2. Definición e historia
Término incorrecto (misnomer).
Solo una parte del conducto deferente (vas deferens) es
extirpado.
Procedimientos incluidos en la definición:
- Partial vasectomy
- Vasal transection
- Vasoligation
- Vasal occlusion
Sheynkin YR. History of vasectomy. Urol Clin North Am. 2009 Aug;36(3):285-94.
3. Vas deferens (vas, duct + deferens, present
participle of deferre, to carry away).
Supuestamente nombrado por Mondino dei
Liuzzi (1275–1327), anatomista de Boloña.
Su libro ‘‘De Anatome’’ (Anothomia) fue
publicado en 1316.
Sheynkin YR. History of vasectomy. Urol Clin North Am. 2009 Aug;36(3):285-94.
5. The earliest reference to section of vasa deferentia as an
alternative procedure to castration to achieve prostatic
atrophy was made by Felix Guyon in 1885.
Karl Gustav Lennander (Sweden - 1894) advocated
vasectomy as a substitute for castration ‘‘as a means of
relieving ills consecutive to prostatic hypertrophy”.
Reginald Harrison performed more than 100 vasectomies
between 1893 and 1900. He found that ‘‘the usual effect of
vasectomy is to induce shrinkage of the hypertrophied
prostate’’ and restore natural micturition.
Sheynkin YR. History of vasectomy. Urol Clin North Am. 2009 Aug;36(3):285-94.
6. In 1895, Guyon failed to obtain any substantial loss of the bulk of the prostate
in four different experiments.
Wood reviewed 192 cases of vasectomies and reported improvement in
urination in 15%, no changes in 15%, and deaths in 6.7%.
Wallace concluded that ‘‘a single or double vasectomy is useless as a means
of producing prostatic atrophy.’’
Meltzer (1928) recommended bilateral vasectomy, rather than vasoligation, as
‘‘a definitive prophylactic measure against the painful complication of
epididymitis.’’ (during, or after open prostatectomy).
One of the last prospective studies conducted in 1975 showed that vasectomy
does not reduce the incidence of epididymitis and its routine use in prostatic
surgery is not indicated.
Sheynkin YR. History of vasectomy. Urol Clin North Am. 2009 Aug;36(3):285-94.
7. Otros usos históricos
Van Meter (1897). Esterilizacion eugénica (evitar la reproducción
de individuos con enfermedades hereditarias).
Eugen Steinach (1920). Rejuvenecimiento.
Viennese urologist Victor Blum (1923) performed a Steinach
operation on Sigmund Freud, who ‘‘hoped that it might bar the
recurrence of his jaw cancer and might even improved his
sexuality, general condition and his capacity to work.’’
Sheynkin YR. History of vasectomy. Urol Clin North Am. 2009 Aug;36(3):285-94.
8. - Sheynkin YR. History of vasectomy. Urol Clin North Am. 2009 Aug;36(3):285-94.
- Vincent J. O‘Conor, M.D. Anastomosis of vas deferens after purposeful division for sterility. JAMA 1948;136(3):162-163.
9. Tipos de Vasectomía
Transacción
- Convencional
- Sin bisturí
Inyección vasal
Oclusión vasal
Anthony Viera, MD, MPH. Vasectomy and other vasal occlusion techniques for male contraception. UpToDate
Jan 2016.
10. Contraindicaciones
Presencia de hematoma escrotal.
Infección genitourinaria o inguinal activa.
Granuloma espermático.
*El procedimiento se puede realizar cuando estos problemas se
hayan resuelto.
Anthony Viera, MD, MPH. Vasectomy and other vasal occlusion techniques for male contraception. UpToDate
Jan 2016.
12. Preparación pre-operatoria
Confirmar la presencia de un conducto y un testículo a cada lado
y la ausencia de anormalidades anatómicas.
Evitar el uso de AAS y AINE’s por siete días antes.
Se puede utilizar un ansiolítico (eg. Diazepam 10mg VO) una
hora antes para relajar al paciente y los músculos escrotales y
cremastéricos.
Aplicación de cremas anestésicas (eg. EMLA, una hora antes)
reduce el dolor de la inyección del anestésico.
