Pros and cons of robotic microsurgery as an appropriate approach to male reproductive surgery for vasectomy reversal and varicocele repair
2018; Elsevier BV; Volume: 110; Issue: 5 Linguagem: Inglês
10.1016/j.fertnstert.2018.08.026
ISSN1556-5653
AutoresPeter Chan, Sijo Parekattil, Marc Goldstein, Larry I. Lipshultz, Parviz K. Kavoussi, Andrew McCullough, Mark Sigman,
Tópico(s)Intraocular Surgery and Lenses
ResumoVasectomy reversal is a technically demanding procedure. Since the introduction of the operating microscope in 1975 for this kind of surgery, there has been an improvement in success rates (1Silber S.J. Microsurgery in clinical urology.Urology. 1975; 6: 150-153Abstract Full Text PDF PubMed Scopus (61) Google Scholar, 2Owen E.R. Microsurgical vasovasostomy: a reliable vasectomy reversal.Aust N Z J Surg. 1977; 47: 305-309Crossref PubMed Scopus (82) Google Scholar). The use of the operative microscope to achieve greater fertility rates and vas patency after vasovasostomy has become a standard for the microsurgeon who treats male infertility (2Owen E.R. Microsurgical vasovasostomy: a reliable vasectomy reversal.Aust N Z J Surg. 1977; 47: 305-309Crossref PubMed Scopus (82) Google Scholar). However, this technique requires a great degree of microsurgical training and a skilled surgical assistant. The development of robotic assisted procedures in several surgical fields continues to expand (3Yates D.R. Vaessen C. Roupret M. From Leonardo to da Vinci: the history of robot-assisted surgery in urology.BJU Int. 2011; 108: 1708-1714Crossref PubMed Scopus (80) Google Scholar, 4Bourla D.H. Hubschman J.P. Culjat M. Tsirbas A. Gupta A. Schwartz S.D. Feasibility study of intraocular robotic surgery with the da Vinci surgical system.Retina. 2008; 28: 154-158Crossref PubMed Scopus (76) Google Scholar, 5Casale P. Robotic pediatric urology.Expert Rev Med Devices. 2008; 5: 59-64Crossref PubMed Scopus (37) Google Scholar, 6Berber E. Siperstein A. Robotic transaxillary total thyroidectomy using a unilateral approach.Surg Laparosc Endosc Percutan Tech. 2011; 21: 207-210Crossref PubMed Scopus (22) Google Scholar, 7Lehr E.J. Rodriguez E. Chitwood W.R. Robotic cardiac surgery.Curr Opin Anaesthesiol. 2011; 24: 77-85Crossref PubMed Scopus (38) Google Scholar). There are several potential benefits: a stable, ergonomic, scalable control system with three-dimensional visualization and magnification; elimination of tremor with simultaneous ability to control three instruments and a camera; ability to potentially integrate up to three visual inputs simultaneously in the surgeon console. All these features may provide surgeons an advantage when performing complex microsurgical procedures. The use of robotic assistance for vasectomy reversal and varicocelectomy could potentially provide the microsurgeon with improved visualization, decreased fatigue and obviate the need for a skilled surgical assistant. However, are there any real outcome benefits of utilizing the robotic platform for microsurgery over standard microsurgery that has excellent outcomes already as shown in multiples studies (8Kirby E.W. Hockenberry M. Lipshultz L.I. Vasectomy reversal: decision making and technical innovations.Transl Androl Urol. 2017; 6: 753-760Crossref PubMed Scopus (8) Google Scholar, 9Nyame Y.A. Babbar P. Almassi N. Polackwich A.S. Sabanegh E. Comparative cost-effectiveness analysis of modified 1-layer versus formal 2-Layer Vasovasostomy Technique.J Urol. 2016; 195: 434-438Crossref PubMed Scopus (10) Google Scholar, 10Herrel L.A. Goodman M. Goldstein M. Hsiao W. Outcomes of microsurgical vasovasostomy for vasectomy reversal: a meta-analysis and systematic review.Urology. 2015; 85: 819-825Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar)? The initial and following reports of robotic assisted vasectomy reversal and varicocelectomy were case reports studies (11Schoor R.A. Ross L.S. Niederberger C.S. Feasibility of micro- surgical vasovasostomy in a model system using the da Vinci robot.AUA Annual Meeting Presentation. 1993; 149: 183-185Google Scholar, 12Kuang W. Shin P.R. Matin S. Thomas Jr., A.J. Initial evaluation of robotic technology for microsurgical vasovasostomy.J Urol. 2004; 171: 300-303Crossref PubMed Scopus (61) Google Scholar, 13Fleming C. Robot-assisted vasovasostomy.Urol Clin North Am. 2004; 31: 769-772Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar, 14Kuang W. Shin P.R. Oder M. Thomas Jr., A.J. Robotic-assisted vasovasostomy: a two-layer technique in an animal model.Urology. 2005; 65: 811-814Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 15De Naeyer G. Van Migem P. Schatteman P. Carpentier P. Fonteyne E. Mottrie A. Robotic assistance in urological microsurgery: initial report of a successful in-vivo robot-assisted vasovasostomy.J Robot Surg. 2007; 1: 161-162Crossref PubMed Scopus (7) Google Scholar, 16Parekattil S.J. Atalah H.N. Cohen M.S. Video technique for human robot-assisted microsurgical vasovasostomy.J Endourol. 2010; 24: 511-514Crossref PubMed Scopus (25) Google Scholar, 17Shu T. Taghechian S. Wang R. Initial experience with robot-assisted varicocelectomy.Asian J Androl. 