Use of the operative microscope marked a new era for microsurgery in male infertility and andrology in the 1970s. More than a decade has passed since the initial description of the first robotic-assisted microsurgical vasovasostomy. Large single-center series have recently been published on robotic-assisted microsurgery for vasectomy reversal, especially in the past few years. Multicenter studies are also beginning to be reported, and the potential for this new platform for microsurgery is starting to become more apparent. This article describes the basic technical details of robotic-assisted microsurgery in male infertility and andrology, and reviews the latest literature.
Key points
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The use of robotic assistance for microsurgery is still evolving.
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Early experiences seem to confer some benefits, and more data are developing from many institutions.
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As with any technology, the long-term feasibility and cost-effectiveness will be determined as further evaluation and randomized controlled studies are presented.
Introduction
The late 1970s witnessed 2 critical innovations in the treatment of infertility: (1) the operative microscope was introduced into male infertility microsurgical procedures, and (2) baby Louise was born as a result of the first use of assisted reproductive technology (ART). Since then, several developments have occurred in ART. However, the technology in microsurgical infertility procedures has not really progressed until recently with the use of the da Vinci robotic platform (Intuitive Surgical, Inc, Sunnyvale, CA) for microsurgical vasectomy reversal. Other disciplines, such as plastic surgery and hand surgery, have also explored the use of robotic assistance for microsurgical procedures.
Recent studies have shown that many microsurgical procedures for male infertility can be performed using the da Vinci robot. This article provides the tips and tricks of robotic-assistance for microsurgical procedures in the treatment of male infertility and andrology, and also reviews the latest literature.
Introduction
The late 1970s witnessed 2 critical innovations in the treatment of infertility: (1) the operative microscope was introduced into male infertility microsurgical procedures, and (2) baby Louise was born as a result of the first use of assisted reproductive technology (ART). Since then, several developments have occurred in ART. However, the technology in microsurgical infertility procedures has not really progressed until recently with the use of the da Vinci robotic platform (Intuitive Surgical, Inc, Sunnyvale, CA) for microsurgical vasectomy reversal. Other disciplines, such as plastic surgery and hand surgery, have also explored the use of robotic assistance for microsurgical procedures.
Recent studies have shown that many microsurgical procedures for male infertility can be performed using the da Vinci robot. This article provides the tips and tricks of robotic-assistance for microsurgical procedures in the treatment of male infertility and andrology, and also reviews the latest literature.
Robotic-assisted microsurgical vasectomy reversal
Vasectomy reversal is one of the most technically challenging procedures in urology (especially vasoepididymostomy). The operating microscope significantly improved outcomes of these demanding procedures. However, these techniques require dedicated training, experience and a skilled microsurgical assistant. Robotic-assisted microsurgical approaches with the da Vinci robotic platform can provide some advantages to overcome some of these caveats. Parekattil and colleagues reported comparable outcomes for robotic assisted microsurgical vasectomy reversal (RAVV) compared with the pure microsurgical technique. However, these outcomes were achieved in the robotic group without the need for a skilled microsurgical assistant, and also included the robotic procedures performed during the early learning curve, thus indicating that perhaps the learning curve was shorter with robotic assistance than with the pure microscopic technique.
Recommended Instruments and Materials
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da Vinci Si surgical robotic system
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Zero-degree robotic camera
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VITOM camera system (KARL STORZ GmbH & Co. KG, Tuttlingen, Germany)
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Black Diamond Micro Forceps (Intuitive Surgical, Inc) in left and right arms
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Potts scissors (Intuitive Surgical, Inc) in the fourth arm
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10-0 nylon sutures (Sharpoint, Surgical Specialties Corporation, Reading, PA)
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9-0 nylon sutures (Ethilon; Ethicon Endo-Surgery, Inc, Cincinnati, OH)
Technique and Outcomes
Both robotic and pure microsurgical approaches are performed with similar microsurgical principles. The 2 ends of the vas deferens are prepared through a scrotal incision and the proximal (testicular) vas fluid is assessed to see if any sperm are present. Robotic microsurgical vasectomy reversal is performed if sperm are found in the proximal vas deferens. If no sperm are found in the proximal vas deferens, robotic-assisted microsurgical vasoepididymostomy (RMVE) is then performed. The da Vinci robotic platform is docked on the right side with the patient in the supine position. Black Diamond Micro Forceps are used as needle drivers in the left and right arms, and the Potts scissors in the fourth arm is used to cut tied sutures ( Fig. 1 ). This configuration allows the surgeon to control 3 instruments, thus obviating the need for a skilled microsurgical assistant.
