Robotic Microsurgery in Male Infertility and Urology

Taking Robotics to the Next Level

Ahmet Gudeloglu; Jamin V. Brahmbhatt; Sijo J. Parekattil

Disclosures

Transl Androl Urol. 2014;3(1):102-112. 

In This Article

Robotics in the Management of Varicocele

The presence of a varicocele leads to a two-fold increase in the likelihood of having abnormal semen analysis parameters in men seeking infertility treatment.[34] Varicocelectomy can lead to significant improvements in semen analysis parameters and a recent meta-analysis showed significant improvements in sperm count and motility regardless of the varicocelectomy technique.[35] The sub-inguinal microsurgical varicocelectomy approach has higher spontaneous pregnancy rates, lower postoperative recurrence and lower complication rates when compared to other techniques.[36]

The initial report showing the safety, feasibility and comparable outcomes of robotic assistance in sub-inguinal microsurgical varicocelectomy was published by Shu et al.[13] in 2008. This group described elimination of tremor and the stable, ergonomic platform as benefits of the robotic approach. Our group further explored this technique in a canine spermatic cord model (prospective randomized control trial) and showed a significantly faster operative time with robotic assisted microsurgical varicocelectomy (RAVx) when compared to the standard microsurgical approach.[15] Recently, Mechlin and McCullough reported preliminary results of their initial experience with RAVx.[37] They found no difference in terms of operative time when comparing RAVx to standard microsurgical varicocelectomy. However, they noted that there was a learning curve to RAVx and that their robotic operative time was progressively diminishing in their more recent cases.

Technique

A sub-inguinal approach is utilized to access the spermatic cord beyond the external inguinal ring. The cord is then brought up to the skin and held in place using a tongue blade platform. The cremasteric muscle layer is then separated and dilated veins are found and ligated with 3–0 silk ties using robotic microsurgical instruments.[6] The Black diamond micro-forceps are used in the right arm, the micro-bipolar forceps in the left arm and the curved monopolar scissors in the fourth arm. Previous studies have shown that 75% of patients have multiple testicular arteries in the spermatic cord at the subinguinal level.[38] 95% of these arteries are surrounded by adherent veins.[38] Thus, to avoid any inadvertent injury to the testicular arteries during the varicocelectomy, we routinely utilize a micro Doppler ultrasound probes to assess the location of the arteries and veins. The use of the robotic platform allows us to use this probe real-time with the additional arm to sense flow in the artery while performing vein ligation simultaneously with the other two arms. There are two micro Doppler ultrasound probes available currently. VTI (Vascular Technology Inc., Nashua, NH, USA) provides an easy to use, audible, disposable micro Doppler probe (Figure 4). Aloka (Hitachi-Aloka, Tokyo, Japan) has a micro-ultrasound Doppler probe (Figure 4) that provides full depth ultrasound imaging of the spermatic cord with Doppler flow sensing as well. The output from this probe can be sent directly to the surgeon console to provide real-timesimultaneous imaging while the surgeon is operating.

Figure 4.

The audible Doppler probe (Vascular Technology Inc., Nashua, NH, USA) on the left and the micro Doppler ultrasound probe (Hitachi-Aloka, Tokyo, Japan) on the right. The upper images illustrate the probes, the lower images illustrate the use of the probes during robotic assisted sub-inguinal varicocelectomy.

Our group has performed 238 RAVx procedures from June 2008 to October 2013. The median robotic OR duration was 20 minutes. Seventy-six percent of patients with oligospermia had a significant improvement in sperm count and/or motility and 28% of patients with azoospermia were converted to oligospermia. Ninety-two percent of patients with testicular pain had a significant reduction in their pain scores. Eighty-four percent of the patients, who had testicular pain, also had robotic assisted targeted microsurgical denervation of the spermatic cord procedure at the same time as the varicocelectomy.

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