Vasectomy and risk of prostate cancer: a systematic review and meta-analysis of cohort studies

[Male contraception]

CONTEXT

Contraception is a major global health issue, which is still dominated by female contraception. Developments in male contraception could help redistribute the contraceptive burden.

METHODS

A literature search was carried out to review the existing options and the criteria for optimal contraception, to establish the principles of a male pre-contraception consultation, and to review the various research avenues with their advantages and disadvantages.

RESULTS

The new male contraception options are detailed, whether hormonal (androgen therapy, combination of progestins and testosterone) or non-hormonal, particularly thermal, with current results and avenues for improvement. Condom use and vasectomy remain the only 2 validated options. The recent development of minimally invasive vasectomy without the need for a scalpel and of occlusion techniques has simplified the procedure, minimised the risk of complications (pain, haematomas, post-vasectomy pain syndrome) and improved efficacy. The issues of regret and the possibility of repermeabilisation are also raised.

CONCLUSION

The question of male contraception will become increasingly important in consultations with urologists. The urologist will have to inform the patient, as required by law, before the vasectomy is performed, and provide the best possible advice on the technique, which will often be minimally invasive without the need for a scalpel. New reversible options should also broaden the range of options available on a routine basis, with a view to gradually moving towards contraceptive equity.

[Recommendations of the Committee of Andrology and Sexual Medicine of the AFU concerning the management of Vasectomy]

OBJECTIVES

To answer the main clinical questions asked by practitioners and men consulting for a vasectomy request.

METHOD

The CPR method was used. The clinical questions were formulated according to the PICO methodology. A Pubmed literature search for the period 1984-2021 identified 508 references, of which 79 were selected and analyzed with the GRADE grid.

RECOMMENDATIONS

Vasectomy is a permanent, potentially reversible contraception. It is a safe procedure. A second vasectomy is necessary in only 1 % of cases. Surgical complications (hematoma, infection, pain, etc.) are rare. The frequency of prolonged scrotal pain after vasectomy is about 5 %, and less than 2 % describe a negative impact of this pain on their quality of life. Vasectomy does not have negative consequences on sexuality. The only contraindication to vasectomy is the minor patient. Patients at increased risk of remorse are single, divorced or separated men under the age of 30. Sperm storage may be particularly appropriate for them. Whatever the reason, the law allows the surgeon to refuse to perform the vasectomy. He must inform the patient of this at the first consultation. The choice of the type of anesthesia is left to the discretion of the surgeon and the patient. It must be decided during the preoperative consultation. Local anesthesia should be considered first. General anesthesia should be particularly considered in cases of anxiety or intense sensitivity of the patient to palpation of the vas deferens, difficulty palpating the vas deferens, or a history of scrotal surgery that would make the procedure more complex. Concerning the vasectomy technique, 2 points seem to improve the efficiency of the vasectomy: coagulation of the deferential mucosa and interposition of fascia. Leaving the proximal end of the vas deferens free seems to reduce the risk of post-vasectomy syndrome without increasing the risk of failure or complications. No-scalpel vasectomy is associated with a lower risk of postoperative complications than conventional vasectomy. Regarding follow-up, it is recommended to perform a spermogram at 3 months post-vasectomy and after 30 ejaculations. If there are still a few non-motile spermatozoa at 3 months, it is recommended that a check-up be performed at 6 months post-vasectomy. In case of motile spermatozoa or more than 100,000 immobile spermatozoa/mL at 6 months (defining failure), a new vasectomy should be considered. Contraception must be maintained until the effectiveness of the vasectomy is confirmed.

Vasectomy and Risk of Prostate Cancer: A Systematic Review and Meta-analysis

Context

Previous reports have shown an association between vasectomy and prostate cancer (PCa). However, there exist significant discrepancies between studies and systematic reviews due to a lack of strong causal association and residual confounding factors such as prostate-specific antigen (PSA) screening.

