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Add no-needle to no-scalpel vasectomy
How can providers ease fears when it comes to vasectomy? Take a look at no-needle, no-scalpel vasectomy (NSV), which utilizes a jet injector to spray an anesthetic solution through the skin and around the vas prior to no-scalpel vasectomy. After anesthesia is administered, the surgeon then performs the no-scalpel vasectomy procedure, using a ring clamp to hold the vas deferens in place and dissecting forceps to dissect the tubes.
Initially described in 2001 by Charles Wilson, MD, a Seattle urologist, the technique calls for delivery of local anesthetic through use of a MadaJet, a jet injection device developed by MADA Medical Products, Carlstadt, NJ.1 Similar injection devices are used in dermatology, cosmetic and plastic surgery, gynecology, dentistry, and podiatry.
The hypospray injection using the MadaJet is more efficient, more effective, and quicker than the needle injection, says Wilson. It is probably less traumatic to the tissues than inserting a needle, and may have less reported pain, depending on the patient, he notes.
Researchers in 2005 modified and refined the jet injection technique for vasectomy, and they attained a close to 100% efficacy rate with no need for supplemental anesthetic.2 In the study, about 465 patients were anesthetized by the jet injection technique with great satisfaction. Researchers used an average volume of anesthetic solution per jet injection of 0.1 cc with 0.2 cc to 0.3 cc for each vas. They recorded almost immediate anesthetic onset — within 10-20 seconds after injection. Patients described the experience as the mild discomfort of a pinch, not unlike a rubber band, with the first injection.
"Probably the greatest advantage is enjoyed by the population of patients who simply hate needles," says Wilson. "For them, the relief of apprehension about the needle, especially in the area of a vasectomy, can significantly affect their perception of their experience, and, by extension, the degree of apprehension their friends might have when they contemplate the procedure."
Multiple benefits eyed
The no-needle approach to NSV has benefits for the physician as well as the patient, reports Marc Goldstein, MD, professor of reproductive medicine and professor of urology at Weill Medical College of Cornell University in New York City. The injector anesthetizes the vas more effectively than the needle; therefore, the volume of anesthesia is lessened. With less anesthesia, swelling is reduced, making the vas easier to "trap" with the NSV ring clamp, says Goldstein, who serves as director of the university's Center for Male Reproductive Medicine and Microsurgery.
The injector must be properly positioned over the vas; otherwise, the injection will go into the anterior scrotum, out the posterior scrotum, and right into the surgeon's finger, says Goldstein. A special finger protector can serve as a shield, he notes.
"The disadvantages of no-needle vasectomy are that it requires special equipment and careful maintenance and sterilization procedures," notes Wilson. "It requires learning an exacting technique to be successful; it depends on having advanced NSV skills to reliably keep within a 1-cm site during vasectomy."
According to Contraceptive Technology, no-scalpel vasectomy offers several advantages over the scalpel method: fewer complications, including infection and hematoma; less pain during the procedure and early follow-up period; and earlier resumption of sexual activity after surgery.3
Acceptance of method 'slowly edging up'
According to a 2002 provider survey, 37.8% of physicians reported current use of no-scalpel vasectomy.4 Goldstein was the first American surgeon to be trained in, and perform the Chinese method of no-scalpel vasectomy in 1985; he says acceptance of the method is "slowly edging up."
It is more difficult to do, Goldstein says. "It is much easier to take a knife and make a nice generous cut and then you can easily find the vas, so the NSV requires much more training to get it out of this little puncture hole," he says. "I tell all my residents when I teach, is it that it is all feel." They are shocked at how difficult it is to learn how to do the procedure. Goldstein says.
While NSV may require more training, it is worth the time investment, because patients definitely prefer it, he says.
The procedure employs two unique instruments: a ring forceps to encircle and secure the vas without penetrating the skin, and sharp-tipped dissecting forceps that puncture and stretch a small opening in the skin and vas sheath. The vas is lifted out and occluded as with other vasectomy techniques. No sutures are needed to close the small wound.3
"I have my patients sit up after [the procedure] and I say, 'Where do you think I did it?" says Goldstein. "They can't find the puncture hole." (Check Internet resources on no-needle, no-scalpel vasectomies at the Cornell University web site, www.cornellurology.com/infertility. Click on "No-Needle, No-Scalpel Vasectomy." Also review information on Wilson's web site, www.TheVasectomyClinic.com.)