Suture materials and techniques are similar to those used in standard microsurgery. Eight to ten 9-0 nylon sutures are used for the muscularis anastomosis. Five to six double-arm 10-0 nylon sutures are used for mucosal lumen anastomosis ( Fig. 2 ). The two posterior 9-0 sutures are first placed to anastomose the posterior muscularis plate. Two 10-0 posterior sutures are then used to anastomose the posterior mucosal plate. Four to Five 10-0 anterior sutures are placed to complete the mucosal lumen anastomosis. Six to eight 9-0 nylon sutures are used to complete the anterior muscularis anastomosis.
In RMVE, 2 double-arm 10-0 sutures are used for vasal mucosal lumen to epididymal tubule anastomosis ( Fig. 3 ) using a longitudinal intussusception technique. The vasal muscularis layer is sutured to the epididymal tunica using six to eight 9-0 nylon sutures.
The 0 degree camera of the da Vinci robotic platform provides up to 12× to 15× magnification. The authors incorporate an additional camera system (VITOM) as a fifth arm to the da Vinci robotic platform to obtain better (up to 16×–20×) magnification (see Fig. 1 ; Fig. 4 ). The TilePro (Intuitive Surgical, Inc) robotic surgical console software system allows viewing of 3 simultaneous real-time images (see Figs. 2 and 3 ). This 5-arm robotic approach enables microsurgeons to perform challenging maneuvers, including ultrafine suture placement and knot tying at 2 different focal lengths (2 different camera views, each at a different magnification), without needing to zoom in and out. The simultaneous viewing capabilities also allow microsurgeons to evaluate seminal fluid or tissues without having to stop operating.
Santomauro and colleagues reported a 93% patency rates in 20 patients undergoing RMVV (18 bilateral RAVV, 2 unilateral RMVV). In this study, surgical residents (novice surgeons) were allowed to perform RMVV on one side, and the staff surgeon (experienced surgeon) performed the anastomosis on the contralateral side. No statistically significant difference in operative times was noted between the experienced and novice surgeons. This study illustrated that the robotic platform could potentially be used to decrease the learning curve for microsurgery.
Gudeloglu and colleagues recently published outcomes for 180 vasectomy reversal procedures (106 RMVV, 74 RMVE). In their series they reported 97% and 55% success rates in RMVV and RMVE procedures, respectively. Median operative durations (skin to skin) were also reasonable, at 120 minutes for RMVV and 150 minutes for RMVE.
Robotic-assisted microsurgery also allows for novel microsurgical approaches; it allows microsurgery to be performed in locations of the body that would otherwise be difficult to access with open and standard microscopic techniques. Trost and colleagues recently described the first bilateral intracorporeal robot-assisted microsurgical vasovasostomy in a patient who had bilateral iatrogenic vasal obstruction from prior bilateral inguinal hernia repair. The investigators reported a successful minimally invasive bilateral intracorporeal anastomosis. This procedure would have been very difficult and would have required a very large abdominal incision with standard microsurgical and open approaches. The robotic approach allowed the surgeon to perform this type of reconstruction successfully with only 4 small skin incisions (port sites, <1 cm each).
Related posts:
Advances in Robotic-Assisted Urologic Surgery
Emerging Technologies to Improve Techniques and Outcomes of Robotic Partial Nephrectomy
Robot-Assisted Surgery for the Treatment of Upper Urinary Tract Urothelial Carcinoma
Economics of Robotic Surgery
Models of Assessment of Comparative Outcomes of Robot-Assisted Surgery
Robot-Assisted Radical Prostatectomy
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