To the Editor:

The informative article by Arnold, et al., provides an excellent summary of current vasectomy knowledge.¹ I hope it leads to more men being referred for vasectomy and more family physicians wanting to learn how to perform this simple procedure. As noted in the article, vasectomies are the safest and least expensive form of permanent sterilization. For example, if pregnancy occurs after a tubal ligation, it is more likely to be a tubal ectopic pregnancy, which carries a high rate of morbidity and mortality, with up to a 15% risk of rupture.²

However, I would highlight that there is no reason to use a needle to inject a local anesthetic through the scrotum along the vas deferens. Because many men have a greater fear of this part of a vasectomy than the procedure itself, some do not consider having one. The no-needle technique uses a device that jet sprays lidocaine under high pressure through the scrotal skin to the vas deferens; it is substantially less painful, causes no swelling, and makes the procedure safer and easier. The device is inexpensive and sprays lidocaine (0.1 mL per spray) at a high speed to penetrate 4 to 5 mm deep and 4 to 5 mm wide in a fan shape. It eliminates not just the fear of needles but also the risk of local needle injury and swelling that can make the vas deferens more difficult to isolate. A rare but devastating complication of vasectomy is accidental ligation of the spermatic artery when the surgeon mistakes it for the vas deferens. Without a large volume of lidocaine, the anatomy is easier to distinguish.

Finally, I recommend open-ended vasectomy, which was first described in the 1970s. This approach may reduce the chance of postvasectomy pain syndrome.³ Leaving the testicular end of the severed vas deferens untreated (open) may reduce the risk of congestive epididymitis and thus postvasectomy pain syndrome.⁴ Failure rates are no different compared with treating both ends. Intuitively, it makes sense to allow sperm to escape the tube instead of being blocked and trapped in the tiny lumen of the vas deferens at ejaculation, which creates back pressure into the testicle. Open-ended vasectomies also simplify the procedure and are easier to reverse if needed.

In Reply:

Thank you for sharing your wealth of experience in performing vasectomies. Because this article was written to address questions for family physicians who perform vasectomies and those who do not, we had to generalize some procedural aspects, but we are excited for the opportunity to elaborate on them.

Thank you for emphasizing use of the no-needle technique. From our lead author's experience, the injection of lidocaine, even with a 30-gauge needle and lower lidocaine volume (2 mL per side), is the part of the procedure that patients fear most. The cost of the no-needle injection device is $700 to $800, with the additional cost of Pyrex chambers ($60–$70 for five) that house the lidocaine.^1,2 For a practice that performs multiple vasectomies per day, the turnaround time for sterilization of the device would require having multiple devices, and some practices may find this cost prohibitive. However, we appreciate that the cost may be worth it if more men receive the procedure.

We also appreciate your emphasis on open-ended vasectomy. Although we only briefly discussed this option, the cover art for the article shows a vasectomy where the abdominal end is cauterized and the testicular end is not.³ Although the American Urological Association does not recommend open-ended vasectomy over cauterizing both ends, it does note that there is no difference in failure rates.⁴ There is a paucity of studies looking at this specific question, but we agree that the 1992 case series that you referenced is significant. In this study, the open-ended group had a congestive epididymitis rate of 2% compared with 6% in the group with both ends cauterized (risk reduction = 0.33; 95% CI, 0.13–0.83).⁵ The American Urological Association guideline acknowledges this study but did not make a recommendation for or against open-ended vasectomy.⁶