No-scalpel vasectomy better

Apr 19 2007

Although no-scalpel vasectomies are becoming more popular among physicians and patients, there are no definitive statistics to confirm the superiority of this choice, and a new review's main conclusion is to underline the importance of training.

Yet training is not always available or sought, said lead reviewer Dr. Lynley Cook, a public health physician and clinical senior lecturer at the University of Otago in Christchurch, New Zealand.

She said, "Training may not be available in all places in the world and surgeons who learned how to do vasectomies using the standard incision method may not be interested in learning a new technique."

Vasectomy, a surgical form of birth control in which a duct known as the vas is cut or tied, has traditionally been performed by making an incision in the skin of the scrotum. Cutting or tying the vas, which carries sperm from the testicles, leaves a man infertile.

Instead of making an incision, the no-scalpel technique uses a sharp instrument to puncture the skin. Advantages of puncturing rather than cutting the skin of the scrotum include less bleeding, bruising, infection and pain. Also, the puncture is usually so small that it does not require stitches.

The review looked at two studies that compared the no-scalpel method of vasectomy to the traditional method. The studies arrived at conflicting results.

The review appears in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates research in all aspects of health care. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing trials on a topic.

The larger study, conducted in 1999, included 1,429 men in five countries: Brazil, Guatemala, Indonesia, Sri Lanka and Thailand. All eight physicians , general surgeons and urologists , had experience with the standard vasectomy technique and three had experience with the no-scalpel method. Inexperienced surgeons received training in the no-scalpel technique.

In this study, men who received no-scalpel vasectomies had less bleeding, bruising, infection and pain during surgery and follow-up. Doctors using the no-scalpel method had more surgical difficulties than those who used the incision method , primarily locating the vas. Even so, the no-scalpel method resulted in a shorter operation. The patients also had a shorter recovery with a quicker resumption of postoperative sexual activity.

The smaller trial included 100 participants treated at a single site in Denmark. None of the eight doctors had substantial experience in the no-scalpel technique. Training was limited to an instructional video and one supervised procedure. Only one surgeon performed more than 10 no-scalpel vasectomies in the trial.

The smaller study showed no difference in postoperative results between the two techniques, but this, review authors say, could have been due to the small numbers of participants. Another important factor was the lack of experience that participating doctors had in the no-scalpel technique.

Both studies found the two techniques to be equally effective in terms of providing permanent fertility control. Although the larger study seemed to demonstrate many advantages to the no-scalpel method, the reviewers found the results inconclusive, largely because results from the studies could not be pooled for analysis.

"From the results of the review, we would agree that the no-scalpel methodology is the preferable method to use, as it has lower rate of adverse events," Cook said. "But the no-scalpel technique requires more training and a higher level of skill. One of the most important issues for men seeking a vasectomy is the experience of the surgeon with that particular method."

"The no-scalpel vasectomy is much more difficult to learn than the conventional one and requires more hands-on training," said Dr. Marc Goldstein, executive director of the Men's Service Center, Cornell University, Weill Medical College. "Adequate training is key." Goldstein was not involved with the review.

Despite the lack of documented evidence, men are increasingly asking their doctors about this method. Goldstein said that one-third of the vasectomies now done in the United States use the no-scalpel method.

Goldstein recommends that a patient considering a no-scalpel vasectomy ask his doctor where he received his training and how many of these surgeries he has done. More studies would help: "Informed patients will benefit from data showing that it is a technique associated with less pain and fewer complications."