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CUA Guidelines > 2022 Canadian Urological Association best practice report: Vasectomy > Flashcards

2022 Canadian Urological Association best practice report: Vasectomy Flashcards

1
Q

Figure 1. Proposed algorithm for post-vasectomy testing protocol.

A
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2
Q

What is the primary purpose of a vasectomy?

A

What is the primary purpose of a vasectomy?

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3
Q

What are the potential complications associated with vasectomy?

A

Vasectomy, although a simple elective procedure, can have potential minor and major complications.

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4
Q

What is the early failure rate of vasectomy?

A

The early failure rate (presence of motile sperm in the ejaculate at 3–6 months post-vasectomy) is between 0.2–5%.

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5
Q

How does the late failure rate of vasectomy compare to the early failure rate?

A

The late failure rate is much lower, ranging between 0.04–0.08%.

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6
Q

Which vasectomy technique is associated with a lower risk of early postoperative complications?

A

The no-scalpel vasectomy technique.

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7
Q

How can the risk of contraceptive failure be reduced in vasectomy?

A

By using cautery or fascial interposition.

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8
Q

Why is careful assessment of the post-vasectomy ejaculate imperative?

A

To check for the presence of sperm, which can indicate failure.

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9
Q

What potential legal issue can arise if adequate information and counselling aren’t provided to patients about vasectomy?

A

Failure to provide and document sufficient information and counselling can lead to litigation.

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10
Q

What is the main focus of the 2022 Canadian Urological Association guideline on Vasectomy?

A

The management of men presenting for vasectomy, covering preoperative counselling, vasectomy efficacy and complications, technical aspects, post-vasectomy semen testing, and interpretation-communication of post-vasectomy semen results.

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11
Q

What is the ultimate objective of the guideline?

A

To help standardize the treatment of men presenting for vasectomy through evidence-based consensus.

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12
Q

What should be described during the initial consultation for a vasectomy?

A

The procedure.

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13
Q

List the early complications of a vasectomy that men must be informed about.

A

List the early complications of a vasectomy that men must be informed about.

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14
Q

List the early complications of a vasectomy that men must be informed about.

A

Infection (0.2–1.5%), bleeding or hematoma (4–20%), and primary (early) surgical failure (0.2–5%).

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15
Q

When might motile sperm be seen in the ejaculate post-vasectomy?

A

3–6 months post-vasectomy.

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16
Q

What are the late complications of vasectomy?

A

Chronic scrotal pain (1–14%) and delayed vasectomy failure after azoospermia at four months (0.05–1%).

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17
Q

How often might complications like bleeding and testicular pain necessitate surgical intervention?

A

Infrequently (<0.1%).

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18
Q

How should information about vasectomy complications be provided to the patient?

A

Verbally and through an information pamphlet.

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19
Q

How should a vasectomy be viewed in terms of contraception?

A

As a permanent form of contraception with a high probability of reversibility.

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20
Q

Which alternatives can be discussed if patients are concerned about the permanent nature of vasectomy?

A

Preoperative sperm banking, postoperative vasectomy reversal, and sperm retrieval for in vitro fertilization.

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21
Q

Is there a clear association between vasectomy and prostate cancer?

A

No.

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22
Q

Which complications need not be discussed unless the patient inquires?

A

Vascular disease, hypertension, testicular cancer.

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23
Q

Why must couples continue to use other contraceptive measures shortly after a vasectomy?

A

Due to the potential for early re-canalization, technical failure, and the rate of primary (early) surgical failure (0.2–5%).

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24
Q

What action is recommended if motile spermatozoa are present in the ejaculate six months after the procedure?

A

A re-do vasectomy.

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25
Q

What is the suggested approach if patients are ready to undergo a vasectomy at the end of the initial consultation?

A

Vasectomy may be performed shortly after the initial consultation unless there are valid medical reasons to wait.

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26
Q

How common is it for men below the age of 25 in the U.S. to choose vasectomy as a form of contraception?

A

Rare.

