The Kindest Cut

By staff November 1, 2005

Half a century ago, husbands passively stood by as their wives endured unnecessary hysterectomies to prevent further pregnancy-then the only legal option for female sterilization. Later, when legislators approved tubal ligation, women once again bore the burden of invasive surgery, although a partner's vasectomy most certainly would have involved far less cost, recovery time and pain.

"My mother got her hysterectomy at 42," says Dr. Douglas G. Stein of Tampa, who remembers his mom being perfectly healthy one day, yet undergoing surgery the next. "Women did it all the time in the '50s. After having four or five kids, they'd go to the gynecologist asking for a hysterectomy, knowing full well that religions that would not tolerate birth control would have to condone surgery [ostensibly] performed for health reasons."

The 21st century has changed all that. New no-needle, no-scalpel vasectomies are increasingly converting men into "mensches" who opt to assume the responsibility of permanent contraception. An estimated 42 million couples rely on vasectomy worldwide, and 500,000 are performed in the United States each year.

Still, only about 40 percent of vasectomies are done sans scalpel, despite the fact that no-scalpel vasectomy (NSV) was introduced to the United States in 1988. "The technique has not been universally adapted," says Stein, who's been using exclusively the NSV method since 1990. "It's about manual dexterity, a fine touch, and a schedule of doing a fair number of procedures." Male health Web sites concur, cautioning those interested in no-scalpel vasectomy to be sure their doctor has a track record in performing the operation.

Stein, whose private practice is in Tampa but who's under contract with several county health departments in Southwest and Central Florida (including Sarasota), says it's surprising how many calls still come in from men who can't imagine the vasectomy being done without a scalpel. "Most of our referrals are from guys who come to me on the recommendation of friends who've told them it [NSV] didn't hurt at all," he says.

Dr. Tracy B. Gapin of Florida Urology Specialists in Sarasota says the public needs to be made aware of the new technology. "A lot of men are hesitant because they don't know what to expect," he says. "Usually they come in not knowing anything except that they want a vasectomy." Gapin's patients often happen upon NSV by pure luck, simply because that's the method he was taught to perform.

And Gapin says that even his training in NSV was a matter of luck. "One of our faculty members taught no-scalpel; all the others didn't," he recalls. "A lot of people are still doing conventional vasectomies. It varies depending on how they were trained."

The technique was developed by Dr. Li Shunqiang in Chongqing, China, and promoted to the American medical community by an organization now called EngenderHealth. Stein was taught the procedure in Florida by Dr. Philip S. Li, an internationally recognized expert in NSV who was mentored by Shunqiang.

NSV technology is a refinement of the conventional vasectomy, which gets its name from a combination of the prefix "vas" (referring to the vas deferens tube in each testicle that carries sperm to the prostate, where it mixes with semen) and the medical suffix "ectomy," meaning to cut out. In conventional vasectomy, one or two incisions are made with a scalpel to reach the vas tubes, which are then cut and sealed to prevent sperm from entering the semen. The procedure renders the patient sterile, although he continues to ejaculate and produce semen. After conventional surgery, sutures are required to close the incision.

In no-scalpel vasectomy, the approach to the vas deferens is refined to eliminate surgical incision. Instead, a tiny opening is made in the middle of the scrotum by a device Shunqiang created by modifying ordinary forceps. After administering local anesthesia, the skin over the vas is pierced with the two sharp points of this instrument.

Next the surgeon uses a clamp or probe to stretch the skin opening so the vas tube can be reached, lifted out and held in place, allowing a small segment to be cut. The surgeon then uses the same skin opening to reach the other vas tube. The big difference is that the opening is so tiny in NSV, it requires no stitches.

Studies reported in the Journal of Urology prove both methods are equally effective. But the no-scalpel technique was found to take less time, have fewer complications, a faster recovery, less discomfort, less bleeding and little or no scarring. Studies also show that intercourse can be resumed sooner after NSV than conventional vasectomy.

Every improvement in the new technology is really all about the pain. Forty percent of men considering vasectomy worried about being cut or feared the pain, according to the Journal of Urology study. The no-scalpel method reduced patients' pain anxiety significantly, but doctors found a second fear factor needed to be addressed: needle phobia.

The urology community was abuzz with interest in the potential for no-needle vasectomy after Dr. Charles L. Wilson reported in 2001 that he administered anesthetic with a jet injection system used by dentists and podiatrists for many years. As recently as May 2005, the Journal of Urology published a report by Dr. Ronald Weiss detailing a modified and refined jet injection technique for no-needle vasectomy.

