Adherence to american urological association (AUA) vasectomy guidelines: a systematic review of current practice among healthcare providers

To date, the only method for male contraception is a vasectomy procedure where the vas deferens is transected to prevent the passage of sperm to the semen during ejaculation permanently. In the United States, ~500,000 vasectomies are performed annually, and the number of procedures has been rising over the past decade [1, 2]. This trend has become more pronounced since the 2022 reversal of Roe v. Wade, which resulted in stricter abortion laws in many states [3, 4]. In the United States, urologists perform over 75% of the vasectomies, and approximately 90% of urology practices offer and perform the procedure [5, 6]. Although urologists perform the majority of vasectomies in the United States; in some regions of the country, up to 35% are performed by family physicians or general surgeons [6].

To ensure the highest quality care for patients undergoing vasectomy procedures, the American Urological Association (AUA) has established comprehensive guidelines for clinicians. These guidelines outline approaches and procedures designed to enhance patient understanding, improve outcomes, and minimize failure and adverse events. The guidelines were originally released in 2012 and were subsequently updated in 2015 [7].

Several studies have evaluated adherence to the AUA guidelines on the other various urological topics. For instance, Breyer et al. demonstrated a 95% utilization of clinical practice guidelines among urologists in the United States in general. In this study, which was based on data from the 2014 AUA census, utilization was assessed by a single question asking whether the participant utilized clinical practice guidelines or not [8]. However, the same results were not reproduced when investigating more specific guidelines. In 2019, a study surveyed members of the Society of Urologic Oncology on their adherence to the AUA guidelines for non-muscle invasive bladder cancer, revealed an average adherence rate of 71%. However, for low-risk cases, adherence dropped to 58%, resulting in an increased use of cytology, imaging, and surveillance cystoscopy beyond recommended levels [9].

The AUA vasectomy guidelines can be summarized in three main components: preoperative evaluation and counselling, surgical technique, and postoperative evaluation and determination of sterility [7]. Pre-operative evaluation includes counseling on risks, benefits, alternative contraception methods, and the importance of confirming vasal occlusion through post-vasectomy semen analysis (PVSA), along with a physical examination to determine suitability. The recommended surgical techniques emphasize the use of one of three methods for dividing and occluding the vas deferens. These methods have a demonstrated failure rate of less than 1%. The statements also recommend against routine histological examination of the excised vas segments. Post-operative care involves providing instructions for recovery and the need for continued contraception until semen analysis confirms successful vasectomy, typically eight to sixteen weeks after the procedure.

The AUA recommends a PVSA to be done in 8–16 weeks [7]. A successful vasectomy is defined by a one well-mixed, fresh, uncentrifuged semen analysis showing azoospermia or only rare non-motile sperm < 100,000/ml. The definition of failure is the presence of any motile sperm in the PVSA at six months post-vasectomy. Different society guidelines have reported similar but slightly different definitions to PVSA screening [10].

Non-adherence to AUA vasectomy guidelines can lead to several negative consequences. Patients who are unaware of or fail to adhere to PVSA recommendations may experience unintended pregnancies. Healthcare providers who do not adhere to guidelines may face increased liability and contribute to unnecessary healthcare costs by performing unnecessary PVSAs.

This paper aimed to review the literature for studies that analyze adherence to the AUA vasectomy guidelines. We also included studies that evaluate the impact of these guidelines on urology and non-urology practices, as well as those that report practices deviating from the guidelines.

The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We performed a comprehensive literature search using the PubMed, Embase, and Scopus databases for studies published after the release of the AUA vasectomy guidelines in 2012. Our search terms included “vasectomy procedure,” “AUA guidelines,” “compliance,” and “adherence.” One researcher, MM, screened the titles, abstracts, and full texts of the retrieved studies.

Studies that examined adherence and compliance to any of the three aspects of AUA vasectomy guidelines, evaluated the impact of these guidelines on urology and non-urology practices, or reported practices deviating from the guidelines were included. Studies published before 2012, those not written in English, and those not assessing vasectomy procedures’ practice were excluded.

Two reviewers, MAMH and EAC, independently collected and assessed data from the included studies. The extracted data included the area of vasectomy practice discussed in the study (pre-procedure counseling, surgical technique, or PVSA), the reported results, and the degree of adherence to AUA guidelines.

Our Institutional Review Board (IRB) approval was not required. The findings were summarized in a table highlighting trends in adherence and common deviations, providing an overview of the alignment between clinical practices and AUA recommendations.

