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Robotic assisted versus pure microsurgical vasovasostomy and vasoepididymostomy: prospective control trial
two testicular artery and one vasal injury. These were all repaired intra-operatively with robotic assisted microsurgical techniques. These patients recovered postoperatively without any further sequela. No patients have developed testicular atrophy postoperatively. The 4th robotic arm allowed the surgeon to control one additional instrument (micro Doppler) leading to less reliance on the microsurgical assistant. CONCLUSION: Mapped nerve robotic assisted microsurgical denervation of the spermatic cord is feasible and the preliminary results appear promising. The four arm robotic approach allows the microsurgeon to maneuver multiple instruments simultaneously.
(table 1). Levels remained significantly elevated for duration of therapy. PSA levels did not increase significantly after 3 month of CC therapy (p¼0.17). 4 patients demonstrated improved sperm concentration and motility at 6 months and a total of 5 subjects achieved pregnancy. TABLE 1. Baseline vs. 1 Month Post-CC Treatment
Parameter
Baseline
1 month
P-value
TT ng/dL (OW) BT ng/dL (OW) TT ng/dL (OB) BT ng/dL (OB)
306 26 187 16 237 20 155 13
663 56 486 55 577 52 371 42
< 0.001 < 0.002 < 0.001 < 0.001
P-135 Tuesday, October 26, 2010 ROBOTIC ASSISTED VERSUS PURE MICROSURGICAL VASOVASOSTOMY AND VASOEPIDIDYMOSTOMY: PROSPECTIVE CONTROL TRIAL. S. J. Parekattil, K. B. Priola, H. Atalah, M. S. Cohen. Urology, University of Florida, Gainesville, FL. OBJECTIVE: Microsurgical vasovasostomy is a technically demanding procedure. Previous studies have shown possible benefit of robotic assistance during such procedures. Our goal was to compare robotic assisted vasovasostomy (RAVV) and vasoepididymostomy (RAVE) to standard microsurgical vasovasostomy (MVV) and vasoepididymostomy (MVE) in a prospective control trial. DESIGN: Prospective control trial of 66 vasectomy reversal cases from Aug’07 to Apr’10 by a single fellowship trained microsurgeon. Primary end point was operative duration and secondary endpoint was total motile sperm count at 2, 5, 9 and 12 months post-operatively. Selection of approach was based on patient choice (robotic more expensive than microscopic). MATERIALS AND METHODS: Case breakdown: 26 bilateral RAVV, 7 RAVE (at least one side), 21 bilateral MVV, and 12 MVE (at least one side). Preoperative patient characteristics were similar in both groups. The same suture material and suturing technique (2 layer 10-0 and 9-0 nylon anastomosis for vasovasostomy; 10-0 nylon double armed longitudinal intussusception for vasoepididymostomy) was used in both approaches. RESULTS: Mean clinical follow-up: 7 months (2-28). 92% patency achieved in RAVV and 76% in MVV (>1 million sperm/high power field). Mean operative duration was significantly decreased in RAVV at 100 min (70-180) compared to MVV at 126 min (90-150), p¼0.007. RAVE at 126 min (90-180) was significantly faster than MVE at 165 min (120-240), p¼0.03. Mean post-operative total motile sperm counts were not significantly higher in RAVV/RAVE versus MVV/MVE, but the rate of post-operative sperm count recovery was significantly greater in RAVV/RAVE. CONCLUSION: The use of robotic assistance in microsurgical vasovasostomy and vasoepididymostomy may have potential benefit in regards to decreasing operative duration and improving the rate of recovery of postoperative total motile sperm counts. Further evaluation and longer follow up is needed to assess its clinical potential and the true cost-benefit ratio.
