VASECTOMY: AUA GUIDELINE - AUA - Home - American .
1American Urological Association (AUA) GuidelineVASECTOMY:AUA GUIDELINEIra D. Sharlip, Arnold M. Belker, Stanton Honig, Michel Labrecque, Joel L. Marmar,Lawrence S. Ross, Jay I. Sandlow, David C. SokalApproved by the AUABoard of DirectorsMay 2012Authors’ disclosure ofpotential conflicts ofinterest and author/staffcontributions appear atthe end of the article. 2012 by the AmericanUrological AssociationNote to the reader:Please note that thisGuideline was edited in2015 to include additionalinformation related tovasectomy and the risk ofprostate cancer.Purpose: The purpose of this Guideline is to provide guidance to clinicians whooffer vasectomy services. This guidance covers pre-operative evaluation andconsultation of prospective vasectomy patients; techniques for local anesthesia,isolation of the vas deferens and occlusion of the vas deferens during vasectomy;post-operative follow-up; post-vasectomy semen analysis (PVSA) and potentialcomplications and consequences of vasectomy.Methods: A systematic review of the literature using the MEDLINE and POPLINEdatabases (search dates January 1949 to August 2011) was conducted to identify peer-reviewed publications relevant to vasectomy. The search identified almost 2,000titles and abstracts. Almost 900 articles were retrieved for full-text review. Theseyielded an evidence base of 275 articles after application of inclusion and exclusioncriteria. These publications were used to create the evidence-based portion of theGuideline. When sufficient evidence existed, the body of evidence for a particulartreatment was assigned a strength rating of A (high), B (moderate) or C (low).Additional information is provided as Clinical Principles and Expert Opinion wheninsufficient evidence existed.Guideline StatementsThe Panel would like toacknowledge Susan L.Norris M.D., M.P.H., M.S.and her team for theirmethodologicalcontributions and to alsothank Martha Faraday,Ph.D. for her additionalmethodological input andfor her invaluablecontributions to thedrafting of the final report.L a a1. A preoperative interactive consultation should be conducted, preferably in person.If an in-person consultation is not possible, then preoperative consultation bytelephone or electronic communication is an acceptable alternative. ExpertOpinion2. The minimum and necessary concepts that should be discussed in a preoperativevasectomy consultation include the following: Expert Opinion Vasectomy is intended to be a permanent form of contraception. Vasectomy does not produce immediate sterility. Following vasectomy, another form of contraception is required until vas occlusion is confirmed by post- vasectomy semen analysis (PVSA).Even after vas occlusion is confirmed, vasectomy is not 100% reliable inpreventing pregnancy.The risk of pregnancy after vasectomy is approximately 1 in 2,000 for menwho have post-vasectomy azoospermia or PVSA showing rare non-motilesperm (RNMS).Repeat vasectomy is necessary in 1% of vasectomies, provided that atechnique for vas occlusion known to have a low occlusive failure rate hasbeen used.Patients should refrain from ejaculation for approximately one week aftervasectomy.Options for fertility after vasectomy include vasectomy reversal and spermretrieval with in vitro fertilization. These options are not always successful,and they may be expensive.Copyright 2012 American Urological Association Education and Research, Inc.
2American Urological AssociationVasectomy The rates of surgical complications such as symptomatic hematoma and infection are 1-2%. These rates varywith the surgeon’s experience and the criteria used to diagnose these conditions. Chronic scrotal pain associated with negative impact on quality of life occurs after vasectomy in about 1-2% ofmen. Few of these men require additional surgery. Other permanent and non-permanent alternatives to vasectomy are available.3. Clinicians do not need to routinely discuss prostate cancer, coronary heart disease, stroke, hypertension, dementia ortesticular cancer in pre-vasectomy counseling of patients because vasectomy is not a risk factor for these conditions.Standard (Evidence Strength Grade B)4. Prophylactic antimicrobials are not indicated for routine vasectomy unless the patient presents a high risk of infection.Recommendation (Evidence Strength Grade C)5. Vasectomy should be performed with local anesthesia with or without oral sedation. If the patient declines localanesthesia or if the surgeon believes that local anesthesia with or without oral sedation will not be adequate for aparticular patient, then vasectomy may be performed with intravenous sedation or general anesthesia. ExpertOpinion6. Isolation of the vas should be performed using a minimally-invasive vasectomy (MIV) technique such as the noscalpel vasectomy (NSV) technique or other MIV technique. Standard (Evidence Strength Grade B)7. The ends of the vas should be occluded by one of three divisional methods:(1) Mucosal cautery (MC) with fascial interposition (FI) and without ligatures or clips applied onthe vas;(2) MC without FI and without ligatures or clips applied on the vas;(3) Open ended vasectomy leaving