A retrospective review of single-institution outcomes with robotic-assisted microsurgical varicocelectomy

Robot-assisted laparoscopic varicocelectomy in a pediatric population

PURPOSE

To present our experience with robot-assisted laparoscopic varicocelectomy in a pediatric population.

METHODS

We reviewed 49 consecutive cases performed by the same experienced surgeon. One-to-four veins were ligated at the internal ring of the inguinal canal, while the testicular artery and lymphatics were spared. Information on patient characteristics, surgical time, complications, and recurrences were collected.

RESULTS

Median patient age was 14 (range 10-17) years. Forty-eight had left-sided varicoceles and one had a bilateral varicocele. Forty-five were grade 3. All patients were referred due to discomfort/pain and 20 also had reduced testicular size. The median operating time from skin incision was 48 min (31-89 min) and the median console time was 18 min (7-55 min). Forty-seven patients were discharged the same day. Two patients experienced pain and problems urinating, respectively. These issues had resolved by the first post-operative day. There were no other complications, but at 6 months, eight recurrences were noted (16%). Scrotal complaints had subsided in all patients. Catch-up growth of the affected testicles was seen in 19/20 cases.

CONCLUSION

Robot-assisted laparoscopic varicocelectomy is feasible and safe in a pediatric population but with a relatively high recurrence rate.

The learning curve of bilateral laparoscopic varicocelectomy: a prospective study

Varicocele occurs in 15% of general male population and in 35% of infertile men. Since 1992, surgical correction with laparoscopic varicocelectomy is the gold standard for treatment of symptomatic patients or patients with abnormal seminal analysis. The learning curve for this frequently performed procedure has not yet been described. In the present study, we investigated the learning curve of a single urologist in training performing his first 21 laparoscopic varicocelectomies using qualitative and quantitative tools to evaluate his performance during the process. Our results show that 14 bilateral laparoscopic varicocelectomies are enough to achieve the plateau of the learning curve.

Robotic Surgery for Male Infertility and Chronic Scrotal Content Pain

Robot-assisted microsurgery is a trending approach for the treatment of male infertility and chronic scrotal pain. The advantages seem to include increased optical magnification, improved surgical efficiency, absent tremor, and similar outcomes with standard methods. This chapter covers robotic microsurgical application and techniques for: robot-assisted vasectomy reversal with vasovasostomy and vasoepididymostomy, varicocelectomy, microsurgical testicular sperm extraction, and targeted denervation of the spermatic cord.

Does plastic surgery need a rewiring? A survey and systematic review on robotic-assisted surgery

Background

This is a paucity of data regarding plastic surgeons' opinions on robotic-assisted surgery (RAS). We developed a questionnaire aimed to survey plastic surgeons regarding training in robotics, concerns about widespread implementation, and new research directions.

Methods

A survey was created using Google Forms and sent to practicing plastic surgeons and trainees. Responses regarding desired conference proceedings about robotics, robotic residency training, and perceived barriers to implementation were elicited. Survey responses were utilized to direct a systematic review on RAS in plastic surgery.

Results

The survey received 184 responses (20.4%; 184/900). The majority (92.8%) of respondents were/are plastic surgery residents, with the most common fellowships being microsurgery (39.2%). Overall, 89.7% of respondents support some integration of robotics in the future of plastic surgery, particularly in pelvic/perineum reconstruction (56.4%), abdominal reconstruction (46.5%), microsurgery (43.6%), and supermicrosurgery (44.2%). Many respondents (66.1%) report never using a robot in their careers. Respondents expressed notable barriers to widespread robotic implementation, with cost (73.0%) serving as the greatest obstacle. A total of 10 studies (pelvic/perineum = 3; abdominal = 3; microsurgery = 4) were included after full-text review.

