Vasectomy with transurethral resection of prostate.

A retrospective study was made of 200 patients undergoing transurethral prostatectomy. Half of these patients received bilateral vasectomies. The vasectomized patients had a 5-percent incidence of epididymitis as compared with a 2-percent incidence in the nonvasectomized patients. Vasectomy failed to provide adequate protection against postoperative epididymitis and cannot be recommended as a routine procedure with a transurethral prostatectomy.

PIP: Transurethral prostatectomy was performed on 200 patients from the Lettermen Army Medical Center. The patients were divided into 2 groups: group 1 (N=100) consisted of those who had bilateral vasectomies immediately before transurethral resection, while group 2 consisted of those who did not have vasectomy and had no prior history of vasectomy or epididymitis (defined as tenderness, swelling, and/or induration of the epididymitis with or without fever). The 2 groups were followed up from 3 months to 6 years. Group 1 exhibited a 5% incidence of epididymitis compared with group 2's 2% incidence. A significant difference observed between the 2 groups was the duration of hospital stay: group 1 averaged 16 days while group 2 averaged 13.25 hospital days. Although prolonged hospital stay has been associated with risk of iatrogenic wound infections, it is not known whether it is a factor in postprostatectomy epididymitis. One possible explanation for the mechanism of epididymitis is the reflux of infected urine into the vas deferens; this is the rationale for performing vasectomy to prevent epididymitis. Incidence of postprostatectomy epididymitis can be reduced by using better equipment and optics (for more accurate resectioning), early treatment of prostatism, and shorter hospital stay. The findings of this study suggest that vasectomy does not reduce incidence of epididymitis and hence cannot be used as a routine procedure with a transurethral prostatectomy.

Coagulation changes following vasectomy: a study in primates.

Thirty vasectomized rhesus monkeys were tested for changes in coagulation factors that might reflect an increased incidence of thrombosis. The results of tests on these monkeys were compared with results of tests on 18 control rhesus monkeys; there were no significant differences between control and vasectomized animals for any of the parameters tested. One vasectomized animal had increased levels of fibrin monomer in his plasma on repeated samples, but no evidence of thrombosis on postmortem examination.

PIP: This study attempted to determine whether fibrin monomer complexes, or other alterations of coagulation factor activities that might predispose to thrombosis, were present in 30 vasectomized Rhesus monkeys that had had bilateral vasectomies 1-11 years earlier. Blood coagulation factors, prothrombin, factors V and VIII, fibrogen, and antithrombin III, are consumed when blood coagulation occurs. If consumption of these factors is in excess of the individual's ability to synthesize them, a decreased concentration results. No significant decreases in activities of any consumable clotting factors were found. If intravascular coagulation is present, certain products of coagulation may be present in the blood even though consumable factors remain normal. Products of intravascular coagulation include fibrin monomer and plasmin digestion products of fibrin. No significant differences in average values of fibrin monomer and fibrin digestion products in control and vasectomized animals were found. 1 animal had increased fibrin monomer, but on postmortem examination, no evidence of intravascular thrombosis was seen.

Is the low fertility rate after vasovasostomy caused by nerve resection during vasectomy?

Cross-sections of human spermatic cords and vasectomy specimens were prepared and the number and cross-sectional area of nerves were determined. On average, about one-half of all nerves in the near neighborhood of the vas deferens were resected during vasectomy. The total cross-sectional area of the nerves along the vasectomy specimens amounted to about one-half of the total area in the spermatic cord samples. The data support the hypothesis that removing nerves to the vas deferens during vasectomy could result in poor functional results after vasovasostomy, i.e., that powerful contraction of the proximal vas deferens and epididymis could be lacking.