2008; 10: 146-148Crossref PubMed Scopus (36) Google Scholar, 18Parekattil S.J. Cohen M.S. Robotic surgery in male infertility and chronic orchialgia.Curr Opin Urol. 2010; 20: 75-79Crossref PubMed Scopus (28) Google Scholar, 19McCullough A. Elebyjian L. Ellen J. Mechlin C. A retrospective review of single-institution outcomes with robotic-assisted microsurgical varicocelectomy.Asian J Androl. 2018; 20: 189-194Crossref PubMed Google Scholar). Then came the first ever prospective randomized control trial in animals with the da Vinci robotic system (Intuitive Surgical, Inc.) by Schiff and colleagues in 2004 (20Schiff J. Li P.S. Goldstein M. Robotic microsurgical vasovasostomy and vasoepididymostomy: a prospective randomized study in a rat model.J Urol. 2004; 171: 1720-1725Crossref PubMed Scopus (75) Google Scholar). They found that robotic vasovasostomy was significantly faster than the conventional microsurgical technique (68.5 vs. 102.5 min, P=.002). The robotic and microsurgical vasoepididymostomy groups did not differ significantly in time. Patency rates were 100% for the robotic vasovasostomy and vasoepididymostomy groups, and 90% in the microsurgical vasovasostomy and vasoepididymostomy groups. These differences were not significant. Sperm granulomas were found in 70% of microsurgical vasovasostomy anastomoses and 27% of robotic vasovasostomy anastomoses (P=.001). No significant difference in the sperm granuloma rate was found between the robotic microsurgical vasoepididymostomy groups (42% and 50%, respectively). The lower rate of sperm granuloma in the robotic vasovasostomy group compared to pure microsurgery may suggest that even early in the learning curve, robotic microsurgeons could have less anastomosis leakage than microsurgeons who are in training in pure microsurgery. The follow up prospective control human trial by Parekattil et al. (21Parekattil S.J. Gudeloglu A. Brahmbhatt J. Wharton J. Priola K.B. Robotic assisted versus pure microsurgical vasectomy reversal: technique and prospective database control trial.J Reconstr Microsurg. 2012; 28: 435-444Crossref PubMed Scopus (34) Google Scholar) also found some advantages to robotic vasectomy reversal over microsurgical reversal. A patency of 96% was achieved in the robotic-assisted vasovasostomy (RAVV) cases and 80% in manual vasovasostomy (MVV) (>1 million sperm/ejaculate, P=.02). Pregnancy rates (within 1 year postop) did not differ significantly for the two groups: 65% for the RAVV and 55% for the MVV. Operative duration (skin to skin) started at 150 to 180 minutes initially for the first 10 cases for RAVV, but median operative duration was significantly decreased in RAVV at 97 minutes (range 40 to 180 min) compared with MVV at 120 minutes (range 60 to 180 min, P=.0003). Robotic-assisted vasoepididymostomy (RAVE) at 120 minutes (range 60 to 180 min) was significantly faster than manual vasoepididymostomy (MVE) at 150 minutes (range 120 to 240 min, P=.0008). The rate of postoperative sperm count recovery was significantly greater in RAVV/RAVE compared to MVV/MVE. This study was a prospective analysis of the author's first 155 reversals done either with the robot or the microscope after dual fellowship training in microsurgery and robotics. This illustrates that the long-term outcomes are similar to published microsurgical series, and it suggests that the learning curve to better outcomes is much shorter utilizing the robotic platform. Next came a validation study by Kavoussi (22Kavoussi P.K. Validation of robot-assisted vasectomy reversal.Asian J Androl. 2015; 17: 245-247Crossref PubMed Scopus (18) Google Scholar) in 2015 showing that a fellowship trained microsurgeon could transition to the robotic platform with comparable outcomes. Anecdotally this author found the robotic platform was easier and less tiring than standard microsurgery. McCullough et al. (19McCullough A. Elebyjian L. Ellen J. Mechlin C. A retrospective review of single-institution outcomes with robotic-assisted microsurgical varicocelectomy.Asian J Androl. 2018; 20: 189-194Crossref PubMed Google Scholar) have found comparable long-term outcomes for robotic assisted microsurgical varicocelectomy in a large series study of 258 varicocelectomies. Median total and free testosterone increased by 145 ng/dl and 4.3 pcg/ml (44.3%), respectively (P<.0001). Median sperm concentration increased by 37.3% (P<.03). Median left and right testicular volume increased by 22.3% (P<.0001) and 12.6% (P<.0006), respectively. Hydroceles occurred in 0.8% and there were no testicular artery injuries. Persistence of varicocele by Doppler ultrasound was 9.6%. The evidence suggests that long-term outcomes are comparable for robotic and microsurgical vasectomy reversal varicocelectomy. The procedures may be performed faster than pure microsurgery as microsurgeons gain robotic experience. The learning curve to better patient outcomes may be achieved faster in microsurgeons utilizing the robotic platform. True cost of a robotic microsurgical and pure microsurgical reversal or varicocelectomy is a complex calculation. In high volume robotic multi-specialty surgical hospitals, the cost to perform a robotic microsurgical case may be