:: Asian Journal of Andrology ::

No-scalpel vasectomy outside China

Bing XU, Wei-Dong HUANG

Chongqing Li Shun-Qiang Andrologic Hospital, Chongqing 400020, China

Asian J Androl 2000 Mar; 2: 21-24

Keywords: vasectomy; no-scalpel vasectomy; sterilization

Abstract

Since 1985, the no-scalpel vasectomy technique has been widely used outside China. The prevalence of this technique has helped to increase the acceptability of male sterilization in many parts of the world. More than 5000 physicians in twenty-five developing countries have been trained in the no-scalpel vasectomy technique. In the United States in 1995, nearly one third of vasectomies employed the no-scalpel technique, and in the whole Northern American region, a total of 1100 doctors have been made familiar with the technique. Doctors believe that there are several advantages of the no-scalpel technique, including no incision, no stitches, faster procedure, faster recovery, less chance of bleeding, less discomfort and high efficacy. The key steps of the technique include fixation of the vas and infiltration anaesthesia of the spermatic cord, as well as grasping, delivering and isolating the vas. No-scalpel technique provides a good approach to expose the vas, in conjunction with which, different vas-end occlusion methods may be used.

1 Introduction

In 1976, the no-scalpel vasectomy (NSV) technique was developed by Dr Shun-Qiang LI and associates from the clamping method and the percutaneous vas occlusion technique. Since then, NSV has been widely promulgated and practiced in China as a routine fertility regulation method. In June 1985, an expert group sponsored by the Association for Voluntary Surgical Contraception (AVSC) visited the Chongqing Family Planning Scientific Research Institute, China, to learn the new vasectomy technique. Surgeons of AVSC concluded that all vasectomists should now use only the no-scalpel vasectomy technique^[1]. In November 1986, the 1st International Training Course on no-scalpel vasectomy was conducted in Bangkok, Thailand. Up to now, this technique has been widely used in many parts of the world, and a total of one million men have undergone NSV in countries and regions employing the method (AVSC International: http://www.noscalpelvasectomy.org). The present article reviews the extensive use of the method outside China during the last decade.

2 Prevalence of NSV outside China

2.1 Asia

As the first country introducing NSV technique, Thailand hopes NSV will become the standard vasectomy procedure, which may then promote the acceptability of vasectomy. Between November 1986 and June 1989, 13 Thai PDA physicians performed NSV in 6238 cases, PDA used a commercial marketing technique to promote the vasectomy activities, i.e. product (vasectomy), promotion, program and pricing. Surgeons at the Ramathibodi hospital, who attended the 1st International training course in Bangkok in 1986, have had a total of 1500-2000 NSV acceptors (Nirapathpongporn A et al, unpublished data, 1989). Ramathibodi hospital started to provide a 3-day NSV training course for 13 Thai physicians from the provincial hospitals in 1987. Since then the demand for the training increased, and the training centre had to be moved to a regional hospital in the next two years, where a sufficient case load for 100 trainees would be available^[2].

A hospital in India has employed the new vasectomy technique since September 1991. The first training course was organized by that hospital in March 1992, and the NSV procedure was thus officially introduced into India. Based on the data of the hospital, after the use of NSV, the number of vasectomy increased three times as compared with the corresponding period in 1988-91^[3]. The no-scalpel vasectomy attracted more educated and higher income men although in India the acceptability of vasectomy is influenced by religious factors^[4].

In 1989, four Turkish urologists were trained in the no-scalpel technique at the PDA, Bangkok. They, in turn, trained 19 colleagues at their home clinics. As a result, vasectomy for which there had been no demand in Turkey, became popular. Between 1990 and 1993, 5726 men and 3320 women were received at the counseling service for vasectomy in hospitals and health centers, and 1203 men underwent no-scalpel vasectomy^[5].

2.2 America

United States is among the countries introducing NSV at an early date. Training courses were held in 1988 in California, Massachusetts and New York (Antarsh L, unpublished data, 1989). By December 1992, 417 urologists and surgeons from 44 states and Washington D.C. were trained in no-scalpel vasectomy, and these doctors in turn trained other practitioners at their hometowns (Antarsh L, restricted publication, 1993). Vasectomy in the United States has traditionally been chosen by white, middle- to upper-middle-class, men. A recent study found that low-income and minority men are also willing to choose NSV. In 1995, approximately 494,000 vasectomies have been performed by 15,800 physicians in the United States and nearly one third (29%) were of the no-scalpel type^[6]. At present, American couples can choose their doctors on the Internet from 297 physicians in 42 states. The number of clinics providing vasectomy rose from 23 to 32, an increase of almost 40%, while the number of vasectomies performed rose by 18%. Seventeen of the 32 clinics are performing more vasectomies after training, and 10 clinics had not provided this procedure previously^[7].

