Vasectomy Reversal With Robotic Help
Sijo Parakattil, MD, and the robotic system he uses to perform RAVV.
Robotic-assisted microsurgical vasovasostomy (RAVV) may decrease operative duration and significantly improve early semen analysis measures compared with pure microscopic vasovasostomy (MVV), according to researchers.
“For a couple who's trying to get pregnant, this is a big deal,” said lead investigator Sijo Parekattil, MD, Director of Male Infertility and Microsurgery at the University of Florida in Gainesville. “The advantages are in operative efficiency and decreased physician fatigue. With the new robotic systems, we can do up to six cases a day with dual rooms.”
Previous published reports showed that RAVV may have technical advantages over MVV in animals and humans. Dr. Parekattil and his colleagues are the first to present a head-to-head comparison of RAVV and MVV. The study, which appears in the Journal of Endourology (published online ahead of print), compares the initial results for 20 RAVV cases with seven MVV cases performed between July 2007 and June 2009.
The mean operative duration for the RAVV cases was 109 minutes compared with 128 minutes for MVV. All the men were patent eight weeks postoperatively, but the mean sperm count was 54 million/mL in the RAVV group compared with 11 million/mL in the MVV group. The differences in sperm counts between the two procedures decreased over time, however.
“The longest follow-up we have is getting to be close to two years. So, it is still early follow-up,” Dr. Parekattil told Renal & Urology News. “At one year, the pregnancy rates are between 60% and 70%, which are pretty much what you would expect. So, no real differences in the robotic approach as far as pregnancy rates.”
Dr. Parekattil has been using the DaVinci robotic system (Intuitive Surgical, Sunnyvale, Calif.), which features a four-arm system with high-definition digital visual magnification. This system allows for greater magnification than the standard robotic system and also provides a greater range of motion and better microsurgical instrument handling, he said.
“This exciting study is an important stepping stone towards discovering whether this technology can help overcome our human limitations of tremor and fatigue,” said Wayne Kuang, MD, Assistant Professor of Urology at the University of New Mexico in Albuquerque. "Rigorous studies are needed to carefully look at patient outcomes and to see whether the lack of tactile feedback will adversely impact the success rates of vasectomy reversals.”
Dr. Kuang said there will probably be patient demand for this new robotic-assisted approach, as there has been with robotic-assisted prostatectomy. He said he is concerned that this approach could be prematurely adopted on a widespread basis.
Most patients pay out of pocket for vasectomy reversal, and the RAVV can cost more than $3,000 more than MVV. However, since many hospital fees are based on time, cutting operating time might offset some of the extra charges associated with the use of the robot, Dr. Kuang said.
Jay Sandlow, MD, Vice Chair of Urology at the Medical College of Wisconsin in Milwaukee, initially had reservations about RAVV, but said preliminary data are promising. “The operative time data are interesting,” Dr. Sandlow said. “However, I do not feel that this is ready for prime time just yet, as there are issues with cost, availability, and long-term outcomes.”