comparable to investing in a pure microsurgical platform and utilizing a microsurgical assistant (mostly obviated in the case of robotic cases due to the extra robotic arm that the surgeon controls) as shown in Table 1. In a hospital that does not have a robot, but has a surgical microscope, the upwards of 2.5 million dollar capital investment to get a robot may not be justified for just one microsurgeon. However, the majority of hospitals in the U.S. now have robotic platforms and they are utilized by surgeons from varying specialties (general surgery, gynecology, otorhinolaryngology, urology, and cardiac surgery). In fact, robotic time is difficult to procure. The three surgeons in this pro debate for robotic microsurgery are at high volume robotic surgical centers. The mean robot utilization at these centers is 105%, and the mean utilization of the microscope is 31%. The cost per case for robotic cases is comparable to microscopic cases due to the high utilization of the robot by multiple surgeons across specialties and the low utilization of the microscope. Table 1 illustrates cost analysis models for two scenarios and demonstrates how the cost per case could be comparable between robotic and microscopic cases based on case volumes. There is an additional mean cost of $450 for disposables for robotic cases over microscopic cases.Table 1Capital investment to cost per case analysis for robotic versus microscopic cases over 5 years: scenarios for comparable cost.Cost analysis modelRobotMicroscope96 microscopic cases/y Purchase price$2,500,000$200,000 Service contract$250,000$20,000 Use in a year, d (48 wk)24048 Cases/d32 Cases/y (48 wk)72096 Total cases over 5 y3600480 Cost per case over 5 y$763.89$458.3324 microscopic cases/y Purchase price$2,500,000$200,000 Service contract$250,000$20,000 Use in a year, d (48 wk)24024 Cases/d32 Cases/y (48 wk)72048 Total cases over 5 y3600240 Cost per case over 5 y$763.89$916.67 Open table in a new tab Vasectomy reversal and varicocelectomy are unique procedures in that patients may pay for these procedures out of pocket. Self-pay pricing for surgical procedures is one measure of how much a procedure actually costs. Table 2 illustrates self-pay pricing for vasectomy reversal and varicocelectomy procedures at six institutions (3 institutions for the pro robotic use argument and 3 institutions for the con argument) based on a survey of pricing on July 25, 2018.Table 2Self-pay pricing comparison for robotic versus microscopic vasectomy reversal and varicocelectomy.Microsurgical centerAnesthesia typeVasectomy removalUnilateral varicocelectomyFacility charge, $Surgeon fee, $Anesthesia, $Total, $Facility charge, $Surgeon fee, $Anesthesia, $Total, $Robotic Institution AWith anesthesia in OR (VV or VE)5,2008009006,9007,4001,5001,0009,900 Institution BWith anesthesia in OR (VV or VE)3,1583,3001,3007,7853,1581,7309005,788 Institution CWith anesthesia in OR (VV or VE)10,00018,000 Mean cost to patient8,2281,229Pure Institution AWith anesthesia in OR (simple)35,00016,0008,00059,00023,0008,0005,00036,000With anesthesia in OR (complex)35,00020,0008,00063,00027,00012,0006,00045,000Under Local016,000016,000 Institution BWith anesthesia in OR (simple)3,6753,8501,2008,7254,8751,486.406,361.40With anesthesia in OR (complex)3,6754,4001,2009,2755,9271,486.407,413.40 Institution C2,0006505003,2502,0003255002,825 Mean cost to patient26,52519,520Note: OR = operating room; VE = vasoepididymostomy; VV = vasovasostomy. Open table in a new tab Note: OR = operating room; VE = vasoepididymostomy; VV = vasovasostomy. The data illustrates that robotic microsurgery counterintuitively may not be more expensive than pure microsurgery. The cost to the patient is based more on profit margins, facility costs and less so on the technology that is being utilized. Use of the robotic platform standardizes the operating room staff processes, since they are simply using the same tool and setup for a number of different type of cases. Since a microsurgical assistant is not needed, less staffing is involved for robotic cases. The robotic microsurgical procedures tend to be faster than pure microsurgical cases, especially once the microsurgeon has completed 10 to 20 robotic cases (21Parekattil S.J. Gudeloglu A. Brahmbhatt J. Wharton J. Priola K.B. Robotic assisted versus pure microsurgical vasectomy reversal: technique and prospective database control trial.J Reconstr Microsurg. 2012; 28: 435-444Crossref PubMed Scopus (34) Google Scholar, 22Kavoussi P.K. Validation of robot-assisted vasectomy reversal.Asian J Androl. 