EARLY WORK:
Cooper6 in the year 1830 performed the first experimental vasectomy on a dog. to study the histological changes following this operation. Thereafter many others undertook similar studies. Amongst them were Gosselin8, Brissaud4, Bouin and Ancel3 Kuntz15 and Oslund19.
There was no unanimity in the observations of various workers and strangely enough only the seminiferous tubular changes were reported by them. There was no mention of interstitial tissue and Leydig cells, till Steinache25 commented from his observations.
In the year 1897 Oschner18 undertook the first clinical vasectomy and published a paper suggesting this operation for eugenic purposes.
Sharp24 in 1899 began vasectomy operations for eugenic and other indications. He followed up the operated cases and reported a definite improvement in the muscular efficiency and lessened nervous fatigue in them.
Castration used to be the treatment then, for senile enlargement of the prostate. In place of such a mutilating procedure vasectomy was considered and employed. When prostatectomy surgery came into practice, vasectomy continued as a part of this procedure, to prevent spread of infection from the prostatic bed. For similar reasons, namely to prevent ascending or descending infection in genito-urinary tuberculosis, vasectomy was routinely employed.
In the early 19th century scientists began the study of interstitial cell changes following vasectomy. Steinache reported an increased interstitial cellular activity and diminished functioning of the seminiferous tubules, which was reactivated after a lapse of time. From the follow up of clinical vasectomy cases he claimed an improvement in physical and sexual capacity, ability to concentrate more, diminished physical and nervous fatigue. According of the sperm passage lead to suppression of the seminiferous tubules, proliferation of interstitial cellular activity and increase in the natural sex hormone of the body.
He explained that this increased natural sex hormone brought about the beneficial after effects and lead to rejuvenation of body tissues including the seminiferous tubules, which after some lapse began its normal functioning.
In an effort to achieve maximum back pressure on the seminiferous tubules he suggested ligation of the vasa deferentia between the epididymis and testis. This came to be known as Steinache II and vasectomy as Steinache’s operation. Among those who followed his example were Tiedje26, Benjamin2 and Sand and many more.
In 1952 Jhaver10 undertook a study to observe the histological changes in the testis of vasectomised laboratory animals and a follow up of clinical vasectomies performed for sterilization of men. From this study he reported increased interstitial cellular activity- temporary suppression and reactivation of the seminiferous tubules and confirmed the beneficial after effects following clinical vasectomy- as earlier reported by Steinache, In conclusion he suggested a ‘quantitative’ histological study and 17 ketosteroid estimations’ (of testicular origin by suppressing the suprarenal 17 k by dexamethasone) in the experimental and clinical work respectively to verify the claims made by Steinache.
Both the studies were undertaken which supported the observations from his previous work. In the end he suggested plasma testosterone study before and after vasectomy.
While experimental work continues, vasectomy besides its use for the indications mentioned earlier, has come to be employed for sterilization of men to prevent the population explosion. Millions of vasectomy operations are being performed- mostly by gynecologists in India. Strangely enough, surgeons and genito-urologists have little say in the sterilization program though they remain active in the field of research on the subject. Surgical, sexual, and psychic complications, reversible vasectomy, better and simpler vasectomy procedures are receiving researcher’s attention.
TECHNIQUES- CONVENTIONAL AND MODERN.
The text book of operative surgery (Grey Turner) describes the operation of vasectomy as follows:
Introduction of 1 percent procaine into the skin and substance of the cord procures adequate local anesthesia. The vas, projected under the skin by digital counter pressure, is underpinned with a curved triangular needle, exposed, freed and delivered, cleared of its coverings to avoid inclusion of the spermatic artery and grasped with two pairs of forceps, the ends of the vas ligated and dropped back, the skin closed by two stitches on either side
It adds:-
Mere division of the vas has been followed by natural reunion and recanalisation in human beings and in animal experiments. To procure sterility and to avoid reunion, a short segment of the vas is resected or the terminal two centimeters of the divided ends are turned and sutured.
