LETTERS to the Editor.
TO THE EDITOR:
In their recent article on vasectomies, Alderman and Morrison state that the no-scalpel vasectomy (NSV) technique offers no advantage over incisional vasectomy. I must heartily disagree and would also like to add some comments on the operative techniques used in their study. Having performed vasectomies for 14 years (5 by single midline incision, and 9 by NSV) and after training more than 40 physicians in the traditional Li NSV technique in association with the Association for Voluntary Contraception, I feel that I have a reasonable perspective of this issue, anecdotal though it may be.
When I did incisional vasectomies early in my career nearly all of my patients experienced significant bruising and some swelling of their scrotum, although they had virtually no frank hematomas. The incisional patients complained of much more postoperative discomfort than my NSV patients do. In my NSV patients, I find it very unusual to have any braising or swelling at all.
The scrotum is comprised of very loose connective tissue that offers little constraint to swelling and expansion of bleeding. When tissue is cut, it becomes inflamed, swollen, and painful as it heals. The NSV technique does not cut the tissues between the skin and vas--it only stretches open a tract through them. It appears to me that this does not injure the tissue, since there is little, if any, apparent tissue reaction postoperatively. I find that my NSV patients appreciate not being bruised and swollen, having been told that this is common by their friends who have had an incisional vasectomy.
I have to wonder about the operative experience of the surgeon in the Alderman and Morrison study, his training, and the exact NSV technique used. I have never had to convert a NSV to open technique intraoperatively as he did in up to 10% of the cases. To me, this level of conversion reflects a lack of training, expertise, and commitment to NSV technique. NSV is a difficult skill to learn, even for an experienced vasectomist. It is best learned by hands-on experience that is directly supervised by an experienced NSV instructor.
Additionally, the methods of anesthesia and occlusion used in this study may have contributed to complications. If epinephrine-containing solutions are used for infiltration and nerve block in the scrotum, local and regional arterial vasoconstriction may occur. This may prevent bleeding intraoperatively but allows it to start hours later when the epinephrine wears off. The use of catgut rather than a braided polyglycolic acid suture invites postoperative inflammation, since catgut is phagocytosed rather than hydrolyzed. Electrocautery is known to necrose holes in the vas deferens wall since electricity follows the path of least resistance and may not fulgurate the mucosa as desired. Thermal cautery has been shown to provide a better seal of the vasal end. Removal of a 2- to 3-cm segment of vas deferens requires excessive traumatic dissection and makes later reversal nearly impossible? There is no reason to excise any vas deferens if thermal cautery and fascial interposition is used for occlusion. The incidence of postoperative epididymitis would likely have been much lower if the testicular end was not sealed. Open-ended vasectomy has been shown in 2 large series to greatly reduce this complication without sacrificing successful occlusion if cautery and fascial interposition is done on the inguinal end.[7,8]
--Ronald D. Reynolds, MD New Richmond Family Practice Ohio
[1.] Alderman PM, Morrison GEC. Standard incision or no-scalpel vasectomy? J Fam Pract 1999; 49:719-21.
[2.] Li S, Goldstein M, Zhu J, Huber, D. The no-scalpel vasectomy. J Urol 1991; 145:341-4.
[3.] Reynolds RD. Vas deferens occlusion during no-scalpel vasectomy. J Fam Pract 1994; 39:577-82.
[4.] Schmidt SS, Minckler TM. The vas after vasectomy: comparison, of cauterization methods. Urology 1992; 40:468-70.
[5.] Denniston GC. Vasectomy by electrocautery: outcomes in a series of 2500 patients. J Fam Pract 1985; 21:35-40.
[6.] Schmidt SS. Prevention of failure in vasectomy. J Urol 1973; 109:296-7.
[7.] Errey BB, Edwards IS. Open-ended vasectomy: an assessment. Fertil Steril 1986; 45:843-6.
[8.] Moss WM. A comparison of open-end versus closed-end vasectomies: a report on 6220 cases. Contraception 1992; 46:521-5.
To THE EDITOR:
It was with great interest that I read the study by Alderman and Morrison comparing standard incision and no-scalpel vasectomy (NSV) for accessing the vas deferens. They found no difference between the 2 techniques and claimed that there is a lack of peer-reviewed medical literature showing the superiority of NSV. I, too, deplore the absence of any randomized controlled trials to guide our choice of technique, but some relevant data were overlooked by the authors.
