No Scalpel Vasectomy - The Vasectomist

VASECTOMY CONCEPTS
NO SCALPEL, OPEN ENDED, FASCIAL INTERPOSITION

THE LINGO

All is revealed in The Video

No Scalpel Vasectomy

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. The Lower end is the end nearest the testicle.

Vasectomy Doctors refer to The upper end as The Abdominal end, and The Lower end 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. Traditional vasectomy requires incisions and stitches on both sides. NSV leaves a small 2-3mm hole at the front of the scrotum. No stitches are required & healing time is minimal. Minimal trauma to the tissue means that you can return to work and physical activities sooner.

How many Vasectomies in Australia are performed in the traditional way with a scalpel on both sides? There are no figures, but they still are certainly performed this way. Dr Dick Beatty’s hunch is that over 70% of vasectomies in Australia are nowadays performed using the NSV method.

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.

HOW ARE THE TUBES BLOCKED?

No Scalpel Vasectomy simply describes the way to ‘get to’ the tubes – no more, and no less.

The tubes need to ‘divided’ (a nicer word than ‘cut’), but what happens next? You want to know how the tubes are blocked, so let’s move onto the other vasectomy buzz word: Occlusion.

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

The different methods of occlusion describe the different types of No Scalpel Vasectomy as follows:

Open or Closed Vasectomy
Fascial Interposition (FI)
Clips or Suture – a way of performing FI

You can’t achieve open vasectomy without using Fascial Interposition, so these two tend to go hand in hand.

Guys who do the research tend to conclude the ‘open’ vasectomy is better than closed, but why is this?

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.

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

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).

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. In The UK, you get a closed vasectomy.

You block the upper end, leaving the lower end open

Sperm may be considered free to swim from the testicle, up the tube and through the open end. This scenario describes an Open Vasectomy.

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

We’ve just said that cautery of just one end has 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.

Thankfully, the tube has a thin slippery outer layer called fascia. The fascia is gently pulled over the stump and kept in place with a titanium clip or absorbable suture. FI only needs to be performed up the upper end so that the lower end may be left open.

FI therefore 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 left open do in fact seal themselves closed within a few weeks of a vasectomy. However, the lower end would close itself slowly, and not suddenly in the case of a closed vasectomy.

Studies comparing open to closed vasectomy provide limited evidence that open vasectomy results in less post-vasectomy discomfort. However, the studies are overall not 100% conclusive which explains why vasectomy guidelines do not categorically state that open-ended is better than closed vasectomy.

The other aim of FI is to improve the success of vasectomy.

There is no downside to leaving the bottom end open (provided the upper end is properly sealed) but there may be a downside to leaving the bottom end closed.

How is the fascia sealed over the upper end? A titanium clip works nicely. The clip covers the stump very nicely although Suture may also be used. The 3mm clip is MRI friendly &doesn’t bleep in airports!

FROM START TO FINISH

You go from the consultation room to the procedure room that is kept at around 23-24 degrees.
You’re asked to (only) remove your shoes and lie on the couch at this stage!
The electric couch lifts to the correct height, and the doctor asks you to lower your clothes to your shins.
You have the choice of ‘no needle anaesthesia‘ or ‘fine needle’ anaesthesia.
The doctor does the ‘wash down’ with warmed antiseptic solution.
The doctor starts with the left side with a specialised instrument that is applied to the left tube.
The left tube is electro-cauterised & separated in two.
The upper ‘stump’ is sealed with its own covering (fascial interposition).
The right tube is brought up through the same small hole & the procedure repeated on this side.