2015; 17: 245-247Crossref PubMed Scopus (18) Google Scholar). There appears to be a shorter learning curve in microsurgical training when utilizing the robotic platform (20Schiff J. Li P.S. Goldstein M. Robotic microsurgical vasovasostomy and vasoepididymostomy: a prospective randomized study in a rat model.J Urol. 2004; 171: 1720-1725Crossref PubMed Scopus (75) Google Scholar). The robot is simply a tool, but it's imperative that microsurgeons are facile with this tool as there are non-microsurgeons exploring the use of the robot for microsurgical applications (23Marshall M.T. Doudt A.D. Berger J.H. Auge B.K. Christman M.S. Choe C.H. Robot-assisted vasovasostomy using a single layer anastomosis.J Robot Surg. 2017; 11: 299-303Crossref PubMed Scopus (11) Google Scholar). The problem is that just being a robotic surgeon does not necessarily provide all the training and education in a formal microsurgical fellowship. For example, the nuances of when to do a vasoepididymostomy and the microsurgical principles involved in performing a vasoepididymostomy. Robotic surgeons trying out a reversal (without any formal training in vasoepididymostomy) are much less likely to do a fluid analysis at the proximal vasal end or even consider any other procedure than a vasovasostomy. There is also evidence to suggest that microsurgeons have a shorter learning curve in acquiring robotic microsurgical skills than surgeons who are purely robotically trained (with no prior microsurgical training) as shown by Clarke et al. (24Clarke N.S. Price J. Boyd T. Salizzoni S. Zehr K.J. Nieponice A. et al.Robotic-assisted microvascular surgery: skill acquisition in a rat model.J Robot Surg. 2018; 12: 331-336Crossref PubMed Scopus (9) Google Scholar) in a rat model. Another reason to train microsurgeons in robotics is that it also provides a useful skill set for microsurgeons who may find themselves taking care of patients that require intra-abdominal robotic surgery. For example, intra-abdominal vasal reconstruction for patients with iatrogenic vasal injury during a hernia repair (25Barazani Y. Kaouk J. Sabanegh Jr., E.S. Robotic intra-abdominal vasectomy reversal: A new approach to a difficult problem.Can Urol Assoc J. 2014; 8: E439-E441Crossref PubMed Scopus (6) Google Scholar, 26Trost L. Parekattil S. Wang J. Hellstrom W.J. 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: 1120-1125Crossref PubMed Scopus (15) Google Scholar). This allows the microsurgeon to take microsurgery to the intra-pelvic area without having to make large inguinal or abdominal incisions providing a much quicker and less painful recovery for these patients compared to standard groin microsurgical explorations and reconstruction. For microsurgeons coming out of fellowship training (who may have robotic training during residency training), this is an attractive platform to further their microsurgical skills and is more likely to be valued as an asset by hospitals recruiting them that have robotic systems in place. The dual console robotic platform provides for unparalleled surgical training where the primary surgeon may take over the controls from the trainee at any point and also illustrate surgical concepts and techniques real-time at the console for hands-on microsurgical training. Another important advantage of the robotic platform is decreased surgical fatigue and improved ergonomics and efficiency. The most expensive resource during microsurgical cases are not the tools we use, but the actual microsurgeon. When we look at other industries, such as automotive and manufacturing, manual skilled labor is increasingly utilizing robotic assisted tools for improved efficiency and throughput. These pressures are already manifesting in medicine in terms of governmental pressure for quality outcomes with increased output. As microsurgeons we have to develop methods to improve efficiency without compromising quality, and this is what robotic microsurgery offers us. Robotic surgery was initially introduced as a less invasive alternative for conventional operations using a few smaller (1–2 cm) incisions instead of 10 to 30 cm ones. Male reproductive surgeries are generally extracorporeal, with the target structures such as the vasa deferentia, epididymides, spermatic cords, or testes, all located superficial enough that superb exposure can be achieved by small incisions with a conventional microsurgery approach. Hence the main advantage of minimal invasiveness of surgical robotics is of no use in this context. In addition to other putative advantages including tremor reduction, scalability and high degree of freedom of motion that can decrease surgeon fatigue, robot advocates (27Gudeloglu A. Brahmbhatt J.V. Parekattil S.J. Robotic-assisted microsurgery for an elective microsurgical practice.Semin Plast Surg. 2014; 28: 11-19Crossref PubMed Scopus (15) Google Scholar) noted that the multiple robotic arms can precisely handle tissues as specified by the single surgeon at the console unit, circumventing the need of an assistant skillful in microsurgery. In reality, for most skilled microsurgeons in male reproductive surgeries, having a surgical assistant is rarely a necessity. With regards to surgical outcomes for male reproductive surgeries, there is currently no valid evidence demonstrating better outcomes with robotic assistance for male reproductive surgeries when compared to the conventional microsurgical approach (19McCullough A. Elebyjian L. Ellen J. Mechlin C. A retrospective review of single-institution outcomes with robotic-assisted microsurgical varicocelectomy.Asian J Androl. 2018; 20: 189-194Crossref PubMed Google Scholar, 28Parekattil S.J. Gudeloglu A. Robotic assisted andrological surgery.Asian J Androl. 