This method uses a MadaJet Medical Injector that delivers a high-pressure spray of local anesthetic solution directly through the scrotal skin down onto the tissue around the vas. Dr. Scott J. Rhamy of RTR Urology in Venice is among the first Southwest Florida urologists using the MadaJet. "More often than not, patients are pleasantly surprised to find out they're getting the new technology," says Rhamy, who was also taught no-scalpel exclusively, and began using no-needle soon after the Journal of Urology report was published. Indeed, leaders in the field estimated that only 5,000 no-needle vasectomies had been performed in the United States and Canada by the time Dr. Weiss' report was released in May.

Weiss' clinical study reports that none of the 465 patients experienced hematoma (bruising) after their no-needle, no-scalpel vasectomies. What's more, patients considered the procedure either low-pain or pain-free.

In order to spread the word, a Web site was created,, where doctors can actually see a video of the no-needle, so-scalpel vasectomy. Throughout the procedure, the patient is often asked to describe his level of pain, which he either expresses as a mild vibration or no pain at all. Rhamy says that for the most part he performs no-needle NSV much the same way as shown on the video, and that he's pleased with the switch to MadaJet anesthetic injection.

Still, every patient has his own threshold for pain. "If you stand outside a blood-taking facility and question people coming out to describe their pain, some will say they felt no pain, and others will say it was painful," Stein says. "It feels like a rubber band snap, or about the same as having a blood sample drawn."

Doctors stress the importance of patient education about vasectomy. While the procedure is considered reversible, they do not advise anyone considering vasectomy to undergo the surgery with the intention of reversing it in the future. Patients are counseled that because there may be complications, they should be quite certain they will not regret their decision if their life changes due to divorce, the loss of a child or other scenarios. "I always ask my patients whether they would be crushed if for some reason they wanted more children and their vasectomy was not reversible," Stein explains.

Rhamy says his typical patient is in his upper 40s or 50s and sexually active, but does not want the risk of another child. And research shows several benefits to those opting for no-needle, no-scalpel vasectomy in this demographic group. The procedure takes less time-between 10 and 30 minutes, depending on the doctor's skill.

According to Gapin, scarring is greatly reduced. "Because there is no incision, the wound heals very quickly," he says. "In 24 hours, you literally cannot see the wound."

Finally, there is no doubting the effectiveness of vasectomy, regardless of the method used. Physicians say the only sure way to know that a woman's tubal ligation is a success is if she doesn't get pregnant. About 2 percent of women do conceive following the procedure, while the failure rate for vasectomy is slightly less than 1 percent across the board. Monitoring is much easier for vasectomy. Doctors say sperm count can be evaluated effectively, even with a high school microscope. Once a man's semen has tested negative for sperm, he has proof positive that he is sterile. "The sperm sample is the guide," says Rhamy.


Many new technologies are under investigation for even more futuristic approaches to male contraception and sterilization. Among them:

Ultrasound Researchers under the direction of Nathaniel M. Fried of Johns Hopkins University are working on an ultrasound vasectomy device that has been tested on dogs. The ultrasound machine has three parts: a water balloon filled with chilled water that covers the skin to prevent it from burning; a clamp that holds the vas deferens in place; and an ultrasound machine that creates intense heat that cooks the tissue of the vas in order to close it. To date, no one knows when this technology can be employed on humans, even for testing.

Reversible Vasectomy According to, this method involves plugging the vas deferens and then removing the plug when birth control is no longer wanted. This method is currently in the research stage.

Hormonal Methods These involve pills or injections men could use to prevent sperm production. So far, either side effects or lack of effectiveness have kept these methods off the market.

GOOD NEWS FOR THE PROSTATE The significant results of a 13-year study by physicians at Sarasota-based Dattoli Cancer Center were presented at the annual meeting of the American Society of Therapeutic Radiation Oncology in Denver last month. Dr. Michael Dattoli and Dr. Richard Sorace gave 282 high-risk prostate cancer patients a combination therapy of Palladium-103 brachytherapy and supplemental beam radiation in 1992. Thirteen years later, 81 percent of the treated patients had not suffered a recurrence of disease after treatment. More importantly, the study found that if the combination therapy holds the cancer at bay for the first five years, the chance of later recurrence drops to nearly zero.

BYPASSING SURGERY Men who don't want to undergo a vasectomy may soon have an alternative: the Intra Vas Device. Developed by the Shepherd Medical Company in Vancouver by Dr. Neil Pollock, the IVD is analogous to the IUD for women; it's a flexible, hollow silicone plug, about a millimeter in diameter, that's inserted into the vas deferens to block the flow of semen.

The outpatient procedure to implant the plug takes only about 20 minutes under local anesthetic, and it's anticipated that the IVD can be removed later, if desired, in a similar procedure, re-establishing sperm flow. The U.S. National Institutes of Health has awarded Shepherd a $1.4 million grant to conduct further human clinical trials.

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