FPIN's Clinical Inquiries

Advantages of the No-Scalpel Vasectomy Technique



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Am Fam Physician. 2012 Jun 15;85(12):online.

Clinical Question

Are there advantages to the no-scalpel vasectomy (NSV) technique compared with the standard incisional method?

Evidence-Based Answer

NSV should be used instead of the standard incisional method. (Strength of Recommendation: A, based on systematic reviews, mixed-quality randomized controlled trials [RCTs], cohort studies, and case-control series.) The NSV technique is associated with fewer complications, produces less perioperative and postoperative pain, results in quicker recovery, takes less time to perform, and is as effective as standard incisional vasectomy.

Evidence Summary

A Cochrane review evaluated NSV compared with the standard incisional technique.1 It included a large multinational, multicenter, partially blinded RCT including 1,429 men2 and a smaller RCT with 99 men from a residency clinic.3 NSV resulted in fewer postoperative hematomas (odds ratio [OR] = 0.23; 95% confidence interval [CI], 0.15 to 0.36), less scrotal pain (OR = 0.66; 95% CI, 0.52 to 0.83), and fewer postoperative infections (OR = 0.34; 95% CI, 0.13 to 0.90).

A lower-quality systematic review of vasectomy techniques found seven additional studies comparing NSV with the standard incisional technique in more than 14,000 men.4 One study was a nonrandomized parallel controlled trial (n = 1,203), and six were low-quality observational studies. The authors were unable to perform a meta-analysis because of the heterogeneity of the studies, but concluded that NSV produced sterilization rates equal to those with the incisional method, with a lower risk of bleeding and infection.

A large multicenter RCT comparing NSV with the standard incisional technique (included in both reviews discussed earlier) demonstrated additional advantages of NSV (Table 1).2 A total of 1,429 men from Brazil, Guatemala, Indonesia, Sri Lanka, and Thailand were randomized to NSV (715 patients) or standard incisional vasectomy (714 patients). NSV produced less pain, bleeding, and infection, and took less time to perform than the standard incisional technique. Patients in the NSV group also reported earlier return to intercourse. There were no significant differences in pain, tenderness, or patient satisfaction between the groups at long-term follow-up (16 to 511 days; mean follow-up interval not specified).

Table 1.

No-Scalpel vs. Standard Incisional Vasectomy

Characteristic NSV (%) Standard incisional technique (%) NNH for standard incisional technique vs. NSV

Able to resume sexual activity within six days

34

22

9 (P < .05)

Hematoma*

1.8

12.2

9 (95% CI, 7 to 13)

Infection*

0.2

1.5

78 (95% CI, 37 to 603)

Intraoperative pain

None

66.8

60.2

16 (P < .05)

Mild

28.4

35

16 (P < .05)

Operating time

Less than 7 minutes

59.9

38.3

5 (P < .01)

More than 11 minutes

13.9

22.6

12 (P < .01)

Postoperative pain*

None

54.7

43.3

8 (95% CI, 6 to 18)

Mild

39.5

45.8

6 (95% CI, 5 to 12)

Moderate

5.1

9.3

23 (95% CI, 14 to 91)

Severe

0.7

1.6

Not statistically significant


CI = confidence interval; NNH = number needed to harm; NSV = no-scalpel vasectomy.

*—Postoperative pain, hematoma, and infection noted at 15 days' follow-up.

Information from reference 2.

Table 1.   No-Scalpel vs. Standard Incisional Vasectomy

View Table

Table 1.

No-Scalpel vs. Standard Incisional Vasectomy

Characteristic NSV (%) Standard incisional technique (%) NNH for standard incisional technique vs. NSV

Able to resume sexual activity within six days

34

22

9 (P < .05)

Hematoma*

1.8

12.2

9 (95% CI, 7 to 13)

Infection*

0.2

1.5

78 (95% CI, 37 to 603)

Intraoperative pain

None

66.8

60.2

16 (P < .05)

Mild

28.4

35

16 (P < .05)

Operating time

Less than 7 minutes

59.9

38.3

5 (P < .01)

More than 11 minutes

13.9

22.6

12 (P < .01)

Postoperative pain*

None

54.7

43.3

8 (95% CI, 6 to 18)

Mild

39.5

45.8

6 (95% CI, 5 to 12)

Moderate

5.1

9.3

23 (95% CI, 14 to 91)

Severe

0.7

1.6

Not statistically significant


CI = confidence interval; NNH = number needed to harm; NSV = no-scalpel vasectomy.

*—Postoperative pain, hematoma, and infection noted at 15 days' follow-up.

Information from reference 2.

A nonblinded RCT with 1,203 men from Thailand compared NSV (680 patients) with incisional vasectomy (523 patients) and found a decreased combined risk of hematoma and infection in the NSV group (absolute risk reduction = 0.4 versus 3.1 percent; number needed to treat = 38; 95% CI, 22 to 85).5

Recommendations from Others

The World Health Organization recommends NSV over the standard incisional technique, noting that NSV produces less pain and bruising, results in fewer infections and hematomas, and takes less time to perform than the standard incisional technique.6 The American College of Obstetricians and Gynecologists does not make a specific recommendation, but notes that NSV has a lower incidence of hematoma formation (0.1 to 2.1 percent versus 0.3 to 10.7 percent) and infection (0.2 to 0.9 percent versus 1.3 to 4 percent) compared with the standard technique.7 Neither the American Urological Association nor the American Academy of Family Physicians has a policy statement on the recommended method for performing vasectomy.

Address correspondence to David A. Moss, MD, at david.moss@nellis.af.mil. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations to disclose.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Air Force Medical Corps or the U.S. Air Force at large.


Copyright Family Physicians Inquiries Network. Used with permission.

REFERENCES

1. Cook LA, Pun A, van Vliet H, Gallo MF, Lopez LM. Scalpel versus no-scalpel incision for vasectomy. Cochrane Database Syst Rev. 2007(2):CD004112.

2. Sokal D, McMullen S, Gates D, Dominik R. A comparative study of the no scalpel and standard incision approaches to vasectomy in 5 countries. The Male Sterilization Investigator Team. J Urol. 1999;162(5):1621–1625.

3. Christensen P, al-Aqidi OA, Jensen FS, Dørflinger T. Vasectomy. A prospective, randomized trial of vasectomy with bilateral incision versus the Li vasectomy [in Danish]. Ugeskr Laeger. 2002;164(18):2390–2394.

4. Labrecque M, Dufresne C, Barone MA, St-Hilaire K. Vasectomy surgical techniques: a systematic review. BMC Med. 2004;2:21.

5. Nirapathpongporn A, Huber DH, Krieger JN. No-scalpel vasectomy at the King's birthday vasectomy festival. Lancet. 1990;335(8694):894–895.

6. World Health Organization, Johns Hopkins Bloomberg School of Public Health. Family planning: a global handbook for providers. 2011 update. http://whqlibdoc.who.int/publications/2011/9780978856373_eng.pdf. Accessed May 17, 2012.

7. Pollack A; ACOG Committee on Practice Bulletins-Gynecology . ACOG practice bulletin. Clinical management guidelines for obstetricians-gynecologists. No. 46, September 2003. Obstet Gynecol. 2003;102(3):647–658.

Clinical Inquiries provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (http://www.cebm.net/?o=1025).

The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submitting questions or writing answers for this series, go to http://www.fpin.org or email: questions@fpin.org.

A collection of FPIN's Clinical Inquiries published in AFP is available at http://www.aafp.org/afp/fpin.



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