Canadian doctors held the first Canadian no-scalpel workshop in April 1993. Fifty doctors from around the country attended the workshop. Vasectomy has been used by 18% of all married couples in Canada at present; the percentage is a little higher than that in the US (17%)^[8]. Approximately, a total of 1100 doctors have been trained on NSV in the whole north American region.

The ratio of tubal ligation to vasectomy was 18 to 1 in Colombia. In 1989, the first group of surgeons underwent NSV training in Bogota. By 1995 the ratio of tubal ligation to vasectomy dropped to 10 to 1 nationwide, and 4 to 1 in Bogota^[9].

Of all contraceptive acceptors in Mexico during 1972-1989, only 0.6% had opted for vasectomy. In early 1990, 19 NSV training centers were established throughout the country. In Mexico City alone, the number of vasectomies performed in the 1st half of 1990 increased by 65.4% over the corresponding period of the previous year^[10]. By June 1995, over 55,000 men received vasectomy from more than 300 doctors (de Cordero C, et al, restricted publication, 1996).

2.3 Africa

At present, African countries are bearing a huge pressure from the population boom. Limited advances have been experienced in male sterilization, although AVSC believes that in the next few years male contraceptive methods, including condoms and vasectomy will become far more popular in Africa. AVSC trained 8 Kenya surgeons in no-scalpel vasectomy and have opened six centers in the country that can provide NSV (Danforth N, restricted publication, 1994). The no-scalpel technique is also the most popularly used vasectomy technique in Uganda, although male sterilization is relatively sparse there.

2.4 Developing countries

According to the International Planned Parenthood Federation, AVSC is now assisting in training more than 5000 physicians in twenty-five developing countries, including Bangladesh, Brazil, Colombia, Dominican Republic, Ghana, Guatemala, Indonesia, India, Jamaica, Kazakhistan, Kenya, Mexico, Nepal, Nigeria, Pakistan, Peru, Rwanda, Sri Lanka, Tanzania, Thailand, Turkey, Uganda, Vietnam, and Zimbabwe^[11].

3 Evaluation on no-scalpel technique

According to AVSC, the no-scalpel technique possesses seven advantages as compared with conventional vasectomy; they are: no incision, no stitches, faster procedure, faster recovery, less chance of bleeding and other complications, less discomfort, and high effeciency (AVSC International, restricted publication, 1997). Nirapathpongporn reported that in a total of 1203 operations performed at the Thai King's birthday vasectomy festival, an average of 57 vasectomies were done per day per physician using NSV, compared to 33 vesectomies done with the standard technique. The complication rate was 0.4% for NSV and 3.1% for the standard vasectomy, the difference being significant^[12]. Another multi-center comparative study involving 716 men reported that there was less bleeding and less time required in NSV than in the conventional vasectomy procedure despite the relative difficulty of vas isolation and entering the scrotum in the case of NSV (Family Health International, unpublished data, 1989). According to the literature, performing one no-scalpel procedure requires 15-20 minutes by American, 8 minutes by Thai, 16 minutes by Danish, and 5-12 minutes by Spanish doctors^[3,13-15].

In an Indian study with 274 and a US study with 273 acceptors, not a single complication was found during follow-up observation^[3,13]. In Colombia, though not statistically significant, men opting for the no-scalpel approach had fewer complications than did men undergoing traditional procedures; it is believed that the attributes of NSV method, including the need for less equipment, also represent cost-saving programmatic advantages over traditional procedures^[16]. By 1995, 7513 NSV procedures were done by five trained surgeons in Colombia, and the incidence of complications was 3%, including 0.3% hematoma, 0.26% infection, 1.14% epidydimitis, 0.22% vaso-cutaneous fistula, and 0.3% other complications^[9]. A review of the first 1000 cases of no-scalpel vasectomy performed in Mexico in 1990-93 confirmed that 97.9% had no postoperative hemorrhage or hematoma and there was not a single case of wound infection; three follow-up visits showed that the postoperative azoospermia rates were 97.4%, 95.7%, and 94.1%, respectively^[17]. Skriver reported that in a comparative study of 256 men undergoing conventional vasectomy and no-scalpel technique, NSV reduced the post-vasectomy pain, the use of analgesics, the frequency of infections, and the necessary contacts with physicians, which were self-assessed on a 10-cm visual analogue scale^[18]. In 100 Spanish men who accepted the no-scalpel procedure in Barcelona, no haematomas or infections were reported^[15]. Holt believed that these benefits are attributable to the minimal dissection and reduced tissue handling required to expose and isolate the vas^[19].

