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Medical Forum / General / General / November 2005Fused Ascending Vasectomy?
Hello, again, sci.med. Inova provided a search of literature on novel vasectomy techinques. Vasectomy offers a choice of about 30 occlusion techniques, all with some failure rate, but in my reading I have not found what I now call a fused ascending vasectomy (FAV). It seems the FAV might offer superior occlusion. FAV is conceptually simple: the vas deferens, both left and right, would be cut as close to the testicle as possible, leaving the ascending (prostatic or vesicular?) segments as long as possible. The ascending segments would be sutured together, open end to open end. It is possible that the vas and fascia could be sutured separately, vas to vas, and fascia to fascia, in the manner of an arterial or venous micrograft, which is in practice. It seems to me that this method would offer superior occlusion, as these are live tissues in contact with similar live tissues. It seems regrowth of tissue, as after a slash to the skin and subsequent wound closure, would seal the vas joint circumfrentially, offering superior occulsion. Scar tissue would seal the joint. The descending (testicular) segments would be left open. The joint might be inspected after healing to verify occlusion. I do not know the anatomy in detail. Perhaps you do! Can the ascending segments of the vas deferens be dissected from the surrounding anatomy to sufficient length for FAV to obtain successful occlusion? Yours, Doug Goncz Replikon Research Falls Church, VA 22044-0394 > Hello, again, sci.med. > [quoted text clipped - 26 lines] > surrounding anatomy to sufficient length for FAV to obtain successful > occlusion? It sounds like your concept is mostly a great way to turn a 15 minute office procedure into an expensive 1 hour major operation with a substantially increased risk of scrotal hematoma for marginal (if any) decrease in fistulization rates. It would also take the procedure itself out of the hands of primary care doctors due to the markedly increased skill level such an approach and anastomosis would require. The scrotum is a complicated place with several different tissue planes. The more operating you do in the scrotum and the more tissue planes you disrupt, the more likely is bleeding. Getting to the vas close to the epididymus put you in major vascular plexus territory with resultant increased rate of post-op bleeding and hematoma formation. Furthermore, creating a proximal vasovasostomy as you propose would necessitate going through the midline raphe, Re-fistulization is the cause of vasectomy failure. Current methods involve removing a segment of vas and relying on distance to prevent that, and some also prefer to place the proximal cut end in a different tissue plane under the dartos fascia. The method you detail above doesn't improve on those concepts but does increase the cost, pain, and potential complications by a large amount. Fistulization from your anastomosis to one or the other distal ends would be no less likely to occur than current methods IMHO. HMc > > Hello, again, sci.med. > > [quoted text clipped - 31 lines] > increased risk of scrotal hematoma for marginal (if any) decrease in > fistulization rates. I do not believe you are correct in this, Howard. NIV allows access to the two vas. They're available externally, held in clamps. Why not pull both out, join them, and let them fall back into place, instead of pulling them out one at a time? It seems clear to me that vas-to-vas anastomosis would have an advantage over vas-to-self occlusion. The tissues should regrow in their original configuration at the joint, all the varios layers joined. That can't happen when one end of a vas is terminated. It would also take the procedure itself out of the > hands of primary care doctors due to the markedly increased skill level such > an approach and anastomosis would require. Well, yes, suturing such a small vessel might require enhanced surgical expertise. But my uro has been inside my abdomen for a varicocelectomy. He can do this. Do that many primary care doctors administer vasectomy? Would the mere existence of this surgical option "take the procedure" "out of the hands" of such doctors? It's just one option on a menu of around 30. > The scrotum is a complicated place with several different tissue planes. I suppose it is. The > more operating you do in the scrotum and the more tissue planes you disrupt, > the more likely is bleeding. But see above. A fat needle punch in stretched in NIV, and clamps bring the work to the surface. No additional tissue planes are disrupted. Getting to the vas close to the epididymus put > you in major vascular plexus territory with resultant increased rate of > post-op bleeding and hematoma formation. OK, well, then I was wrong to suggest cutting so closely. Thank you. Still, there may be a point enhancing available length while reducing bleeding and