Preoperative:
Personal and, family history, history of
the past and present illness-particularly diabetes, hypertension,
bleeding tendency, drug sensitivity, psychic and sexual status is
carefully recorded.
General physical check up, blood pressure, routine laboratory examinations of urine and blood, sensitivity test for procaine and penicillin and if indicated psychoanalysis is carried out. The area is shaved and prepared for surgery.
Premedication:
A mild tranquilizer when surgery is done
under local infiltration anesthesia is helpful. Other
premedication like anti-tetanus serum, antibiotics etc may be
administered as per the environmental requirement where the
surgery is being performed.
Anesthesia:
Local infiltration anesthesia is commonly
employed unless vasectomy is performed along with some other
surgical operation for which general anesthesia is
indicated.
Incision:
Two incisions (one for each vas deferens)
in the scrotal or inguino-scrotal region or one incision (for
both vas deferens) on the anterior scrotal wall, which may be
either transverse or longitudinal.
Jhaver introduced the single incision approach for bilateral vasectomy in 1955. After performing a large series of vasectomy operations by this method, he published this technique in 1958, where it was described at length. He later presented a paper at a surgeon’s conference where he described the single incision single stitch, in short "siss technique" for vasectomy.
Peril20 in 1961, Tilak27 in 1963 and Lee16 in 1966 also published single incision approach for bilateral vasectomy. Schmidt does not approve of the single incision approach; he thinks it could lead to operating twice on the same vas deferens, missing the other completely.
The SISS approach has the advantage that it enables bilateral vasectomy to be performed by one operation with minimum surgical trauma and post-operative care. Whereas one undergoing vasectomy co-operates during the first prick for local anesthesia and pull on the cord, when it has to be repeated on the other side in the two-incision approach, he is apprehensive and strains, thus makes things difficult for himself and the surgeon.
When the vas has been approached and identified it is freed and delivered on the surface. It is then dealt with as by the textbook description. The vas is divided, the ends of the vas may be turned and lighted and covered with fascia or simply ligated with non-absorbable ligature-linen, silk or nylon.
RECENT INNOVATIONS FOR DEALING WITH VAS DEFERENS
Some in use, others experimental, may be classified as follows:
I. "Extra luminary
methods" in which the vas deferens is divided:
1. Silver or tantalum occlusion clips on the divided vas
ends13.
2. Fulguration of the lumen of cut vas ends by needle
electrode23.
II. "Intraluminary methods" where the vas deferens is dealt without dividing it.
In this group, the vas is left in continuity, its lumen opened and blocked with one of the following, removal or manipulation of which is claimed to restore fertility:
Silastic thread silicone rubber
plug- Zeinsser.
Biowa IVT (nylon thread) - Lee
IVCD (nylon wire) -Kothari & Pardanani.
RVD (Plastic plug)- Brodie
Gold and stainless steel valve - Davis and Freund.
No single comparative study on these new methods of dealing with the vas deferens has been attempted so far. Each claims his innovation to be the best.
In the absence of a comparative study, consideration of the above methods, in the light of the principles of surgery and anatomical factors brings the following facts to the fore:
1. The extremely narrow lumen and thick walls are unusual features of the vas deferens compared to that of other conduit tubes in body. Identification of the lumen of vas and manipulation of any device into the lumen has to be without any injury, which may jeopardize the viability of the vas and surrounding structures of the spermatic cord. Is it simple and possible in the hands of everyone?
2. The sperm leak from the vas into the surrounding scrotal tissue is known to cause spermatic granuloma. How will sperm react to a perpetual foreign body in the lumen of vas with which they will remain in continuous contact? And how will these blocks cope up with dilatation of the testicular side of the vas due to engorgement with sperm?
3. The lumen of vas has the potential danger of spreading the infection to the genital and urinary systems. It is for this reason that vasectomy is routinely and in genito-urinary tuberculosis. Knowing this fact, is it advisable to introduce a foreign body in the lumen of vas which if infected will lead to infection not only locally but into the whole of the genital and urinary systems?
