MadaJet: How many applications per patient is ideal?

The oldest documentation of use of the MadaJet for vasectomy (left) is in the older versions of the booklet sold by Mada with the MadaJet over a decade ago. The MadaJet was invented by Ralph Adam (now deceased) in 1969. Bob Sorbello has worked with Mada since 1997 and this diagram was already in the booklet then. It implies that 4 applications were administered on the lateral aspect of each side of the scrotum, so it may have been used for the "traditional technique" even prior to the introduction of the NSV technique around 1990.

In Charles Wilson's description of the use of the MadaJet for vasectomy in 2001, he reported using only 1 application per vas for anesthesia adequate to complete the vasectomy without supplemental anesthesia in 90% of cases.

Ron Weiss's 2005 Journal of Urology article described use of the MadaJet 2-3 times for each vas.

My routine protocol has been 2 applications on each side, the right vas 2-3 mm to the left of midline (4-5 mm from each other), then the left vas 2-3 mm to the right of midline. The tips of the ring clamp are applied at the inferior pair of MadaJet marks, and the entry site is in the center of the box created by the 4 marks.

Recently, I decided to try one application on each side. I had tried before with limited success, but thought it was worth another try for the reasons that follow.

While prevention of pain is the utimate goal, there are benefits to minimizing the number of MadaJet applications:

1. Sometimes a small (usually grape-sized) hematoma occurs after use of the MadeJet. This makes the vasectomy more difficult and usually intensifies and prolongs post-vasectomy discomfort. This may occur less frequently when fewer applications are used.
2. Sometimes the MadaJet fires a powerful stream of anesthetic through the scrotum and into the supporting finger of the operator. This usually occurs when the MadaJet is cocked at an angle (drawing air into the cylinder) especially when the device is nearly empty. To cock the MadaJet for the second application of a certain side, the operator catches the cocking lever on the hand supporting the vas and lifts the MadaJet to complete the process. This is more likely to occur at an angle than if the MadaJet is held upright and cocked with two hands, and therefore more likely to result in an emission powerful enough to penetrate the support finger. Using the MadaJet only once on a side frees the support hand to cock the MadaJet upright.
3. Operators with many patients in series sometimes don't notice when the MadaJet is nearing empty, making them vulnerable to injury. Given a series of many patients, the MadaJet will not near empty as often if fewer applications are used per patient.
4. There is an obvious savings with use of less anesthetic.
5. With fewer firings, the MadaJet may experience less wear and tear and require service at longer intervals.
6. Fewer applications means less time per case; seconds granted, but they add up on a busy day, and patients like quick vasectomies.

... sometimes.

On Day 1, I did 8 cases using the MadaJet only once on each side without supplementing one patient. (Yay!!) I was using a "soft" MadaJet. It did not fire with a brisk click and there was not much recoil.
However, on Day 2, using a different MadaJet (I own 8 MadaJets and each has its own "feel"), I had to supplement the skin (not the vas) for 4 of my first 6 patients! (Booo!) That's when I switched to 3 applications. The first is applied to one vas at the midline, the second to the same vas below and a bit to one side. The third is applied to the other vas across the midline from the second appllication site, creating a triangle ... like this:

After switching to 3 applications, no other patient on Day 2 required a supplement.
On Day 3, with a 3rd MadaJet, I used this 3-shot (triangle) technique for 25 cases (I was in a busy outfield office and did not want to take a chance on needing to supplement). Not one patient had any more than the slightest twinge of sensation ... no supplements. (Three additional men where so anxious that I did not want to take a chance on having inadequate skin anesthesia, so I utilized 2 applications on each side [box technique].)

Take-home Message: MadaJets are Not All Created Equal

MadaJets with a softer feel when fired are less robust with regard to tissue penetration, but seem to deposit more anesthetic in the skin. The MadaJets with a feistier feel penetrate better, but may not provide as wide an anesthetic circle in the skin. So if you own only one MadaJet and cannot get by with one application on each side, and if you need to use the MadaJet twice on one side (triangle method) or twice on each side (box method) to prevent the sensation of skin pinching or poking when spreading the skin, you are not doing anything wrong. You may just have a strong MadaJet that penetrates the skin without leaving much anesthetic within the skin.
However, if your patients are feeling squeezing of the testis after one or even two applications of the MadaJet to each vas, you may need to send your MadaJet to Mada for service and adjustment to a stronger setting.

And when use of the MadaJet produces a skin wheal, remember that even the strongest MadaJets sold for vasectomy may not be able to penetrate the thick leathery skin of some men, so keep those back-up syringes handy! And use them before mild discomfort turns into pain.