2013; 15: 67-74Crossref PubMed Scopus (36) Google Scholar, 29Etafy M. Gudeloglu A. Brahmbhatt J.V. Parekattil S.J. Review of the role of robotic surgery in male infertility.Arab J Urol. 2017; 16: 148-156Crossref PubMed Scopus (7) Google Scholar) In fact, it appears that results from experienced micro-surgeons are superior to those obtained by the robotic approaches (30Goldstein M. Li P.S. Matthews G.J. Microsurgical vasovasostomy: the microdot technique of precision suture placement.J Urol. 1998; 159: 188-190Crossref PubMed Scopus (105) Google Scholar, 31Chan P.T. Goldstein M. Vasectomy and vasectomy reversal.in: Kandeel F.R. Male reproductive dysfunction. Informa Healcare, New York2007: 385-405Crossref Google Scholar, 32Chan P.T. Brandell R.A. Goldstein M. Prospective analysis of outcomes after microsurgical intussusception vasoepididymostomy.Br J Urol Int. 2005; 96: 598-601Crossref PubMed Scopus (77) Google Scholar, 33Chan PT, Lee R, Li PS, Libman J, Goldstein M. Six years of experience with microsurgical longitudinal intussusception vasoepididymostomy (LIVE): a prospective analysis. Proceedings of the 2008 Annual Meeting of the American Urological Association, Orlando, Florida, May 17–22, 2008. J Urol 2008;179(Suppl):591-2.Google Scholar, 34Goldstein M. Surgical management of male infertility.in: Wein A.J. Kavoussi L.R. Partin A.W. Peters C.A. Campbell-Walsh urology. 11th ed. Elsevier, Philadelphia2016: 580-611Google Scholar). To best the microsurgical approach for male reproductive surgeries, in the defense of the robot advocates, is not an easy task. Take vasovasostomy, for example, the current patency rate with micro-surgery from most experienced reproductive urologists is over 90% in the current literature (30Goldstein M. Li P.S. Matthews G.J. Microsurgical vasovasostomy: the microdot technique of precision suture placement.J Urol. 1998; 159: 188-190Crossref PubMed Scopus (105) Google Scholar, 34Goldstein M. Surgical management of male infertility.in: Wein A.J. Kavoussi L.R. Partin A.W. Peters C.A. Campbell-Walsh urology. 11th ed. Elsevier, Philadelphia2016: 580-611Google Scholar) with a low complication rate and short hospitalization (same day surgery); a scenario very different from the comparison between robot-assisted uro-oncology procedures with the conventional approaches which are more invasive with higher rates of complications, longer recovery period and hospital stay and comparison can be made with robust outcomes such as quality of life and survival rates. To clearly demonstrate non-inferiority with two alternative surgical approaches in male reproductive surgeries, a well-designed head-to-head comparison study will likely require a high number of patients and therefore a long study period. Keep in mind it is difficult to eliminate biases from confounding factors such as surgeon experience (as it is unlikely the same surgeon during the same long study period would be performing both robotic and microsurgical approaches in similar volume) and patient characteristics. Further, outcomes used to evaluate success in various male reproductive surgeries such as semen parameter improvement, sexual function, serum testosterone levels, subjective pain sensation, pregnancy or live birth rates are all subject to significant intra-individual variations or can be confounded by the reproductive status of the female partners. Despite the many limitations and inadequacy of the current surgical robotic system, as described below, we believe it has roles in male reproductive surgeries. In the scenario of vasal injury deep in the intracorporeal end, occurred often iatrogenically from previous hernia repair or other pelvic surgeries, the retroperitoneal vas can be dissected out intra-pevically with the robot to allow a vasovasostomy to be performed (27Gudeloglu A. Brahmbhatt J.V. Parekattil S.J. Robotic-assisted microsurgery for an elective microsurgical practice.Semin Plast Surg. 2014; 28: 11-19Crossref PubMed Scopus (15) Google Scholar, 35Najari B. Li P. Mehta A. Green D. Tewari A. Goldstein M. Robotic-assisted laparoscopic mobilization of the vas deferens for correction of obstructive azoospermia induced by mesh herniorrhaphy.J Urol. 2013; 189: e654Crossref PubMed Google Scholar). One may argue, however, that this represents a rare case scenario even among urologists who perform a high volume of robotic assisted surgeries. As such, it is clearly not enough to justify the routine use of the robot in managing male infertility cases. The ergonomic benefits of robotic assistance could be appealing to trainees or practising reproductive urologists who either experience significant fatigue from performing microsurgery or have significant physiological tremors or inadequate dexterity to proficiently handle and manipulate the various conventional microsurgical instruments to provide good surgical outcomes and low complication rates at par to those obtained by experienced microsurgeons. As demonstrated by Parekattil et al. (21Parekattil S.J. Gudeloglu A. Brahmbhatt J. Wharton J. Priola K.B. Robotic assisted versus pure microsurgical vasectomy reversal: technique and prospective database control trial.J Reconstr Microsurg. 