PIP: The possibility that an aspect inherent in the surgical technique of vasectomy is responsible for the low rate of fertility after vasovasostomy was investigated by studying the localization of nerves in the neighborhood of the vas deferens in the spermatic cord and by determining whether and to what extent nerves are resected during vasectomy. In addition, the roles of nerves in vasectomy and vasovasostomy were investigated. Spermatic cords were dissected in cross-sections from 17 cadavers; specimens from vasectomies (vas deferens) were provided by a urology dept. (n=45). In the spermatic cord material, an arbitrary radius around the vas was studied for nerve characterization, and there was no obvious prevailing localization of nerves, but they were found in the whole circumferential adventitia of the vas deferens. In the vasectomy specimens, the adventitial tissue of the vas was missing; in most cases the larger areas of the vas were bare of adventitial tissue, and the vessels and nerves found were located on 1 or 2 sides of the vas. Quantitatively, the mean number of nerves per cross-section was about 1/2 of the number in spermatic cords; the total area of nerves resected on average during vasectomy amounted to nearly 50% of all nerves found near the vas in spermatic cords. This nerve resection could result in poor functional results after reversal of sterilization because the powerful contractions of the proximal vas deferens would be lacking.

Vasectomy: etiology of infectious complications.

Semen was cultured prior to vasectomy for voluntary sterilization. Postvasectomy infectious complications occurred only in patients with positive preoperative semen cultures. The offending pathogen was the same organism found in the semen culture. This evidence for an endogenous cause of postoperative vasectomy infections suggests that a semen culture and antimicrobial sensitivity be obtained prior to vasectomy. In this manner the correct antimicrobial agent can be instituted as an aid to rapid resolution of a postvasectomy infection.

PIP: Semen from 134 fertile prevasectomy patients was obtained and cultured to determine any relationship between prevasectomy culture and development of postvasectomy infection. Significant bacterial growth was found in the semen of 5 of 134 patients. Postvasectomy complications occurred in 6 patients (4.5%), and 3 of these were infectious complications (bacterial epididymitis and superficial wound infection). The infectious complications were associated with enterococci in the wound (n=1), escherichia coli in urine (n=1), and proteus mirabilis in urine (n=1). The same offending pathogen was found in semen culture. Only those patients with prevasectomy positive cultures encountered infectious complications postvasectomy; therefore, endogenous genital tract infection prevascetomy is associated with postvasectomy infection. Semen cultures prevasectomy are recommended so that appropriate antimicrobial therapy may be instituted at sterilization.

Immunologic implications of vasectomy. I. Cell-mediated immunity.

PIP: The development of sperm-specific, cell-mediated immunity in postvasectomized rats was determined using 3 different types of assays: footpad swelling response to injected syngeneic spermatozoa; radioactive release from chromium labeled spermatozoa; and release of macrophage migration inhibition factor from lymphocytes responding to spermatozoa. 30 male rats underwent vasectomy with 1 of the following in groups of 10: 1) ligation of the vas deferens; 2) vasectomy without ligation of the vas deferens; or 3) sham vasectomy. Assays for cell-mediated immunity were performed 90 days postvasectomy. Cell-mediated immunity was present only in rats without ligation of the vas deferens. The swelling response to spermatozoa in Group 2 rats was statistically significant (p less than .01). A lymphocyte cell-mediated release of chromium from labeled spermatozoa was highly significant when Group 2 animals were the source of spleen cells (p less than .0005). Macrophage migration inhibition was significant (p less than .01) in supernatants taken from cultures of syngeneic spermatozoa with spleen cells of Group 2 rats, vasectomized without vas ligation. Possible reasons for these results were presented.^ieng

The significance of intravasal azoospermia during vasovasostomy: answer to a surgical dilemma.

PIP: The presence of sperm in the intravasal fluid during vasovasostomy is an indication that the procedure will be successful in a large percentage of cases. Intravasal azoospermia (IVA) raises the possibility of an additional obstruction caused by fibrosis of the epididymis, a pressure related effect of vasectomy. The frequency of epididymal fibrosis may be related to the obstruction interval, the time between vasectomy and reversal. 161 microsurgical vasovasostomies were reviewed. In each case the presence or absence of sperm in the intravasal fluid was determined and when present, microscopic morphology and degree of motility were noted. 20 of the 161 patients had bilateral IVA; 10 were available for longterm follow-up. The obstruction interval ranged from 4-12 years, with an average of 7.5 years. 6 cases, with an average obstruction of 7 years, gained a normal sperm count within 1 year of the operation. The 4 cases remaining azoospermic had an average obstruction interval of 8.25 years. Gross appearance of the intravasal fluid was recorded for each of the 10 cases. For patients who gained a normal sperm count, the fluid was watery in 3 vasa, opalescent in 3 vasa, and creamy in 6. In cases remaining azoospermic, intravasal fluid was opalescent in 4 and creamy in 4. The data indicate that for obstruction intervals of less than 12 years, IVA during vasovasostomy is not usually associated with epididymal fibrosis and is reversible in over 1/2 of the cases. Therefore, finding IVA is not necessarily an indication for vasoepididymostomy. The tunica vaginalis should be opened and the epididymis inspected. Obstruction is characterized by the presence of a specific area of fibrosis with homogeneous proximal dilatation of the epididymal tubule which is visualized through the epididymal capsule and filled with creamy or white fluid. If the epididymis is not clearly obstructed, IVA is not an indication for vasoepididymostomy, especially at the shorter intervals. At longer intervals, more than 12 years, a higher degree of suspicion of epididymal sclerosis is appropriate.^ieng