Objective

To assess the association between vasectomy and PCa, in both unadjusted and PSA screen-adjusted studies.

Evidence acquisition

We performed a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses. The PubMed, Scopus, and Web of Science databases were searched in January 2022 for studies that analyzed the association between vasectomy and PCa.

Evidence synthesis

A total of 37 studies including 16 931 805 patients met our inclusion criteria. A pooled analysis from all studies showed a significant association between vasectomy and any-grade PCa (odds ratio [OR] 1.23; 95% confidence interval [CI], 1.10–1.37; p < 0.001; I² = 96%), localized PCa (OR 1.08; 95% CI, 1.06–1.11; p < 0.00001; I² = 31%), or advanced PCa (OR 1.07; 95% CI, 1.02–1.13; p = 0.006; I² = 0%). The association with PCa remained significant when the analyses were restricted to studies with a low risk of bias (OR 1.06; 95% CI, 1.02–1.10; p = 0.02; I² = 48%) or cohort studies (OR 1.09; 95% CI, 1.04–1.13; p < 0.0001; I² = 64%). Among studies adjusted for PSA screening, the association with localized PCa (OR 1.06; 95% CI, 1.03–1.09; p < 0.001; I² = 0%) remained significant. Conversely, vasectomy was no longer associated with localized high-grade (p = 0.19), advanced (p = 0.22), and lethal (p = 0.42) PCa.

Conclusions

Our meta-analysis found an association between vasectomy and any, mainly localized, PCa. However, the effect estimates of the association were increasingly close to null when examining studies of robust design and high quality. On exploratory analyses including studies, which adjusted for PSA screening, the association for aggressive and/or advanced PCa diminished.

Patient summary

In this study, we found an association between vasectomy and the risk of developing localized prostate cancer without being able to determine whether the procedure leads to a higher prostate cancer incidence.

Association between vasectomy and risk of prostate cancer: a meta-analysis

BACKGROUND

The debate over the association between vasectomy and prostate cancer has been lasted about 40 years and there is no sign of stopping. In the present study, we aimed to evaluate whether vasectomy is associated with prostate cancer based on the most comprehensive and up-to-date evidence available.

METHODS

The PubMed, Cochrane Library, and EMBASE databases were systematically searched inception to March 14, 2021 without year or language restriction. Multivariable adjusted risk ratios (RRs) were used to assess each endpoint. Risk of bias was assessed using the Newcastle-Ottawa scale.

RESULTS

A total of 58 studies involving 16,989,237 participants fulfilled inclusion criteria. There was significant association of vasectomy with risk of any prostate cancer (risk ratio, 1.18, 95% CI, 1.07-1.31). Association between vasectomy and advanced prostate cancer (risk ratio, 1.06, 95% CI, 1.01-1.12), low-grade prostate cancer (risk ratio, 1.06, 95% CI, 1.02-1.10), and intermediate-grade prostate cancer (risk ratio, 1.12, 95% CI, 1.03-1.22) were significant. There was no significant association between vasectomy and prostate cancer-specific mortality (risk ratio, 1.01, 95% CI, 0.93-1.10).

CONCLUSIONS

This study found that vasectomy was associated with the risk of any prostate cancer and advanced prostate cancer. From the current evidence, patients should be fully informed of the risk of prostate cancer before vasectomy.

Review of Vasectomy Complications and Safety Concerns

Vasectomy is a simple, safe, effective, and economical method used worldwide for long-term male contraception. As a surgical operation, it has short-term and long-term complications such as hematoma formation, infection, sterilization failure, sperm granulomas, short-term postoperative pain (nodal pain, scrotal pain, and ejaculation pain), and chronic pain syndrome. Whether it increases the risk of autoimmune disease, cardiovascular disease, testicular cancer, or prostate cancer is still controversial. Changes in plasma concentrations of luteinizing hormone, follicle-stimulating hormone, and testosterone after vasectomy have also been studied, as well as the relation between vasectomy and sexual function. Sperm quality decreases very slowly after vasectomy, and vasovasostomy and intracytoplasmic sperm injection could help a couple achieve a pregnancy if they change their minds at any point. We include a follow-up strategy and suggestions for follow-up care at the end of this review.

