy should effectively be gentle? Maybe not, but it’s comforting to know that The UK Vasectomy guideline (FSRH 2014) states that ‘a minimally invasive approach should be used to expose and isolate the Vas Deferens during vasectomy as this approach results in fewer early complications in comparison to other methods.’

NSV is also recommended above traditional vasectomy in The American Urological Association Vasectomy Guideline which specifically states in their amended 2015 guideline that ‘Minimally Invasive Vasectomy should be used for Vas Isolation.’ The European Association of Urology Guidelines on Vasectomy guideline (2012) adds to the consensus.

No Scalpel Vasectomy is the de-facto method of gaining access to The Vas Deferens. However, NSV is 20+ year-old technology and can be considered to be ‘old news.’ A crucial but little known fact is that No Scalpel Vasectomy (NSV) simply describes the way to ‘get to’ the tubes – no more, and no less. What happens next describes the different types of NSV.

HOW ARE THE TUBES BLOCKED?

Each tube clearly need to ‘divided’ (or ‘cut’), leaving two ends. Most guys think that’s the end of the story, but you can’t just leave it at that or the ends will grow back. Let’s introduce the vasectomy buzz word that separates one vasectomist from another: Occlusion.

What really separates one vasectomist from another is the method of occlusion

Different methods of occlusion are:

Electrocautery to the internal lining of the tube (the lumen) – with a machine that looks a bit like a laser.
Thermal cautery to the lumen – typically with a battery operated pen device.
Capping the end of the tube with its outside lining – allowing for an open vasectomy.

Guys who do the research tend to conclude that open vasectomy is better type of NSV than closed NSV. You can’t achieve open vasectomy without using Fascial Interposition – these terms go hand in hand.

Most Vasectomies in Australia today are No Scalpel Vasectomy. Now let’s take a look at open and closed vasectomy in more detail.

Dr Beatty The Vasectomist

Dr Beatty The Vasectomist

OPEN .V. CLOSED VASECTOMY

So the tube has been divided, leaving an upper end and a lower end. Do you now block the upper end, the lower end, or both? This is where things get a little convoluted. Dr Dick Beatty gets out the whiteboard with three scenarios:

You block the lower end, leaving the upper end open

The lower end is blocked, the sperm have ‘nowhere to go’, so this is called a closed vasectomy. ‘Closed Vasectomy’ means that the lower end is blocked.

You can’t cauterise just one end and leave the other open, or the tubes have a 10% risk of growing back. When heat is used on its own, you therefore ‘have to’ seal both ends …

You block both ends

Closed Vasectomy also results from blocking both the upper end and the lower ends and is the most common form of closed vasectomy. Heat in the form of electrocautery may be used on its own to seal tube (this is done before the tube is divided).

The concern with closed vasectomy is that the sperm have ‘nowhere to go’ and may lead to discomfort caused by congestion.

In the UK, you get a closed vasectomy and this is how Dr Beatty started doing vasectomies.

You block the upper end, leaving the lower end open

Open Vasectomy describes the scenario where the lower end is left untouched so that sperm are free to swim upstream from the testicle through the open end.

Open-ended vasectomy is considered by many Vasectomists to be the gold standard method of performing No Scalpel Vasectomy.

You can’t just cauterise the upper end and be done, because there would be a 10% failure rate. What else can you do to the upper end to ensure the vasectomy works? The answer is Fascial Interposition.

FASCIAL INTERPOSITION

Fascial Interposition (FI) is regarded by many Vasectomists as the holy grail of vasectomy technique. Why? Because FI is the technique that allows the vasectomy to be open-ended.

The tube has a thin slippery outer layer called fascia. The fascia is gently pulled over the stump and secured in place with a titanium clip or absorbable suture (we currently use an absorbable suture). FI only needs to be performed on one end. FI to the upper end is the preferred method, allowing the bottom end to be left alone (an open vasectomy).

FI allows for an open-ended vasectomy, and hopefully less post-procedure discomfort. Dr Dick Beatty performs open-ended vasectomy.

The theory goes that sperm swim out of the lower tube after an open vasectomy. An experiment in rats demonstrated that the tubes that are left open do in fact seal themselves closed within a few weeks of a vasectomy. However, closure would certainly be slower than the abrupt surgical closure of a closed vasectomy.

Studies comparing open to closed vasectomy suggest that open vasectomy results in less post-vasectomy discomfort. Research is not 100% conclusive which explains why vasectomy guidelines do not categorically state that open-ended is better than closed vasectomy. However, there is no downside to leaving the bottom end open (provided the upper end is properly sealed) but there may be increased post-vasectomy pain by blocking the lower end.

The other aim of FI is to improve the success of vasectomy. The Vasectomist has performed both types of vasectomy and can attest to extremely low failure rate of open vasectomy.

Suture .v. Clip

A clip or suture tie work equally well for fascial interposition. A clip is quicker to apply and lasts forever. A suture tie takes a little longer to perform, and is absorbed over around 8 weeks. The vasectomist has used both methods but currently uses suture.