Open-ended vasectomy: an assessment.

Leaving open the testicular end of vas at vasectomy could reduce symptoms of epididymal congestion and improve the success rate of vasovasostomy but might have the disadvantage of increasing the incidence of painful sperm granulomas and spontaneous recanalization. In 4330 open-ended vasectomies the rate of epididymal congestion was significantly less than in 3867 standard vasectomies. The rate of painful sperm granulomas was not increased: it was significantly reduced. Spontaneous recanalization was rare in both groups. Whether or not open-ended vasectomy improves the success rate of vasovasostomy, it represents an improvement in technique because it reduces the rate of complications after vasectomy. Closure of the sheath over the prostatic end of vas is essential if recanalization is to be prevented.

Reversal of vasectomy and the treatment of male infertility. Role of microsurgery, vasoepididymostomy, and pressure-induced changes of vasectomy.

PIP: Pressure-mediated effects of vasectomy on the epididymis and resolution of this effect via microsurgery of the epididymis are reported, and a technique of vasectomy modified to limit these pressure effects, making vasectomy more reversible, is suggested. Assuming mastery of microsurgical techniques for vas reanastomosis, the lack of which is one reason for low reversibility of vasectomy, other problems are still encountered that result in low sperm counts and demonstrable infertility. All vasectomies produce micromechanical, pressure-induced changes; 1000 vasovasectomies observed through the operating microscope always showed some degree of dilatation of the lumen of vas deferens and some congestion of the epididymis with dilatation of the epididymal tubule. Rather than augmenting infertility, the presence of a sperm granuloma seems to be a safety valve that decompresses the vas and prevents build-up of excessive pressure; this microscopic study discovered epididymal blowouts with extravasation of sperm from the epididymal tubule into the interstitium, causing secondary obstruction. Simple suture of the vas deferens is not sufficient for reanastomosis, but suturing of the inner lumen to the vas directly to the one cut epididymal tube leaking sperm must be performed. Open-ended vasectomy has a greater chance of reversibility as well as greater likelihood of spontaneous recanalization, a problem with solutions if research is started.^ieng

Vasectomy.

Vasectomy is an excellent method of permanent contraception for the couple whose family is complete, who are mature and fully informed, and who will accept permanent sterility. It is also valuable in preventing bacterial epididymitis. Vasectomy is customarily performed in the office or clinic setting under local anesthesia. Many techniques may be used, but the cut-fulgurate-and-cover technique has never failed in my experience. Postoperative testing is mandatory, and negative results on two samples, collected one month apart, will ensure that delayed spontaneous recanalization has not occurred. The specific complications of vasectomy are spermatic granulomas of vas or epididymis, congestive epididymitis, and antisperm antibodies. Numerous studies have shown no deleterious effects upon the patient's general health. Manhood, pleasure, and sensation are unchanged, and the woman need no longer fear the possibility of an unwanted pregnancy.

