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V1394 VIDEO TECHNIQUE FOR ROBOTIC ASSISTED VASOVASOSTOMY
Vol. 183, No. 4, Supplement, Tuesday, June 1, 2010
THE JOURNAL OF UROLOGY姞
Infertility, Sexual Dysfunction, Trauma & Teaching Techniques Video Session 7 Tuesday, June 1, 2010
8:00 AM-10:00 AM
V1394 VIDEO TECHNIQUE FOR ROBOTIC ASSISTED VASOVASOSTOMY Sijo Parekattil*, Hany Atalah, Marc Cohen, Gainesville, FL INTRODUCTION AND OBJECTIVES: Microsurgical vasovasostomy is a technically demanding procedure. Previous studies have shown the possible benefit in the use of robotic assistance during such procedures. This video presents a technique for robotic assisted vasovasostomy (RAVV) and compares preliminary outcomes to standard microsurgical vasovasostomy (MVV) in a human clinical series. METHODS: A four-arm technique for RAVV was developed utilizing the DaVinci type S high definition robotic platform. A prospective comparison of all 33 bilateral vasovasostomy cases performed from Aug 2007 to Sept 2009 by a single fellowship trained microsurgeon. 21 cases were performed using RAVV, and 12 using MVV. Selection of approach (RAVV vs. MVV) was based on patient choice after thorough discussion of options. Mean age of the RAVV patients was 42, and 38 for MVV. Mean duration since vasectomy was 9 years (range 1-19) for RAVV and 7 years (range 3-19) for MVV. The same suture material and suturing technique (3 layer 10-0 and 9-0 nylon anastomosis) was used in both approaches. Operative duration was measured for all cases (skin to skin). Semen analysis was performed at 2 months, 5 months and 9 months post-op. RESULTS: This video presents a step-by-step technique guide for RAVV. Mean clinical follow-up was 3 months (range 1 – 24 months). 90% patency was achieved in the RAVV cases and 80% in MVV (⬎1 million sperm/high power field). Mean operative duration was significantly decreased in the RAVV series at 106 min (70-180) compared to MVV at 127 min (105-150), p⫽0.02. At 5 months post-op, the mean postoperative sperm count was significantly higher in RAVV vs. MVV (64 million vs. 11 million, p⫽0.02). CONCLUSIONS: The use of robotic assistance in microsurgical vasovasostomy may have potential benefit over MVV with regards to decreasing operative duration and improving post-operative sperm counts. Further evaluation and longer follow up is needed to assess its clinical potential, reproducibility and the true cost-benefit ratio. Source of Funding: None
V1395 VIDEO TECHNIQUE FOR ROBOTIC ASSISTED MICROSURGICAL SUBINGUINAL VARICOCELECTOMY Sijo Parekattil*, Karen Priola, Hany Atalah, Marc Cohen, Gainesville, FL INTRODUCTION AND OBJECTIVES: A previous study by Wang et al. have shown possible benefits to robotic assisted microsurgical subinguinal varicocelectomy over the standard microsurgical approach. This video presents a detailed technique guide for robotic assisted subinguinal varicocelectomy (RAVx) and presents our initial human results. METHODS: A four-arm technique for RAVx was developed utilizing the DaVinci type S high definition robotic platform. The outcomes of our initial 46 human RAVx cases from Jun’08-Sept’09 (mean follow up 3 months: range 1-15) were also reviewed. RESULTS: This video presents a step-by-step technique guide for RAVx. Mean duration per side was 38 min (25-80). Indications for the procedure were the presence of a grade two or three varicocele and the following conditions: 4 with azoospermia, 25 with oligospermia and 17 with testicular pain (failed all other conservative treatment options).