Vasectomy and the risk of prostate cancer in a Finnish nationwide population-based cohort

INTRODUCTION & OBJECTIVES

There are conflicting reports on the association of vasectomy and the risk of prostate cancer (PCa). Our objective was to evaluate the association between vasectomy and PCa from a nationwide cohort in Finland.

MATERIALS & METHODS

Sterilization registry of Finland and the Finnish Cancer Registry data were utilized to identify all men who underwent vasectomy between years 1987-2014 in Finland. Standard incidence ratio (SIR) for PCa as well as all-cause standardized mortality ratios (SMR) were calculated.

RESULTS

We identified 38,124 men with vasectomy with a total of 429,937 person-years follow-up data. The median age at vasectomy was 39.7 years (interquartile range [IQR] 35.9-44.0), after vasectomy PCa was diagnosed in 413 men (122 cases 0-10 years, 219 cases 10-20 years and 72 cases >20 years from vasectomy). SIR for PCa for the vasectomy cohort was 1.15 (95% CI: 1.04-1.27). By the end of follow-up, 19 men had died from PCa, while the expected number was 20.5 (SMR 0.93 [95%CI: 0.56-1.44]). The overall mortality was decreased (SMR 0.54 [95%CI: 0.51-0.58]) among men with vasectomy.

CONCLUSION

We found a small statistically significant increase in PCa incidence after vasectomy, but in contrast the mortality of vasectomized men was significantly reduced. This may be due to higher likelihood of vasectomized men to undergo prostate-specific antigen testing, having healthier general lifestyle and other biological factors e.g. high reproductive fitness.

Long-term safety, health and mental status in men with vasectomy

Vasectomy is an efficient male contraceptive method, but the long-term effects of this technology in a large population are unclear. To investigate the influence of vasectomy on long-term health effects, we recruited 485 men with a vasectomy and 1940 men without vasectomy in China. After obtaining basic information from the Aging Males’ Symptoms (AMS) scale and other questionnaires, peripheral blood was drawn to assess the hormone levels, prostate specific antigen (PSA) and blood biochemistry. Using multiple linear regression analysis, these factors had no relationship with vasectomy except for four factors including the Somatic score (0.31, 0.02 and 0.61) in AMS, SF-36 score (−18.8, −32.00 and −5.60), “Role emotional” (−6.28, −10.34 and −2.22) and “Mental health” (−1.55, −3.08 and −0.02). A stratified analysis showed that with increased age, smoking and drinking, residence in township or a higher level of education, the mental health of men was worse. Vasectomy had no long-term effect on the level of sexual hormones in men, and it did not increase the level of PSA. The impact of the vasectomy on quality of life in men were mainly reflected in psychological effects, which suggests that men with vasectomy groups many benefit from professional psychological counseling.

Association between vasectomy and risk of testicular cancer: A systematic review and meta-analysis

Objectives

A number of researchers have reported that vasectomy is a risk factor for testicular cancer. However, this conclusion is inconsistent with a number of other published articles. Hence, we conducted this meta-analysis to assess whether vasectomy increases the risk of testicular cancer.

Materials and methods

We identified all related studies by searching the PubMed, Embase, and Cochrane Library database from January 01, 1980 to June 01, 2017. The Newcastle-Ottawa Scale (NOS) checklist was used to assess all included non-randomized studies. Summarized odds ratios (ORs) and 95% confidence intervals (CIs) were used to assess the difference in outcomes between case and control groups. Subgroup analyses were performed according to the study design and country.