PIP: In this discussion of vasectomy, attention is directed to preoperative counseling, performance of vasectomy as an office or clinic procedure -- anesthesia and surgical techniques, and postoperative care. Vasectomy requires preoperative counseling. Every man is aware of the effects of castration, and it is essential to explain to a man how and why vasectomy differs. He also must understand that sterility is not immediate. The couple's every question must be answered. Although counseling may take the form of movie, booklet, or conversation with a trained counselor or the surgeon, or any combination of these, preoperative contact with the surgeon is very important. Patient confidence is essential. In the US, vasectomy for sterilization is generally legal, but this does not protect the surgeon from malpractice suits. The patient should sign a written consent containing the following points: that the patient requests the operation for the purpose of preventing him from fathering further children; that he realizes that the operation could fail to produce sterility; and that he agrees to submit semen specimens for testing and to use contraception until testing has shown that he is sterile. A number of local anesthetics may be used when performing a vasectomy. Both procaine, which takes effect in 1 minute, and lidocaine, effective in 5 seconds, are safe and given anesthesia for at least 1 hour in 1% strengths. The most common vasectomy technique worldwide is that of dividing the vas, removing a segment, and either ligating the cut ends of the vas or closing them with metal clips. This usually fails in 1-3% of patients, either initially or by subsequent recanalization of the vas. Regarding postoperative care, the patient should apply an icebag over the bandages for the 1st several hours with the scrotum immobilized and abstain from sexual activity for the first 2 days. To ensure that a spontaneous anastomosis has not occurred, this surgeon requests 2 semen specimens, 1 month apart. The complications of the operation are largely preventable. Preoperative counseling has prevented most psychological complications. The specific complications of vasectomy include spermatic granulomas of the vas and epididymis, and antisperm antibodies. Numerous studies have reported no deleterious effects upon the patient's general health.

Evaluation of one-hundred open-ended vasectomies.

Open-ended vasectomy was performed on one-hundred men. Sixty-three of them showed up for follow-up six months later. Spontaneous recanalisation had occurred in two. Sperm granuloma without orchialgia was found in 14 out of 59 men (23.9%). Twenty-one out of the 63 thought their sex life had improved, while 40 thought it was unchanged; only one man mentioned pain during intercourse since vasectomy.

PIP: Open-ended vasectomy was performed on 100 men in Brussel, Belgium, ranging in age from 27-61 years old (average 35 yrs). A personal, social, sexual, and family history was taken before vasectomy and the patient was given information on the technique to be used. 63 of the men showed up for follow up 6 months later. Spotaneous recanalisation had occurred in 2, requiring repeat vasectomy, a failure rate of 3% Sperm granuloma without orchialgia was found in 14 out of 59 men (23.9%). 21 out of the 63 thought their sex life had improved, while 40 thought it unchanged. Only 1 man mentione pain during intercouse since vasectomy. Eveb with improved techniques the failure rate of open-ended vasectomy is likely to be highdr than that of close-ended methods. Studies comparing different techniques of vasectomy show that bipolar electrocoagulation of both ends of the vas with fascial interposition appears to have a very low failure rate (0.0%) with spermatic granulomaformation incidence of 0.4% (author's modified).

A comparison of open-end versus closed-end vasectomies: a report on 6220 cases.

This study was done to determine if there was a difference in results when both vas ends were closed or when the prostatic end was closed and the testicular end left open. The author performed 6220 vasectomies between June 1, 1972 and June 1, 1992. The first series consisted of 3081 vasectomies in which both ends of the vas deferens were closed. The second series consisted of 3139 vasectomies in which the testicular end of the vas deferens was left open while the prostatic end only was closed. No portion of the vas was excised. Congestive epididymitis was diagnosed in 6% of cases utilizing closed-end vasectomy and 2% of cases where the open-end vasectomy was performed. Open-end vasectomy is recommended because the incidence of congestive epididymitis is reduced.

Vasal sterilization in China.

Vasal sterilization has become the most popular method of contraception in many countries since the 1960's. In China, an estimated 30 million men have undergone voluntary sterilization. There have been two major developments in vasectomy technique, the no-scalpel method and the percutaneous chemical vas occlusion. These methods have significantly increased the acceptability of male sterilization in some cultures since no incisions in the skin are required. The effective rate is over 98% for both methods. The clients experience less pain, fewer complications and more rapid recovery. Epidemiological studies of large numbers of volunteers receiving no-scalpel or chemical vas occlusion procedures have resulted in a clearer picture of their safety, effectiveness, simplicity and economy. Meanwhile, some promising reversible vasal sterilization techniques have also been studied.

