Use of EMLA cream with vasectomy

Efficacy of EMLA for Office-based Andrology Procedures Under Local Anesthesia: A Randomized Control Trial

OBJECTIVE

To evaluate the effectiveness of Eutectic Mixture of Local Anesthetic (EMLA), a topical anesthetic cream, in office-based invasive andrological procedures such as hydrocelectomy, spermatocelectomy, and others, aimed at minimizing pain perception and enhancing the overall patient experience.

METHODS

A double-blinded randomized controlled trial was conducted for patients undergoing scrotal andrology surgeries under LA. Power calculation was performed with an estimated sample size of 72. Participants were randomly assigned in a 1:1 ratio to topical EMLA + LA versus LA alone. In the post-operative recovery area, patient will be asked to complete a VAS questionnaire rating pain with LA administration and pain with procedure. Analysis comparing VAS pain scores of both groups was performed using the independent sample t-test method.

RESULTS

Seventy-two patients were included in our analysis, with 36 in the control and 36 in the intervention arm. For patient pain with administration of LA, the control arm reported an average VAS pain score of 4.31, compared to 3.72 in the intervention arm (P = .319). For patient pain with procedure, patients in the control arm reported a median VAS pain score of 3.47 compared to 3.03 (P = .432) in the intervention arm. Overall, 86% (62/72) of patients reported that they would either be "very likely" (4/5) or "highly likely" (5/5) to undergo future procedures under local anesthetic.

CONCLUSION

While performing scrotal surgeries under LA appears to be well tolerated and a feasible option, the application of EMLA cream does not appear to significantly alter patient-reported outcomes.

A Systematic Review of Loco-Sedative Anesthesia for Urologic Surgery

OBJECTIVE

To perform a systematic review of the characteristics and outcomes of conscious sedation and local anesthesia for various urologic procedures. Urologic care has much to gain from the routine integration of ambulatory surgery via loco-sedative anesthetic techniques for both surgeon and patient.

METHODS

A comprehensive systematic literature search was conducted on PubMed, and Scopus databases following PRISMA criteria from June to August 2021. Articles were included if they were English, prospective, randomized, or nonrandomized controlled trials that used local anesthetic or conscious sedation for urologic interventions in adult patients. Additionally, included studies provided primary data on the use loco-sedative anesthesia and the efficacy and complications. All studies included were further reviewed to assess the biases and conflicts of interests.

RESULTS

Thirty-two studies with 6897 patients were included in the review. Mean patient age was 46.4years. The most common anesthetic and analgesic relief was the use of local anesthetic with 1% lidocaine. The majority used lidocaine as an injection, whereas the second most common route of administration was a topical cream. However, there was significant heterogeneity in the type of local or conscious sedation method and whether a combination was used. 44.4% of the studies used the visual analog scale as their primary endpoint. All the studies reported an 83%-100% successful procedure rate without note of significant sedation-related complications.

CONCLUSION

Given the high efficacy rates, loco-sedative anesthesia is a promising technique for urologic interventions and should be further investigated to determine whether it may become be the standard of care.

Outpatient Vasectomy: Safe, Reliable, and Cost-effective

Vasectomy is a safe, effective, and practical option for permanent contraception in men. Vasectomy is a surgical procedure used in men to disrupt and occlude the vas deferens, which delivers sperm from the testicles. By interrupting sperm transport, this procedure provides permanent sterilization. Vasectomies are typically done under local anesthesia in outpatient settings, and patients usually go home within an hour of the surgery. Surgical techniques used for vasectomy vary widely throughout the world, with limited evidence to guide the most effective approach. Current vasectomy guidelines largely rely on information from observational studies, with few controlled clinical trials.

Development of a Piglet Grimace Scale to Evaluate Piglet Pain Using Facial Expressions Following Castration and Tail Docking: A Pilot Study