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27
Q

What is the likelihood of men in their 20s seeking vasectomy reversal if they underwent vasectomy in their 20s?

A

12.5 times greater.

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28
Q

What is the estimated prevalence of varicoceles in the general male population?

A

15%.

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29
Q

What special considerations should be made when performing vasectomy in men with a clinical varicocele or with prior varicocelectomy?

A

Carefully isolate the vas deferens and completely exclude the associated deferential arteries and veins to avoid potential injury.

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30
Q

Evolution of vasectomy techniques

A

Over the years, the technique of vasectomy has seen significant modifications. This includes changes in equipment, materials, and methods of anesthesia.

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31
Q

Importance of continuing medical education for surgeons performing vasectomies

A

Surgeons should obtain regular continuing medical education on vasectomy. This includes updates on surgical techniques and staying informed on new studies in the latest peer-reviewed journals and clinical guidelines.

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32
Q

Preferred anesthesia for vasectomy procedures

A

Local anesthesia is typically sufficient for most vasectomy patients. However, anxious patients or those with complicating factors might need sedation or a general anesthetic.

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33
Q

What are some complicating factors that may require a patient to receive sedation or general anesthesia for a vasectomy?

A

Previous orchidopexy or other scrotal surgeries.

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34
Q

Controversy surrounding the use of topical anesthetic before injection of local anesthetic for vasectomy

A

There is controversy regarding the benefit of using topical anesthetic prior to injecting a local anesthetic for vasectomy procedures.

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35
Q

Recommended needle gauge for vasectomy local anesthesia

A

A small, 27–32-gauge needle is thought to be beneficial for local anesthesia during vasectomy.

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36
Q

Effectiveness of pneumatic injectors in vasectomy procedures

A

Pneumatic injectors have not shown a clear benefit for vasectomy procedures. However, they might be suitable for patients with a needle phobia.

37
Q

Use of buffered xylocaine in vasectomy patients

A

The use of buffered xylocaine has not been studied in vasectomy patients.

38
Q

What are the two most common surgical techniques for accessing the vas during vasectomy?

A

Traditional incisional method
No-scalpel vasectomy (NSV) technique

39
Q

Differentiate between the conventional incisional technique and the NSV technique.

A

Conventional incisional technique uses a scalpel to make one or two incisions in the scrotal skin to access the vas deferens. NSV technique uses a sharp, forceps-like instrument to puncture the skin to access the vas deferens.

40
Q

Conventional incisional technique uses a scalpel to make one or two incisions in the scrotal skin to access the vas deferens. NSV technique uses a sharp, forceps-like instrument to puncture the skin to access the vas deferens.

A
41
Q

What advantages does the NSV approach have over the standard incision technique based on the Cochrane review?

A

What advantages does the NSV approach have over the standard incision technique based on the Cochrane review?

42
Q

What advantages does the NSV approach have over the standard incision technique based on the Cochrane review?

A

Lower risk of postoperative hematoma
Less pain during surgery
Reduced postoperative scrotal pain
Fewer wound infections
Faster procedure

43
Q

Provide the odds ratios (OR) and 95% confidence intervals (CI) for the postoperative hematoma, pain during surgery, postoperative scrotal pain, and wound infections in NSV compared to the standard incision technique.

A

Provide the odds ratios (OR) and 95% confidence intervals (CI) for the postoperative hematoma, pain during surgery, postoperative scrotal pain, and wound infections in NSV compared to the standard incision technique.

44
Q

Is there a significant difference in the effectiveness between NSV and the conventional scalpel technique?

A

Is there a significant difference in the effectiveness between NSV and the conventional scalpel technique?

45
Q

What is the recommendation regarding NSV based on the risk of postoperative complications?

A

NSV should be performed because it is associated with a significantly lower risk of postoperative complications such as hematoma, pain, and infection than conventional vasectomy (Grade A–B).

46
Q

Vasectomy Technique: Importance of Fascial Interposition

A

Fascial interposition during vasectomy results in a significantly higher rate of azoospermia at three months than simple ligation and excision without fascial interposition. (OR 0.42, 95% CI 0.26–0.70).