2012; 28: 435-444Crossref PubMed Scopus (34) Google Scholar) and supported by another case series (22Kavoussi P.K. Validation of robot-assisted vasectomy reversal.Asian J Androl. 2015; 17: 245-247Crossref PubMed Scopus (18) Google Scholar), a fellowship-trained microsurgeon who achieved a patency rate of only 80% with conventional microsurgery for vasectomy reversal (median time from vasectomy 6.5 y) could significantly improve his results to 96% using robotic assisted vasectomy reversal. The message is clear: the robotic systems currently available do not offer overall benefits in surgical outcomes other than the elimination of tremor in the hands of tremor-prone microsurgeons. This message is important both for patients and for healthcare professionals providing counselling to couples on the options of care they need to manage their fertility problems. Over the years, male reproductive surgeries have undergone significant changes in the technical approaches, with the most important one being the introduction of the use of an operating microscope (1Silber S.J. Microsurgery in clinical urology.Urology. 1975; 6: 150-153Abstract Full Text PDF PubMed Scopus (61) Google Scholar, 2Owen E.R. Microsurgical vasovasostomy: a reliable vasectomy reversal.Aust N Z J Surg. 1977; 47: 305-309Crossref PubMed Scopus (82) Google Scholar), which is now considered a standard for most male reproductive surgeries. The adoption of microsurgery for male reproductive surgeries not only has led directly to improved surgical outcomes but it has also led to reduction of complications, as documented clearly in the literature (8Kirby E.W. Hockenberry M. Lipshultz L.I. Vasectomy reversal: decision making and technical innovations.Transl Androl Urol. 2017; 6: 753-760Crossref PubMed Scopus (8) Google Scholar, 36Pastuszak A.W. Wenker E.P. Lipshultz L.I. The history of microsurgery in urology.Urology. 2015; 85: 971-974Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar). Further, the learning curve of microsurgery for male reproductive urology can be readily overcome through proper training offered by reputable fellowship programs. Most importantly, the low maintenance of surgical microscopes along with the durability and therefore high reusability of microsurgical instruments make the cost of microsurgery acceptable in all forms of urological practice worldwide. These features make the introduction of microsurgery in male reproductive surgery a true technological progress and belie the need of any putative advantages attributed to robotic assistance. With regards to robot-assisted surgery, one of the most important shortcomings is its high cost (37Barbash G.I. Glied S.A. New technology and health care costs–the case of robot-assisted surgery.N Engl J Med. 2010; 363: 701-704Crossref PubMed Scopus (703) Google Scholar). Interestingly, though the da Vinci robot (Intuitive Surgical, Inc.) has been in use in the U.S. since its approval by the Food and Drug Administration for almost two decades, its price over the years has remained high (approximately US$1.5 million). Further, despite various announcements from new industrial and academic teams on development of alternative options of robotic surgical units (38Tan Y.P.A. Liverneaux P. Wong J.K.F. Current limitations of surgical robotics in reconstructive plastic microsurgery.Front Surg. 2018; 5: 22Crossref PubMed Scopus (14) Google Scholar), none has actually made it into the market for clinical use. Thus, with the lack of significant competitions, the price of a robot is unlikely to decrease in the near future. Besides the cost to acquire the robotic platform, the costs of its maintenance (USD$100–200,000 annually) and the consumables tools and supplies needed for each case (USD$2,000–4,000) must also be taken into account (39Higgins R.M. Frelich M.J. Bosler M.E. Gould J.C. Cost analysis of robotic versus laparoscopic general surgery procedures.Surg Endosc. 2017; 31: 185-192Crossref PubMed Scopus (81) Google Scholar, 40Broome J.T. Pomeroy S. Solorzano C.C. Expense of robotic thyroidectomy: a cost analysis at a single institution.Arch Surg. 2012; 147: 1102-1106Crossref PubMed Scopus (41) Google Scholar). More space in the operating theater is also needed to allow the robot and its console unit to be safely installed for unimpeded surgical workflow. Needless to say, specially trained nursing staff is required to allow robotic surgery to be performed proficiently and to trouble-shoot any technical glitches that may occur intra-operatively (41Ben-Or S. Nifong L.W. Chitwood Jr., W.R. Robotic surgical training.Cancer J. 2013; 19: 120-123Crossref PubMed Scopus (13) Google Scholar). Taken together, the investment and operating cost of robotic surgery is considerable. For male reproductive surgeries, the additional costs associated with the use of robot may not be all covered by insurance and will be passed on to the patients or the overall medical system. Surgeons who offer robotic surgeries for male infertility may thus have to adjust their fees to absorb the extra fixed costs associated with robotic usage, both to minimize the out-of-pocket cost and to be competitive against conventional surgeries (28Parekattil S.J. Gudeloglu A. Robotic assisted andrological surgery.Asian J Androl. 