4. Sperm agglutinating and sperm immobilizing antibodies were found in 54.2 percent and 31.3 per cent cases respectively, six months after vasectomy1. An anatomical restoration of vassal potency after keeping it blocked by any device, therefore, cannot guarantee successful restoration of fertility.
5. To ensure subsequent childbirth in an eventuality, will sperm preservation in a semen Bank prior to vasectomy be not a better way rather than complex intra-lumenary devices and a second surgery? The incidence of such eventuality is less than two in a thousand according to a recent statiscal analysis. It is fair to subject everyone to intralumenary devices and risk genito-urinary infection?
Simple ligature of the vas (two ligature at a distance of 2 cm apart) was followed by complete absence of sperm in the semen for a period of ten to fourteen months when sperm reappeared and reached the previous normal sperm count14. Such auto reversible vasocclusion if it worked for 3 years would have been an ideal procedure for spacing of child birth. Removable Vas Occlusion clips were designed with this in mind. An absolutely painless procedure, devoid of all complications via tissue reaction, adhesions, inflammation, infection, ligature rejection and easy reversibility was attained with the use of clips in place of conventional ligatures on the ends of the vas, experimental and clinical cases.
After dealing with the vas: It is dropped back, the incision closed with one stitch, sterilized dressings and elastic scrotal supporter given.
Post Operative
Care:
A long acting sulphonamide or antibiotics
and analgesics are routinely prescribed. The skin stitch is
removed after a day or two. Abstinence for two weeks and
contraceptives for ten consecutive occasions is advised, and
thereafter, a semen ckeck-up. After two negative sperm reports,
contraceptive precautions are withdrawn.
DIFFICULTIES AND COMPLICATIONS
A short scrotum or a brisk cremesteric reflex makes it difficult to reach the vas deferens by palpation. A pendulous scrotum though poses no problem during the operation but the risk of hematoma is greater due to the large loose space.
The thickness of the vas varies from person to person. In some it is reasonably thick and easily palpable, in others it is so thin that identification by palpation is a problem.
Cases of anteverted testes, inguinal testes, inguino-scrotal hernia, and hydrocele of the tunica vaginalis make palpation of the vas and approach difficult.
Injury to the structures of the spermatic cord, namely the testicular artery, plexus of veins and nerves may lead to hematoma, profuse bleeding in the scrotum (which may require orchidectomy to control it) gangrene of testis, embolism, painful erection and inability perform sexual intercourse.
Cutting structures other than the vas due to mistaken identity are tight ligatures cutting through the vas may lead to sperm leak, spermatic granuloma reunion and recanalisation of vas, thus failure of operation.
Infection leads to scrotal abscess, an extremely painful condition accompanied by severe constitutional symptoms. Occasionally tetanus infection after vasectomy has resulted in deaths.
Delayed infection in the ligatures with localized puss formation and subsequent ligature rejection by the body is not uncommon.
Psychological complications reported are impotence sexual weakness and depression.
A thorough screening of the patient, for his physical and psychological state, absolute aseptic operating conditions, perfect surgical technique and post operative care are important factors in preventing complications. If any complication is suspected or occurs, prompt care is required.
REPAIR OF VAS DEFERENS (VASOVASAL ANASTOMOSIS)
Parlovechoi following an accidental vasectomy during a herniorraphy5 first attempted repair of the vas in 1907, Handley9 reported successful repair of the vas many years after vasectomy. Numerous other reports of successful vasectomy have appeared in the recent past. O’connor17, Phadke21 describe the technique of vasorraphy (vasovasal anastomis).
The result of the repair depend not upon the time lapse after vasectomy but the distance from testis where the vas was divided, the length of vas excised and adhesions which result from tissue reaction to the ligatures and post operative infection.
In the era of vascular surgery, anatomosis of the vas is no surgical feat. Need not be over glorified. An end-to-end anastomosis over a temporary internal splint is the technique commonly employed. Some has favored end-2-side or side-to-side anatomists without an internal splint.