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Three-month follow up was available for 23 patients: 76% (13 patients) with oligospermia had a significant improvement in sperm count (three achieved a pregnancy), and 3 with azoospermia remain unchanged. For testicular pain: 88% (15/17 patients) had complete resolution of pain. One recurrence or persistence of a varicocele occurred (by physical and ultrasound exam) and one patient developed a small post-operative hydrocele. The 4th robotic arm allowed the surgeon to control one additional instrument during the cases decreasing reliance on the microsurgical assistant. The fourth arm also enabled the surgeon to perform real-time intra-operative Doppler mapping of the testicular arteries while dissecting the veins with the other arms if needed. CONCLUSIONS: Robotic assisted microsurgical subinguinal varicocelectomy appears to be feasible. The four arm robotic approach allows the microsurgeon to maneuver multiple instruments simultaneously including a micro Doppler probe. The preliminary human results appear promising. Further evaluation and follow up is warranted. Source of Funding: None
V1396 MANAGEMENT OF FERTILITY IN ADULT INTRA-ABDOMINAL CRYPTORCHIDISM John Kefer*, Kashif Siddiqi, Jihad Kaouk, Edmund Sabanegh, Cleveland, OH INTRODUCTION AND OBJECTIVES: Adult cryptorchidism is a rare problem, but one that offers significant challenges towards management of both infertility and oncological risks. Options towards management include observation, orchidopexy, or orchiectomy with testicular sperm extraction (onco-TESE). This video demonstrates our technique for the management of a rare but significant disease process. METHODS: A 22 year old male with a past surgical history of two previously failed attempts at bilateral orchidopexy (FowlerStevens). Relevant laboratory analysis included a testosterone of 770, FSH of 29, LH of 17, and semen analysis demonstrating normal volume azoospermia. Testicular tumor markers were also drawn, indicating Alpha fetoprotein (AFP) of 29 (normal ⬍11), Beta human chorionic gonadotropin (BHCG) of 0.1, and lactate dehydrogenase (LDH) of 181. Based on the wishes of the patient and family, and after extensive counseling regarding the risks of testicular malignancy, the decision was made to undergo bilateral laparoscopic orchiectomy with ex vivo onco-TESE if normal testicular tissue was found. RESULTS: Based on the location of the left and right testicles on preoperative MRI, we chose to perform bilateral procedures using separate port placements for left and right orchiectomy. Operative time was 95 minutes. Estimated blood loss was minimal. Surgical landmarks included identification of the surgical clips from the previous failed Fowler-Stevens procedures. Both testicles were identified and excised. No normal testicular tissue was identified on ex vivo onco-TESE. No sperm was isolated. A palpable solid mass was noted in the right testicle, and pathology revealed a mixed germ cell tumor. The patient was discharged on post-operative day 2 without complication. CONCLUSIONS: Adult cryptorchidism is a rare problem, and requires management of fertility issues and oncologic risks. Treatment algorithms should include cryopreservation of testicular tissue when possible, and aggressive management of oncologic risks, including orchidopexy when possible to assist with testicular screening exams, or orchiectomy when orchidopexy is not possible. Source of Funding: None
V1397 SYSTEM AND METHODOLOGY FOR URETHRAL DELIVERY OF THERAPEUTIC COMPOUNDS Joel Marmar*, Camden, NJ INTRODUCTION AND OBJECTIVES: Penile injection of Trimix liquid has been used for treatment of erectile dysfunction. However,
THE JOURNAL OF UROLOGY姞
Infertility, Sexual Dysfunction, Trauma & Teaching Techniques Video Session 7 Tuesday, June 1, 2010
8:00 AM-10:00 AM
V1394 VIDEO TECHNIQUE FOR ROBOTIC ASSISTED VASOVASOSTOMY Sijo Parekattil*, Hany Atalah, Marc Cohen, Gainesville, FL INTRODUCTION AND OBJECTIVES: Microsurgical vasovasostomy is a technically demanding procedure. Previous studies have shown the possible benefit in the use of robotic assistance during such procedures. This video presents a technique for robotic assisted vasovasostomy (RAVV) and compares preliminary outcomes to standard microsurgical vasovasostomy (MVV) in a human clinical series. METHODS: A four-arm technique for RAVV was developed utilizing the DaVinci type S high definition robotic platform. A prospective comparison of all 33 bilateral vasovasostomy cases performed from Aug 2007 to Sept 2009 by a single fellowship trained microsurgeon. 21 cases were performed using RAVV, and 12 using MVV. Selection of approach (RAVV vs. MVV) was based on patient choice after thorough discussion of options. Mean age of the RAVV patients was 42, and 38 for MVV. Mean duration since vasectomy was 9 years (range 1-19) for RAVV and 7 years (range 3-19) for MVV. The same suture material and suturing technique (3 layer 10-0 and 9-0 nylon anastomosis) was used in both approaches. Operative duration was measured for all cases (skin to skin). Semen analysis was performed at 2 months, 5 months and 9 months post-op. RESULTS: This video presents a step-by-step technique guide for RAVV. Mean clinical follow-up was 3 months (range 1 – 24 months). 90% patency was achieved in the RAVV cases and 80% in MVV (⬎1 million sperm/high power field). Mean operative duration was significantly decreased in the RAVV series at 106 min (70-180) compared to MVV at 127 min (105-150), p⫽0.02. At 5 months post-op, the mean postoperative sperm count was significantly higher in RAVV vs. MVV (64 million vs. 11 million, p⫽0.02). CONCLUSIONS: The use of robotic assistance in microsurgical vasovasostomy may have potential benefit over MVV with regards to decreasing operative duration and improving post-operative sperm counts. Further evaluation and longer follow up is needed to assess its clinical potential, reproducibility and the true cost-benefit ratio. Source of Funding: None
V1395 VIDEO TECHNIQUE FOR ROBOTIC ASSISTED MICROSURGICAL SUBINGUINAL VARICOCELECTOMY Sijo Parekattil*, Karen Priola, Hany Atalah, Marc Cohen, Gainesville, FL INTRODUCTION AND OBJECTIVES: A previous study by Wang et al. have shown possible benefits to robotic assisted microsurgical subinguinal varicocelectomy over the standard microsurgical approach. This video presents a detailed technique guide for robotic assisted subinguinal varicocelectomy (RAVx) and presents our initial human results. METHODS: A four-arm technique for RAVx was developed utilizing the DaVinci type S high definition robotic platform. The outcomes of our initial 46 human RAVx cases from Jun’08-Sept’09 (mean follow up 3 months: range 1-15) were also reviewed. RESULTS: This video presents a step-by-step technique guide for RAVx. Mean duration per side was 38 min (25-80). Indications for the procedure were the presence of a grade two or three varicocele and the following conditions: 4 with azoospermia, 25 with oligospermia and 17 with testicular pain (failed all other conservative treatment options).