P-136 Tuesday, October 26, 2010 CLOMIPHENE CITRATE IS EFFECTIVE IN THE TREATMENT OF THE HYPOGONADAL, SUBFERTILE MALE WITH BODY MASS INDEX (BMI) >25 KG/M2. D. Shin, G. Pregenzer, P. Hinds. Department of Urology, Hackensack University Medical Center, Hackensack, NJ; Division of Urology, UMDNJ-New Jersey Medical School, Newark, NJ. OBJECTIVE: BMI has been shown to be negatively correlated with total testosterone (TT) and bioavailable testosterone (BT) levels in infertile males. Clomiphene citrate (CC), a selective estrogen receptor modulator, is used in the empiric treatment of subfertile males to increase testosterone levels. We sought to study the efficacy of CC for treatment of subfertile males who are overweight (OW, BMI 25-29.9 kg/m2) or obese (OB, BMI>30 kg/m2). DESIGN: Prospective observational cohort study. MATERIALS AND METHODS: Hypogonadal patients were started on CC, and TT, BT and prostate specific antigen (PSA) levels were recorded at baseline and measured at 1, 3 and 5 months during therapy. Followup semen analysis or pregnancy status was recorded. Student’s t-test was used to compare pre- and post-treatment biochemical parameters. RESULTS: The study included 20 men, mean age 32.9 0.9(SEM). Lower mean baseline TT levels were seen in the OB group (n¼12) compared to the OW group (n¼8) (TT: 237 20 vs 306 26 ng/dl; p¼0.053). Within 1 month of CC therapy, TT and BT were significantly increased in both groups
FERTILITY & STERILITYÒ
Results reported as mean SEM. CONCLUSION: Significant improvement in testosterone levels are seen with the use of CC in the treatment of the subfertile male with BMI>25 kg/m2. Subfertile men who are overweight or obese can benefit from treatment with CC in order to increase testosterone levels and potentially improve semen parameters.
P-137 Tuesday, October 26, 2010 OBESITY NEGATIVELY INFLUENCES THE OUTCOME OF MICROSCOPIC VARICOCELECTOMY IN INFERTILE MEN. J. W. Weedin, K. Hwang, D. Avila, D. J. Lamb, L. I. Lipshultz. Scott Department of Urology, Baylor College of Medicine, Houston, TX; Molecular and Cell Biology, Baylor College of Medicine, Houston, TX. OBJECTIVE: Compared to men with normal weight, obesity is associated with a higher incidence and grade of varicocele together with lower serum testosterone, diminished semen parameters, and infertility. We sought to determine if obesity influences the outcome of varicocele repair. DESIGN: A retrospective review of infertile men undergoing microscopic varicocelectomy from 2005-2009. MATERIALS AND METHODS: Inclusion criteria included infertility, presence of a clinical varicocele, and postoperative follow-up more than 4 months. Men were excluded if they had a prior varicocele repair, genetic abnormalities, azoospermia, or an obstructive cause of infertility. Obesity was defined as body mass index (BMI)>30. Multiple variables were analyzed with respect to preoperative and postoperative sperm density, motility, and morphology. Univariate and multivariate analysis was used to analyze variables associated with greater than 50% improvement in sperm density. RESULTS: 245 (71 obese) men were included with mean age of 34.4 years and follow-up of 12.5 months. After varicocelectomy, sperm density, motility, and normal morphology significantly improved (p<0.05). Preoperatively, obesity was associated with low testosterone (p<0.01) and increased seminal reactive oxygen species (ROS) (p¼0.03). BMI correlated with increased operative time (r¼0.4, p<0.01) and operative complications (p¼0.04). Compared to obese men, non-obese men displayed a greater improvement in sperm density (11.6x106/mL vs 5.3x106/mL, p<0.01) and normal morphology (5.6% vs -5.4%, p<0.01), but not motility (3.4% vs 0.1%, p¼0.09). On multivariate analysis, only initial sperm density and obesity was negatively associated with a 50% improvement in sperm density (p<0.05). CONCLUSION: As previously reported, obesity is associated with low testosterone and increased ROS. After microscopic varicocelectomy, the seminal parameters of obese men show less improvement then non-obese men suggesting that BMI can influence varicocelectomy success.
