Instructional video on vasectomy: evidence-based procedure should be demonstrated

Family physicians performed 26 725 (48.4%) of the 55 216 vasectomies done in Canada in 2011 and 2012.¹ We are thankful to Canadian Family Physician for recognizing this important role by publishing Dr Garcia-Rodriguez’s instructional video of the procedure.² However, in light of the current evidence-based guidelines on vasectomy published by the American Urology Association³ and the European Association of Urology,⁴ the published video does warrant some comments.

After the administration of the local anesthesia, the vasectomy procedure is divided into 2 steps: isolation of the vas deferens outside of the scrotum, and occlusion of the vas deferens. The video, entitled “Vasectomy. Traditional Method,” illustrates a vas isolation technique that should not be presented as an acceptable method in 2013. There is ample evidence that the no-scalpel vasectomy (NSV) approach for isolating the vas introduced in Canada more than 20 years ago (in 1992) should be the standard technique performed, as recommended in the current guidelines.^3,4 Systematic reviews of randomized trials have shown that NSV is associated with a considerably reduced risk of surgical complication such as bleeding and infection compared with the traditional method.^5,6 We wonder if Dr Garcia-Rodriguez might even be familiar with the NSV technique because he is using the ring forceps of the NSV technique in the traditional procedure he performs. Various videos demonstrating NSV are available:

• www.vasectomie.net/vasectomiehautevitesse.wmv

• www.dailymotion.com/video/x9yac7_no-scalpel-no-needle-vasectomy-hd-v_tech

• www.pollockclinics.com/video.html

• https://no-scalpelvasectomy.com/nsv_video.html

Dr Garcia-Rodriguez advocates that prophylactic antibiotics be given routinely for vasectomy, which is contrary to the current guideline recommendations.³ If he has been experiencing an increased incidence of infection, he might improve upon sterile preparation by placing his sterile drape after prepping the patient rather than before.

Although the occlusion method demonstrated in the video (division and excision of a 2-cm vas segment, combined with ligation of the vas, mucosal thermal cautery, and folding back of both vas ends) might be effective to avoid occlusive and contraceptive failure, it is unnecessarily complex and is not a recommended occlusion method.^3,4 If a vas segment is to be excised, a 2-cm vas segment is excessively long according to expert consensus.³ Combined with the other procedures demonstrated in the video (mucosal cautery and folding back), a total of about 4 cm of the vas is severed, possibly increasing the risk of complications and compromising the results of a vasectomy reversal if one is attempted in the future.³ Mucosal thermal cautery combined with fascial interposition with or without excision of a very short segment of the vas deferens (< 1 cm) provides the most effective occlusion based on the available evidence.^3–5,7 The videos above also demonstrate mucosal cautery combined with fascial interposition.

Dr Garcia-Rodriguez suggests sending the excised segment to the pathology laboratory. This practice has been discouraged by the American Urology Association, as noted in 1998, 2003, 2007, and 2012, and should no longer be carried out.³ Further, he states that men who have undergone vasectomy need to wait until no sperm are found in a postvasectomy semen sample before stopping other methods of contraception. This is unnecessarily conservative, resulting in unneeded additional semen analyses and undue delays before using vasectomy as a contraceptive method. Current recommendations state that men are considered sterile as soon as a single uncentrifuged, fresh postvasectomy semen sample shows 100 000 nonmotile sperm per millilitre or less.^3,4

We believe that complying with the current evidence-based guidelines on vasectomy^3,4 optimizes effectiveness, security, and acceptability of the procedure. Canadian family physicians should be made aware of these guidelines so that they are best able to provide the optimal standard of care for their patients.

• Copyright© the College of Family Physicians of Canada