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DITORIAL COMMENTingh et al1 suggest that many men view delayed sterility as arawback to a vasectomy, and the authors therefore recom-ended an intraoperative vas flush with 30 mL of sterile water

s a more rapid way to clear the sperm from the abdominal vas.ased on these data, the authors advocated routine adoption of

his procedure. However a vas flush is not new, and data fromarlier studies have been contradictory.2

Mumford and Davis3 reviewed the results of flushing witharious agents, including some that were spermicidal, but noneeemed clearly superior in achieving early sterility. Craft and

cQueen4 determined that 3 mL of solution completely filledhe vas and seminal vesicle and that 10 mL spilled into theladder. Although the volume in other vas flush studies rangedetween 10 and 40 mL, none demonstrated a clear advantage.n other studies, the number of postvasectomy ejaculates weresually unequal among the study groups, which represented aotential source of bias; but the men in each group of theurrent report had similar numbers of ejaculates. The currentata revealed a 20% advantage for sterility at 4 weeks and a0% advantage at 8 weeks; however, by 12 weeks post vasec-omy, there was no significant difference in the percentage ofterile men with or without a flush.

As there was no survey to address the question of whether a- to 6-week delay in sterility represented a drawback to aasectomy, how does one interpret these data? There is infor-ation from a specific survey completed by men who had a

asectomy: 25.4% of their wives were on birth control pillsefore the vasectomy, and 26.6% of the men were using con-oms.5 It would seem that a percentage of this group couldontinue their current method of contraception without hard-hip for 1 more month. Perhaps a vas flush should be limited toen who had difficulty with their current method of contra-

eption, or to those who were not using contraception at all.After a vasectomy, there are known complications, and the

as flush may add others. A small percentage of these men mayevelop hematospermia from either the vasectomy or the vasush, with the potential for tissue damage from the latter.6 Inddition, infection has been reported after a vas flush.7 As%-6% of men seek a reversal after a vasectomy, mucosalamage and scarring may prevent successful reconstruction.owever, this matter still remains hypothetical, because there

s no evidence in the literature regarding the outcome of a vaseversal after a vasectomy with a vas flush.

For follow up, the authors used spun semen analyses in all cases,hereas other studies recommend a spun sample only to confirm

terility in whole semen.8 Therefore, the protocols for post-vasec-omy semen analyses remain variable. The authors suggest that theas flush should be used routinely for all vasectomies, but based onheir data and information from other reports, this procedurehould probably should be used very selectively.

oel L. Marmar, M.D., Division of Urology, Robert Woodohnson Medical School at Camden & Cooper Universityospital, Camden, New Jersey

eferences. Singh D, Dasila NS, Vasudeva P, et al. Intraoperative distal vasal

flushing: does it improve the rate of early azoospermia following ano-scalpel vasectomy? A prospective, randomized, controlled study.

Urology. 2010;76:343-348. p

ROLOGY 76 (2), 2010

. Mason RG, Dobbs L, Swami SK. Sterile water irrigation of the distalvas deferens at vasectomy: does it accelerate clearance of sperm? Aprospective randomized trial. Urology. 2002;59:424-427.

. Mumford SD, Davis JE. Flushing of distal vas during vasectomy.Urology. 1979;14:433-441.

. Craft I, McQueen J. Effect of irrigation of the vas on postvasectomysperm counts. Lancet. 1972;1:515-516.

. Martinez GM, Chandra A, Abma JC, et al. Fertility, contraceptionand fatherhood: data on men and women from cycle 6 of theNational Survey of Family Growth. National Center for HealthStatistics. Vital Health Stat. 2006;23:26.

. Edwards IS. Vasectomy: irrigation with euflavine. Med J Aus. 1977;1:847-849.

. Quhart-Hay D. Immediate sterility after vasectomy. Br Med J. 1973;3:378-379.

. Hancock P, McLaughlin E. British Andrology Society guidelines forthe assessment of post vasectomy semen samples. J Clin Pathol.2002;55:812-816.

oi:10.1016/j.urology.2010.02.066ROLOGY 76: 345, 2010. © 2010 Elsevier Inc.