Conclusions

Evidence from our survey and review supports the growing interest and utility of RAS within the plastic and reconstructive surgery (PRS) and mirrors the established trend in other surgical subspecialties. Cost analyses will prove critical to implementing RAS within PRS. With validated benefits, plastic surgery programs can begin creating dedicated curricula for RAS.

The Management of Clinical Varicocele: Robotic Surgery Approach

Varicocele is a pathologic dilation of the testicular veins within the spermatic cord. Varicocele is considered the most common problem in reproductive medicine practice. It is identified in 15% of healthy men and up to 35% of men with primary infertility. The exact pathophysiology of varicoceles is not very well understood, and several theories have been proposed to explain it. Varicocele can impair sperm quality and fertility via various mechanisms: reflux of adrenal metabolites, increased testicular hypoxia, oxidative stress, and increased testicular temperature have been proposed. Several studies have reported the significant benefits on semen parameters with the surgical treatment of varicocele: reducing oxidatively induced sperm DNA damage and potentially improving fertility. Varicocele repair should be offered as a part of treatment option for male partners of infertile couples presenting with palpable varicoceles. Nowadays, there are several surgical approaches available for the treatment of varicocele, such as the retroperitoneal approach, inguinal approach, and the subinguinal approach. The subinguinal microscopic approach offers the best outcomes, such as shorter hospital stays, preservation of the testicular arteries and lymphatics, least number of postoperative complications, recurrence, and a higher number of pregnancies. Currently robotic-assisted laparoscopic surgery is widely adopted in urology and surgeons began to explore the potential applications of the robotic platform to male infertility microsurgical operations. Robotic approach offers many advantages: elimination of tremor, retraction with third arm, high quality, 3-dimensional visualization and surgeon ergonomics, all contributing to the precision of surgery.

European Association of Urology Guidelines on Male Sexual and Reproductive Health: 2021 Update on Male Infertility

CONTEXT

The European Association of Urology (EAU) has updated its guidelines on sexual and reproductive health for 2021.

OBJECTIVE

To present a summary of the 2021 version of the EAU guidelines on sexual and reproductive health, including advances and areas of controversy in male infertility.

EVIDENCE ACQUISITION

The panel performed a comprehensive literature review of novel data up to January 2021. The guidelines were updated and a strength rating for each recommendation was included that was based either on a systematic review of the literature or consensus opinion from the expert panel, where applicable.

EVIDENCE SYNTHESIS

The male partner in infertile couples should undergo a comprehensive urological assessment to identify and treat any modifiable risk factors causing fertility impairment. Infertile men are at a higher risk of harbouring and developing other diseases including malignancy and cardiovascular disease and should be screened for potential modifiable risk factors, such as hypogonadism. Sperm DNA fragmentation testing has emerged as a novel biomarker that can identify infertile men and provide information on the outcomes from assisted reproductive techniques. The role of hormone stimulation therapy in hypergonadotropic hypogonadal or eugonadal patients is controversial and is not recommended outside of clinical trials. Furthermore, there is insufficient evidence to support the widespread use of other empirical treatments and surgical interventions in clinical practice (such as antioxidants and surgical sperm retrieval in men without azoospermia). There is low-quality evidence to support the routine use of testicular fine-needle mapping as an alternative diagnostic and predictive tool before testicular sperm extraction (TESE) in men with nonobstructive azoospermia (NOA), and either conventional or microdissection TESE remains the surgical modality of choice for men with NOA.

CONCLUSIONS

All infertile men should undergo a comprehensive urological assessment to identify and treat any modifiable risk factors. Increasing data indicate that infertile men are at higher risk of cardiovascular mortality and of developing cancers and should be screened and counselled accordingly. There is low-quality evidence supporting the use of empirical treatments and interventions currently used in clinical practice; the efficacy of these therapies needs to be validated in large-scale randomised controlled trials.

