Are evidence-based vasectomy surgical techniques performed in low-resource countries?

Recommended techniques

The recommended techniques of the two surgical steps of the vasectomy procedure (isolation/exposition and occlusion of the vas deferens) were extracted by the author from the following vasectomy practice guidelines: the European Association of Urology (2012)⁹, American Urological Association (2012, 2015)¹⁰, the Faculty of Sexual & Reproductive Healthcare (FSRH) of United Kingdom (2104)¹¹, and the Canadian Urological Association (2016)¹². The level of evidence, strength of recommendation and the most relevant underlying evidence from systematic reviews supporting the recommendations was also extracted.

Data from low-resource countries

A convenience sample of eight low-resource countries from Africa, Asia and America known by the author to provide vasectomy services on different scales was selected. India, Nepal, Mexico, and Colombia (through Profamilia, a non-profit non-governmental organisation) have large and structured vasectomy programs with thousands of men vasectomized each year while private or governmental smaller scale initiatives exist in Kenya, Rwanda, Honduras and Haiti.

For each country, the most recent document describing vasectomy techniques that should be used (national standards/norms) and/or that are performed was first identified through personal contact with individuals from or acquainted with vasectomy in selected countries. In addition, in order to validate the currency of documents retrieved, a Google search was performed twice, in spring 2018 and April 2019, using the name of the country, “vasectomy” or “male sterilization”, and key words from the title of documents already identified. No date limits were imposed. The retrieved Google search pages were scanned until no more related documents were found. PubMed or Google Scholar search was not performed because, as expected, none of the relevant documents initially retrieved was published as peer-reviewed article.

The surgical techniques recommended and/or commonly performed to isolate/expose (classic technique with a scalpel, NSV) and to occlude the vas (simple LE, LE+FI, cautery) in the selected countries were extracted from the retrieved documents. Additional information on the surgical techniques commonly performed as obtained by personal contact with key informants was also reported. Guideline recommendations were compared to and contextualized with vasectomy techniques performed in the selected countries.

Guideline recommendations

Excerpts of recommendations from the four practice guidelines are presented in Table 1. Although the assessment of the evidence and the strength of the recommendations vary across the four guidelines, they all agree that a minimally invasive (MIV) technique including the no-scalpel technique (known as the no-scalpel vasectomy (NSV)) should be perform to isolate and expose the vas deferens. The criteria of a MIV technique are: 1) a skin opening of ≤10 mm, 2) minimal dissection of the vas and perivasal tissues, and 3) no use of skin sutures¹⁰. Among the MIV techniques, NSV is the most studied. Two systematic reviews concluded that NSV - based on high-quality evidence - is significantly associated with a lower risk of surgical complications, namely bleeding and/or hematomas^6,7.

The guidelines also all agree that cautery of the mucosa of the vas lumen, preferably combined with interposing the fascia between the divided ends of the vas (fascial interposition (FI)), should be used to occlude the vas. Moderate-quality evidence from cohort studies showed that the “classical” ligation and excision (LE) technique consisting in putting two ligatures on the vas deferens and excising a small (1 cm) vas segment in between is associated with a high risk of occlusion failure based on post-vasectomy semen analysis, from 8 to 13%^2,3,14–16, and contraceptive failure, from 4% after 3 years to 9% after 10 years^17–19. Although a high-quality randomized trial² demonstrated that LE combined with FI on the testicular end can reduce the risk of failure by 50%, occlusion failure rate remained high at 5.9% (95% confidence interval 3.8% to 8.6%). Moderate quality evidence based on comparative cohort studies showed that combining cautery of the mucosa of the vas with either electro- or thermal-cautery, preferably combined with FI, is associated with the lowest risk of occlusion failure (<1%)^10,11.

National standards and practices

National standards and practices in targeted low-resource countries are described in Table 2 All countries selected have national standards/norms^20–27; editions range from 2009 to 2018 (Table 2).

The NSV is the preferred recommended technique to expose the vas in all eight countries. Only three countries, Kenya²⁰, India²², and Haiti²⁷, mention that the “classic” technique, requiring a larger opening of the scrotal skin with a scalpel, is still acceptable.

The most commonly vas occlusion technique recommended in the national standards is the LE combined with FI. Documents from India²² and Nepal²³ mention that simple LE is also acceptable, Kenya only name LE²⁰, and Haiti do not mention any occlusion technique²⁷. The use of cautery is limited to four countries: Kenya, Rwanda, Haiti, and Colombia. Haiti and Kenya benefit from the support of No-Scalpel Vasectomy International (NSVI), a non-governmental organisation promoting and providing free NSV services in low-resource countries. In these two countries most vasectomies are done through NSVI. Thermal cautery, using a low-cost portable thermal cautery unit, combined with FI²⁸ is the vas occlusion technique recommended by NSVI (personal communication with Dr. Doug Stein, President of NSVI). In Rwanda, mucosal cautery of the vas combined with FI²⁸ has been successfully introduced in 2010²⁹ and is now recommended to be used for occluding the vas²¹. Profamilia in Colombia has recently introduced thermal cautery combined with FI²⁸ as one of their recommended techniques, in addition to LE+FI²⁶. They aim to train all urologists from their family planning clinic network over year 2019 (personal communication with Dr. Diana Torres, chief urologist at Profamilia). Colombia is then the only one of the four large vasectomy programs to recommend using cautery (Table 2).