SPERM BIOLOGY P-138 Tuesday, October 26, 2010 SPERM NUCLEAR VACUOLES ARE HOLLOW STRUCTURES DEVOID OF NUCLEIC ACIDS THAT ARE NOT LINKED TO DEFECTIVE CHROMATIN PACKAGING. A. Mesner, L. Hesters, V. Blin, R. Fanchin, C. Pou¨s, N. Frydman. Service de Biologie et Genetique de la Reproduction, Hoˆpital Antoine Becle`re, Clamart Cedex, France; Service de Gynecologie-Obstetrique et de Medecine de la Reproduction, Hoˆpital Antoine Becle`re, Clamart Cedex, France; Laboratoire de Biochimie et Biologie Cellulaire, Universite Paris-sud 11, Chaˆtenay-Malabry Cedex, France. OBJECTIVE: Recently, it has been reported that the normal morphology of the sperm nucleus defined by MSOME was positively associated with
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(table 1). Levels remained significantly elevated for duration of therapy. PSA levels did not increase significantly after 3 month of CC therapy (p¼0.17). 4 patients demonstrated improved sperm concentration and motility at 6 months and a total of 5 subjects achieved pregnancy. TABLE 1. Baseline vs. 1 Month Post-CC Treatment
Parameter
Baseline
1 month
P-value
TT ng/dL (OW) BT ng/dL (OW) TT ng/dL (OB) BT ng/dL (OB)
306 26 187 16 237 20 155 13
663 56 486 55 577 52 371 42
< 0.001 < 0.002 < 0.001 < 0.001
P-135 Tuesday, October 26, 2010 ROBOTIC ASSISTED VERSUS PURE MICROSURGICAL VASOVASOSTOMY AND VASOEPIDIDYMOSTOMY: PROSPECTIVE CONTROL TRIAL. S. J. Parekattil, K. B. Priola, H. Atalah, M. S. Cohen. Urology, University of Florida, Gainesville, FL. OBJECTIVE: Microsurgical vasovasostomy is a technically demanding procedure. Previous studies have shown possible benefit of robotic assistance during such procedures. Our goal was to compare robotic assisted vasovasostomy (RAVV) and vasoepididymostomy (RAVE) to standard microsurgical vasovasostomy (MVV) and vasoepididymostomy (MVE) in a prospective control trial. DESIGN: Prospective control trial of 66 vasectomy reversal cases from Aug’07 to Apr’10 by a single fellowship trained microsurgeon. Primary end point was operative duration and secondary endpoint was total motile sperm count at 2, 5, 9 and 12 months post-operatively. Selection of approach was based on patient choice (robotic more expensive than microscopic). MATERIALS AND METHODS: Case breakdown: 26 bilateral RAVV, 7 RAVE (at least one side), 21 bilateral MVV, and 12 MVE (at least one side). Preoperative patient characteristics were similar in both groups. The same suture material and suturing technique (2 layer 10-0 and 9-0 nylon anastomosis for vasovasostomy; 10-0 nylon double armed longitudinal intussusception for vasoepididymostomy) was used in both approaches. RESULTS: Mean clinical follow-up: 7 months (2-28). 92% patency achieved in RAVV and 76% in MVV (>1 million sperm/high power field). Mean operative duration was significantly decreased in RAVV at 100 min (70-180) compared to MVV at 126 min (90-150), p¼0.007. RAVE at 126 min (90-180) was significantly faster than MVE at 165 min (120-240), p¼0.03. Mean post-operative total motile sperm counts were not significantly higher in RAVV/RAVE versus MVV/MVE, but the rate of post-operative sperm count recovery was significantly greater in RAVV/RAVE. CONCLUSION: The use of robotic assistance in microsurgical vasovasostomy and vasoepididymostomy may have potential benefit in regards to decreasing operative duration and improving the rate of recovery of postoperative total motile sperm counts. Further evaluation and longer follow up is needed to assess its clinical potential and the true cost-benefit ratio.