2013; 15: 67-74Crossref PubMed Scopus (36) Google Scholar). The lack of any outcome advantages, as stated in the other parts of this debate, consequently fails to outweigh the capital cost. In addition, the inconvenience and short-comings associated with robotic use are logically important reasons why robotic male reproductive surgeries fail to gain significant tractions among both experienced and the new generations of male reproductive urologists. We argue that the current robotic platform not only offers limited benefits but has several significant limitations. This is not surprising considering that the da Vinci robot was not designed for microsurgery. Despite the modifications in the various generations of the robot, few changes were made to allow the machine to provide what microsurgeons need. Currently, the most common EndoWrist instruments used in male reproductive surgeries are the Black Diamond forceps, microbipolar forceps, Potts scissors, and the curved monopolar scissors. The Black Diamond and bipolar forceps (Intuitive Surgical, Inc.) in the current model can be dubbed as needle drivers to control sutures as fine as 11-0 and 6-0 sutures, respectively. But this should by no means indicate similar performance to conventional microsurgical instrument; keep in mind that microsuture placement represents only a small part of most male reproductive microsurgeries. A more important consideration is that the fixed robotic forceps fail to provide the needed options that are available from a large armamentarium of well-designed microsurgical instruments required to properly perform in various surgeries. In addition, the lack of tactile or haptic feedback for the surgeon represents a significant handicap. At best it may just limit the surgeon's ability in properly handling the fine micro-sutures and needles leading to bending and damage of the needles and breakage of the sutures (42Taleb C. Nectoux E. Liverneaux P.A. Telemicrosurgery: a feasibility study in a rat model.Chir Main. 2008; 27: 104-108Crossref PubMed Scopus (34) Google Scholar, 43Nectoux E. Taleb C. Liverneaux P. Nerve repair in telemicrosurgery: an experimental study.J Reconstr Microsurg. 2009; 25: 261-265Crossref PubMed Scopus (45) Google Scholar, 44Robert E. Facca S. Atik T. Bodin F. Bruant-Rodier C. Liverneaux P. Vascular microanastomosis through an endoscopic approach: feasibility study on two cadaver forearms.Chir Main. 2013; 32: 136-140Crossref PubMed Scopus (10) Google Scholar). At worst the lack of tactile feedbacks can lead to damage to the delicate tissue and potentially lead to tearing, damage and scarring of tissues that can compromise the outcomes. This issue has been raised by surgeons from a wide range of subspecialties including reproductive urology (38Tan Y.P.A. Liverneaux P. Wong J.K.F. Current limitations of surgical robotics in reconstructive plastic microsurgery.Front Surg. 2018; 5: 22Crossref PubMed Scopus (14) Google Scholar, 45Mattos L.S. Caldwell D.G. Peretti G. Mora F. Guastini L. Cingolani R. Microsurgery robots: addressing the needs of high-precision surgical interventions.Swiss Med Wkly. 2016; 146: w14375PubMed Google Scholar, 46Ibrahim A.E. Sarhane K.A. Selber J.C. New Frontiers in robotic-assisted microsurgical reconstruction.Clin Plast Surg. 2017; 44: 415-423Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar). Yet little progress is made to correct this important short-coming. Instead, suggestions were made to use other input signals such as visual cues to provide perception of haptic feedback (47Hagen M.E. Meehan J.J. Inan I. Morel P. Visual clues act as a substitute for haptic feedback in robotic surgery.Surg Endosc. 2008; 22: 1505-1508Crossref PubMed Scopus (68) Google Scholar, 48Okamura A.M. Haptic feedback in robot-assisted minimally invasive surgery.Curr Opin Urol. 2009; 19: 102-107Crossref PubMed Scopus (422) Google Scholar). Experts in microsurgery would agree that these alternative amendments serve little to replace the importance of the "human touch" obtainable only from the delicate hepatic feedbacks during microsurgeries. Another important drawback of robotic surgery is the inferior optical view. The importance of having consistently superb quality of image during microsurgery cannot be overemphasized. Despite the technical upgrade in the robot console in providing stereo vision (which for decades has come as a "standard" feature for virtually all advanced operating microscopes), the quality of image obtained from electronic transmission from camera to a television screen, even at industrial high-definition (HD) standard introduced in the da Vinci S system in 2006, is no match to the quality of image viewed directly through the advanced optics in standard operating microscopes. The recent development of adding multiple views on the screen viewed by the surgeon at the console unit, including optional video signals from sources such as a camera connected to a bench top microscope examining for sperm in seminal fluid, can hardly be considered an advancement in technology and could potentially be a distraction to the surgeon