Facial expressions are increasingly being used to assess pain in non-human species, including rodents, horses, and lambs. The development of these species-specific grimace scales has allowed for more rapid pain detection, which can lead to better animal welfare if intervention promptly occurs. For grimace scales to ever be used as a stand-alone measure of pain, it is important they correlate with established pain assessment tools, such as behavioral analysis. This preliminary study aimed to determine whether piglets exhibit pain grimacing and if these facial expressions correlate with their behavior. It also assessed and compared the behavior of boar piglets given an analgesic and topical anesthetic prior to surgical castration and tail docking to piglets that did not receive anything for pain relief. Five-day-old male Yorkshire piglets (n = 19) from four pens were randomly assigned, within their pen, to one of five possible treatments: meloxicam (0.4 mg/kg, intramuscularly) + EMLA^® cream, meloxicam (0.4 mg/kg, intramuscularly) + non-medicated cream, saline (intramuscularly) + EMLA^® cream, saline (intramuscularly) + non-medicated cream, or no treatment prior to surgical castration and tail docking. Piglet behaviors were video recorded for 8 h immediately after castration, as well as for 1 h at 24 h pre- and post-castration. Their individual behaviors were scored continuously for the first 15 min of every hour of video collected. Facial images were also captured across all time points. A Piglet Grimace Scale (PGS) was developed and used by two observers blinded to treatment, time, and procedure to score over 600 piglet faces. All piglets displayed significant behavioral changes up to 7 h post-castration when compared to baseline, and the use of meloxicam and EMLA^® cream was not associated with a reduction in painful behaviors. Significantly higher PGS scores were noted at 0, 3, 4, and 5 h post-castration when compared to PGS scores at 7 h and there was no effect of treatment. PGS scores significantly correlated with piglet behavioral activity. The results suggest that the PGS may have utility for pain evaluation in neonatal pigs.

CUA guideline: Vasectomy

<p>Vasectomy is a safe and effective method of birth control. Although it is a simple elective procedure, vasectomy is associated with potential minor and major complications. The early failure rate of vasectomy (presence of motile sperm in the ejaculate at 3‒6 months post-vasectomy) is in the range of 0.3‒9% and the late failure rate is in the range of 0.04–0.08%. The no-scalpel vasectomy technique is associated with a lower risk of early postoperative complications and the use of cautery or fascial interposition will reduce the risk of contraceptive failure. As such, detailed preoperative counselling and careful assessment of the post-vasectomy ejaculate (for presence of sperm) is imperative. Failure to provide and document adequate information and counselling to patients may lead to litigation.</p><p>The focus of this guideline is the management of men presenting for vasectomy. Specifically, the topics covered include: preoperative counselling, vasectomy efficacy and complications, technical aspects of vasectomy, post-vasectomy semen testing, and interpretation-communication of post-vasectomy semen results. By performing an extensive literature review, we have generated an evidence-based consensus on the management of these men. The objective of this guideline is to help standardize the treatment of men presenting for vasectomy.</p>

Short-term morbidity following No-Scalpel Vasectomy: an assessment of clients' perceptions by novel postcard system

OBJECTIVE

Data on short-term (within a week) morbidity of No-Scalpel Vasectomy (NSV) is lacking. We studied clients' perceptions of early post-vasectomy morbidity by self innovated postcard pictorial questionnaire.

METHODS

Between March 2011 and April 2012, 821 men underwent NSV and provided pre-printed revalidated pictorial postcards depicting various grades of severity of local pain, swelling, and bleeding. Clients were asked to tick mark their problems and post them on the third day after NSV. Data were compiled and statistically analyzed.

RESULTS

Completed postcards were returned by 702 clients (85.5%). 25 postcards were excluded due to illegitimate filling of card. About 80.8% of clients complained of pain and minimal, moderate and severe pain was experienced by 77.69%, 18.09% and 4.20%, respectively. 16.24% of clients observed local swelling, which was minimal in 90.9%, moderate and severe in 7.27% and 1.81% of cases. 2.95% of clients noted mild bloody discharge. Most of clients managed their problems by following the instructions given in postcards; level 1 and 2 morbidity did not affect their daily activity.

CONCLUSION

Early morbidity after NSV is usually mild in severity and easily manageable. The postcard system is a feasible, effective, and economical way of collecting data and managing short-term post NSV problems.

Update on vasectomy protocol

Vasectomy is a commonly practiced form of male contraception with over half a million procedures performed annually. Among urologists who perform the procedure, there is considerable variation in pre-procedure patient counseling, vasectomy technique, and post-procedure practices regarding confirmation of sterility. We report an overview of the vasectomy literature published within the past year with a focus on guidelines that have been recently published by two major organizations, the American Urological Association (AUA) and the European Association of Urology (EAU).