PIP: In China, an estimated 30 million men have undergone vasal voluntary sterilization, and about 11.97% of Chinese couples rely on vasectomy, according to a 1990 survey. The no-scalpel vasectomy (NSV) and the percutaneous chemical vas occlusion methods are major developments in vasectomy technique with an effectiveness rate of over 98% for both. In a study in Thailand, complication rates were 0.4/100 cases for NSV and 3.1 for the incisional approach. Since 1971, over 10 million Chinese men have undergone NSV. Vas ligation is the most popularly used method in China. It has provided 98% of effectiveness in a comprehensive survey involving 64,656 vasectomies in 8 provinces. As an alternative to vas ligation, electrocoagulation creates a firm scar that effectively occludes the ends of the vas. The contraceptive efficacy of electric cautery was reported at 99.62%-100% in 7439 vasectomies during a period of 10 years; azoospermia and complication rates were 0% and 0.53%, respectively, in 1088 vasectomies. The complication rate was less than 2%, including hematoma, infection, painful sperm granuloma, epididymitis, and sexual dysfunction, in a comprehensive survey involving 179,741 vasectomies in 8 provinces. 2 large cross-sectional epidemiologic studies done in Sichuan Province showed that men with vasectomies were not at greater risk of coronary heart disease, hypertension, hyperlipidemia, and diabetes than men who had not undergone the procedure. Recently, 2 epidemiological studies conducted in the US suggested that vasectomy may be associated with an increased risk of prostate cancer. The risk of developing prostate cancer by the age of 80 is about 1 in 500 in Shanghai. Whereas approximately 1 of 11 men in the US will develop prostate cancer. It is possible that the disease goes undiagnosed, but a combination of diet and hormonal factors related to race may help explain some of the variation.

Vasectomy and its reversal.

Techniques, results, complications, and medicolegal aspects of vasectomy are discussed in this article. Emphasis is placed on techniques that prevent spontaneous recanalization of the ends of the vas deferens after vasectomy. Factors that affect the reversibility of vasectomy are discussed. New microsurgical techniques of vasectomy reversal are described, and results of these new techniques are compared with results of nonmicrosurgical techniques of vasectomy reversal. Indications for bypass vasoepididymostomy during vasectomy reversal procedures, as well as techniques for performing vasoepididymostomy, are discussed.

PIP: Frequently, patients inquire about reversible vasectomy devices, which would permit fertility if later desired. Prototype reversible vasectomy devices have been developed, but none has yet satisfied the requirements of assured permanent sterility with reversible fertility when desired. There are numerous technical factors that make the ultimate development of a satisfactory reversible vasectomy device seem unlikely. Compared with tubal ligation in women, vasectomy is simpler, less expensive, and safer. Vasectomy can be performed in the physician's office or in an ambulatory surgery facility. Vasectomy should be performed at a relatively high level in the straight scrotal portion of the vas. This level is recommended for vasectomy because later reversal of the vasectomy is easier if the procedure was performed at this level rather than in the lower, convoluted portion of the vas. After the vas has been transected, a portion of the vas is excised for identification. This identification is required for medicolegal purposes but serves no useful purpose in preventing spontaneous recanalization of the ends of the vas. Because of the extreme mobility of the vas, its severed ends may still come in contact after resection of as much as 2 or 3 cm of its length. Because of reports of spontaneous recanalizations and resulting undesired conceptions after originally successful vasectomies, the method used to seal the ends of the vas assumes paramount importance. Simple ligation of the ends of the vas, ligation of each end of the vas doubled back on itself, and application of metallic clips to the ends of the vas all have been advocated. Each of these methods has about the same rate of spontaneous recanalization postoperatively. Limitation of activity for 24-48 hours postoperatively, aspirin, and occasional use of an ice pack should relieve the usual pain after vasectomy. Couples must be cautioned that contraception is required after vasectomy until absence of sperm from the semen is documented. Local hemorrhage and wound infection occur in a small percentage of patients after vasectomy. A rare patient requires evacuation of a scrotal hematoma in the early postoperative period. Microsurgical techniques have improved considerably the results of vasovasostomy, which may be performed with local anesthesia on an outpatient basis. Factors affecting the success of vasectomy reversal are the obstructive interval (time from vasectomy until its reversal) and the sperm quality in the vas fluid at the time of the reversal procedure.

Fournier's gangrene of the scrotum following day case vasectomy.