EPLYe thank the editor for his thoughtful comments. We agree

hat vasal flush is not a new thing and that data from earliertudies are contradictory; therefore we have tried to resolve thisssue by performing a large, properly randomized, controlledrial. Roshani et al, in a recent study of 126 patients, alsoeported significantly higher azoospermic rates of 100% at 12eeks and 88.1% at 16 weeks in patients who underwent distalasal flushing with 40 mL of sterile water and saline solution,espectively, when compared with patients without vasal flush-ng (26.2% azoospermic at 16 weeks).1 For vasectomy with vasrrigation, no conclusions can be made based on previouslyublished studies, as those studies were of poor quality, rela-ively small, and therefore underpowered.2 None of the thosetudies mentioned about the method of semen analysis (spun vs.nspun sample) except, Mason et al 2002 used centrifugedemen sample for postvasectomy semen analysis.

Allocation concealment and participant or outcome assessorlinding were not described in the study by Mason et al 2002.3

he number of men randomized into each group, and theumber of men in each group excluded after randomizationecause of semen analysis protocol violation was also not re-orted. Inadequate allocation concealment and exclusion ofarticipants after randomization may result in bias.4,5 In othertudies, the number of postvasectomy ejaculates were usuallynequal among the study groups, which represented a potentialource of bias, but the men in each group of our study hadimilar numbers of ejaculations.

We agree that no formal survey was done in the present studyo address the question of whether a 4- to 8-week delay interility represented a drawback to a vasectomy; but we have aarge amount of NSV experience, and many of our clients (morehan 50%) raised concerns about the long duration of postva-ectomy condom use. Vasal flushing may also reduce, to somextent, the chances of unwanted pregnancies in uneducated,oor, and neglected communities of developing countries inddition to increasing the acceptance rate for vasectomy andeducing the monthly cost of barrier methods.

We agree with the editor that, after a vasectomy, there arenown complications, and the vas flush may add others. A small

ercentage of these men may develop hematospermia from either

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he vasectomy or the vas flush, which are usually self-limiting.owever we have not found any significant difference regarding

he rate of complications between vasectomy with and withoutasal flushing. Regarding the concern that vasal flushing induceducosal damage and that resultant scarring may prevent successful

econstruction, this concern is only hypothetical, as there is noupportive evidence in the literature.

For follow-up semen analyses, similar to other studies,6 weave used a spun sample only to confirm sterility after a testith whole semen. Samples with no sperm (azoospermia) on

he initial unspun semen analysis were centrifuged for 15 min-tes at 600 g and then reassessed for sperm concentration andotility. The simple reason is that direct spun sample semen

nalysis will not be cost-effective.Based on our data, we have concluded that distal vasal

ushing with 30 mL of sterile water may shorten the time tozoospermia for 20% to 30% of vasectomy patients. Thus thisrocedure may be an option for some patients who choose vasalush to avoid the long duration of postvasectomy alternatativeontraceptive methods.

haramveer Singh, M.B.B.S., M.S., M.Ch. (Urology),andan S. Dasila, M.B.B.S., Divakar Dalela, M.B.B.S.,.S., M.Ch. (Urology), Satyanarayan Sankhwar,.B.B.S., M.S., M.Ch. (Urology), Apul Goel, M.B.B.S.,.S., M.Ch. (Urology), D.N.B. (Urology), and Anjanaingh, M.B.B.S., Centre of Excellence for no-scalpel

asectomy (approved by Ministry of Health and Family U

46

elfare, Government of India), Department of Urology,SM, Medical University (Upgraded King George’s Medicalollege), Uttar Pradesh, India

eferences

. Roshani A, Falahatkar S, Khosropanah I, et al. Vasal irrigation withsterile water and saline solution for acceleration of postvasectomyazoospermia. Urol J. 2008;5:37-40.

. Cook LA, Van Vliet HAAM, Lopez LM, Pun A, Gallo MF. Vasec-tomy occlusion techniques for male sterilization. Cochrane DatabaseSyst Rev. 2009; issue 1; article no. CD003991. 10.1002/14651858.CD003991.pub3.

. Mason RG, Dodds L, Swami SK. Sterile water irrigation of the distalvas deferens at vasectomy: does it accelerate clearance of sperm? Aprospective randomized trial. Urology. 2002;59:424-427.

. Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidenceof bias. Dimensions of methodological quality associated with esti-mates of treatment effects in controlled trials. J Am Med Assoc.1995;273:408-412.

. Schulz KF, Grimes DA. Sample size slippages in randomized trials:exclusions and the lost and wayward. Lancet. 2002;359:781-785.

. Hancock P, McLaughlin E. British Andrology Society guidelines forthe assessment of post vasectomy semen samples. J Clin Pathol.2002;55:812-816.

oi:10.1016/j.urology.2010.03.031

ROLOGY 76: 345–346, 2010. © 2010 Elsevier Inc.

UROLOGY 76 (2), 2010