Vasectomy: the other (better) form of sterilization

Male sterilization (vasectomy) is the most effective form and only long-acting form of contraception available to men in the United States. Compared to female sterilization, it is more efficacious, more cost-effective, and has lower rates of complications. Despite these advantages, in the United States, vasectomy is utilized at less than half the rate of female sterilization. In addition, vasectomy is least utilized among black and Latino populations, groups with the highest rates of female sterilization. This review provides an overview of vasectomy use and techniques, and explores reasons for the disparity in vasectomy utilization in the United States.

Office based vasectomy can be performed by supervised urological residents with patient pain and morbidity comparable to those of a staff surgeon procedure

PURPOSE

Although it is routinely performed in the ambulatory setting, vasectomy is an intricate surgical procedure with the potential for significant pain and morbidity. We determined from our prospective, institutional review board approved database whether vasectomy pain was affected by whether a staff surgeon or resident was the primary surgeon on the case.

MATERIALS AND METHODS

One staff surgeon and 14 residents in training year 2, 3 or 5 performed bilateral percutaneous no-scalpel vasectomy. Men scheduled to undergo vasectomy were assigned to the staff urologist (134) or to a resident (133) as the primary surgeon. The staff surgeon demonstrated the first vasectomy each month when a new resident rotated on service and all residents were directly assisted by the staff surgeon. Pain associated with each side of the bilateral vasectomy was assessed with a 0 to 100 mm visual analog scale.

RESULTS

The average visual analog scale score of the 2 sides was 19.5 in patients in the staff cohort and 21.8 in those in the resident cohort. Although mean scores were slightly lower when vasectomy was performed by the staff surgeon, the difference between the staff surgeon and residents was neither statistically nor clinically significant. Furthermore, there were no significant differences in visual analog scale scores among residents of different training years.

CONCLUSIONS

Office based vasectomy can be performed by residents under staff supervision with pain comparable to that of the procedure performed by a staff urologist. Urological resident training can be accomplished without compromising high standards of care.

Comparison of topical lidocaine/prilocaine anesthetic cream and local infiltration of 2% lidocaine for episioplasty in mares

Local anesthesia and tissue inflammation associated with lidocaine infiltration and lidocaine/prilocaine topical anesthetic cream for episioplasty in mares were compared. Twenty-two mares were randomly assigned to lidocaine or lidocaine/prilocaine topical anesthetic cream treatment groups. Perineum and vulva were cleaned, 8-12 g (approximately 1 g/cm per side of vulva) of topical anesthetic cream was applied, and the area was covered by plastic wrap 30 min prior to beginning procedure. Alternately, lidocaine was injected (1 mL) every centimeter just prior to the procedure. Episioplasty was conducted using standard methods, but employing simple interrupted sutures. Horses were not sedated and use of a twitch was recorded. Four millimeter punch biopsies were harvested 1, 3, and 10 days following episioplasty and scored for degree of inflammation by a blinded pathologist. Clinical inflammation scores were assigned when biopsies were obtained. Seven of 11 horses receiving lidocaine infiltration required twitching, but none of the horses that received the anesthetic cream required twitching. Six of 11 and seven of 11 of the lidocaine and anesthetic cream groups, respectively, required twitching for episioplasty. Except for the clinical scores on day 3, no statistical differences for clinical and histopathologic scores between samples from the two treatment groups for a given day were identified. Use of lidocaine/prilocaine topical anesthetic cream was as effective as lidocaine infiltration in providing local anesthesia when performing episioplasty in mares. Its use decreased the need for twitching horses as well as the risk of deformation of the labia caused by lidocaine infiltration.

Vasectomy: a "seminal" analysis

Vasectomy is one of the most reliable and cost-effective permanent methods of contraception. Despite its popularity, certain issues pertaining to the procedure remain unresolved. Appropriate selection of candidates for vasectomy requires thorough counseling and screening, though a foolproof method of eliminating dissatisfaction and regret remains a mystery. Debate continues over the relative merits of the various techniques of isolating and sealing the vasal ends. Postoperative complication rates remain minimal regardless of the technique used, and no single strategy attempting to maximize patient compliance with postoperative semen analysis has enjoyed unmitigated success. Long-term consequences, other than regret, are rare. Finally, issues regarding residency training in the procedure and its impact on procedure morbidity are scarcely addressed in the literature. This study reviews the evolution of vasectomy as a contraceptive procedure and attempts to summarize current literature addressing these unresolved issues.