PIP: A case of Fournier's gangrene of the scrotum is reported in a 31-year old man who had outpatient vasectomy during an intercurrent diarrheal illness. The surgery was done through a midline incision, under local anesthesia of plain 2% lignocaine, with a preoperative chlorhexidine scrub. Although his scrotum was red and swollen within 3 hours, he did not have medical care until admission to hospital 48 hours later. At admission he had Fournier's gangrene of the scrotum and penis, Gram-negative septic shock, and acute renal failure. In the intensive care unit he was treated with continuous dialysis, parenteral metronidazole, benzylpenicillin, Ceftazidime and inotropes. He had a cardiorespiratory arrest after emergency radical debridement. After resuscitation he developed adult respiratory distress syndrome and disseminated intravascular coagulation. Pathological exam showed necrosis of the dermis and subcutaneous layers, thrombosis and beta-hemolytic streptococci. After adding gentamicin and vancomycin, 2 weeks of ventilator care, 4 more surgical debridements, a left orchidectomy, and a despite a grossly abnormal EEG recording, the man regained consciousness and recovered. His scrotal and penile skin re-epithelialized over 3 months. Patients requesting vasectomy should be assessed for local and systemic illness before performing the procedure.^ieng

Vasectomy: preliminary report on 25 cases.

Preliminary data on 25 men who underwent vasectomy for contraception between June 1986 and May 1988 at the Marie Stopes Clinic--Nairobi is presented. The majority (76.0%) of the subjects were aged between 25 and 39 years. 68.0% had 4 living children or less. Professionals including lecturers, lawyers, teachers, engineers etc, formed 88.0% of the total. Three clients(12.0%) had documented complications; one had aseptic wound, one had haematoma and the last one had a failed vasectomy. All were treated successfully. Complications of vasectomy and the need for follow-up of vasectomised men are discussed.

PIP: Preliminary data on 25 men who underwent vasectomy for contraception between June 1986 and May 1988 at the Marie Stopes Clinic - Nairobi is presented. The majority (76%) of the subjects were aged between 25 and 39 years. 68.0% had 4 living children or less. Professionals including lecturers, lawyers, teachers, and engineers formed 88.0% of the total. 3 clients (12.0%) had documented complications; one had aseptic wound, one had hematoma, and the last one had a failed vasectomy. All were treated successfully. Other complications that may occur include orchitis, epididymitis, disturbed sexual function, granuloma, and antibody or arterio-venous fistula formation. Follow-up is a necessary process since patients may not return, even if there is a problem. In this study only 4 (16.9%) of the men reported back after 6 weeks. The other 3 (12.0%) returned because of their complications.

Does vasectomy accelerate testicular tumour? Importance of testicular examinations before and after vasectomy.

PIP: An association between vasectomy and the development of testicular tumors, and the importance of testicular examinations both before and after a vasectomy is discussed. Patients diagnosed with testicular tumors within the last ten years were examined at Bangour General Hospital in Scotland. From 1977-87, 37 patients under age 60 were detected with testicular tumors. 3079 men underwent a vasectomy during this time. 8 were diagnosed with the tumors. Average time between the vasectomy and the diagnosis of the tumors was 1-9 years. The number of cases in men aged 20-59, and the age specific incidence were calculated from population on figures. Incidences of tumors, combined with the number of patient years of risk contained in the group who underwent a vasectomy, were used to ascertain the expected number of tumors in the 1-9 year group. Observed number was 8. As result, the ratio for patients with a vasectomy was 4.2 (95% confidence interval 1.8 to 8.2) with absolute annual incidence of testicular tumor in men who had had a vasectomy at 53/100000 men. Further suggested is that vasectomy accelerates the incidence of a palpable tumor from a carcinoma in situ, or possibly that tumors are often overlooked during a vasectomy. An examination before a vasectomy should detect palpable tumors, with carcinomas being detected by cytological examination of semen. Men should be screened by examination 12-18 months after a vasectomy. In light of the growing popularity of vasectomy as a more accepted means of contraception, how vasectomy affects the etiology of testicular malignancy is an important issue.^ieng

[Vasectomy as a risk factor for atherosclerosis (author's transl)]. / Vasektomie als ein Risikofaktor fur Atherosklerose.