Results

A total of eight studies (2176 testicular cancer patients) were included in this systematic review and meta-analysis. Six articles were case-control studies, and two were cohort studies. The pooled estimate of the OR was 1.10 (95% CI: 0.93–1.30) based on the eight studies in a fixed effects model. Two subgroup analyses were performed according to the study design and country. The results were consistent with the overall findings. Publication bias was detected by Begg’s test and Egger’s test and p values > 0.05, respectively.

Conclusions

Our meta-analysis suggested that there was no association between vasectomy and the development of testicular cancer. More high-quality studies are warranted to further explore the association between vasectomy and risk of testicular cancer.

The Effect of Vasectomy Reversal on Prostate Cancer Risk: International Meta-Analysis of 684,660 Vasectomized Men

PURPOSE

Evidence of the effect of vasectomy on prostate cancer is conflicting with the issue of detection bias a key criticism. We examined the effect of vasectomy reversal on prostate cancer risk in a cohort of vasectomized men. Evidence of a protective effect would be consistent with a harmful effect of vasectomy on prostate cancer risk while nullifying the issue of detection bias.

MATERIALS AND METHODS

Data were sourced from a total of 5 population level linked health databases in Australia, Canada and the United Kingdom. Cox proportional hazards regression analysis was used to compare the risk of prostate cancer in 9,754 men with vasectomy reversal to the risk in 684,660 with vasectomy but no reversal. Data from each jurisdiction were combined in a meta-analysis.

RESULTS

The combined analysis showed no protective effect of vasectomy reversal on the incidence of prostate cancer compared to that in men with vasectomy alone (HR 0.92, 95% CI 0.70-1.21).

CONCLUSIONS

These results align with those of previous studies showing no evidence of a link between vasectomy and prostate cancer.

The Association Between Vasectomy and Prostate Cancer: A Systematic Review and Meta-analysis

Importance

Despite 3 decades of study, there remains ongoing debate regarding whether vasectomy is associated with prostate cancer.

Objective

To determine if vasectomy is associated with prostate cancer.

Data Sources

The MEDLINE, EMBASE, Web of Science, and Scopus databases were searched for studies indexed from database inception to March 21, 2017, without language restriction.

Study Selection

Cohort, case-control, and cross-sectional studies reporting relative effect estimates for the association between vasectomy and prostate cancer were included.

Data Extraction and Synthesis

Two investigators performed study selection independently. Data were pooled separately by study design type using random-effects models. The Newcastle-Ottawa Scale was used to assess risk of bias.

Main Outcomes and Measures

The primary outcome was any diagnosis of prostate cancer. Secondary outcomes were high-grade, advanced, and fatal prostate cancer.

Results

Fifty-three studies (16 cohort studies including 2 563 519 participants, 33 case-control studies including 44 536 participants, and 4 cross-sectional studies including 12 098 221 participants) were included. Of these, 7 cohort studies (44%), 26 case-control studies (79%), and all 4 cross-sectional studies were deemed to have a moderate to high risk of bias. Among studies deemed to have a low risk of bias, a weak association was found among cohort studies (7 studies; adjusted rate ratio, 1.05; 95% CI, 1.02-1.09; P < .001; I2 = 9%) and a similar but nonsignificant association was found among case-control studies (6 studies; adjusted odds ratio, 1.06; 95% CI, 0.88-1.29; P = .54; I2 = 37%). Effect estimates were further from the null when studies with a moderate to high risk of bias were included. Associations between vasectomy and high-grade prostate cancer (6 studies; adjusted rate ratio, 1.03; 95% CI, 0.89-1.21; P = .67; I2 = 55%), advanced prostate cancer (6 studies; adjusted rate ratio, 1.08; 95% CI, 0.98-1.20; P = .11; I2 = 18%), and fatal prostate cancer (5 studies; adjusted rate ratio, 1.02; 95% CI, 0.92-1.14; P = .68; I2 = 26%) were not significant (all cohort studies). Based on these data, a 0.6% (95% CI, 0.3%-1.2%) absolute increase in lifetime risk of prostate cancer associated with vasectomy and a population-attributable fraction of 0.5% (95% CI, 0.2%-0.9%) were calculated.