47
Q

Potential Complications of Fascial Interposition in Vasectomy

A

Fascial interposition may increase the complication rate of vasectomy.

48
Q

Mucosal Cautery vs. Fascial Interposition: Risk of Vasectomy Failure

A

Cautery of the vas is associated with a lower risk of failure (defined as >100,000 sperm in the ejaculate) than fascial interposition (1% vs. 4.9%, OR 4.8, 95% CI 1.6–14.3).

49
Q

Recommendation for Vasectomy Technique

A

Mucosal cautery and/or fascial interposition (with vas ligation and excision) should be performed during vasectomy. These techniques are associated with the lowest failure rates (Grade B). However, surgeons can use their preferred occlusion technique if they achieve consistently low vasectomy failure rates.

50
Q

After a vasectomy, what care instructions should be given to patients regarding their wound and scrotum?

A

Men should be instructed about proper wound and scrotal care and informed about short-term physical limitations.

51
Q

How should men be instructed to collect the semen sample post-vasectomy?

A

Men should be told to collect the semen sample with completeness, using a specific type of container, and to submit it to the laboratory within 30–60 minutes after producing the sample.

52
Q

Men should be told to collect the semen sample with completeness, using a specific type of container, and to submit it to the laboratory within 30–60 minutes after producing the sample.

A
53
Q

What is the recommended abstinence period before collecting a semen sample after vasectomy?

A

Semen samples should be collected after an abstinence period of two or more days and no more than seven days.

54
Q

Semen samples should be collected after an abstinence period of two or more days and no more than seven days.

A
55
Q

How should the semen sample be maintained before delivery to the laboratory?

A

The semen sample should be maintained at body temperature before delivery to the laboratory.

56
Q

What information should be provided to men regarding post-vasectomy semen analysis labs?

A

Men should be given a list of local laboratories that perform proper post-vasectomy semen analysis.

57
Q

Men should be given a list of local laboratories that perform proper post-vasectomy semen analysis.

A
58
Q

Until when should men continue to use other contraceptive measures after a vasectomy?

A

Men must continue to use other contraceptive measures until post-vasectomy semen testing has confirmed the absence of motile sperm.

59
Q

Early failure rate of vasectomy range and its determinants.

A

0.2–5%. Linked to surgeon experience and technique.

60
Q

Plausible explanations for early vasectomy failure.

A

Technical failure (e.g., missed vas deferens) and early re-canalization of the vas deferens.

61
Q

Define “late vasectomy failure” and its reported range.

A

Presence of motile spermatozoa in the ejaculate after documented azoospermia in two post-vasectomy semen analyses. Range: 0.04–0.08% (approximately 1/2000 cases).

62
Q

How is late vasectomy failure usually first identified?

A

It’s first identified as a pregnancy and later confirmed by semen analysis documenting the presence of motile spermatozoa.

62
Q

Reappearance rate of sperm (often immotile) after documented azoospermia three months post-vasectomy.

A

Nearly 10% of ejaculates from men undergoing semen assessment prior to vasectomy reversal.

63
Q

Significance of reappearance or persistence of immotile sperm years after vasectomy.

A

It’s unlikely to be of clinical significance as it hasn’t been associated with documented pregnancies.

64
Q

What should the post-vasectomy semen analysis be performed on?

A

Fresh (unprocessed) semen and on the centrifuged semen.

65
Q

Why is the centrifuged semen analysis done post-vasectomy?

A

To confirm the absence of low numbers of motile sperm.

66
Q

What should the laboratory provide an estimation of during a post-vasectomy semen analysis?

A

Sperm concentration or numbers of spermatozoa observed per high power field (×400 magnification).

67
Q

What percentage of men fail to submit even a single sample for post-vasectomy semen testing?

A

Up to 30%.

68
Q

When is a single semen analysis deemed sufficient to consider the vasectomy effective?