P-136 Tuesday, October 26, 2010 CLOMIPHENE CITRATE IS EFFECTIVE IN THE TREATMENT OF THE HYPOGONADAL, SUBFERTILE MALE WITH BODY MASS INDEX (BMI) >25 KG/M2. D. Shin, G. Pregenzer, P. Hinds. Department of Urology, Hackensack University Medical Center, Hackensack, NJ; Division of Urology, UMDNJ-New Jersey Medical School, Newark, NJ. OBJECTIVE: BMI has been shown to be negatively correlated with total testosterone (TT) and bioavailable testosterone (BT) levels in infertile males. Clomiphene citrate (CC), a selective estrogen receptor modulator, is used in the empiric treatment of subfertile males to increase testosterone levels. We sought to study the efficacy of CC for treatment of subfertile males who are overweight (OW, BMI 25-29.9 kg/m2) or obese (OB, BMI>30 kg/m2). DESIGN: Prospective observational cohort study. MATERIALS AND METHODS: Hypogonadal patients were started on CC, and TT, BT and prostate specific antigen (PSA) levels were recorded at baseline and measured at 1, 3 and 5 months during therapy. Followup semen analysis or pregnancy status was recorded. Student’s t-test was used to compare pre- and post-treatment biochemical parameters. RESULTS: The study included 20 men, mean age 32.9 0.9(SEM). Lower mean baseline TT levels were seen in the OB group (n¼12) compared to the OW group (n¼8) (TT: 237 20 vs 306 26 ng/dl; p¼0.053). Within 1 month of CC therapy, TT and BT were significantly increased in both groups
FERTILITY & STERILITYÒ
Results reported as mean SEM. CONCLUSION: Significant improvement in testosterone levels are seen with the use of CC in the treatment of the subfertile male with BMI>25 kg/m2. Subfertile men who are overweight or obese can benefit from treatment with CC in order to increase testosterone levels and potentially improve semen parameters.
P-137 Tuesday, October 26, 2010 OBESITY NEGATIVELY INFLUENCES THE OUTCOME OF MICROSCOPIC VARICOCELECTOMY IN INFERTILE MEN. J. W. Weedin, K. Hwang, D. Avila, D. J. Lamb, L. I. Lipshultz. Scott Department of Urology, Baylor College of Medicine, Houston, TX; Molecular and Cell Biology, Baylor College of Medicine, Houston, TX. OBJECTIVE: Compared to men with normal weight, obesity is associated with a higher incidence and grade of varicocele together with lower serum testosterone, diminished semen parameters, and infertility. We sought to determine if obesity influences the outcome of varicocele repair. DESIGN: A retrospective review of infertile men undergoing microscopic varicocelectomy from 2005-2009. MATERIALS AND METHODS: Inclusion criteria included infertility, presence of a clinical varicocele, and postoperative follow-up more than 4 months. Men were excluded if they had a prior varicocele repair, genetic abnormalities, azoospermia, or an obstructive cause of infertility. Obesity was defined as body mass index (BMI)>30. Multiple variables were analyzed with respect to preoperative and postoperative sperm density, motility, and morphology. Univariate and multivariate analysis was used to analyze variables associated with greater than 50% improvement in sperm density. RESULTS: 245 (71 obese) men were included with mean age of 34.4 years and follow-up of 12.5 months. After varicocelectomy, sperm density, motility, and normal morphology significantly improved (p<0.05). Preoperatively, obesity was associated with low testosterone (p<0.01) and increased seminal reactive oxygen species (ROS) (p¼0.03). BMI correlated with increased operative time (r¼0.4, p<0.01) and operative complications (p¼0.04). Compared to obese men, non-obese men displayed a greater improvement in sperm density (11.6x106/mL vs 5.3x106/mL, p<0.01) and normal morphology (5.6% vs -5.4%, p<0.01), but not motility (3.4% vs 0.1%, p¼0.09). On multivariate analysis, only initial sperm density and obesity was negatively associated with a 50% improvement in sperm density (p<0.05). CONCLUSION: As previously reported, obesity is associated with low testosterone and increased ROS. After microscopic varicocelectomy, the seminal parameters of obese men show less improvement then non-obese men suggesting that BMI can influence varicocelectomy success.
SPERM BIOLOGY P-138 Tuesday, October 26, 2010 SPERM NUCLEAR VACUOLES ARE HOLLOW STRUCTURES DEVOID OF NUCLEIC ACIDS THAT ARE NOT LINKED TO DEFECTIVE CHROMATIN PACKAGING. A. Mesner, L. Hesters, V. Blin, R. Fanchin, C. Pou¨s, N. Frydman. Service de Biologie et Genetique de la Reproduction, Hoˆpital Antoine Becle`re, Clamart Cedex, France; Service de Gynecologie-Obstetrique et de Medecine de la Reproduction, Hoˆpital Antoine Becle`re, Clamart Cedex, France; Laboratoire de Biochimie et Biologie Cellulaire, Universite Paris-sud 11, Chaˆtenay-Malabry Cedex, France. OBJECTIVE: Recently, it has been reported that the normal morphology of the sperm nucleus defined by MSOME was positively associated with
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