Anthony Viera, MD, MPH. Vasectomy and other vasal occlusion techniques for male contraception. UpToDate
Jan 2016.
13. Anatomía del escroto y cordón
Piel
Fascia dartos
(Del griego δέρνω/derno y/o δέρμα/derma (skin), significa “aquello que es
despellejado/desollado“)
Fascia espermática externa
(se continua en el pene como Fascia de Buck [Gordon, U.S. surgeon, 1807–1877])
Músculo y fascia cremastericos
(continuación del musculo oblicuo interno)
Fascia espermática interna
(derivado de la fascia transversalis)
*En 12% de los varones la túnica vaginalis envuelve todo el testiculo (riesgo de hidrocele).
Art KS, Nangia AK. Techniques of vasectomy. Urol Clin North Am. 2009 Aug;36(3):307-16.
19. Anatomía del conducto deferente
Mide 45cm (~) en total
Inicia en la cola del epidídimo y termina en los conductos
eyaculatorios.
Irrigación:
- Arteria deferencial (rama de la arteria vesical inferior)
- Circulación colateral por ramas de la cremastérica y la
testicular.
Art KS, Nangia AK. Techniques of vasectomy. Urol Clin North Am. 2009 Aug;36(3):307-16.
22. Prophylactic antimicrobials are not indicated for routine
vasectomy unless the patient presents a high risk of
infection.
Recommendation (Evidence Strength: Grade C)
- AUA Guidelines 2012
*No lo menciona en las guías europeas.
*Tasa de infecciones de herida quirurgica en cirugía scrotal van de 1.5%-
9%
*Art KS, Nangia AK. Techniques of vasectomy. Urol Clin North Am. 2009 Aug;36(3):307-16.
23. Material a utilizar
Chlorhexidina o Yodo povidona
Bisturí electrico, gazas estériles
Sutura absorbible 4/0 (Vycril [Poliglactina 910] o Catgut crómico)
Lidocaína “sin epinefrina/adrenalina”
Instrumental quirúrgico
Anthony Viera, MD, MPH. Vasectomy and other vasal occlusion techniques for male contraception.
UpToDate Jan 2016.
44. The ends of the vas should be occluded by one of three divisional methods:
1. Mucosal cautery (MC) with fascial interposition (FI) and without ligatures or clips applied on the
vas;
2. MC without FI and without ligatures or clips applied on the vas;
3. Open ended vasectomy leaving the testicular end of the vas unoccluded, using MC on the
abdominal end and FI; OR by the non-divisional method of extended electrocautery.
Recommendation (Evidence Strength: Grade C)
- AUA Guidelines 2012
45.
46.
47.
48.
49. ¿Se debe enviar de forma
rutinaria a anatomía
patológica el segmento
seccionado?
50. Routine histologic examination of the excised vas segments is not required. (Expert
Opinion)
- AUA Guidelines 2012
There is no need for routine pathologic examination of the vas because usually it
can be recognised easily. Not performing this examination also saves costs for the
patient. In case of doubt about the nature of the tissue removed, pathologic
examination is advised.
- EAU Guidelines 2012
51. Complicaciones
Hematoma
Infección
Granuloma espermatico
Síndrome de dolor post-vasectomía
Vasectomia fallida
The most important determinant of postoperative complications is
operator experience.
Surgeons performing >50 vasectomies per year had 1/3 the
complication rate of those performing <10 procedures. *
Anthony Viera, MD, MPH. Vasectomy and other vasal occlusion techniques for male contraception. UpToDate Jan 2016.
*Kendrick JS, Gonzales B, Huber DH, Grubb GS, Rubin GL Complications of vasectomies in the United States. J Fam Pract.
1987;25(3):245.
52. Hematoma - La complicación mas común. En algunos casos el sangrado
puede ser tan severo que requiera reoperación. El sitio mas común de
sangrado es el plexo pampiniforme.
- Ocurre en 0.1 a 2-1% con la técnica sin bisturí.
- 0.3 a 10.7% en la técnica incisional (convencional)
Infección – ocurre en un 0.2 a 0.9% en la técnica sin bisturí y un 1.3 a 4% en
la técnica incisional.
