Vasectomy: What the Evidence Shows
Guidelines do not exist despite many controversial issues; a specialist examines published data.
Even though the American Urological Association has developed guidelines for numerous conditions, there are none for vasectomy. Yet this is one of the most common procedures performed by urologists, with more than 500,000 done annually in the
Guidelines would be especially helpful because there are disagreements over preoperative counseling, operative technique, postoperative follow-up, and possible long-term complications. Fortunately, the AUA Practice Guidelines Committee is considering addressing these issues in 2007. In the interim, I want to offer a review of opinions and evidence based data in the literature.
Is routine histological evaluation of vas specimens necessary at the time of vasectomy?
Androlog, an internet-based discussion group for andrologists, addressed this issue and published their findings in the Journal of Andrology 2006;27:637-640. An international discussion relayed information regarding the benefits and drawbacks of sending vas specimens to pathology.
The major benefit of histological confirmation is removal of the appropriate organ. This does not guarantee a successful outcome, however. If a specimen is not confirmed as the vas deferens, it signals the surgeon that the operation is clearly not successful. Jerry Yuan, MD, with Urology Associates of North Georgia, wrote in the Androlog review that he does not send vas segments for histology unless it is an unusual case.
Occasionally, we are all confronted with a structure that we are not 100% sure is the vas deferens, as can happen with patients who have a cryptorchidism testes after an orchidopexy. Sometimes the vas is somewhat atretic, and histologic confirmation reassures the surgeon that what he removed was actually the vas deferens.
Pathological confirmation does not confirm postoperative success, though. Success can only be confirmed with postoperative semen analysis. In addition, pathological confirmation of vasa does not assure that a segment was removed from both the left and right vasa as opposed to two segments from the same vas deferens. In cases of postoperative failure, this gives lawyers more ammunition to confirm poor surgical technique.
The AUA has a policy statement regarding the standard of care for sending vas specimens. It reads as follows:
“Routine histologic confirmation is unnecessary in performing vasectomy. The American Urological Association, Inc. (AUA) recommends that physicians in practice and that residency training programs no longer require histologic confirmation of the vas deferens as a measurement of vasectomy success. The finding of azoospermia after a bilateral vasectomy is the standard for success.
The persistence of sperm in the semen after a bilateral vasectomy is a surgical failure regardless of a pathologic confirmation that two segments of the vas were removed. The lack of clinical value makes the routine histologic evaluation of surgical specimens obtained by a surgeon experienced in performing vasectomies clinical unnecessary. The surgeon should decide whether a histologic evaluation is warranted. The surgeon should document in the patient's record comprehensive preoperative counseling, careful patient selection, meticulous surgical technique and whether azoospermia was achieved in the postoperative semen.”—Board of Directors, 1998, reaffirmed 2003.
Therefore, for now, histologic confirmation of vas deferens is not considered the standard of care.