To the Editor:

Thank you for publishing the informative article “Vasectomy: Common Questions and Answers” in the September issue of American Family Physician.¹ I greatly appreciated the article and would like to offer a few updates reflecting practices that are becoming increasingly common as vasectomy gains popularity among patients.

The article notes that vasectomy anesthesia typically involves 10 mL of lidocaine using a 25- or 27-gauge needle. In contemporary practice, the volume and needle size are often lower.² From my experience with training many physicians in performing vasectomies and observing numerous vasectomy clinics in the United States and internationally, the 30-gauge needle has become more widely used, and the volume of anesthetic administered is smaller. Our teaching emphasizes that precise placement matters more than high volume.

Additionally, readers could infer that excising a segment of the vas deferens is recommended during vasectomy. However, the 2015 American Urological Association (AUA) vasectomy guideline states: “The panel found no consistent evidence indicating that division with excision of a short vas segment (less than 4 cm) are preferable to division without excision of a vas segment.”^3,4 Excision does not improve the effectiveness of vasectomy and adds procedural complexity, including following protocols for tissue disposal and increasing cost without benefit to the patient.

Thank you for considering these clarifications to ensure that American Family Physician readers have the most up-to-date, evidence-based information.

In Reply:

Thank you for your comments. We agree that less lidocaine volume and a smaller needle gauge is preferable for most patients. We did highlight the mini-needle technique that uses 2 mL of lidocaine 2% with a 30-guage needle and noted that its effectiveness is similar to more traditional techniques.^1,2 The lead author of our article has trained residents in vasectomies for 20 years during his time in the military, and he has found that 2 mL of lidocaine 1% or 2% per side was enough when the overlying skin and vas deferens were appropriately targeted with palpation. However, it is helpful for learners to have extra lidocaine readily available when it is noted that initial anesthesia was incomplete during dissection of the vas deferens.

We also agree that removal of a vas deferens segment and simple excision are both acceptable options; there is no difference in sterility rates, especially with the addition of mucosal cautery and/or fascial interposition.^3,4 We would like to note that the 2012 AUA guidelines were published in print, whereas the 2015 update is available only online (the AUA notes that the 2012 published document should be cited when the 2015 update is referenced). Both versions note the same literature review time frame in their methods and make the same recommendations, but there is more detailed literature discussion in the published version. As such, both guidelines note that there is inconclusive evidence to recommend segment removal or simple incision, with the 2012 guidelines noting that a 1-cm segment is probably adequate if a segment is removed. Both guidelines recommend against removing longer segments (greater than 4 cm) because it requires further dissection of the spermatic cord and may have higher complication rates, even if it decreases failure rates.^3,4 In December 2025, the AUA released a new guideline that reviewed the same studies we addressed in our article.⁵ The new guideline recommends techniques using fascial interposition and mucosal cautery together (category B rating) and used studies where segment excision (1-2 cm) was included. The AUA continues to recommend against using only ligation (with suture or clip) and segment removal due to high failure rates (category A rating).⁵ We would also like to acknowledge that segment removal requires additional procedural complexity, and disposal may be cost prohibitive in some settings. However, for learners, the further dissection needed to obtain a segment allows for better understanding of the vas deferens anatomy.