Apart from the quasirandomizcd trial by Nirapathpongporns, results of another comparative study from Denmark published in 1997 indicated better results with NSV. Although their sample size was small and the incidence of surgical complications appeared unacceptably high in both groups studied, they found that NSV reduced postoperative pain, use of analgesics, frequency of infections, and contacts with a physician.
My own experience with NSV also differs from that of Alderman and Morrison. Using the same research design (a retrospective cohort study with a historical control group), I observed that NSV is associated with fewer hematomas and infections than a standard bilateral incision approach. In my own practice, I currently perform approximately 1000 vasectomies per year. In 1992, I switched to performing NSV, after having performed standard incision vasectomies since 1986. I encountered 53 (3.5%) hematomas and infections among 1527 standard incision vasectomies performed between 1986 and 1992 and 40 (1.0%) among the 4030 NSV performed between 1993 and 1998.
Differences in the standard techniques used to access the vas may explain the divergent results. Alderman and Morrison performed a single small transverse midline incision. My complete technique has been described earlier. Briefly, through a 1-cm incision performed on each side of the scrotum, I was dissecting the vas with a hemostat clamp and grasping and extruding it with an Allis clamp. The fascia was opened with a scalpel. Skin sutures were applied in the earlier years, but these were abandoned approximately i year before switching to the NSV technique. Differences in the occlusion techniques may also influence the incidence of hematomas and infections.
Historical comparisons of retrospective case series are subject to many biases related to non-blinded assessments of outcomes and differences over time in the definition of complications, completeness of recording, and experience of the surgeons. Cautious interpretation of results is thus essential. However, across all cohorts of men on whom an NSV was performed, there is a striking consistency in the incidence of hematomas and infections: approximately 1%.[1,2,6] This is far better than the average incidence of more than 5% reported with standard approaches (2% hematomas and 3.4% infections).
Changing from a standard to the NSV technique to access the vas may be pointless for some experienced surgeons. However, on the basis of available data, one should consider switching to NSV if his or her incidence of hematomas and infection with a standard incision technique exceeds 1%.
--Michel Labrecque MD, MSc, FCFP Laval University Quebec City, Quebec, Canada
[1.] Alderman P, Morrison GEC. Standard incision or no-scalpel vasectomy? J Fam Pract 1999; 48:719-21.
[2.] Nirapathpongporn A, Huber DH, Krieger J. No-scalpel vasectomy at the King's birthday vasectomy festival. Lancet 1990; 335:1195-6.
[3.] Skriver M, Skovsgaard F, Miskowiak J. Conventional or Li vasectomy: a questionnaire study. Br J Urol 1997; 79:596-8.
[4.] Labrecque M. La vasectomie: une technique a la portee du medecin de famille. Can Faro Physician. 1987; 33:2067-71.
[5.] Labrecque M, Bedard L, Laperriere L. Efficacite et complications associees a la vasectomie dans deux cliniques de la region de Quebec. Can Fam Physician 1998; 44:1860.
[6.] Li SQ, Goldstein B, Zhu J, Huber D. The no-scalpel vasectomy. J Urol 1991; 145:341-4.
[7.] Kendrick J, Gonzales B, Huber DH, Grubb GS, Rubin GL. Complications of vasectomies in United States. J Fam Pract 1987; 25:245-8.
THE PRECEDING LETTERS WERE REFERRED TO DR MORRISON, WHO REPLIED AS FOLLOWS:
The thoughtful comments on our paper are appreciated. Two points raised by Dr Reynolds need clarification. Catgut ligatures to control venous bleeding encountered during dissection of the vas from an adherent sheath were used in approximately 15% of all cases. Correlation between the use of these sutures and complications was looked for but not found. When we began to use no-scalpel vasectomy (NSV), if the vas could not be confidently secured under the skin with the ringed clamp the NSV was abandoned. No cases were changed intraoperatively.
We are familiar with the literature cited by Dr Reynolds. The most appropriate anesthetic and methods of interruption/occlusion remain debatable. Training under supervision and experience is eminently desirable for any vasectomy technique to ensure predictably permanent sterilization with a minimum of complications.
We agree with Professor Labrecque's statement that differences in standard techniques may explain divergent results and that a surgeon should consider changing his or her technique if the complication or failure rate exceed 1%. That change need not necessarily be to NSV.
--Gary E. C. Morrison, MD West Vancouver, British Columbia, Canada
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|Publication:||Journal of Family Practice|
|Date:||Feb 1, 2000|
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