A comprehensive electronic search and literature review yielded 138 results (Fig. 1). After screening titles and abstracts, 116 irrelevant articles were excluded. Of the remaining 22 articles, 4 were excluded as they were review or commentary articles. Eight additional studies, which discussed aspects of the guidelines but did not assess adherence or deviations, were also excluded. Ten articles met the inclusion criteria and were included in the systematic review. Five assessed adherences to the AUA vasectomy guidelines [11,12,13,14,15] (Table 1), and five evaluated the use of home-based PVSA [16,17,18,19,20] (Table 2).

Preferred reporting items for systematic reviews and meta-analysis flow diagram.

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Adherence to the statements of AUA vasectomy guidelines

Of the five studies that assessed adherence to the AUA guidelines [11,12,13,14,15], only one evaluated adherence to all three aspects of the guidelines, including pre-procedure counseling, surgical technique, and PVSA [12]. The remaining four focused solely on the practice of PVSA [11, 13,14,15].

Posielski et al. and Shapiro et al. found that urologists demonstrated better adherence to AUA guidelines compared with family medicine providers (FMPs) [11, 12]. However, even among urologists, adherence to PVSA guidelines was not consistently optimal. Manka et al. found that while the frequency of repeated PVSAs has decreased after 2013, there remains a significant disparity between the recommended guidelines and actual clinical practice [13]. Padmanabhan et al.’s survey revealed low adherence to PVSA recommendations among AUA members [14]. Finally Chen et al. study revealed 32% reduction in the number of men requiring multiple PVSA following the guidelines release [15].

The use of home-based PVSA test

Five studies were included that evaluated the compliance to home-based PVSA, a method that involves collecting semen samples at home and mailing them for analysis. This approach is not currently endorsed by the AUA guidelines [16,17,18,19,20]. Compliance was defined as purchasing the home-based PVSA kit as instructed and/or returning it back by mail for analysis [16,17,18,19,20]. Conflicting results were found regarding the compliance to this alternative test compared to traditional office-based PVSA across the five studies. While Kiessling et al. reported high compliance (89%) [16], the other studies have shown varying levels of compliance. Welliver et al. found lower compliance with home-based testing [17], while Atkinson et al. reported higher compliance [18]. In contrast, Trussler et al. and Punjani et al. found no significant difference in compliance between the two methods [19, 20].

Across all of the studies examined, which primarily focused on PVSA, adherence to the AUA guidelines varied. Overall, urologists exhibited greater adherence to the guidelines compared to other healthcare providers performing the procedure. However, the adherence rates were still suboptimal. There is a dearth of studies evaluating adherence to the other key components of the AUA guidelines, namely pre-procedure counseling and surgical technique.

The AUA guidelines for vasectomy offer comprehensive recommendations to both urologists and non-urology providers who perform the procedure. The statements of the guidelines are based on the best evidence in the literature and on expert panel [7]. We sought to review the literature for the studies measuring the level of adherence to these guidelines.

Despite the AUA guidelines addressing three key aspects – pre-procedure counseling, surgical technique, and PVSA practice – most of the studies identified, with the exception of one, only evaluated adherence to PVSA recommendations. This indicates that the compliance with pre-operative counseling regarding instructions and procedure details, as well as with the recommended surgical techniques that ensure the lowest failure rate, remains undetermined.

In their article, Posielski et al. compared the post vasectomy practice pattern between urologists and FMPs among 4 094 vasectomy patients and the impact of AUA guidelines release on such practice [11]. They found that 43.1% of urologists and 42.7% of FMPs ordered multiple PVSA before the 2012 guideline release. Afterward, the number of urologists ordering multiple PVSA significantly decreased to 28.9%, whereas the decline among FMPs was less pronounced (from 47.5–38.4%). Additionally, the timing of PVSA orders changed post-guideline. Urologists shifted from a median of 14 weeks to an earlier time frame, while FMPs delayed from 12.6 weeks but they continued to obtain PVSAs before 8 weeks. These findings suggest less penetration of AUA guidelines to non-urology specialties, potentially due to limited awareness of the guidelines or insufficient access to relevant resources. A similar finding was reported in a study by Hyman et al. which explored suspected variations in AUA vasectomy guideline exposure and adherence between urologists and non-urologists [21]. The study found that the publication of the guidelines led to a 1.5% increase in the percentage of men counseled by urologists who subsequently underwent vasectomy between 2012 and 2015. This suggests improved adherence to guideline recommendations and increased utilization of vasectomy among urology patients. While urologists demonstrated improved compliance with the guidelines, as evidenced by changes in their practice, their adherence remains incomplete. Further efforts are necessary to enhance their adherence to the guidelines.