the testicular end of the vas unoccluded, using MC on the abdominal end andFI;OR by the non-divisional method of extended electrocautery. Recommendation (Evidence Strength Grade C)8. The divided vas may be occluded by ligatures or clips applied to the ends of the vas, with or without FI and with orwithout excision of a short segment of the vas, by surgeons whose personal training and/or experience enable themto consistently obtain satisfactory results with such methods. Option (Evidence Strength Grade C)9. Routine histologic examination of the excised vas segments is not required. Expert Opinion10. Men or their partners should use other contraceptive methods until vasectomy success is confirmed by PVSA.Clinical Principle11. To evaluate sperm motility, a fresh, uncentrifuged semen sample should be examined within two hours afterejaculation. Expert Opinion12. Patients may stop using other methods of contraception when examination of one well-mixed, uncentrifuged, freshpost-vasectomy semen specimen shows azoospermia or only rare non-motile sperm (RNMS or 100,000 non-motilesperm/mL). Recommendation (Evidence Strength Grade C)13. Eight to sixteen weeks after vasectomy is the appropriate time range for the first PVSA. The choice of time to do thefirst PVSA should be left to the judgment of the surgeon. Option (Evidence Strength Grade C)14. Vasectomy should be considered a failure if any motile sperm are seen on PVSA at six months after vasectomy, inwhich case repeat vasectomy should be considered. Expert Opinion15. If 100,000 non-motile sperm/mL persist beyond six months after vasectomy, then trends of serial PVSAs andclinical judgment should be used to decide whether the vasectomy is a failure and whether repeat vasectomy shouldbe considered. Expert OpinionCopyright 2012 American Urological Association Education and Research, Inc.
3American Urological AssociationVasectomyTable 1: LUSVASWHOTable 1: Abbreviationsanti-sperm antibodiesAmerican Urological Associationcubic centimetercoronary heart diseaseconfidence intervalClinical Laboratory Improvement Actcentimeterconventional vasectomydivision with or without excision of a vas segmentevidence strengthfascial interpositionfollicle-stimulating hormonehigh power field(s)intracytoplasmic sperm injectionin vitro fertilizationligation and excisionluteinizing hormoneMinimally-invasive vasectomyMillilitermillimeterMarie Stopes Internationalno-scalpel vasectomyodds ratioPrimary Progressive Aphasiaprovider-performed microscopypost-vasectomy semen analysisrandomized controlled trialrare non-motile spermrelative riskMicroliterUnited Statesvisual analog scaleWorld Health OrganizationCopyright 2012 American Urological Association Education and Research, Inc.
4American Urological uctionSection 1: Guideline PurposeThe purpose of this Guideline is to provide guidance toclinicians who offer vasectomy services. The Guidelinecovers pre-vasectomy evaluation and consultation ofprospective vasectomy patients; techniques for localanesthesia, isolation of the vas deferens and occlusion ofthe vas deferens during vasectomy; post-operative follow-up; post-vasectomy semen analysis (PVSA) to verifysterility and potential complications and consequences ofvasectomy. Currently, the practice of vasectomy ischaracterized by wide variation in pre-operativecounseling, surgical technique and post-operative followup. The intent of this Guideline is to provide a set ofapproaches and procedures that maximizes successfulvasectomy outcomes and minimizes failure and otheradverse events.The strategies and approaches recommended in thisdocument were derived from evidence-based andconsensus-based processes. There is a continuallyexpanding literature on vasectomy. The Panel notes thatthis document constitutes a clinical approach to thepractice of vasectomy. This Guideline is not intended toreplace the judgment of an individual clinician faced witha particular patient. As the science relevant to vasectomyevolves and improves, the strategies presented here willrequire updating to remain consistent with the higheststandards of clinical care.Section 2: Guideline MethodologyProcess for Literature Selection. A systematic reviewwas conducted to identify published articles relevant tokey questions specified by the Panel (See Appendix C).The key questions focused on identifying necessaryelements of pre-operative evaluation and consultation,optimal procedures for anesthetic administration, the leasttraumatic and most effective procedures for isolation ofthe vas deferens, the most effective procedures foroccluding the vas deferens, the complications andconsequences of vasectomy and the necessarycomponents of post-operative follow-up, including semenanalysis to verify sterility.Literature searches were performed using theMEDLINE and POPLINE databases from January1949 to August 2011 with the goal of identifyingliterature broadly relevant to the practice of vasectomy.This literature included studies that focused on theprevalence of vasectomy; the demographics of patientsand couples who chose vasectomy; vasectomy operativetechniques, including techniques for vas isolation and vasocclusion and associated failure rates; short-term