Robotic Surgery In Male Infertility And Chronic Orchialgia

Main Category: Fertility
Also Included In: Urology / Nephrology
Article Date: 19 Mar 2010 - 5:00 PDT


UroToday.com - The perceived benefits of robotic surgery in terms of elimination of tremor, field magnification, motion scaling, ergonomic surgeon controls and ergonomic surgeon posturing are likely to have an even greater impact in the field of microsurgery than laparoscopy. When the standard of care in microsurgery gradually migrated to the use of an operating microscope over standard visual loop magnification, there was a great deal of argument in terms of increased cost. However, a number of studies consolidated the improved outcomes by the use of the microscope in procedures such as vasectomy reversal and sub-inguinal varicocelectomy.1-4 The question now is, does robotic assisted microsurgery provide a significant enough improvement over already refined pure microsurgical outcomes to justify the tremendous increase in cost?

Our article in Current Opinions of Urology presents our preliminary review of outcomes of 69 robotic microsurgical cases (vasectomy reversal, sub-inguinal varicocelectomy and denervation of the spermatic cord) and also presents a prospective randomized control trial in a canine model for varicocelectomy (the canine study showed a significant decrease in operative duration for robotic versus pure microscopic). The robot is merely used in lieu of the microscope for these procedures - so the initial dissection and preparation of tissues are done identical to the microscopic technique. We currently have performed over 200 robotic assisted microsurgical procedures. The operative duration seems to be significantly decreased in the robotic reversals versus the pure microscopic. Even though the mean sperm count, concentration and motility in the post-op semen analysis evaluations are higher in the robotic group vs. the microscopic - these were not significant. The operative duration for a robotic assisted microsurgical subinguinal varicocelectomy or denervation of the spermatic cord for chronic orchialgia can be as low as 15-20 minutes now. Our microsurgical operative efficiency has significantly improved with the use of the robotic system. We were routinely able to perform about 2 microsurgical procedures a day before the introduction of the robotic system (the primary surgeon would usually fatigue after about 6 or 7 hours of tedious pure microsurgery). Now, we have been able to perform up to 6 or 7 cases a day with dual robotic rooms in the same workday period without significant surgeon fatigue. The improved efficiency, ease of operating, decreased operative times and increased volume may balance out the increase in disposable and maintenance costs over the microscope. But, there still is the issue of the difference in the initial purchasing investment. If the facility already has a robot and it is not being fully utilized, then this would not be as much of an issue.

Operating efficiency most likely results from the ability of the microsurgeon to control multiple instruments simultaneously (camera and three instruments). This really decreases dependence on a skilled assistant. It allows for the fluid motion of tasks with minimal interruption. It also allows for some very unique maneuvers - for example, when performing an intussusception end-to-side vasoepididymostomy, usually two curved double arm needles are placed in the epididymal tubule. The surgeon then comes in with a fine scissor or blade to incise the tubule. In the robotic platform, the microsurgeon can actually hold and elevate these two needles to further expose the tubule and then bring in the fine scissor with the fourth arm to incise the tubule with absolute stability and no motion artifact. This is a maneuver that is just not possible using the fingers alone in microsurgery. Use of the fourth arm for real-time Doppler monitoring of the arterial vessels during varicocelectomy or denervation procedures is very helpful.

One caveat is that the robotic platform currently only allows approximately 10-15x magnification on the High Definition systems (with digital zoom). However, there is a 100x digital camera that can be used in conjunction with the regular optics via the TilePro™ software interface that allows the microsurgeon dual 15x and 100x views of the field. We have utilized this new camera for animal studies, and will soon be incorporating this into human applications. There are also new imaging options that are on the horizon to allow the surgeon to better visualize vessels and nerve structures real-time during procedures. These are enhancements that will clearly give microsurgeons options that are just not possible via standard microsurgery. The ultimate goal would be to have a cost-effective robotic platform that provides equivalent if not better outcomes and improved surgical efficiency. We may not be there yet, but it is getting a lot closer!

References:

1. Marmar, J. L., Kim, Y.: Subinguinal microsurgical varicocelectomy: a technical critique and statistical analysis of semen and pregnancy data. J Urol, 152: 1127, 1994

2. Owen, E. R.: Microsurgical vasovasostomy: a reliable vasectomy reversal. Aust N Z J Surg, 47: 305, 1977

3. Schultheiss, D., Denil, J.: History of the microscope and development of microsurgery: a revolution for reproductive tract surgery. Andrologia, 34: 234, 2002

4. Silber, S. J.: Microsurgery in clinical urology. Urology, 6: 150, 1975

Written by Sijo Parekattil, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations, etc., of their research by referencing the published abstract.

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