PATIENT SUMMARY

Approximately 50% of infertility will be due to problems with the male partner. Therefore, all infertile men should be assessed by a specialist with the expertise to not only help optimise their fertility but also because they are at higher risk of developing cardiovascular disease and cancer long term and therefore require appropriate counselling and management. There are many treatments and interventions for male infertility that have not been validated in high-quality studies and caution should be applied to their use in routine clinical practice.

Contribution of pre-varicocelectomy color Doppler ultrasonography finding to surgery and its correlation with semen parameters

BACKGROUND

This study aimed to determine the contribution of color Doppler ultrasonography (CDUS) performed before varicocelectomy to the success of surgical treatment and to evaluate the correlation between CDUS findings and semen parameters.

METHODS

A total of 84 patients diagnosed with grade 3 left varicocele in our clinic between 2016 and 2018 were evaluated. The patients in whom the decision for varicocelectomy was based on only physical examination (PE) findings and abnormal semen analysis (SA) were defined as Group 1, while the patients undergoing varicocelectomy based on PE, CDUS and SA findings were defined as Group 2. The patients diagnosed with varicocele based on PE and CDUS findings who were included in a followup protocol due to normal semen parameters were defined as Group 3.

RESULTS

In Group 1, there was a total of 28 patients and the mean number of ligated internal spermatic veins was 4.53 (range, 2-10). In Group 2, there was a total of 30 patients and the number of ligated internal spermatic veins was 3.76 (range, 1-8). No statistically significant difference was found between Group 1 and 2 in terms of the number of internal spermatic veins ligated during varicocelectomy. No statistically significant correlation was found between semen parameters and the number of veins ligated during varicocelectomy in Group 1 and 2 and between semen parameters and CDUS findings group 2 and 3.

CONCLUSIONS

In patients with primary grade 3 varicocele, diagnosed by physical examination there is no need for additional imaging in primary cases.

Robotic Surgery for Male Infertility

The robotic platform offers theoretical and practical advantages to microsurgical male infertility surgery. These include reduction or elimination of tremor, 3-dimensional visualization, and decreased need for skilled surgical assistance. This article reviews the application of robotic surgery to each of the 4 primary male infertility procedures: vasectomy reversal, varicocelectomy, testicular sperm extraction, and spermatic cord denervation. Historical perspective is presented alongside the available outcomes data, which are limited in most cases. Before the robotic approach can be widely adopted, further clinical trials are needed to compare outcomes and costs with those of other validated surgical techniques.

Recent advances in clinical diagnosis and treatment of male factor infertility

Infertility is a significant global health issue affecting around 8-12% of couples worldwide with male factor infertility accounting for a substantial proportion of these cases. Despite significant advances within the past few decades, an etiology for male factor infertility cannot be identified in up to 80% of patients and thus, this continues to be an area of active study. This review aims to provide an update on recent advances in the field of male infertility including semen analysis and at-home semen testing, genetics, DNA fragmentation, surgical approaches, and the rise of telemedicine in the era of COVID19.

Robotic-assisted laparoscopic artery-sparing varicocelectomy using indocyanine green fluorescence angiography: Initial experience

We reported our initial experience of robotic-assisted laparoscopic artery-sparing varicocelectomy using indocyanine green (ICG) fluorescence angiography in treatment of varicocele. A total of 45 varicocelectomies in 27 patients were performed. The mean operation time was 49.1 ± 8.5 min for unilateral and 65.6 ± 8.3 min for bilateral repair. 47.2 s after ICG injection, testicular artery (TA) was visualised. After an interval of 31.3 s, fluorescent veins were identified. Of all the 45 spermatic cords, 68.9% had a solitary artery, while 31.1% had 2 arteries. The mean hospital stay was 1.6 ± 0.9 days. Semen concentration and motility were significantly improved 6 months after surgery, no recurrence, hydrocele or testicular atrophy was observed. Our study demonstrated that robotic-assisted laparoscopic artery-sparing varicocelectomy using ICG fluorescence angiography is a safe, effective and promising technique in treatment of varicocele.