Granuloma espermatico – Esperma es muy antigénico y desencadena una
reacción inflamatoria importante. Suele formarse por extravasado de
esperma del lado testicular cuando este ha sido dejado abierto (rara vez aun
cuando ha sido cauterizado).
- Rara vez son sintomáticos, pero pueden llegar a requerir excision.
Anthony Viera, MD, MPH. Vasectomy and other vasal occlusion techniques for male contraception.
UpToDate Jan 2016.
53. Sindrome de dolor post-vasectomia.
Historicamente se mencionaban tasas de <1%, encuestas modernas revelan una
incidencia de hasta 15% y hasta un 2% reportan dolor que afecta la calidad de vida.
La causa mas comun es la epididimitis congestiva crónica, esta suele ser asintomática
pero algunos tienen dolor sordo que aumenta con la eyaculación.
Otras causas son el atrapamiento de nervios o los granulomas espermáticos.
1ra linea de tratamiento: AINE’s y baños tibios.
Si no funciona, inyecciones de esteroides o bloqueos, por un especialista del dolor.
Casos refractarios pueden requerrir vaso-vasostomia (efectiva en un 70-82%) o
epididimectomia completa (en casos severos), esta puede causar orquialgia residual.
Anthony Viera, MD, MPH. Vasectomy and other vasal occlusion techniques for male contraception.
UpToDate Jan 2016.
54. Vasectomia fallida
Puede ser por error en la técnica, recanalizacion o relaciones sexuales antes
de alcanzar la azoospermia.
La recanalizacion es rara, ocurre en un 0.2% de los pacientes.
Se define como la presencia de cualquier cantidad de espermatozoides
despues de 1 o más muestras azoospermicas apropiadamente recolectadas y
documentadas.
*Puede ocurrir en cualquier momento posterior a una vasectomia.
Anthony Viera, MD, MPH. Vasectomy and other vasal occlusion techniques for male contraception.
UpToDate Jan 2016.
56. Wound examinations are not routinely needed.
Oral and written information about the need of semen analysis at 3 months.
Each patient should be counseled that no technique is 100% effective.
Sterility can be concluded if no spermatozoa are found in the ejaculate.
In case of the presence of <100 000 nonmotile spermatozoa per millilitre,
clearance can also be given 3 mo after the procedure
*EAU Vasectomy
Guidelines 2012
57. Semen analysis three months postoperatively; the patient should have had at
least 20 ejaculates since the time of vasectomy.
A coital frequency of at least three times per week seems to be associated
with more rapid clearance, regardless of age.
Azoospermia in a semen sample is definitive evidence of infertility.
The laboratory performing the analysis should examine a fresh specimen
using direct microscopy; if sperm are not seen on the initial prepared slide, a
centrifuged specimen should be evaluated.
- Anthony Viera, MD, MPH. Vasectomy and other vasal occlusion techniques for male contraception. UpToDate
Jan 2016.
- Griffin T, Tooher R. How little is enough? The evidence for post-vasectomy testing. J Urol. 2005;174(1):29.
58. If there are motile sperm at the 3 month check-up, a follow-up test is
performed 1-2 months later.
Vasectomy is considered a failure if motile sperm are confirmed on the follow
up examination, there have been >20 ejaculations and >3 months have
elapsed since the procedure. The patient should be advised to use alternative
contraception and potentially undergo a second procedure.
The accuracy of determining whether sperm have normal motility is
dependent on the timely examination of the semen specimen, ideally <4
hours from the time collected by the patient.
Anthony Viera, MD, MPH. Vasectomy and other vasal occlusion techniques for male contraception.
UpToDate Jan 2016.
59.
60. Vasectomy Reversal (Vaso-vasosostomia)
Efectividad del 50-70% (disminuye conforme transcurre el tiempo).
Predictores de NO solicitar recanalización:
- Mayores de 30 años.
- Hombres sin hijos.
Características que NO intervienen en el arrepentimiento:
- Religión
- Trabajo/Ocupación
- Numero de matrimonios
Potts JM, Pasqualotto FF, Nelson D, et al. Patient characteristics associated with vasectomy reversal.
J Urol. 1999;161(6):1835.