Marc Goldstein, MD, MS

 is a resource for urologists and other clinicians who focus on men’s health. ‘Y’tube covers surgical aspects of a variety of men’s health issues with the ultimate goal of accumulating a library of videos to serve as a reference. In this installment, urologists demonstrate key elements of no-scalpel vasectomy techniques.  

	The no-scalpel vasectomy is a minimally invasive technique for accessing the vas deferens. A single median raphe puncture hole is dilated, thereby pushing blood vessels aside instead of cutting across them. The vas is delivered and sealed with a combination of cautery, clips, and fascial interposition, which minimizes failure. The technique is associated with significantly lower rates of hematoma, infection, and pain than conventional vasectomy.

Dr. Goldstein and Dr. Li’s video highlights crucial steps to performing a successful no-scalpel vasectomy: mastering the three-finger technique, allowing for mobilization and fixation of the vas in the midline in order to obtain access; freeing the vas deferens from the vasal sheath, permitting one to readily strip the vas of the adjacent deferential vessels; and performing vasal occlusion methods consistent with AUA guidelines. Although not shown here, one may opt to perform a “no-needle, no-scalpel” vasectomy employing a jet injector for administration of local anesthesia which may be better tolerated by many patients than the standard needle and syringe.

Vasectomy is one of the most commonly performed (and litigated) procedures in urology. It is estimated that roughly 500,000 men undergo vasectomy each year. These videos by Dr. Goldstein/Li and Dr. Williams illustrate the crucial parts of this procedure. As a center that, much like Dr. Williams, performs many microsurgical cord denervations for post-vasectomy pain, we have come to believe that one of the key components necessary to avoid this is strict isolation of only the vasal segment without any surrounding tissue.

	Particular attention is given to the isolation of the vas through the scrotal wall through a C-grip in order to stabilize it. Dr. Goldstein, a pioneer of no-scalpel vasectomy, illustrates how this procedure can be easily performed in a bloodless fashion. His use of the supersharp dissector to isolate the vas and bring it out of the puncture site can save significant procedural time. Further, the principle of holding the vasal segment once the clips are placed to ensure hemostasis has been obtained prevents nearly all post-operative hematomas.

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Dr. Goldstein and Dr. Li’s video highlights crucial steps to performing a successful no-scalpel vasectomy, says Cigdem Tanrikut, MD.

Vasectomy: Crucial steps for a bloodless procedure

 is a resource for urologists and other clinicians who focus on men’s health. ‘Y’tube covers surgical aspects of a variety of men’s health issues with the ultimate goal of accumulating a library of videos to serve as a reference. Here, three leading groups demonstrate varicocelectomy techniques. All make use of a microdoppler and delicate dissection to identify, isolate, and preserve the testicular artery. Two of the videos demonstrate the subinguinal approach to the varicocele. We have found this to result in less pain and quicker recovery for patients. The third video demonstrates a single-port approach to a laparoscopic varicocelectomy and use of a microdoppler in the laparoscopic setting.

	This video describes a microsurgical, subinguinal, artery- and lymphatic-sparing technique of varicocelectomy. The technique includes delivery of the testis, which provides direct visual access to every possible route of venous return, reducing failures and recurrences.

This video from the Cornell group represents the standard approach performed by most andrologists. Relevant details include the identification and preservation of lymphatics, and utilization of a microDoppler (20 MHz). Dr. Goldstein has long been a proponent of delivery of the testis and division of gubernacular and external spermatic veins. Many surgeons believe that this is difficult to accomplish via a subinguinal incision; this video clearly demonstrates the technique while offering tips for making access to the testis easier.

 This video can be considered one of the gold-standard approaches to varicocelectomy. While not all urologists advocate for delivery of the testis, the meticulous microsurgical anatomic dissection of the veins, preservation of the lymphatics, and use of a microdoppler are something that all urologists should consider standard of care for this procedure.

Varicocelectomy: Microscopic subinguinal (Marmar) technique

Varicocelectomy: Single-port laparoscopic technique

This video describes a microsurgical, subinguinal, artery- and lymphatic-sparing technique of varicocelectomy.

Author | Marc Goldstein, MD, MS

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Vasectomy: Crucial steps for a bloodless procedure

Varicocelectomy: Microsurgical, subinguinal technique