V1586: A Critique of the Modified In-Line Vasectomy by the American Urological Association Evidence Based Vasectomy Guideline

Video

Introduction and Objectives
The AUA Vasectomy Guideline is available on auanet.org, Clinical guidelines.Based on the evidence from 259 articles related to several vasectomy topics,the Guideline suggested that some procedures maybe better than others in specific situations.For example, these articles reviewed local anesthesia with a small needle,open access for all men including those with thick scrotal skin, isolation of the straight vas with minimally invasive methods and the development of specializedinstruments,the role of vas transection, occlusion by mucosal cautery and fascial interposition.By utilizing specific steps, the the Guideline suggest that these vasectomies should have fewer complications and lower failure rates.

The I-LV included many of these steps, and the procedure was modified for several reasons:clinical experience, review of videos,development of 2 new instrumends and elimination of un-neccessary steps such as posterion dissection of the vas.

The purpose of the video is to describe the modifications of the I-LV and critique each step by data from the Guideline

Methods
The I-LV was done with 2 high openings to secure the straight vas and to leave a long testicular remnant to diffuse epididymal pressure.The local was delivered with #32G needle without skin pain and numbness occurred within 1-3 seconds.Each 4mm opening was accomplished by a calibrated scissor.An opening was made in line with anterior vas wall by the pointed tip of the scissor. The thermal cautery tip entered both the abdominal and testicular lumen to burn the mucosa.The vas was transcted while on stretch without injury to the posterior mesentery.The abdominal stump retracted into its sheath and it was covered by fascial interposition after a twisting maneuver.

Results
COMPLICATION GUIDELINE I-LV (675 pts)

Epididymitis 1-3% 1.3%

Hematoma 1-2% 0.5%a

Granuloma
Infection 1.0% 0.2%

Failure
Post Vasectomy 1-2% 0.00

Pain Syndrome



a. No hematomas with FI by clip closure



The Guidelind developed ranges and thresholds for the common complications. The modified I-LV was either at the low end of the range or below the thresholds.

Conclusions
The modified I-LV is a minimally invasive vasectomy procedure with specialized instruments

When critiqued by the AUA Vasectomy Guideline, the I-LV has fewer complications and fewer failure rates than most of the studies cited in the Guideline.Therefore, modified I-LV is rapid, safe and reliable

Funding: none