Conclusions and Relevance

This review found no association between vasectomy and high-grade, advanced-stage, or fatal prostate cancer. There was a weak association between vasectomy and any prostate cancer that was closer to the null with increasingly robust study design. This association is unlikely to be causal and should not preclude the use of vasectomy as a long-term contraceptive option.

Vasectomy and Risk of Prostate Cancer in a Screening Trial

Background: Vasectomy has been implicated as a risk factor for prostate cancer in multiple epidemiologic studies over the past 25 years. Whether this relationship is causal remains unclear. This study examines the association between vasectomy and prostate cancer in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial, which randomized men to usual care or annual prostate cancer screening.Methods: We performed a retrospective analysis of 13-year screening and outcomes data from the PLCO trial. Multivariable Cox proportional hazards regression stratified by study arm and age at vasectomy was performed.Results: There was an increased risk of prostate cancer in men who had undergone a vasectomy and were randomized to the usual care arm of the study (adjusted HR, 1.11; 95% confidence interval, 1.03-1.20; P = 0.008). There was no association between vasectomy and diagnosis of prostate cancer in men randomized to the prostate cancer screening arm. Only men undergoing vasectomy at an older age in the usual care arm of the study, but not the prostate cancer screening arm, were at increased risk of being diagnosed with prostate cancer.Conclusions: Vasectomy was not associated with prostate cancer risk among men who were screened for prostate cancer as part of a clinical trial, but was associated with prostate cancer detection in men receiving usual care.Impact: The positive association between vasectomy and prostate cancer is likely related to increased detection of prostate cancer based on patterns of care rather than a biological effect of vasectomy on prostate cancer development. Cancer Epidemiol Biomarkers Prev; 26(11); 1653-9. ©2017 AACR.

Evidence for Masturbation and Prostate Cancer Risk: Do We Have a Verdict?

INTRODUCTION

Prostate cancer (PCa) is one of the leading causes of cancer death in men and remains one of the most diagnosed malignancies worldwide. Ongoing public health efforts continue to promote protective factors, such as diet, physical activity, and other lifestyle modifications, against PCa development. Masturbation is a nearly universal safe sexual activity that transcends societal boundaries and geography yet continues to be met with stigma and controversy in contemporary society. Although previous studies have examined associations between sexual activity and PCa risk, anecdotal relations have been suggested regarding masturbation practice and PCa risk.

AIM

To provide a summary of the published literature and examine the contemporary evidence for relations between masturbation practice and PCa risk.

METHODS

A survey of the current literature using seven academic electronic databases was conducted using search terms and key words associated with masturbation practice and PCa risk.

MAIN OUTCOME MEASURES

The practice of masturbation and its relation to PCa risk.

RESULTS

The literature search identified study samples (n = 16) published before October 2015. Sample inclusions varied by study type, sample size, and primary objective. Protective relations (n = 7) between ejaculation through masturbation and PCa risk were reported by 44% of the study sample. Age range emerged as a significant variable in the relation between masturbation and PCa.

CONCLUSION

Findings included relations among masturbation, ejaculation frequency, and age range as individual factors of PCa risk. No universally accepted themes were identified across the study sample. Throughout the sample, there was insufficient agreement in survey design and data reporting. Potential avenues for new research include frequency of ejaculation and age range as covarying factors that could lead to more definitive statements about masturbation practice and PCa risk.

WITHDRAWN: Re: Vasectomy and Prostate Cancer Incidence and Mortality in a Large US Cohort

The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.eururo.2016.11.008. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Vasectomy and risk of prostate cancer: population based matched cohort study

OBJECTIVE

 To determine the association between vasectomy and prostate cancer, adjusting for measures of health seeking behaviour.