4 NSV Training

Although no-scalpel technique is a simple outpatient procedure, physicians generally find the technique difficult to master when only reading the teaching materials. They believed that the key steps of the technique including three finger fixation of the vas, anaesthesia infiltration of the spermatic cord, and grasping, exposing, delivering and isolating the vas are critical and certain movement and position of hands and fingers, to assure great accuracy, is required at each step of the technique^[1,14]. Scarcity of acceptors can be a problem in some countries where vasectomy is not popular due to large time intervals between surgeries. The US trainers use a scrotal model as an essential part of training. This consists of a gauze-like material that simulates the scrotal skin and a strip of plastic tubing that represents the vas deferens. The doctors usually spend one or two hours practicing on the scrotal model^[20]. In 1994, a training film was prepared by WHO and AVSC International for providing a standard NSV training procedure. The film was then distributed to all the member countries and regions.

Based on the analysis of 489 Chinese NSV trainees, Xu et al believed that the minimum solo practice should be no less than five cases during the training course, although 10-15 cases would be better^[21]. It has been reported that 6-9 solo operations in the US (Family Planning International, unpublished data, 1989), 10-15 in Denmark^[14], and 15-20 in Thailand (Nirapathpongporn A, unpublished data, 1989) are required to develop proficiency. Obviously, training is important to ensure the quality of the no-scalpel procedure. There is a good example in Gentofte county hospital, Denmark, where 102 consecutive no-scalpel vasectomies were performed by 2 urologists during a period of 1.5 years. An experienced surgeon performed the operation with a less experienced resident and neither had received NSV training. Although the doctor believed that there was a low rate of primary surgical complications, 7 cases of infection, one case of granuloma, 39 (45%) cases of discolouration, and 34 postoperative cases of discomfort occurred, and 5 of these were hospitalized^[22]. All these are related to inadequate techniques on infiltration of anaesthesia, dissection of scrotal wall and vas, which are especially emphasized in NSV training course.

Chinese data shows that the result of NSV training is influenced by the sex of the trainees (males appear to be more proficient, which might be due to psychological differences between the two sexes), their affiliation and location, their previous experience with vasectomy, and the number of cases performed during the training course. Besides, paramedics should also be required to efficiently practice NSV in a high-quality training course^[21]. It should be emphasized, however, that when the use of a new technique is rapidly expanding, it is difficult to maintain a consistent quality control standard, as experienced in China during the past two decades^[23].

5 Occlusion techniques used in NSV

In NSV a loop of vas deferens is delivered outside the scrotal skin by two special instruments without the practice of vas occlusion. Thus, unnecessary and invasive dissection on the scrotal wall is avoided, however, the occlusion technique of vas ends is nearly the same as the traditional methods. In a multi-center perspective study during 1988-1990, Li SQ et al^[24] randomized 2713 NSV cases into seven groups using 7 different occlusion techniques. The results showed that sperms were still present in the ejaculate of 78 men (3.29%), and a total of 27 spouses (1.14%) became pregnant at the end of 2 years post-vasectomy. The rates of recanalization and occurrence of complications between 7 occlusion groups were significantly different, the open-ends method without fascial interposition showing the highest rates (recanalization 7.53% and complications 2.17%). The authors suggested that ligation of the vas ends with fascial interposition is the most advisable occlusion technique.

Reynolds described modified techniques on dissecting and fascial interposing of the vas, including the use of an extra-delicate curved mosquito hemostat, cautery of the cut vas ends, and the employment of the purse-string suture to close the sheath^[25]. The only widely accepted modification was cautery of the vas^[1]. The most common occlusion technique in the United States (1995) was the concurrent use of ligation and cautery, and slightly less than one half (48%) of all US physicians interposed the fascial sheath over one end of the vas^[6]. In 1223 Canadian vasectomies, two groups of doctors used the noscalpel technique in combination with either the tantalum clip or cautery. One group using tantalum clips on the ends of the vas had complication and recanalization rates of 5% and 2.8%, respectively; the other group using cauterisation of the prostatic end of the vas, leaving the epidydimal end open had rates of 12.3% and 1.2%, respectively. The authors concluded that the occlusive techniques used by the two groups might partially explain the differences^[26].

References

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Correspondence to: Dr. Bing XU, Deputy Director, Chongqing Li Shunqiang Andrologic Hospital, 167 East Jianxin Road, Jiangbei District, Chongqing, 400020, China.
Tel: +86-23-6775 6755 Fax: +86-23-6775 6759
e-mail: lsq@lia.com.cn and wdhuang@cta.cq.cn
Received 2000-01-18 Accepted 2000-02-20