Advances in male reproductive surgery: robotic-assisted vasovasostomy

[Surgery to improve male fertility]

BACKGROUND

At a time when increasing attention is being paid to the limitations and risks of in vitro fertilisation techniques, surgeries to improve male fertility are attracting growing interest.

METHODS

Systematic review based on a Pubmed search of surgeries to improve male fertility.

RESULTS

Vasovasostomy (VV) gives patency rates of 70-97% and pregnancy rates of 30-76%. Vasoepididymostomy (VE) gives patency rates of 80-84%, with pregnancy rates of 40-44%. The duration of obstruction and the age of the partner are 2 predictive parameters for the occurrence of a natural pregnancy. In cases of obstructive azoospermia due to pelvic obstruction (prostatic cyst, obstruction of the ejaculatory ducts), several surgical procedures may be proposed. Transurethral resection of the ejaculatory ducts leads to an improvement in sperm parameters in 63-83% of patients, with spontaneous pregnancy occurring in 12-31% of cases. Microsurgical cure of varicocele by the subinguinal route is a benchmark technique with recurrence rates of less than 4%. It improves live birth and pregnancy rates, both naturally and by in vitro fertilization, as well as sperm count, motility and DNA fragmentation rates.

CONCLUSION

Whenever possible, the urologist should present the surgical options for improving male fertility to the ART team and to the couple, discussing the benefit/risk balance of the operation as part of a personalized approach.

Robot-assisted vasovasostomy and vasoepididymostomy: Current status and review of the literature

OBJECTIVE

Microscope-assisted vasovasostomy (MAVV) is a standard procedure used to reverse vasectomies. Robotic surgery has been established primarily for technically demanding urological procedures and has also been recently implemented in male reproductive surgery. We aimed to review the current evidence of robot-assisted vasovasostomy (RAVV) and robot-assisted vasoepididymostomy (RAVE).

MATERIAL AND METHODS

We performed a systematic literature review using PubMed to identify relevant original articles. We identified 2017 records through database search, and after removing duplicates, 782 records remained for further analysis.

RESULTS

In total, 12 human and three animal studies were selected. Reported vasal patency rate ranges were 88%-100% for RAVVs and 55%-61% for RAVEs. The sperm count and postoperative pregnancy rates of RAVV ranged between 8.4 × 10⁶-120 × 10⁶ sperm/mL and 65%, respectively. Finally, procedure times in the human studies, recorded for extracorporeal RAVVs and RAVEs ranged from 97 to 238 minutes.

CONCLUSION

Robot-assisted vasal reversal is feasible with similar patency rates as for the microsurgical approach and showing comparable outcomes. Additional benefits of this technique include improved vision and movement precision.

Surgical treatment for male infertility

Given the nature of the multiple causes of male infertility, some of them are «reversible» and can be managed with a surgical procedure to recover, in some cases, the fertilizing capacity of the male reproductive tract. With appropriate use of diagnostic tools and clinical judgement, the physician can identify the ideal candidates for these procedures. Together with the expertise and experience of the surgeon, these treatments can manage to resolve the barrier, and men may become fertile again. In this chapter, we will review some of the most commonly used surgical procedures for the treatment of male infertility and make a brief description of their technical details.

Vasovasostomy and vasoepididymostomy: Review of the procedures, outcomes, and predictors of patency and pregnancy over the last decade

BACKGROUND

In the era of improving assisted reproductive technology (ART), patients with obstructive azoospermia (OA) have 2 options: vasal repair or testicular sperm extraction with intracytoplasmic sperm injection. Vasal repair, including vasovasostomy (VV) and vasoepididymostomy (VE), is the only option that leads to natural conception.

METHODS

This article reviews the surgical techniques, outcomes, and predictors of postoperative patency and pregnancy, with a focus on articles that have reported over the last 10 years, using PubMed database searches.

MAIN FINDINGS

The reported mean patency rate was 87% and the mean pregnancy rate was 49% for a patient following microscopic VV and/or VE for vasectomy reversal. Recently, robot-assisted techniques were introduced and have achieved a high rate of success. The predictors and predictive models of postoperative patency and pregnancy also have been reported. The obstructive interval, presence of a granuloma, and intraoperative sperm findings predict postoperative patency. These factors also predict postoperative fertility. In addition, the female partner's age and the same female partner correlate with pregnancy after surgery.

CONCLUSION

In the era of ART, the physician should present and discuss with both the patient with OA and his partner the most appropriate procedure to conceive by using these predictors.