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INVITED COMMENTARY
Year : 2015  |  Volume : 17  |  Issue : 2  |  Page : 332

Commentary on "validation of robot-assisted vasectomy reversal"


Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA

Date of Web Publication30-Dec-2014

Correspondence Address:
Wayne JG Hellstrom
Department of Urology, Tulane University School of Medicine, New Orleans, LA,
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1008-682X.145632

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How to cite this article:
Sangkum P, Yafi FA, Hellstrom WJ. Commentary on "validation of robot-assisted vasectomy reversal". Asian J Androl 2015;17:332

How to cite this URL:
Sangkum P, Yafi FA, Hellstrom WJ. Commentary on "validation of robot-assisted vasectomy reversal". Asian J Androl [serial online] 2015 [cited 2019 Oct 18];17:332. Available from: http://www.ajandrology.com/text.asp?2015/17/2/332/145632 - DOI: 10.4103/1008-682X.145632

Approximately 6% of men who undergo vasectomy for elective male sterilization request vasectomy reversal (VR). VR is more cost-effective than assisted reproduction techniques (ART), with cumulative pregnancy rates at least as high as with ART. [1] Microsurgical VR (MVR) is recognized as the gold standard technique with patency rates of 80%-90% and pregnancy rates of approximately 50%. [2] However, MVR requires specific microsurgical skills and has a steep learning curve, particularly for microsurgical vaso-epididymostomy. Urologists who are not fellowship-trained in microsurgery often lack the expertise to perform these procedures.

Robot-assisted VR (RAVR) benefits the surgeon in that it eliminates physiologic tremor, provides stability, scalability of motion and three-dimensional high-definition, and provides improved ergonomics, decreased surgeon fatigue, and the use of third retracting arm. [2],[3] The latter aspect conceivably circumvents the need for a microsurgical trained assistant. In 2012, Parekattil et al. reported a patency rate of 96% in the robot-assisted group compared with 80% in a standard microsurgical group. [4] The present study by Kavoussi reported comparable patency rates between the microsurgical and robot-assisted groups (89% vs 92%, P = 0.72). [3] Furthermore, there was no statistically significant difference in mean total operative time, postoperative mean sperm concentration, and total motile counts.

There is much discussion regarding the cost-effectiveness and time requirements inherent to robotic surgery. The present study, however, reports a nonstatistical increase of only 10 min in mean operative time and an additional cost of only $315 with RAVR.

In this study, the author used a modified one layer technique for RAVR. Implementing this surgical approach may be met with some resistance by experts in the field with a strong preference for a multilayer anastomosis. [1] While the robotic system was not specifically designed for microsurgery, Santomauro et al. recently reported their positive experience with a two-layer anastomosis with RAVR. [5]

Trost et al. [6] recently performed the first intracorporeal RAVR for the treatment of bilateral vasal obstruction following bilateral inguinal hernia repairs with mesh placement. This case is relatively uncommon, and the procedure was technically challenging, but successful, with delivery of a healthy child. Intracorporeal RAVR has the advantage of bypassing the inguinal segment, which precludes the need for inguinal dissection, eliminates the risk of recurrent hernia, improves tissue quality of the anastomotic segment, and avoids a very large abdominal incision with standard microsurgical and open approaches.

The learning curve for robotic-assisted microsurgery remains unknown. To date, there have been no studies directly comparing the learning curves between MVR and RAVR. One study aimed to compare outcomes of vascular anastomosis between fully trained surgeons and midlevel surgical residents. Both groups performed standard microsurgical anastomoses and robotic-assisted microsurgical anastomoses. Both were able to master the robotically assisted procedure equally. [7] Similar to the study from Santomauro et al., [5] there was no statistically significant difference in mean console time between fully-trained surgeons and residents for RAVR. As such, one may speculate that RAVR might be mastered without the advanced microsurgical skills required for MVR.

Robot-assisted VR is an intriguing area for future research and may become the standard of care for VR. For that to happen, however, large-scale prospective randomized controlled trials are needed to validate its wider adoption.

 
  References Top

1.
Schwarzer JU, Steinfatt H. Current status of vasectomy reversal. Nat Rev Urol 2013; 10: 195-205.  Back to cited text no. 1
    
2.
Fleming C. Robot-assisted vasovasostomy. Urol Clin North Am 2004; 31: 769-72.   Back to cited text no. 2
    
3.
Kavoussi PK. Validation of robot-assisted vasectomy reversal. Asian J Androl 2015. doi: 10.4103/1008-682X.142141.  Back to cited text no. 3
    
4.
Parekattil SJ, Gudeloglu A, Brahmbhatt J, Wharton J, Priola KB. Robotic assisted versus pure microsurgical vasectomy reversal: technique and prospective database control trial. J Reconstr Microsurg 2012; 28: 435-44.  Back to cited text no. 4
    
5.
Santomauro MG, Choe CH, L'esperance JO, Auge BK. Robotic vasovasostomy: description of technique and review of initial results. J Robot Surg 2011; 6: 217-21.  Back to cited text no. 5
    
6.
Trost L, Parekattil S, Wang J, Hellstrom WJ. Intracorporeal robot-assisted microsurgical vasovasostomy for the treatment of bilateral vasal obstruction occurring following bilateral inguinal hernia repairs with mesh placement. J Urol 2014; 191: 1120-5.  Back to cited text no. 6
    
7.
Karamanoukian RL, Bui T, McConnell MP, Evans GR, Karamanoukian HL. Transfer of training in robotic-assisted microvascular surgery. Ann Plast Surg 2006; 57: 662-5.  Back to cited text no. 7
    




 

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