The other study by Shapiro et al. who conducted a survey among urologists and FMPs at a single institution to evaluate their adherence to AUA guidelines for vasectomy procedure, including the three guidelines aspects revealed that FMPs discussed fewer pre-procedure topics with patients compared to urologists, such as the abstaining from ejaculation for one-week post-vasectomy, the potential for scrotal pain, and the risk of pregnancy following the procedure [12]. The study found that FMPs were significantly more likely than urologists to send a segment of the vas deferens for histopathological analysis (65% vs. 17%, p = 0.02). Furthermore, there was a discrepancy in the number of negative PVSAs required to discontinue alternative contraception; while all urologists recommended only one, 65% of FMPs required at least two. When presented with clinical scenarios, most urologists demonstrated adherence to AUA guidelines, whereas the majority of FMPs did not. This was the only study that looked into the adherence related to the pre-procedure counseling and surgical technique. However, it is important to note that the sample size of the survey was relatively small, with only 23 urologists and 6 FMPs participating. This may have limited the statistical power of the study and potentially affected the accuracy of the conclusions.

Manka et al. analyzed PVSA practices between 2013 and 2017 among urologists and nonurologists who performed over 4 827 vasectomy procedures [13]. The study observed a decline in the frequency of repeated PVSAs after the publication of the guidelines. However, there was still a significant non-adherence to the AUA guidelines, with 72% of repeat PVSAs performed unnecessarily. While 58.2% of patients were azoospermic on the first analysis, many underwent redundant testing, leading to unnecessary healthcare costs. The study also found that many patients with motile sperm, who should undergo repeat PVSA, did not do so, indicating undertesting as well. Like many retrospective studies, this study has limitations, such as the inability to obtain complete clinical data related to the procedure. Nonetheless, it underscores the need for enhanced provider education to improve adherence to guidelines and minimize unnecessary testing.

Padmanabhan et al., in their survey of AUA members, assessed adherence to five specific different clinical practice guidelines, one of them is the PVSA [14]. While an overall adherence rate of 72.7% was observed for the different guidelines, the timing of PVSA exhibited the lowest adherence, at 53.33%. Insurance coverage issues and disagreement with the guidelines were identified as the primary barriers to adherence. To address these challenges, the study suggests implementing strategies such as email reminders, simplified guideline formats, and integration into electronic medical records to enhance dissemination and improve adherence. These are an important solution; however, it is important to note that the survey response rate was low, with only 10.6% of members participating, and only 6.0% responding to all questions regarding AUA guidelines which could be a source of systematic bias.

Chen et al. analyzed a database of 87 201 men to assess the impact of the 2012 AUA guidelines on national vasectomy follow-up practices. The findings demonstrated that the publication of the guidelines resulted in a decrease in the number of men requiring multiple PVSA procedures [15]. The likelihood of needing more than one PVSA declined from 39% in the pre-guideline years (2007–2012) to 31.1% in the post-guideline period (2013–2015). This reduction indicates improved adherence to the updated guidelines, enabling a reduction in testing while maintaining clinical efficacy. Nonetheless, further enhancement of adherence would be beneficial.

While the AUA guidelines for PVSA stipulate that a fresh semen specimen should be examined within two hours of collection [7], requiring patients to schedule an appointment with the surgeon’s office or a clinical laboratory, many healthcare providers have recently adopted a practice of home-based testing. Conflicting results were found regarding the test compliance in the studies evaluating the use of home-based PVSA [16,17,18,19,20].

The heterogeneity of home-based tests used in different studies and the different definitions of compliance, in addition to the retrospective studies design, limits our ability to draw definitive conclusions on the benefits of home-based PVSA. While these studies may prompt discussions about including home-based PVSA in the guidelines, it is crucial to carefully consider both its potential advantages and disadvantages before incorporating it into future recommendations.

Limitations

While this review provides valuable insights into the adherence of the health care providers to AUA vasectomy guidelines, it is important to acknowledge its limitations. The number of studies is limited, particularly those assessing adherence to pre-procedure counseling and recommended surgical techniques. Additionally, some of the included studies had small sample sizes, low response rates to surveys, and heterogeneity in the definition of compliance for home-based PVSA tests. Further research is needed to address these limitations and provide a more comprehensive assessment of adherence to AUA vasectomy guidelines.

This review demonstrates that while urologists generally adhere to the AUA vasectomy guidelines, adherence remains incomplete, particularly for PVSA. Future research should focus on addressing these gaps and evaluating the potential benefits and limitations of home-based PVSA. By enhancing adherence to the guidelines, we can improve patient outcomes and reduce unnecessary healthcare costs associated with vasectomy procedures.