COMPARATIVE EVALUATION OF NO-SCALPEL VASECTOMY AND STANDARD INCISIONAL VASECTOMY

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ABSTRACT

No-scalpel vasectomy employs a refined method of dissection and delivery of the vas deferens. We compared no-scalpel vasectomy with standard incisional vasectomy in 176 patients over a 33 month period. The haemorrhage rate was 1.08 per cent for no-scalpel vasectomy compared with 11.9 per cent for standard vasectomy (p < 0.005). The infection rate was 3.26 per cent for no-scalpel vasectomy as against 14.28 per cent for standard vasectomy (p < 0.01). There was a 37.5 per cent reduction in operating time and a substantial reduction in pain during and after the procedure when no-scalpel vasectomy was performed and also there was no failure of vasectomy. No-scalpel vasectomy is a satisfactory alternative to standard vasectomy with fewer complications and increased patient acceptability.

Introduction

No-scalpel vasectomy (NSV) is a new and innovative technique developed in China in 1974 for delivery and dissection of the vas deferens [1]. It has increased the acceptability of vasectomy by eliminating the fear of incision and reduced the morbidity by limiting the extent of dissection.

We made a comparative evaluation of no-scalpel vasectomy and standard incisional vasectomy (SIV) in 176 procedures done between December 1993 and August 1996. A study of the complication rate, time taken and effectiveness was made. We also studied the applicability of NSV for practice in the Armed Forces.

One hundred and seventy six serving personnel between 30-39 years of age were included in this study. After informed consent the men underwent NSV or SIV at random. After the procedure each man was instructed to use a contraceptive for next 3 months and to have a semen analysis before resumption of unprotected intercourse. Tablet co-trimoxazole 160-800 mg bd for 5 days and tablet soluble aspirin 600 mg tds for 3 days was prescribed. Patients were told to return for review after one week, or earlier if required. All patients were questioned about the pain they felt during and after the procedure.

NSV was performed according to the technique of Li and associates [1] with minor modifications. The scrotal skin was shaved and prepared with warm savlon solution (chlorhexidine gluconate and cetrimide).

Local Anaesthesia : The vas deferens was manipulated under the median raphe of the scrotum. The right vas was firmly trapped over the middle of the left hand and under the index finger and the thumb. A superficial wheal was raised using a 23 gauge needle and 2 per cent plain lignocaine. The needle is then advanced in the perivasal sheath toward the external inguinal ring and 2-5 mL of lignocaine injected. This effects a vasal nerve block away from the actual vasectomy site. The left vas was then fixed under the previous skin puncture site and anaesthetized using the same 3-finger technique.

Fixation and delivery of the vas : After both vas had been anaesthetized, the right vas was again fixed under the site of the skin wheal with the left hand. The vas and overlying skin was grasped with an Allis forceps (Fig 1). We found the Allis forceps a satisfactory substitute for the special extracutaneous vas deferens fixation clamp designed by Li [1]. A curved mosquito artery forceps with the point sharpened was used as a dissecting clamp. The point of the clamp was used to puncture the scrotal skin, vas sheath and vas wall where the vas was most superficial and prominent. The blades were gently opened spreading all layers down to the bare vas wall (Fig 2). The vas was delivered through the puncture hole using the dissecting clamp while simultaneously releasing the Allis forceps (Fig 3). The Allis forceps was used to grasp the delivered vas. The sheath and vasal vessels were stripped gently away from the vas using the dissecting clamp.

One cm segment of the vas was resected and the two cut ends occluded with 2/0 silk sutures. The abdominal end of the vas was buried by closing its sheath with a silk suture. After occlusion the ends of the right vas were returned to the scrotum and the left vas fixed directly under the same puncture hole using the 3-finger technique. The remainder of the procedure was identical to that of the right side.

After both vas had been occluded and returned to the scrotum the puncture wound was pinched tightly for a minute and inspected for bleeding. The puncture hole would contracted and remain invisible to the patient (Fig 4). No suture was required for the closure. Povidone iodine 5 per cent ointment was applied and a sterile dressing held in place with a suspensory bandage.

The SIV technique was essentially similar to that described by Blandy [2] and Nirapathpongporn and co-workers [3]. After administration of local anaesthesia a 0.5-1.0 cm incision was made with a scalpel in the median raphe of the scrotum. The vas was grasped with an Allis forceps, its sheath incised longitudinally and the vas lifted out of its sheath. The vas was ligated and divided in a manner similar to NSV. The procedure was repeated on the other side. Haemostasis was ensured and the skin and dartos closed with one or two 2/0 silk sutures. Wound was dressed like in NSV.

Statistical analysis of results was done using the chi-square test.

One hundred and seventy six vasectomies were done in a 33 month period in our hospital. Ninety two (52.27%) underwent NSV while 84 (47.72%) underwent SIV. Common complications were haemorrhage and wound infection (Table). Haemorrhage was seen in 10 who underwent SIV (11.90%). Two required drainage of large scrotal haematomas. One haemorrhagic complication was observed after NSV (1.08%) (chi-square 8.76, df=1, p<0.005). Infection was seen in 12 men who underwent SIV (14.28%). Three patients after NSV had wound infection (3.26%) (chi-square 6.86, df=1, p<0.01). No damage to scrotal skin was noted with use of Allis forceps in NSV.

Nineteen patients (22.61%) who underwent SIV complained of moderate to severe pain, while 7 patients (7.60%) of the NSV group had such complaints.

The average time taken for SIV was 14 min with a range of 10-19.5 min, whereas the average operating time for NSV was 8.75 min with a range of 5-13 min. This represented a 37.5 per cent reduction in average operating time.

Both procedures were 100 per cent effective as shown by the absence of live sperms in the ejaculates of all 176 men at the end of 3 months.

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Discussion

NSV is a novel technique for delivery and dissection of the vas deferens. It has been successfully used in over 80 lakh men in China, Thailand and other developing countries [3]. Our study indicates that NSV has advantages over the conventional incisional technique. NSV has a significantly lower complication rate than SIV. Haematoma is a common complication of SIV with an average incidence of 2 per cent and a range of 1-29 per cent [4]. Nirapathpongporn and associates [3] reported 9 bleeding

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