CONCLUSION
Experimental work on vasectomy for almost one and half century and after millions of clinical vasectomy operations still leaves much to be learnt and done. In view of its role in the program for population control, a comprehensive study of this surgical procedure is imperative.
REFERENCES
(1) Ansbacher R: Sperm-Agglutinating Sperm-immobilizing Antibodies in Vasectomised Men, Fertility and Sterility, 22: 629, 1971
(2) Benjamin H: The steinache Operation: Report of Twenty two cases with Endocrine Interpretation, 1922.
(3) Bouin F and Ancel P Arch D, Zool. Exper (series 4) 1: 437, 1903
(4) Brissaud E: Les effects de la ligature due canal deferent, Arch D. Physio, 2nd series, pp. 769/789, 1880
(5) Cameron C.S Anastomosis of Vas Deferens: Restoration of Fertility after Five Years of Bilateral Vasectomy, J.A. M.A 127: 1119, 1120, 1945
(6) Cooper A: Observations on the Structure and Diseases of the Testis, London, 1930.
(7) Ferber A.S Tietze C. and Lewit S: Men with Vasectomies: A study of Medical, Sexual and Psychosocial Changes, Psychosomatic Medicine, Vol XXIX, No 4, July-Aug, 1967.
(8) Gosselin P Memoir surles obliterations Devoies Spermatique, Arch. Gen. de Med. (4th Series). 14, 405-424, 1947.
(9) Handley C.A Reconstitution of Vas Deferens After Operation for Sterilization. Arch Middlesex Hosp. 1: 74, 1954.
(10) Jhaver P.S Male sterilization and its Effects-Clinical Studies in Men and Histological Studies in Sterilized Experimental Animals. Thesis, University of Agra, 1955.
(11) Ohri B.B., and Jhaver P.S. Clinical Use of Vasectomy for Sterilization, Ind. J Surg. Vol XX, Nol 6, 480 : 1958.
(12) Jhaver P.S. Surgery of Epididymis and Vas, J. Ind. Med. Assoc. 44, No 11,591: June 1, 1965.
(13) Jhaver P.S. et al: Reversibility of Sterilization Produced by Vas Clip. Fertility and Sterility, Vol 22, No; 4, 263: 1971.
(14) Jhaver P.S. Sterilization in the Male for Spacing of Child Birth. J. Ind. Med. Assoc Vol 34, No: 12, 491: 1960
(15) Kuntz Z Degenerative Changes in the Seminal Epithelium and Associated Hyperplasia of the Interstitial Tissue in the Mammalian Tissues, Endocrinol. 5: 190-204, 1921.
(16) Lee H.Y New Medical Journal of Korea, Feb 1966.
(17) O’Connor V.J. Anastomosis of Vas Deferens After Purposeful Division for Sterility, J.A.M.A 136: 162-163, 1948.
(18) Ochsner A.J. Surgical J.A.M.A 32: 8678, 1899.
(19) Oslund R..A Study of Vasectomy on Rats and Guinea Pigs, Am. J. Physiol, 67: 422, 1924.
(20) Peril C.V Journal of Christian Medical Association, May 1971.
(21) Phadke G.N. Reanastomosis of the Vas Deferens, J Ind. Med.Assoc.Vol 36, No; 9,pp386-390 May 1, 1961.
(22) Sand G.J. Physiol 19: 305, 494 and 515, 1921.
(23) Schmidt S.S Technics and Complications of Electric Vasectomy, Fertility and Sterility, Vol 17, No; 4 July-Aug, 1966.
(24) Sharp H.C Beginning of Sterilization, J Hered, 28: 374-376, 1937.
(25) Steinache E: Arch f. Entwickmech 46: 557, 1921 (26) Tiedje P Deutch. Med. Wehnschr. 47: 352, 1921.
(26) Tilak G.H. Vasectomy Ind. Med. Assoc. 41: 548-50, Dec.