A

When it shows azoospermia or rare non-motile sperm (<100,000 non-motile sperm/ml), assuming the analysis is done by an experienced, reputable lab.

69
Q

What is the risk of conversion from azoospermia or rare non-motile sperm to greater numbers of sperm, based on Alderman’s study of 5233 vasectomies?

A

Very rare, approximately 0.1% of cases.

70
Q

What is the predictive value of a single semen analysis with rare non-motile sperm for vasectomy success, as estimated by Barone et al.?

A

99.7%.

71
Q

When should a second semen analysis be requested post-vasectomy?

A

In men with greater numbers of non-motile sperm (>100,000 non-motile sperm/ml) and/or any number of motile sperm on the first semen analysis.

72
Q

What might be a potential advantage of clinicians requesting two semen samples at the onset?

A

It may reduce the number of post-vasectomy counselling sessions (e.g., phone calls or office visits).

73
Q

What might be a potential drawback of clinicians requesting two semen samples at the onset?

A

It may decrease the overall compliance.

74
Q

What is the recommendation regarding the number of semen samples post-vasectomy?

A

A single semen sample showing azoospermia or rare non-motile sperm (<100,000 non-motile sperm/ml) is sufficient to deem the vasectomy effective. A second analysis should be requested in certain conditions, like greater number of non-motile sperm or presence of motile sperm in the first analysis (Grade C).

75
Q

What is the primary reason for the debate regarding the timing of post-vasectomy semen testing?

A

The difficulty in establishing a set time point for semen testing largely comes from the variable success of the vasectomy occlusion techniques.

76
Q

Which vasectomy occlusion technique takes longer to achieve azoospermia, and which ones achieve it faster?

A

Azoospermia is achieved much later with the ligation (and excision) compared to the cautery or fascial interposition techniques.

77
Q

Azoospermia is achieved much later with the ligation (and excision) compared to the cautery or fascial interposition techniques.

A

Waiting at least three months will reduce the number of false-positive samples, thus minimizing the need for repeat laboratory assessment and counseling.

78
Q

According to the 2022 Canadian Urological Association best practice report, when should post-vasectomy testing ideally be conducted?

A

Post-vasectomy testing should be conducted at three months after vasectomy.

79
Q

What grade does the Canadian Urological Association give to the recommendation of conducting post-vasectomy testing at three months after the procedure?

A

Grade C.

80
Q

What indicates a successful vasectomy according to the report?

A

Azoospermia or rare immotile sperm (<100,000 per/ml).

81
Q

After producing one azoospermic sample or one semen sample with rare immotile sperm, what can men do regarding contraceptive measures?

A

They may abandon contraceptive measures.

82
Q

Whose responsibility is it to communicate the results of a vasectomy to the patient?

A

It’s the physician’s responsibility, not the laboratory’s.

83
Q

What risk must physicians remind couples about even after an initial successful vasectomy test?

A

The risk of late failure, approximately 1 in 2000.

84
Q

What percentage of samples have rare non-motile sperm at three months post-vasectomy?

A

Approximately 20–40%.

85
Q

: If there’s doubt regarding the analysis of a sample, what might physicians want to do?

A

Contact the laboratory to confirm there was no reporting error and ensure the sample wasn’t incorrectly labeled as “non-motile”.

86
Q

How does the literature view the risk of pregnancy from non-motile sperm at three months post-vasectomy?

A

The risk of pregnancy is small, perhaps no more than the risk of late pregnancy after two azoospermic semen samples due to spontaneous re-canalization.

87
Q

What should physicians instruct patients to do if any motile sperm or substantial numbers of immotile sperm (>100,000 sperm/ml) are detected?

A

Inform the patient to continue using other contraceptive measures and request a repeat semen analysis. A repeat vasectomy might be indicated if persistent motile sperm or large numbers of non-motile sperm are found.

88
Q

: Under what conditions is a vasectomy considered a failure according to the recommendation?

A

Persistence of any number of motile sperm or >100,000 sperm/ml on two semen samples.

CUA Guidelines (17 decks)

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