Are evidence-based vasectomy surgical techniques performed in low-resource countries?

Survey on vasectomy practices in France in 2022

OBJECTIVES

Prior to the publication of the recommendations of the French Association of Urology (AFU) on vasectomy, we conducted a survey to assess current practices and required training interventions in France regarding vasectomy.

METHOD

An invitation with a link to a 38-item questionnaire on MonkeySurvey was sent in November 2022 to the 1760 urologist members of the AFU.

RESULTS

A total of 352 (20%) urologists completed the survey. Among the participants, 20% reported refusing the surgery to patients aged 25 to 30 years old and 17% if they had no children, respectively. Three quarters of participants mentioned systematically performing a scrotal exam at the time of the pre-vasectomy consultation. Forty-one percent of respondents reported systematically performing vasectomy under general anesthesia. While 56% of participants mentioned performing a minimally invasive technique for exposing the vas, 70% said they were willing to learn the no-scalpel technique for this purpose. The most frequently reported occlusion techniques combine excision of a vas segment and ligation of both ends of the divided vas. Only 26% reported performing fascial interposition and 4% using the "open end" technique. A post-vasectomy semen analysis showing less than 100,000 non-motile sperm per millilitre makes only 38% of respondents recommending stopping other contraceptive methods. Half of the respondents considered that current reimbursement fee structure for the procedure restrains the development of this clinical activity.

CONCLUSION

Our survey suggests that vasectomy practice and services in France do not meet the international standards. We identified the clinical and organizational changes needed to improve practices and access to vasectomy services in France.

LEVEL OF EVIDENCE

Grade 3.

Risk of vasectomy failure by ligation and excision with fascial interposition: A prospective descriptive study

OBJECTIVE

To evaluate the occlusive failure risk of ligation and excision with fascial interposition vasectomy technique. There are doubts about the effectiveness of this technique largely used in Asia and Latin America.

STUDY DESIGN

We conducted a prospective longitudinal observational descriptive study among men who underwent a vasectomy performed under local anesthesia in a clinic specializing in sexual and reproductive health services in Bogotá, Colombia. Three urologists used the Percutaneous No-Scalpel Vasectomy technique to isolate the vas deferens. They then ligated the vas, excised a 1 cm segment between ligations, and ligated the fascia on the prostatic end to cover the testicular end. We requested all patients to submit a semen sample three months after the vasectomy. We defined probable and confirmed vasectomy failure as 1-4.9 million sperm/ml and 5 million sperm/ml or more or any number of motile sperm observed on the last semen sample available, respectively.

RESULTS

Among 1149 participants, 581 (51%) had at least one post-vasectomy semen analysis. The overall failure risk was 5.2% (30/581; 95% confidence interval [CI] 3.6%-7.3%) with probable and confirmed failure risk of 1.9% (11/581; 95% CI 1.1%-3.4%) and 3.3% (19/581; 95% CI 2.1%-5.1%), respectively. Older men and one urologist had statistically significant higher risk of overall failure.

CONCLUSION

Our study confirmed that the ligation and excision with fascial interposition vasectomy technique is associated with an unacceptable risk of failure.

IMPLICATIONS

Surgeons who use the ligation and excision with fascial interposition vasectomy technique and countries with large vasectomy programs in Asia and Latin America that still recommend this technique should consider adopting alternatives to reduce the failure risk to below 1% as recommended by the American Urological Association.