andlong-term complications of vasectomy, other outcomespotentially associated with vasectomy (e.g., coronaryheart disease, stroke, prostate and testicular cancer,sexual outcomes, psychosocial outcomes) and PVSAprocedures and timing. Inclusion criteria for operativeprocedures were conventional vasectomy (CV) andminimally-invasive vasectomy (MIV), including the noscalpel vasectomy (NSV) technique. All methods foroccluding the vas were included. The following topicswere excluded from the scope of the review:laparoscopic vasectomy, vasectomy reversal, postvasectomy options for pregnancy, treatment of postvasectomy pain syndrome, examination of antibodies toantigens other than sperm post-vasectomy and techniquesfor teaching vasectomy.Articles on antibioticprophylaxis also were excluded as the topic of antibioticprophylaxis in surgical procedures without entering theurinary tract is covered in an AUA Best Practice roprop08.pdf). All settings and all ages ofvasectomy patients were included. All study designswere included except for single-group cohort studies onimmediate post-operative complications with fewer than500 participants. Review article references were checkedto ensure inclusion of all possibly relevant studies.Multiple reports on the same patient group were carefullyexamined to ensure exclusion of redundant information.Nearly 2,000 citations were reviewed by title and/orabstract. After application of inclusion and exclusioncriteria, 275 articles were chosen to form the evidencebase of this Guideline. Data were extracted on studydesign (e.g., randomized controlled trial, comparativeobservational study, case-series); pre-operative, operativeand post-operative parameters; complications and otherconsequences of vasectomy (e.g., patient satisfaction,patient regret) and vasectomy effectiveness and failurerates.Quality of Individual Studies and Determination ofEvidence Strength. Quality of individual studies thatwere randomized controlled trials (RCTs) or comparativeobservational studies was assessed using the CochraneRisk of Bias tool.1 Since there is no widely-acceptedquality assessment tool for single-cohort observationalCopyright 2012 American Urological Association Education and Research, Inc.
5American Urological AssociationVasectomyIntroductionstudies, the quality of these studies was not assessed.evidence.The categorization of evidence strength is conceptuallydistinct from the quality of individual studies. Evidencestrength refers to the body of evidence available for aparticular question and includes consideration of studydesign; individual study quality; the consistency offindings across studies; the adequacy of sample sizes andthe generalizability of samples, settings and treatmentsfor the purposes of the Guideline. The AUA categorizesbody of evidence strength (ES) as Grade A (wellconducted RCTs or exceptionally strong observationalstudies), Grade B (RCTs with some weaknesses ofprocedure or generalizability or generally strongobservational studies) or Grade C (observational studiesthat are inconsistent, have small sample sizes, or haveother problems that potentially confound interpretation ofdata).Panel Selection and Peer Review Process.TheVasectomy Panel was created in 2008 by the AmericanUrological Association Education and Research, Inc.(AUA). The Practice Guidelines Committee (PGC) ofthe AUA selected the Panel Chair and Vice Chair who inturn appointed the additional panel members, all of whomhave specific expertise with regard to vasectomy.AUA Nomenclature:Linking Statement Type toEvidence Strength. The AUA nomenclature systemexplicitly links statement type to body of evidencestrength and the Panel’s judgment regarding the balancebetween benefits and risks/burdens (see Table 2).2Standards are directive statements that an action should(benefits outweigh risks/burdens) or should not (risks/burdens outweigh benefits) be undertaken based onGrade A or Grade B evidence. Recommendations aredirective statements that an action should (benefitsoutweigh risks/burdens) or should not (risks/burdensoutweigh benefits) be undertaken based on Grade Cevidence. Options are non-directive statements that leavethe decision to take an action up to the individualclinician and patient because the balance betweenbenefits and risks/burdens appears relatively equal orappears unclear; Options may be supported by Grade A,B or C evidence. For some clinical issues, there was littleor no evidence from which to construct evidence-basedstatements. Where gaps in the evidence existed, thePanel provides guidance in the form of ClinicalPrinciples or Expert Opinion with consensus achievedusing a modified Delphi technique if differences ofopinion existed among Panel members.3 A ClinicalPrinciple is a statement about a component of clinicalcare that is widely agreed upon by urologists or otherclinicians for which there may or may not be evidence inthe medical literature. Expert Opinion refers to astatement, achieved by consensus of the Panel, that isbased on members' clinical training, experience,knowledge and judgment and for which there is noThe AUA conducted an extensive peer review process.The initial draft of this Guideline was