hemotoma. Furthermore, creating a proximal > vasovasostomy as you propose would necessitate going through the midline > raphe, Yes. At least I think it would. There's more length available that way, isn't there? I still say incision is not necessary, that the needle punch, stretched, can provide the needed access. > Re-fistulization is the cause of vasectomy failure. Current methods involve > removing a segment of vas and relying on distance to prevent that, and some > also prefer to place the proximal cut end in a different tissue plane under > the dartos fascia. The method you detail above doesn't improve on those > concepts Yes, it does. No other method restores the integrity of the vas. It's as if Nature put two balls in there for this specific reason; so that the ascending segments could be cross connected to establish what in my mind would be perfect occlusion. but does increase the cost, pain, and potential complications by a > large amount. Jet anesthesia reduces vasectomy pain to very low levels. Cost is a trade-off. How much does an unintended pregnancy cost? I see fewer complications than, say, an abdominal vasectomy, if surgeone are still doing those. Fistulization from your anastomosis to one or the other distal > ends would be no less likely to occur than current methods IMHO. No. The tissues at the cut end want to grow for about five hours post cut. When mated to their corresponding ends, this urge to growth is given vent. No other procedure makes use of this fleeting "moment" in which growth can occur. All others expect the ends to seal in a way Nature did not intend, and that, I believe, is the cause of refistulization. Fascial interposition (FI) does make use of this urge, but the cut fas ends are not given the opportunity to regrow. Are you suggesting that in a heart bypass, for some reason, a vessel would reach out to find a nearby abandoned vessel and grow to join with it? I don't think that happens. > HMc Many thanks for your participation in this thread, Howard. Do you have any reply? Does any interested reader have a reply or comment? Doug >> > Hello, again, sci.med. >> > [quoted text clipped - 130 lines] > > Doug Having done many, many vasectomies over the years, I see nothing in the technique you describe to suggest that it would be superior, overall. Please report back after you have completed your randomized prospective study of "FAV" compared to current techniques. Perhaps your data will change my mind... HMc Well, that's what I had in mind the whole time; I'd hoped to get a study started. I didn't just want this technique for myself. Heck, it's probably classified as human experimentation or something unless the study protocol is approved. How many subject might be needed to be sure of statistically significant results? 100? 1,000? 10,000? Anyone have an opinion on that? Thanks again, Dr. McCollister. Doug > Well, that's what I had in mind the whole time; I'd hoped to get a > study started. I didn't just want this technique for myself. Heck, it's [quoted text clipped - 11 lines] > > Doug Given the usually reported incidence of vasectomy failure due to recanalization, I should think the sample would have to be huge. trifold www.vasectomy-information.com > > Well, that's what I had in mind the whole time; I'd hoped to get a > > study started. I didn't just want this technique for myself. Heck, it's [quoted text clipped - 17 lines] > trifold > www.vasectomy-information.com Vasectomy failure rates are based on lack of oligospermia, not on pregnancy like other forms of birth control. Recanalization is exceedingly rare. > > Given the usually reported incidence of vasectomy failure due to > > recanalization, I should think the sample would have to be huge. [quoted text clipped - 4 lines] > Vasectomy failure rates are based on lack of oligospermia, not on pregnancy > like other forms of birth control. Recanalization is exceedingly rare. That's my point. If the purpose of the study would be to determine how this method of vasectomy compares with others in terms of recanalization risk, wouldn't the sample base have to be huge? trifold www.vasectomy-information.com > > > Given the usually reported incidence of vasectomy failure due to > > > recanalization, I should think the sample would have to be huge. [quoted text clipped - 11 lines] > trifold > www.vasectomy-information.com Oh, sorry. I think you may have been responding to somebody in my killfile, so I couldn't make sense of the thread. --Patti > Hello, again, sci.med. > [quoted text clipped - 7 lines] > would be cut as close to the testicle as possible, leaving the > ascending (prostatic or vesicular?) segments as long as possible. Would the testicular segments be left unsealed? > > Hello, again, sci.med. > > [quoted text clipped - 9 lines] > > Would the testicular segments be left unsealed? Yes. I propose that they be left unsealed. They could certainly be cauterized. Doug |
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