and ultimately reducing the number of repeat

vasectomies.

Of the 1,740 vasectomies performed only 972 men

(55.9%) returned for at least 1 PVSA. Several pre-

vious studies showed a signiFcant noncompliance

rate of men returning for the recommended PVSA,

comparable with our cohort.

9,20,21

±or example, in a

series of 1,892 consecutive vasectomies 34% of men

did not return and 33% returned for only 1 of 2 rec-

ommended PVSAs.

Another series of 1,029 vasec-

tomies showed that only 54.4% of men returned for 2

recommended PVSAs.

Compliance is higher if a

followup appointment is made by the ofFce.

The

primary issue identiFed in studies of post-vasectomy

followup compliance is failure to return for addi-

tional PVSAs when sperm are found in the initial

sample. Our data indicate that subsequent PVSAs

are rarely required under the new guidelines.

Although 3 patients in our cohort underwent

repeat vasectomy for persistent RNMS, the putative

vasectomy failure was established by centrifuged

pellet analysis. Based on the current guidelines all

3 patients would have avoided repeat vasectomy.

Even after repeat vasectomy 2 men continued to

have RNMS in the ejaculate, while the other did

return for PVSA after repeat vasectomy. These re-

sults suggest that RNMS after vasectomy arise from

the distal or abdominal side of the vas deferens, the

ampulla of the vas deferens or the seminal vesicles.

To our knowledge no evidence shows that RNMS

indicate a persistently patent vas deferens or

recanalization.

Using class C evidence the 2012 AUA vasectomy

guidelines recommend that the vas should be

occluded by mucosal cautery with fascial interposi-

tion and without clips, mucosal cautery without

fascial interposition and without clips, open ended

vasectomy with fascial interposition and mucosal

cautery on the abdominal end or the nondivisional

method of extended electrocautery.

In our study

100% contraceptive success was achieved by re-

moving a vasal segment and applying clips without

fascial interposition. The guidelines include a

caveat that vasal occlusion with clips with or

without fascial interposition and with or without

excision of a vasal segment may be performed by

experienced surgeons. At our center conventional

vasectomy has been performed with removal of a

vasal segment, application of clips to each end and

without

fascial

interposition

for

decades

with

excellent results.

Our study revealed that 896 PVSAs would have

been avoided under the guidelines with an esti-

mated cost savings of $134,400. Thus, by deFning

vasectomy success as 2 sequential azoospermic

PVSAs with concurrent pellet analysis 46.5% more

PVSAs were performed in our cohort than if the

criteria of the guidelines had been used. In contrast

to British Andrology Society guidelines, which

also recommend 2 consecutive azoospermic PVSAs,

a prospective study of 832 men in the United

Kingdom reported a cost savings of 40% by only

requiring

PVSA

without

compromising

the

outcome.

We similarly present a potential cost

savings of 46.7% by following the AUA vasectomy

guidelines and including RNMS in the deFnition of

occlusive success, also without a change in the

contraceptive success rate.

CONCLUSIONS

The AUA vasectomy guidelines provide clear,

evidence-based criteria to determine vasectomy

success, which include azoospermia or RNMS in a

single uncentrifuged PVSA. The guidelines simplify

followup protocols, improve patient compliance and

save cost and time by avoiding unnecessary subse-

quent PVSAs and repeat vasectomy.

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