e539
Three-month follow up was available for 23 patients: 76% (13 patients) with oligospermia had a significant improvement in sperm count (three achieved a pregnancy), and 3 with azoospermia remain unchanged. For testicular pain: 88% (15/17 patients) had complete resolution of pain. One recurrence or persistence of a varicocele occurred (by physical and ultrasound exam) and one patient developed a small post-operative hydrocele. The 4th robotic arm allowed the surgeon to control one additional instrument during the cases decreasing reliance on the microsurgical assistant. The fourth arm also enabled the surgeon to perform real-time intra-operative Doppler mapping of the testicular arteries while dissecting the veins with the other arms if needed. CONCLUSIONS: Robotic assisted microsurgical subinguinal varicocelectomy appears to be feasible. The four arm robotic approach allows the microsurgeon to maneuver multiple instruments simultaneously including a micro Doppler probe. The preliminary human results appear promising. Further evaluation and follow up is warranted. Source of Funding: None
V1396 MANAGEMENT OF FERTILITY IN ADULT INTRA-ABDOMINAL CRYPTORCHIDISM John Kefer*, Kashif Siddiqi, Jihad Kaouk, Edmund Sabanegh, Cleveland, OH INTRODUCTION AND OBJECTIVES: Adult cryptorchidism is a rare problem, but one that offers significant challenges towards management of both infertility and oncological risks. Options towards management include observation, orchidopexy, or orchiectomy with testicular sperm extraction (onco-TESE). This video demonstrates our technique for the management of a rare but significant disease process. METHODS: A 22 year old male with a past surgical history of two previously failed attempts at bilateral orchidopexy (FowlerStevens). Relevant laboratory analysis included a testosterone of 770, FSH of 29, LH of 17, and semen analysis demonstrating normal volume azoospermia. Testicular tumor markers were also drawn, indicating Alpha fetoprotein (AFP) of 29 (normal ⬍11), Beta human chorionic gonadotropin (BHCG) of 0.1, and lactate dehydrogenase (LDH) of 181. Based on the wishes of the patient and family, and after extensive counseling regarding the risks of testicular malignancy, the decision was made to undergo bilateral laparoscopic orchiectomy with ex vivo onco-TESE if normal testicular tissue was found. RESULTS: Based on the location of the left and right testicles on preoperative MRI, we chose to perform bilateral procedures using separate port placements for left and right orchiectomy. Operative time was 95 minutes. Estimated blood loss was minimal. Surgical landmarks included identification of the surgical clips from the previous failed Fowler-Stevens procedures. Both testicles were identified and excised. No normal testicular tissue was identified on ex vivo onco-TESE. No sperm was isolated. A palpable solid mass was noted in the right testicle, and pathology revealed a mixed germ cell tumor. The patient was discharged on post-operative day 2 without complication. CONCLUSIONS: Adult cryptorchidism is a rare problem, and requires management of fertility issues and oncologic risks. Treatment algorithms should include cryopreservation of testicular tissue when possible, and aggressive management of oncologic risks, including orchidopexy when possible to assist with testicular screening exams, or orchiectomy when orchidopexy is not possible. Source of Funding: None
V1397 SYSTEM AND METHODOLOGY FOR URETHRAL DELIVERY OF THERAPEUTIC COMPOUNDS Joel Marmar*, Camden, NJ INTRODUCTION AND OBJECTIVES: Penile injection of Trimix liquid has been used for treatment of erectile dysfunction. However,