DESIGN

 Population based matched cohort study.

SETTING

 Multiple validated healthcare databases in Ontario, Canada, 1994-2012.

PARTICIPANTS

 326 607 men aged 20 to 65 who had undergone vasectomy were identified through physician billing codes and matched 1:1 on age (within two years), year of cohort entry, comorbidity score, and geographical region to men who did not undergo a vasectomy.

MAIN OUTCOMES MEASURES

 The primary outcome was incident prostate cancer. Secondary outcomes were prostate cancer related grade, stage, and mortality.

RESULTS

 3462 incident cases of prostate cancer were identified after a median follow-up of 10.9 years: 1843 (53.2%) in the vasectomy group and 1619 (46.8%) in the non-vasectomy group. In unadjusted analysis, vasectomy was associated with a slightly increased risk of incident prostate cancer (hazard ratio 1.13, 95% confidence interval 1.05 to 1.20). After adjustment for measures of health seeking behaviour, however, no association remained (adjusted hazard ratio 1.02, 95% confidence interval 0.95 to 1.09). Moreover, no association was found between vasectomy and high grade prostate cancer (adjusted odds ratio 1.05, 95% confidence interval 0.67 to 1.66), advanced stage prostate cancer (adjusted odds ratio 1.04, 0.81 to 1.34), or mortality (adjusted hazard ratio 1.06, 0.60 to 1.85).

CONCLUSION

 The findings do not support an independent association between vasectomy and prostate cancer.

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>

The human epididymis: its function in sperm maturation

BACKGROUND

Spermatozoa acquire their fertilizing ability and forward motility properties during epididymal transit. Our knowledge of gamete physiology is based on studies conducted in laboratory and domestic species; our knowledge of these processes in humans is limited. Medical indications for assisted reproductive technologies (ART) have progressed to include male infertility. Surgical procedures allow collection of spermatozoa from all along the human excurrent ducts, and the former have been used with some success in reproductive medicine. This has raised questions over the role of the epididymis in human sperm physiology.

OBJECTIVE AND RATIONALE

To reanalyze what we now know about epididymal physiology in humans and to assess the relevance of laboratory animal models for understanding human physiology and the pathophysiology of the epididymis.

SEARCH METHODS

A systematic bibliographic search of PubMed for articles published in English before May 2015 was carried out using the search terms 'epididymis' and 'sperm maturation'. Literature on the consequences of vasectomy on the epididymis was also searched.

OUTCOMES

Whereas the proximal epididymis is almost exclusively occupied by efferent ducts, the sperm reservoir capacity is poorly developed in humans. At the molecular level, the human transcriptome and proteome show some segment specificity; conflicting results persist with regard to secretome variation along the tubule. The number of genes regulated along the excurrent ducts in men is lower when compared to rodent species, but remains significant. It is challenging to reconcile biochemical and physiological studies with clinical data obtained from men undergoing reanastomosis of the vas deferens at different points along the excurrent duct. We propose that vasectomy/vasovasostomy is a model to understand the consequences of obstruction on epididymis function in humans.

WIDER IMPLICATIONS

Despite the scarcity of biological material available, the interspecies variability of the male reproductive tract urges us to use modern molecular and cellular biology tools to better understand human epididymis physiology in order to apply ART in a more responsible manner.

Vasectomy: potential links to an increased risk of aggressive prostate cancer?

Several studies have found associations between aggressive prostate cancer (PC) and having a vasectomy. However, findings from two very recent meta-analyses have found that this is not the case. Therefore, the data are mixed. Herein, we detail the controversy between vasectomy and PC risk, particularly aggressive PC, by shedding some light on the molecular pathways, potential risk factors and suggested links for those considering vasectomy and medical professionals who perform it. We conclude by supporting the American Urological Association's position that there is no need to discuss potential prostate cancer risks with patients considering vasectomy given reasonably strong data finding no link between vasectomy and prostate cancer risk.