distributed to 72peer reviewers; 55 responded with comments. The panelreviewed and discussed all submitted comments andrevised the draft as needed. Since the changes weresubstantial, a second draft was circulated to 64 peerreviewers.The panel reviewed and discussed allsubmitted comments in response to this second round ofpeer review and again revised the document. Oncefinalized, the Guideline was submitted for approval to thePGC. It was then submitted to the AUA Board ofDirectors for final approval. Funding of the panel wasprovided by the AUA. Panel members received noremuneration for their work.Table 2: AUA NomenclatureLinking Statement Type to Evidence StrengthStandard: Directive statement that an action should(benefits outweigh risks/burdens) or should not (risks/burdens outweigh benefits) be taken based on Grade Aor B evidenceRecommendation: Directive statement that an actionshould (benefits outweigh risks/burdens) or should not(risks/burdens outweigh benefits) be taken based onGrade C evidenceOption: Non-directive statement that leaves the decision regarding an action up to the individual clinicianand patient because the balance between benefits andrisks/burdens appears equal or appears uncertain basedon Grade A, B or C evidenceClinical Principle: a statement about a component ofclinical care that is widely agreed upon by urologistsor other clinicians for which there may or may not beevidence in the medical literatureExpert Opinion: a statement, achieved by consensusof the Panel, that is based on members' clinical training, experience, knowledge, and judgment for whichthere is no evidenceCopyright 2012 American Urological Association Education and Research, Inc.
6American Urological AssociationTHE PRACTICE OF VASECTOMYThe Practice of VasectomySection 1: The Importance of VasectomyVasectomy is the most common non-diagnostic operationperformed by urologists in the United States (US).Estimates of the number of vasectomies performedannually in the US vary depending on survey type. Datafrom the National Study of Family Growth in which onlymarried couples were polled indicate a range from175,000 to 354,000.4 In a physician survey, an estimated526,501 vasectomies were performed in the US in 2002.5This number seems to have been approximately stable forthe previous decade. More than 75% of vasectomies inthe US are done by urologists, and about 90% of urologypractices in the US perform vasectomy.5,6In 2002, data collected in the US show that vasectomywas used by 5.7% of men ages 15-44 and that thisrepresents the fourth most commonly-used contraceptivemethod. The first three were condoms, used by 29.5% ofmen, oral contraceptives for women used by 25.6% ofcouples and tubal ligation used by 8.1% of couples.7Compared to tubal ligation , which is also a method ofpermanent contraception, vasectomy is equally effectivein preventing pregnancy; however, vasectomy is simpler,faster, safer and less expensive. Vasectomy is one of themost cost-effective of all methods of contraception; itscost is about one-fourth of the cost of tuba lligation.8Vasectomy requires less time off work, requires onlylocal rather than general anesthesia and is usuallyperformed in a doctor’s office or clinic. The potentialcomplications of vasectomy are less serious than those oftubal ligation.VasectomyThe Practice of Vasectomyrelied on vasectomy for contraception compared to 225million who relied on tubal ligation.11 There are onlyeight nations in which vasectomy use is equal to or morefrequent than tubal ligation for contraception – Korea,Canada, the United Kingdom, New Zealand, Bhutan, theNetherlands, Denmark and Austria (World ContraceptiveUse 2011).Given that vasectomy and tubal ligation have equivalentcontraceptive effectiveness and that vasectomy enjoysadvantages compared to tubal sterilization of lower cost,less pain, greater safety and faster recovery, vasectomyshould be considered for permanent contraception muchmore frequently than is the current practice in the UnitedStates and most nations of the world.SECTION 2: PREOPERATIVE PRACTICEBackground InformationVasectomy and WhyAboutWhoChoosesReasons for Choosing Vasectomy. Several
2 American Urological Association Vasectomy The rates of surgical complications such as symptomatic hematoma and infection are 1-2%.These rates vary with the surgeon’s experience and the criteria used to diagnose these conditions. Chronic scrotal pain associated with negative impact o
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It is recommended that you wait at least one week before resuming sexual activities. You may then resume sexual activities if you are not experiencing any discomfort. Having ejaculations too soon after a vasectomy may increase the chance
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provided as Clinical Principles and Expert Opinions. Guideline Statements Assessment 1. For initial infertility evaluation, both male and female partners should undergo concurrent assessment. (Expert Opinion) Approved by the AUA Board of Directors October 2020 Authors' disclosure of po-tential conflicts of interest and author/staff contribu-
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