PIP: Recent investigations have implicated vasectomy as a possible risk factor for the development of atherosclerosis in animals. Physicians are undecided as to the true importance of the information and how they should act upon it when counselling their patients. In an attempt to explore the problem in humans, we performed a case-controlled study in 55 men under age 50 with documented coronary disease and in a matched control group of brothers and 1st cousins who were asymptomatic. Within the limitations of the study, no association of coronary disease with prior vasectomy was found: 25.5% (14/55) of the mean in each group were vasectomized. Further work is needed to evaluate whether certain individuals such as hypertensives or hyperlipidemics may be at greater risk and whether a longer delay between vasectomy and symptoms of atherosclerosis may be required than were present in this study. (author's)^ieng

Vasectomy as a contraceptive method.

The paper reports a series of 1,000 consecutive vasectomies, mostly self referrals, performed at a family planning clinic. Comprehensive counseling was a mandatory prerequisite, the average time spent considering vasectomy prior to counseling was 22 months. The couples characteristics were as follows: age 30-39 years, married 11.3 years, with 3.4 children, upper social class preponderance. To minimise the risk of recanalisation (0.2%), 20 mm of vas deferens was resected. In the early part of the series, inflammatory tissue reaction due to slow absorption of synthetic suture posed a minor problem which was subsequently eliminated by use of a soft gut variety. The majority (99%) was pleased with the procedure and did not suffer complications. One per cent experienced some psycho-sexual problems such as decreased libido, ejaculatory problems, depression. Based on data collected from other centres we estimate that 3,303 sterilizations were performed in Ireland in 1986 with a male:female ratio of 3.2.

PIP: A retrospective analysis of 1000 consecutive vasectomies performed at a Dublin family planning clinic in 1981-85 was carried out, with particular emphasis on the personal attributes of vasectomy acceptors and the degree of patient satisfaction with the procedure. The majority of patients were self-referred; the 2 most frequently cited reasons for seeking sterilization were the family was complete (98%) and alternative methods of contraception were unacceptable (58%). 69% of the vasectomy acceptors were in the 30-39 year age group. The average duration of marriage prior to seeking vasectomy was 11.3 years; the average number of children was 3.4. The overwhelming majority of men were from the higher socioeconomic groupings. The vasectomy procedure, which was performed under local anesthesia, involved resection of 20 mm of vas deferens. Despite a generally low incidence of short and longterm postoperative complications, 12% of vasectomy patients experienced some inflammatory tissue reaction associated with the synthetic suture material's slow absorption rate; this problem was subsequently eliminated by use of a soft gut suture. The failure or recanalization rate in this series was 0.2%; 62% of patients were azoospermic at 16 and 18 weeks after the procedure. 99.7% of patients reported satisfaction with their vasectomy, perhaps because they had taken an average of 22 months to decide on the procedure and were carefully counseled an assessed. An estimated 3303 sterilizations were carried out in Ireland in 1986, with a male to female ratio of 3 to 2.

Vasectomy.

Bilateral vasectomy is a common method of achieving elective sterilization in men. Knowledge of male genital anatomy is important in the performance of this procedure as well as in screening patients with anatomical contraindications. Careful counseling techniques will help avoid medicolegal problems. There are several operative techniques used to perform a vasectomy. Postoperative evaluation and semen analysis should be accomplished to recognize and allay complications. Major complications are rare; minor complications are relatively frequent, with early diagnosis and treatment important in hastening recovery. Psychological consequences are rare. Thus, vasectomy is a relatively safe, inexpensive, and dependable contraceptive procedure.

Complications of vasectomies in the United States.

Physicians in the United States were surveyed in 1983 to gather information concerning the number of vasectomies they performed in 1982 as well as their use of anesthesia and complications of those vasectomies. Most urologists performed vasectomies, whereas family physicians and general surgeons were less likely to do so. As expected, most physicians used local anesthesia, occasionally in combination with a sedative; however, 22 percent of physicians reported using general anesthesia for at least some vasectomies. Complication rates were in the ranges reported by previous case series. Physicians who performed between one and ten vasectomies in 1982 had higher rates of hematoma and hospitalization for treatment of a complication than physicians who performed more vasectomies. Maintenance of surgical skills appears to be important in preventing complications of this usually low-risk procedure.