MODEL TO PREDICT IF A VASOEPIDIDYMOSTOMY WILL BE REQUIRED FOR VASECTOMY REVERSAL

ABSTRACT Purpose: We devised a model to predict, preoperatively, the need for a vasoepididymostomy (VE) when performing a vasectomy reversal. Urologists could use it to identify those patients who need a referral to an experienced VE surgeon. Materials and Methods: We performed a retrospective review of 483 patients who underwent vasectomy reversal by a single surgeon (AJT) including 393 vasovasostomies and 90 vasoepididymostomies. Selection was based on chart availability. Established criteria were used in deciding the type of reversal (eg gross appearance and microscopic examination of vasal fluid). Type of reversal, patient age and time since vasectomy were recorded. Univariate analysis revealed that patient age (p Ͻ0.001) and time since vasectomy (p Ͻ0.001) were significant predictors of reversal type. On multivariate logistic regression analysis, time since vasectomy (p Ͻ0.001) was the only significant independent predictor. We designed a linear regression algorithm based on time since vasectomy and patient age to predict if a VE would be performed. The model was designed using 433 patients and then tested on a separate randomly selected 50 patient group. The model was designed to be 100% sensitive in detecting patients requiring VE. Results: In the test group the model was 100% sensitive in predicting VE with a specificity of 58.8%. The area under the ROC curves for the design and test groups was 0.8. Palm (PalmSource Inc., Sunnyvale, California) and Windows (Microsoft Corporation, Redmond, Washington) versions are available as free shareware from www.uroengineering.com. Conclusions: The model is 100% sensitivity in detecting those patients who may require a VE during vasectomy reversal (specificity of 58.8%). It may allow urologists to preoperatively identify these patients

The NOTES Approach to Management of Urinary Bladder Injury

This blinded feasibility study shows that urinary bladder injury occurring during NOTES can be successfully managed via a NOTES approach using currently available endoscopic accessories

Update in the evaluation of the azoospermic male

Approximately 1% of all men in the general population suffer from azoospermia, and azoospermic men constitute approximately 10 to 15% of all infertile men. Thus, this group of patients represents a significant population in the field of male infertility. A thorough medical history, physical examination and hormonal profile are essential in the evaluation of azoospermic males. Imaging studies, a genetic workup and a testicular biopsy (with cryopreservation) may augment the workup and evaluation. Men with nonobstructive azoospermia should be offered genetic counseling before their spermatozoa are used for assisted reproductive techniques. This article provides a contemporary review of the evaluation of the azoospermic male

Robotically Assisted Microsurgery: Development of Basic Skills Course

Robotically assisted microsurgery or telemicrosurgery is a new technique using robotic telemanipulators. This allows for the addition of optical magnification (which defines conventional microsurgery) to robotic instrument arms to allow the microsurgeon to perform complex microsurgical procedures. There are several possible applications for this platform in various microsurgical disciplines. Since 2009, basic skills training courses have been organized by the Robotic Assisted Microsurgical and Endoscopic Society. These basic courses are performed on training models in five levels of increasing complexity. This paper reviews the current state of the art in robotically asisted microsurgical training

Review of the Role of Robotic Surgery in Male Infertility

Objectives To present the current state of the art in various robot-assisted microsurgical procedures in male infertility and review the latest literature, as the technology in infertility procedures has substantially developed since the incorporation of the Vinci® robotic platform (Intuitive Surgical, Inc., Sunnyvale, CA, USA). Materials and methods The search strategy in this review was conducted in accordance with Cochrane guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A search strategy was conducted in MEDLINE, PubMed and the Cochrane electronic databases (from 2000 to present) to identify studies that included both robotic and male infertility. Results In all, 23 studies were found, 12 of which met our inclusion criteria. Articles were excluded if the study did not include both male infertility and robotics. Conclusions Robotic assistance for microsurgical procedures in male infertility appears to be safe and feasible. It has several advantages including elimination of tremor, multi-view magnification, additional instrument arms, and enhanced dexterity with articulating instrument arms. It also has a short learning curve with a small skin incision. However, larger, prospective studies are needed to establish the clinical benefits over standard microsurgery.PubMedScopu

Robotic Microsurgery Optimization

The increased application of the da Vinci robotic platform (Intuitive Surgical Inc.) for microsurgery has led to the development of new adjunctive surgical instrumentation. In microsurgery, the robotic platform can provide high definition 12×-15× digital magnification, broader range of motion, fine instrument handling with decreased tremor, reduced surgeon fatigue, and improved surgical productivity. This paper presents novel adjunctive tools that provide enhanced optical magnification, micro-Doppler sensing of vessels down to a 1-mm size, vein mapping capabilities, hydro-dissection, micro-ablation technology (with minimal thermal spread-CO2 laser technology), and confocal microscopy to provide imaging at a cellular level. Microsurgical outcomes from the use of these tools in the management of patients with infertility and chronic groin and testicular pain are reviewed. All these instruments have been adapted for the robotic console and enhance the robot-assisted microsurgery experience. As the popularity of robot-assisted microsurgery grows, so will its breadth of instrumentation

Robotically Assisted Microsurgery: Development of Basic Skills Course

Robotically assisted microsurgery or telemicrosurgery is a new technique using robotic telemanip­ulators. This allows for the addition of optical magnification (which defines conventional micro­surgery) to robotic instrument arms to allow the microsurgeon to perform complex microsurgical procedures. There are several possible applications for this platform in various microsurgical disciplines. Since 2009, basic skills training courses have been organized by the Robotic Assisted Microsurgical and Endoscopic Society. These basic courses are performed on training models in five levels of increasing complexity. This paper reviews the current state of the art in roboti­cally asisted microsurgical training

Trifecta nerve complex: potential anatomical basis for microsurgical denervation of the spermatic cord for chronic orchialgia.

PURPOSE: We identified structural abnormalities in the spermatic cord nerves that may explain how microsurgical denervation of the spermatic cord provides pain relief in patients with chronic orchialgia. MATERIALS AND METHODS: We retrospectively reviewed a prospective database to compare spermatic cord biopsy specimens from 56 men treated with a total of 57 procedures for microsurgical denervation of the spermatic cord for chronic orchialgia vs a control group of men without pain treated with cord surgery, including varicocelectomy in 4 and radical orchiectomy in 6. Tissue biopsies were obtained from mapped regions of the spermatic cord in all cases. Biopsies stained with hematoxylin and eosin were examined by an independent pathologist. Three human cadaveric spermatic cords were dissected to confirm localization of the nerve distribution identified on pathological mapping. RESULTS: We identified a median of 25 small diameter (less than 1 mm) nerve fibers in the spermatic cord. Of the 57 procedures for orchialgia 48 (84%) showed wallerian degeneration in 1 or more of these nerves but only 2 of 10 controls (20%) had such degeneration (p = 0.0008). In decreasing order of nerve density the 3 primary sites (trifecta nerve complex) of these changes were the cremasteric muscle fibers (19 nerves per patient), perivasal tissues and vasal sheath (9 nerves per patient), and posterior cord lipomatous/perivessel tissues (3 nerves per patient). Cord nerve distribution mapped by the biopsies was confirmed by cadaveric dissection. CONCLUSIONS: In men with chronic orchialgia there appears to be wallerian degeneration in reproducible patterns in the spermatic cord nerve fibers. Transection of these nerves may explain the effect of the denervation procedure