focusing on performing difficult steps of the surgery. Even for basic optical features required for microsurgery such as magnification, the current da Vinci robotic 3D high definition camera is limited to a digital magnification of 10× to 15× which is far from what is required in male reproductive microsurgeries (range 20×–25×), but is achievable with virtually all makes of advanced operating microscopes. Further, digital magnification at maximum is prone to reveal pixilation that can significantly compromise the quality of images. Initial efforts were made to further increase the power of robotic surgical vision by adding an optical magnification video lens system (e.g. the VITOM lens system) (27Gudeloglu A. Brahmbhatt J.V. Parekattil S.J. Robotic-assisted microsurgery for an elective microsurgical practice.Semin Plast Surg. 2014; 28: 11-19Crossref PubMed Scopus (15) Google Scholar) for extracorporeal robotic surgery to attain 16× to 25× magnification. But this is no different than using add-on lenses on a smart phone camera to simulate longer zoom or macro lenses; you gain magnification but further lose quality of image that is already suboptimal. More importantly, with regards to operating time, though most studies quoted mean console time (17Shu T. Taghechian S. Wang R. Initial experience with robot-assisted varicocelectomy.Asian J Androl. 2008; 10: 146-148Crossref PubMed Scopus (36) Google Scholar, 19McCullough A. Elebyjian L. Ellen J. Mechlin C. A retrospective review of single-institution outcomes with robotic-assisted microsurgical varicocelectomy.Asian J Androl. 2018; 20: 189-194Crossref PubMed Google Scholar, 22Kavoussi P.K. Validation of robot-assisted vasectomy reversal.Asian J Androl. 2015; 17: 245-247Crossref PubMed Scopus (18) Google Scholar) being comparable to the operating time in conventional microsurgeries for male infertility (21Parekattil S.J. Gudeloglu A. Brahmbhatt J. Wharton J. Priola K.B. Robotic assisted versus pure microsurgical vasectomy reversal: technique and prospective database control trial.J Reconstr Microsurg. 2012; 28: 435-444Crossref PubMed Scopus (34) Google Scholar), the involvement of a robot will likely prolong the surgery and anesthesia due to the extra time required for robot preparation for docking (estimated to be 30–60 mins) and the back-and-forth switching of surgeon from the patient side to the console unit at different parts of the surgery. Interestingly, some robot advocates claimed a similar time required for the preparation of a surgical robot compared to a surgical microscope (21Parekattil S.J. Gudeloglu A. Brahmbhatt J. Wharton J. Priola K.B. Robotic assisted versus pure microsurgical vasectomy reversal: technique and prospective database control trial.J Reconstr Microsurg. 2012; 28: 435-444Crossref PubMed Scopus (34) Google Scholar, 28Parekattil S.J. Gudeloglu A. Robotic assisted andrological surgery.Asian J Androl. 2013; 15: 67-74Crossref PubMed Scopus (36) Google Scholar). This is truly surprising as most fellowship-trained reproductive urologists would agree that the time to sterilely drape and set-up a surgical microscope takes less than 10 mins. From an education perspective, for residency or fellowship program directors, it appears that the expansion of access to a robot for the various types of male reproductive microsurgery adds little to the training. As access to the console unit of the robot is limited to a single surgeon controlling an entire system, there is limited opportunity to advance trainees' skills compared to conventional male reproductive microsurgeries. For those who choose to join or are in a fellowship program where robotic male reproductive surgery is a routine practice, they must keep in mind that the access to a robot for male reproductive urology in most centers where they will practice may be limited and not expand significantly in the near future. Thus, it would be prudent for them to acquire further training with advanced microsurgery for reproductive urology through courses, observerships or fellowships led by reproductive microsurgery experts in the fields. Further, for practicing reproductive urologists who are satisfied with the outcomes of their microsurgeries, it should be reassuring to realize that these are not enough reasons to acquire training to switch to robotic assisted reproductive surgeries, considering the time and resources they have to invest with limited gain in surgical outcomes. Is preimplantation genetic testing for aneuploidy an essential tool for embryo selection or a costly 'add-on' of no clinical benefit?Fertility and SterilityVol. 110Issue 3PreviewChromosome aneuploidy is common in human gametes and preimplantation embryos and is a major cause of in vitro fertilization (IVF) failure, miscarriage, and still births, with an incidence at birth of less than 0.3%. Most aneuploidies originate in the oocyte through errors in maternal meiosis and these increase exponentially in women in their late 30s and early 40s. This is associated with a sharp increase in the incidence of miscarriage and a corresponding decline in live birth rates in these women following IVF. Full-Text PDF
Referência(s)