Robotic Microsurgery for Male Infertility

Fig. 10.1

Operative setup for robotic microsurgery cases

The robot is brought in from the right side of the patient in all our cases. Figures 10.1 and 10.2 illustrate the trocar placement and robotic arm placement. Trocars are loaded to allow the instruments to function and to stabilize their movements outside the patient’s body. To optimize range of motion the instruments should be advanced 4–5 cm beyond the tip of the trocar. The fourth robotic arm may be placed lateral to the left robotic arm to minimize instrument clashes. A zero degree camera lens is used to optimize the visual field. An additional fifth arm (nitrogen powered, Karl-Storz, Inc., Tuttlingen) is utilized to hold a high definition camera (VITOM, Karl-Storz, Inc., Tuttlingen) with enhanced optical magnification (16–18×) that provides the surgeon dual enhanced magnification views in the surgeon console (Fig. 10.3). This provides the surgeon with dual views of the operative field. If the case requires microscopic examination of fluid or tissues (for example examining the fluid from the proximal vas in a vasectomy reversal or examining tissue for any sperm in micro-TESE), an additional view of the microscopic field from the andrologist/embryologist’s microscope can also be fed into the surgeon console so that the microsurgeon has all three views simultaneously as shown in Fig. 10.3.

Fig. 10.2

Trocar, robotic arm, and VITOM camera placement

Fig. 10.3

Tri-view for the robotic microsurgeon in the surgeon console

Robotic-Assisted Microsurgical Vasovasostomy

Technique

The proximal and distal (beyond the previous vasectomy site) vas deferens is palpated through the scrotal skin. Through the scrotal skin the distal vas is fixed into place with a towel clip. Local anesthesia is infiltrated into this area (Fig. 10.4). Using a #15 blade a 1–2 cm vertical incision is made over the vas starting inferiorly from the previously placed towel clip. Using fine electrocautery and sharp dissection the distal and proximal ends of the vas are dissected free (Fig. 10.5).

Fig. 10.4

Securing the left-sided previous vasectomy site and infiltration of local anesthesia

Fig. 10.5

Dissection out the proximal and distal ends of the vas deferens

The proximal vas is carefully transected with an #11 blade. Efflux from the lumen is expressed and collected on a glass slide. Phase contrast microscopy is used to assess for the presence of sperm on the slides. If there is any sperm found or the efflux is copious and clear or milky, then a vasovasostomy is performed. If the efflux has no sperm and is thick and pasty, then a vasoepididymostomy is performed (described in the next section). The distal end of the vas is now transected. The two clean ends of the vas are now approximated to each other to confirm a tension-free anastomosis. The adventitia from either end of the vasa is now secured together with a 3-0 prolene suture to create a tension-free anastomosis.

The robot is now positioned to perform the microsurgical vasovasostomy. The left side vasovasostomy is generally performed first. Black diamond micro-forceps are loaded on the right and left robot arms. The zero degree camera lens is loaded onto the robot camera arm. The micro-Potts scissors are loaded onto the fourth robot arm. The two ends of the vas are placed over a 1/4″ Penrose drain. The assistant irrigates the field with saline using a 10 cc syringe with an 18-gauge angiocatheter tip. Weck sponge sticks are used to dry the field.

The assistant now passes the 9-0 nylon suture that is kept in its inner packaging to the surgical field. The suture is grasped using the black diamond right hand grasper and cut to about 2 in. length using the micro-Potts scissors (left hand fourth arm). The 9-0 nylon suture is held and manipulated using the black diamond forceps in both left and right arms as needle drivers. Posterior muscularis layer of the two ends of the vas is now approximated (Fig. 10.6). Suture is cut using the micro-Potts scissors.

Fig. 10.6

Posterior 9-0 Nylon sutures to reapproximate the posterior muscularis layer

Two or three double-armed 10-0 nylon sutures are now placed to reanastomose the posterior mucosal lumen of the vas (Figs. 10.7 and 10.8). The sutures are placed inside out to ensure good mucosal approximation. All sutures are placed before they are tied.

Fig. 10.7

Posterior 10-0 nylon sutures placed to reapproximate the vasal lumen (illustration)

Fig. 10.8

Posterior 10-0 nylon sutures placed to reapproximate the vasal lumen (Intraoperative image)

Three double-armed 10-0 nylon sutures are used to close the anterior mucosal lumen of the vas. Five to six 9-0 nylon sutures are used to approximate the anterior muscularis layer of the vas. The Penrose drain is gently removed from under the repair. The vas is placed back into the scrotal cavity. The same procedure is now performed on the contralateral right side by repositioning the robot away from the patient to the right scrotum.

The dartos layer is closed using a running 3-0 chromic suture. The skin is closed using a 5-0 vicryl running suture. Bacitracin ointment is applied over the incision. Fluff dressing with athletic scrotal support is applied. An ice pack is carefully applied to the scrotum in the recovery room.

Robotic-Assisted Microsurgical Vasoepididymostomy

Technique

The robotic vasoepididymostomy procedure starts from above if there is no sperm in the fluid from the proximal vas and the fluid is thick and pasty. The scrotal incision is enlarged by another 1–2 cm inferiorly. The testicle is delivered and the tunica is incised to expose the epididymis. The adventitial layer of the epididymis is incised above the level of epididymal obstruction (blue/gray zone with dilated epididymal tubules above this area). A 3-0 prolene suture is utilized to approximate the adventitia of the epididymis to the muscularis of the vas to prevent tension between the anastomosis. The robot is now positioned to perform the microsurgical vasoepididymostomy as described earlier. The black diamond micro-forceps are loaded on the right and left robot arms. The zero degree camera lens is loaded onto the robot camera arm. An ophthalmologic microblade is held in the fourth arm with black diamond micro-forceps or a Potts scissor may be used in the fourth arm. Two 10-0 nylon double-armed suture needles are placed longitudinally through a single epididymal tubule to expose the tubule (Fig. 10.9). This tubule is then incised longitudinally using the microblade between the two suture needles to create a lumen in the tubule. Alternatively, the tubule may be incised with a Potts scissor in the fourth robotic arm. The fluid is then aspirated (Fig. 10.10) and then examined under a separate phase contrast microscope for the presence of sperm.