Philip S. Li, MD

 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. In this installment, two expert infertility groups demonstrate approaches for obtaining sperm in men with azoospermia.  

	Male infertility can be secondary to azoospermia (lack of sperm in the ejaculate) secondary to testicular failure. Sperm retrieval in combination with intracytoplasmic sperm injection (ICSI) offers a chance of fathering a biological child. The video reviews microdissection testicular sperm extraction (microTESE) as well as multiphoton microscopy, a novel tool that can aid in identification of sperm within the testis. 

Microsurgical testis sperm extraction is now a leading technique in harvesting sperm and confers many advantages. Challenges remain in improving yields, as a visually identified fat tubule may not necessarily bear sperm. In this video, the investigators demonstrate a promising technique using multiphoton microscopy to find tubules containing sperm during microsurgical testis sperm extraction. Should it be demonstrated safe and effective, it may be a significant step in the hunt to track down the ever-elusive testicular sperm.

 The Weill Cornell team demonstrates a novel approach to optimize chances of obtaining sperm in men with spermatogenic failure through microTESE. Dr. Schlegel, who pioneered this technique in 1999 and has the largest case series of microTESE cases, demonstrates meticulous tissue handling, operating in a bloodless field to optimize visual identification of dilated tubules that are more likely to contain mature sperm. The video then goes on to demonstrate an animal model of spermatogenic failure and the use of multiphoton microscopy to identify tubules containing sperm and, importantly, shows that this technique does not harm the sperm. Improvement of identification of sperm in microTESE would represent a major advancement in this technique and would allow more men with spermatogenic failure to have biologic children. We look forward to further work demonstrating the efficacy of this technique in humans. 

Sperm extraction: Two percutaneous techniques

In this video, the investigators demonstrate a promising technique using multiphoton microscopy to find tubules containing sperm during microsurgical testis sperm extraction.

Author | Philip S. Li, MD

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Vasectomy: Crucial steps for a bloodless procedure

Sperm extraction: MicroTESE and multiphoton microscopy